^HS^I


 
UNITED STATES OF AMERICA
*> •  .
FOUNDED  1836
WASHINGTON,  D. C.
GPO  16—67244-1 
 
 
.•>,>-J— — •-■■   . 
                   DICTIONARY

                                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;

                              AND AN

              frpptnlHj:  of  &j>j>rofee* iPormttlae:

      THE WHOLE FORMING A LIBRARY OP PATHOLOGY AND PRACTICAL MEDICINE,
                  AND A DIGEST OF MEDICAL LITERATURE.
              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.

                        1847. 
CT?4d
 l?5'!o_
  v.  5
Entered, according to Act of Congress, in the year 1846, by

               Harper & Brothers,

In the Clerk's Office of the Southern District of New York. 
CONTENTS.
INSANITY, CONNATE—Definition   -  625
---------, IDIOTIC—Grades of -    -  626
    Causes, &c......627
---------, PUERPERAL—Descrip-
  tion, &c.......628
    Pathology—Treatment   -    -    -  633
---------, SUICIDAL—Occasions of,
  &c........636
    Causes, Pathology, &c, of          648
    Treatment, &c.    -    -    .      652
    Bibliography and References  -    -  655
INTESTINES—Inflammation of small-
  Symptoms, &c.  -,   -    -    -    -  659
    Inflammation of' large    -           665
    Diagnosis.....671
    Terminations of, &e.    ...  673
    Post-mortem Appearances of -    -  675
    Treatment of, &c.  -               679
    Spasm of.....684
    Rupture of.....687
    Bibliography and References  -    -  689
IRRITABILITY—Definitions, &c.     -  691
    Grades of, &c.    -    -    -    -  693
    Bibliography and References  -    -  696
IRRITATION—Pathology and causes of  697
    Treatment of.....710
ITCH—Pathology, Description, &c, of -  716
    Causes—Treatment     ...  718
    Bibliography and References  -    -  721
KIDNEYS—Diseases of     -    -    -  721
    Inflammation of                   722
    Diagnosis.....728
    Consecutive Inflammation of -    -  731
    Cachectic      "       "          736
    Inflammation of Pelvis, &c.   -    -  757
    Organic Lesions of -    -   -    -  765
    Bibliography and References  -    -  771
LACTATION—Disorders of -   -    -  773
    Bibliography and References  -    -  776
LARYNX AND TRACHEA—Nervous
  Affections of.....776
    Inflammation of                   787
    Treatment.....799
    Foreign Bodies in  -    -    -    -  803
    Bibliography and References  -    -  807
LEPROSY—Description, &c, of  -    -  808
    Bibliography and References  -    -  815
LEUCORRHOEA — Vaginal, Description
  of, &c.......816
    Uterine......820
    Treatment.....824
    Bibliography and References  -    -  826
LICHENOUS RASHES—Description of 827
LIVER—Causes of its Diseases  -    -  829
    Functional Disorders of -   -    -  834
    Congestions of    ....  839
    Haemorrhage of                   843
    Inflammation of                   844
    Diagnosis, <kc.    -               852
    Prognosis—Treatment   ...  854
    Structural Changes in              866
    Treatment, &c.                    875
    Bibliography and References  -    -  877
LUNGS—Diseases of  -    -   -    -  878
    Acute Pneumonia  -               879
    Inflammation of                   880
    Diagnosis     .....  883
    Complications.....887
    Causes and Treatment   ...  890
                                     Pagd
    Chronic Inflammation, &c, of-    -  901
    Emphysema of the -    -    -    -  902
    Abscesses perforating the    -    -  907
    Gangrene of   -    -    -    -    -  909
    Bibliography and References  -    -  912
LUPUS—Definition, &c, of  -    -    -  913
    with Hypertrophy—Diagnosis -    -  915
    Treatment.....917
LYMPHATIC SYSTEM—Inflammation,
  &c, of......919
    Alterations of Structure  -           921
------------GLANDS—Inflammation
  of.......923
    Structural Changes of              925
    Treatment—Bibliography, &c.      -  928
MAMMA—Diseases of the    -    -    -  928
    Functional Affections of -    -    -  929
    Organic Lesions of the   -    -    -  933
    Bibliography and References  -    -  938
MEASLES—History and Description   -  939
    Terminations—fatal Signs    -    -  944
    Diagnosis, Causes, &c.   -           946
    Treatment, &c.    -    -    -    -  949
    Bibliography and References  -    -  951
MEDIASTINUM—Causes and Treatment  952
MEL^ENA—Causes and Treatment    -  953
MELANOSIS—Forms,  Causes,  and
  Cure.......956
MENSTRUATION—Phenomena of    -  959
---------------, DELAYED—Diag-
  nosis  .......963
    Treatment.....965
---------------, OBSTRUCTED    -  967
---------------, SUPPRESSED    -  969
    Complicated Amenorrhoea    -    -  971
 -------------, DIFFICULT—De-
  scription, &c......973
---------------, EXCESSIVE—Men-
  orrhagia   ......977
    Treatment, &c.    -    -    -    -  979
    Bibliography and References  -    -  982
MESENTERY—Diseases of the Glands of  983
    Prognosis and Treatment    -    -  989
    Bibliography and References  -    -  992
MILIARY ERUPTION—Definition, &c.  992
MUSCULAR  STRUCTURE —Diseases
  of, &c.......993
    Treatment and Bibliography  -    -  998
NERVES—Structural Changes of -    -  999
    Inflammation of                  1002
    Treatment—Bibliographv. &c.      - 1005
NEURALGIC  AFFECTIONS—Notices
  of.......1006
    Of the Extremities, &c.  -    -    - 1011
    Causes and Cure   ...    - 1015
    Bibliography and References  -    - 1028
NIGHT BLINDNESS—Pathology-
  Treatment, &c......1031
NOSTALGIA—^Etiology, &c.    -    - 1033
OBESITY—Definition of—Characters  - 1035
    Pathology and Treatment    -    - 1038
03DEMA—Definition—Treatment -    - 1039
CESOPHAGUS — Structural  Changes-
  Diseases  ......1041
    Ulceration, &c.                   1047
    Treatment—Bibliography, &c.      - 1052
OSSEOUS  SYSTEM—Inflammation  of
  the Bones......1054
    Necrosis, &c......1055 
 
CONTENTS
THE  SECOND  VOLUME.
GALL-BLADDER AND DUCTS    ....   6
GANGRENE    ........   9
GASTRO-ENTERIC DISEASE.....29
GLANDERS........34
GOUT.........'37

HEMORRHAGE—Patholog)'of    ....  72
------------FROM THE SKIN   ...  87
--------------------NOSE   ...  88
.--------------------MOUTH AND THE
  THROAT........94
--------------------RESPIRATORY OR-
  GANS   .........95
,--------------------STOMACH    .    . 108
--------------------INTESTINES .    .118
--------------------URINARY ORGANS 122
--------------------UTERUS .    .    .127
------------. INTO SEROUS CAVITIES .    . 142
----------------THE AREOLAR  TISSUE
  AND SUBSTANCE OF ORGANS    .    .    .143
HEMORRHOIDS.......144
HAIR..........159
----TRICHOMATOUS—PLICA  .   .    .    .164
HEADACHE........167
HEARING.........182
HEART AND PERICARDIUM—Diseases of the   . 193
HERPETIC ERUPTIONS......267
HICCOUGH........271
HOOPING-COUGH.......273
HYDATIDS    .       ......292
HYPERTROPHY.......298
HYPOCHONDRIASIS......300
HYSTERIC AFFECTIONS    .    .   .    .    .314

JAUNDICE.........341

ICHTHYOSIS........360
IMPETIGINOUS AFFECTIONS    .   .    .    .363
IMPOTENCE AND STERILITY   .   .    .    .369
----.-----IN THE MALE.....370
---------AND STERILITY IN THE FEMALE 373
INDIGESTION........377
INDURATION........400
INFECTION........401
INFLAMMATION.......426
INFLUENZA........489
INSANITY.........500
--------, IDIOTIC......625
                       A
                                        Page
INSANITY, PUERPERAL.....628
---------, SUICIDAL......636
INTESTINES—Diseases of, etc.....658
IRRITABILITY........690
IRRITATION........696
ITCH..........716

KIDNEYS—Diseases of, etc......721
LACTATION—Disorders of.....772
LARYNX AND TRACHEA.....776
LEPROSY.........807
LEUCORRH03A.......816
LICHEN.........826
LIVER—Diseases of, etc.......829
LUNGS—Diseases of, etc.......878
LUPUS.........913
LYMPHATIC AND LACTEAL SYSTEM —Dis-
  eases of.........918
LYMPHATIC GLANDS......923

MAMMA.........928
MEASLES.........938
MEDIASTINUM.......951
MELENA.........953
MELANOSIS........955
MEMBRANES........959
MENSES        )
MENSTRUATION ( Phenomena of .   .    .    .959
------------, DELAYED   .   .    .    .963
------------, OBSTRUCTED    .    .    .966
-------------, SUPPRESSED    .    .    .968
-------------.DIFFICULT  .   .    .    .972
------------, EXCESSIVE  .   .    .    .976
MESENTERY........983
MILIARY ERUPTIONS......992
MUSCULAR STRUCTURE—Diseases of    .    .  993

NERVES.........998
NEURALGIC AFFECTIONS.....1006
NIGHT-BLINDNESS, ETC......1029
NOSTALGIA......-     1033

OBESITY.........1035
C3DEMA.........1039
(ESOPHAGUS........1041
OSSEOUS SYSTEM......1053
OVARIA.........1061
OZENA  -        .......1067 
 
APPENDIX  OF  FORMULA
  In order to prevent repetitions, and to facilitate  references, the  following collection of For-
mulae is here appended and  arranged in alphabetical order, in addition to those which it  was
necessary to give in the body of the work.   The author has not added any of the formulas pre-
scribed by the three British Colleges of Physicians, as  they are  already in the hands of every
practitioner.   The preparations and recipes he has  given,  both here and at other places, consist
of a careful selection of those which are most approved, contained in the Pharmacopoeias of va-
rious  hospitals and  foreign countries, and from the writings of a number of eminent practical
physicians, as well as of those which he has been led chiefly to confide in during a practice of
upward of twenty years.   He has followed the Nomenclature adopted by the London College
in the latest edition of their Pharmacopoeia; and to avoid circumlocution,  he has retained the
short and  characteristic  names  usually employed, although  many  of them  are by  no means
classical.
  Form. 1. Acetum Antihystericum. (Disp. Fuld.)
R Castorei, Asafcetidae,  aa, Jij.;  Galbani, fss.; Herbs
    Rutae recenlis, Jj.; Aceti Vini, Ibij.  Macera bene et
    cola.
         Form. 2.  Acetum Camphoeatum.
R Camphors Pulver. cum Alcoholis pauxillo solutae, §ss.;
    Sacchari Albi, §ijss. ; Aceti Vini, f vss.  Solve, (fj. con-
    tains 3s«. of camphor).

     Form. 3.  Acetum Camphor* et Ammonia.
R Camphors, 3ij., teratur in  mortario vitreo, cum Alco-
    holis  guttis, xx. vel xxx.; Sacchari Albi, Jss.,  tritis
    adde, Acidi Acetici Fortioris, 31J.; Liquoris Ammonia;
    Acetatis, f iijss. ; Iufusi Cinchona;, vel Aquae Destillatas,
    fiijss.  Fiat Mist., cujus  sumat aeger Cochlear., ij.,
    ampla secunda vel tenia vel quarta quaque hora.  (In
    the last stage of Febrile Diseases attended with de-
    pressed powers of life.)

     Form. 4.  Acidum Nitro-H,ydrochloricum.
R Acidi  Nitrici, Acidi Hydrochlorici, singulorum partes
    (mensura) aequales.  Dosis a minim., vj. ad W[xx., bis,
    ter, saepiusve quotidie, in Hordei Decocti, fiv., cum
    Sirupo Simplice.
Form. 5.  Acidum Nitro-Hydrochloricum Dilutum.
R Acidi  Nitro-Hydrochlorici, Aquas Destillatae, aa, Oj.
    Misce.  (The nitro-hydrochloric acid bath may consist
    of three ounces of this diluted acid to every gallon of
    water.)

         Form. 6. Ether Phosphoratus.
R Phosphori Puri, gr. ij.; Olei Menthae Piper., 3j.~3ss.
    Solve, et adde Ether. Sulphur., f j.  M.  Vel,

                     Form. 7.
R Phosphori Puri, gr. ij.;  Ether.  Sulph., 5jss.; Olei Va-
    lerianae, ttlxij.  M.  (In doses  of vj. to xij. drops on
    sugar.)

            Form. 8.  Aqua Cosmetica.
R Mist. Amygdal. Amar. vel Dul. colatae, fiij.; Aquae  Rosae
    et Aquae Flor. Aurantii, aa, f iv.; Sodae Biboratis, 3j. ;
    Tinct. Benzoini comp., 3ij.  M.  Fiat Lotio.

             Form. 9.  Aqua Styptic a.
R Ferri  Sulphatis, Aluminae  Sulphatis, aa, fjss.; Aquae,
    f xij.  Solve et cola ; dein  adde Acidi Sulphurici, J j.

     Form. 10.  Aqua Styptica Cupri et Zinci.
R Zinci  Sulphatis, Cupri  Sulphatis, aa, 3j.; Aquas Rosae,
    fviij.  Solve.
          Form. 11. Aqua Styptica Zinci.
R Zinci  Sulphatis, Aluminae  Sulphat.  Calcin., 55,  3j. ;
    Aquae Rosae, Jvj. Solve.

      Form. 12. Aqua Traumatica Thedenii.
R Acidi  Acetici, foiij.; Alcoholis,  Ibij- ; Acid. Sulphur.,
    Ibss. ; Mellis Despumati, Ibj.  Misce.

             Form. 13.  Aqua Vanii.l*.
R Fruct. Vanillae coneis. et cont.,  Jvj.;  Potassse Carbon.,
    3vj. ; Aquae Destil., Oij.; Spirit. Vini Ten., Ojss.  Ma-
    cera leni cum calore per triduum, et cola.


     Form. 14.  Balneum Ioduretum.  (Lvool.)
R  Solut. lodinae Rubefac. (Vide Form, inter Solutionis),
    fj.-fiv. ; Aquae Cong., xj.-l.

         Form. 15.  Balneum Sulphureum.
R MagnesiaB Sulphatis, 3iv.; Potassae Bitart., 3j.; Potassii
    Sulphureti, 3j.: tere simul, et solve in Singulis Congiis
    Aquae Balnei.

     Form. 16.  Balneum Potassii Sulphureti.
R  Potassii Sulphureti, f j. ad  f iv.; Aquae Communis, foe.
    ad Ibcc.  Solve.  (Nearly the same as the sulphureous
    baths of Bareges. In Chronic Affections of  the Skin,
    and in Chronic Visceral Affections.)

 Form. 17.   Balneum Potassii  Sulphureti et Gela-
                      tin*.
R  Potassii Sulphureti, J ij. ad Jiv.; Aquae Communis, foe.
    ad Ibcc.  Solve, et adde Ichthyocollae, tbj. ad foij., in
    Aqua; bullientis solutae, fox.  (Dupuytren.)


         Form. 18.  Balsamum Astringens.
R  Olei Terebinthinae part., ij.; adde guttatim Acidi Sul-
    phurici, part, ijss., in vase vitreo, ope  balnei arenarii
    calefacto.  Liquori  refrigerate, adde gradatim Alco-
    holis, part.  viij.  Macera per dies septem.  (Dosis
    3ss.-3j. vehiculo  quovis, idoneo, in Morbis Hsemorrha-
    gicis.)

         Form. 19.  Balsamum Astringens.
R  Olei Terebinthinae, Acidi  Hydrochlorici Concent., 53,
    part. j. ; agita bene, et post diem adde Alcoholis, part.
    viij. ; Camphors, part. ss.

        Form.  20.  Balsamum Succinatum.
R  Balsami  Copaibas, Terebinthinae Venet., Olei Snccini,
    55, 3j.   Misce.  Capiat Ttlxxx. ter quotidie  in quovis
    vehiculo idoneo.  (In Leucorrhcea, Gleet, Emissions,
    &c.)

  Form. 21.  Balsamum Sulphuris, vel Oleum Sul-
                     fhuris.
R Florum Sulphuris, partem j. ; Olei Amygdal. Dulc, part.
    iij.; Olei Anisi, part. ij.  Macera per  dies septem. in
    balneo arsnario.

Form. 22.  Balsamum Sulphuris Terebinthinatum.
              (Balsamum Vita Rulandi.)
R  Florum  Sulphuris, part. iij. » Olei Lini, part.  vij.; Olei
    Anisi, part. v.  Solve  in balneo arenario, et  adde Olei
    Terebinthinae, part. xx.   Misce.  (Excitant, diuretic,
    expectorant, &c. Dose 1Ux.-xxx.)

     Form. 23.  Balsamum  Terebinthinatum.
R  Olei Olivae, fvj. ; Terebinthinae, J ij.; Cerae Flavae, f j.;
    Bals.  Peruvian.,  3ij.;  Camphora rasae, 3jss.   Solve
    Oleum, Terebinth., et Ceram ; dein adde alia.  (Near-
    ly the same as the Balsam of Chiron, a long-celebrated
    medicine.) 
VI
APPENDIX OF FORMULAE—Bolus—Decoctum.
                                                                       • n  s  ut fiat
                                  giberis, 85, jj.; Acidi  Acetici Py^'P"8*' Sy." Misce.
                                  Cataplasma ; dein adde Olei Terebinth.no, 5>J-
                                    Form. 43.  Cataplasma S.napeos  M.ti^-
                              R Cataplasmatis Lini, part. ij.; Farina; S.napeos, pars ,.  M.

                                     Form. 44.  Conpectio M""^^^^
                              R Mentha; Viridis Fol. recent., ?iv.,              a(]jec.
                                  f xij.  Folia in mortano  ^Xec "orpus sit unum.
                                  to Saccharo, iterum contunde, donee i.oiy
                                  (SPBAQUE.)
                                    Form. 45.  Confectio Senn* Composita.
                              R Sulphuris Sublimati, Potassae Sulphatis, H,3«^
                                  fiJi ;„..;„ s»nn»  ?H. • Siruw Aurantii, q. s.  Capiat,
            Form. 24.  Bolus Anodynus.
R Pulv. Jacobi veri, gr. iv.; Camphors Pulverizat.,gr. iij. ;
    Pulv.  Potasses Nitratis, gr.  x.; Extracti  Hyoscyaiui,
    gr. vij. ;  Conservae Rosar., q. s., ut fiat Bolus, H. s. s.
    (In Cerebral Affections, <fcc.)

          Form. 25.  Bolus Ante Spasmos.
R Pulveris Castorei Optimi, 3ij.; Pulv. Radicis Valerianae,
    fss.;  Camphorae  rasae, 3j.  Misce  accurate, et adde
    Sirupi Papaveris satis quantum ut riant Boli granorum
    duodecim :  involvantur pulvere Stigmatorum  Croci
    Sativi.
              Form. 26.  Bolus Arnice.
R Pulv. Flor. Arnicas Montan., Camphorae rasae, 55, gr. iv.;
    Conservae Rosar., q. s., ut fiat Bolus.

      Form. 27.  Bolus Bismuthi Compositus.
R Moschi, gr. x. ; Bismuthi Trisnitratis, gr. iij.-viij. ; Opii
    Puri, gr. ss.-j.; Conservae Rosar., q. s., ut fiat Bolus,
    pro re nata sumendus.

            Form. 28.  Bolus Cambogi*:.
R Cambogiae Gummi Resinas, gr. viij.:  tere cum Olei Ju-
    niperi, Itliij., et adde Potassae Bitart., gr. xx.;  Pulv.
    Scllas, gr. j.; Sir. Zingiberis, q. s., ut fiat Bolus.

            Form. 29.  Bolus Camphors.
R  Camphorae  rass et ope Alcoholis subacts, gr. iij.-x.;
    Pulv. Flor. Amies Montana, gr. iij.-vj.; Confect. Ross
    Caninae, q. s., ut  fiat Bolus, quarta  vel sexta quaque
    hora sumendus.

       Form. 30.  Bolus Catechu Thebaiacus.
R  Catechu  Ext. contriti, gr. xv.; Confectionis Opii, gr.
    viij.;  Pulv. Crets, gr. iv. ;  Sirupi  Aurantii, q. s., ut
    fiat Bolus, bis, ter, sspiusve in die deglutiendus.

               Form. 31.  Bolus Ferbi.
R  Ferri Sesquioxidi, gr.  x.-xx.; Pulv. Aromatici, gr. v.;
    Sirupi Zingiberis, q. s., ut fiat Bolus, bis terve quotidie
    deglutiendus.

        Form. 32.  Bolus Guaiaci Ammoniati.
R  Guaiaci Gum. Resins, gr. viij.—xij.; Camphors rass,
    Ammonis  Sesquicarbon., 55, gr. iv.; Pulv. Acaciae, gr.
    iij.;  Coufect. Ross, q. s., ut fiat Bolus, hora somni su-
    mendus.

        Form. 33.  Bolus Guaiaci Compositus.
R Guaiaci Resin, cont., 3j.; Ipecacuanhs Rad. Pulv., gr.
    j. ;  Opii Puri, gr. j. ;  Confectionis Ross Canins, q. s.,
    ut fiat Bolus, semel, bis, terve quotidie capiendus.

         Form. 34.   Bolus  Kino Thebaiacus.
R Pulv. Kino  Compos., gr. v.-x. ; Pulv. Crets Compositi,
    gr. xv. ; Pulv. Opii, gr. ss.; Sir. Zingib., q. s.,  ut fiat
    Bolus, bis, ter, sspiusve in die sumendus.

        Form. 35.  Bolus Moschi Compositus.
R  Moschi, gr. xxiv. ; Pulv.  Rad. Valerians,  3ij. ; Cam-
    phors rass, gr. xx. ; Conservs Rosar., q. s., ut liant
    Boli, iv.   Capiat unam 4ta quaque hora.

   Form. 36.   Bolus Nitro-camphoratus cum Opio.
R Camphors rass, gr. iij.—vij.; Potass* Nitratis, gr. x.-xv.;
    Opii Puri, gr. ss.-jss ;  Conservs Rosar., q. s.,  ut fiat
    Bolus, hora somni sumendus.

          Form. 37.   Bolus  Rhei Compositus.
R Rhei Pulv., gr. x.-xv.; Pulv. Crets Comp.,gr. vij.  ; Pulv.
    Ipecacuanhs Comp., gr.  iij.—vij. ; Sirupi Zingiberis, q.
    s., ut fiat  Bolus, hora somni sumendus.

             Form. 38.  Bolus Sedativus.
R Acidi Boracini, 3j.~3ss.;  Conserv. Rosar. et Sirupi, q.
    s., ut fiat  Bolus, pro re nata sumendus.

          Form. 39. Bolus Sudorem Ciens.
R  Camphors  rass,  gr.  j.-iij.;  Potasss  Nitratis, gr. xij. ;
    Pulv.  Ipecacuanhas,  e-t  Pulv.  Opii  Puri,  55,  gr. j.;
    Sirup. Zingib., q. g., ut fiat Bolus.

      Form. 40.  Bolus Valeriana cum Ferro.
 R  Ferri  Sesquioxidi, gr. v.-3j.;  Pulv. Valerians, 3ss.;
    Sirupi Zingib., q. s.  Fiat Bolus.


          Form. 41.  Cataplasma Ioduretum.
 R  Cataplasm. Faiins  Semin. Lini tepid., q. s. j Solut. Io-
    dins Rubef., q. s.  Sit Cataplasma.

       Form. 42.  Cataplasma Sinapeos Fortius.
 R Pulv.  Sinapeos,  ftss. ;  Pulv. Capsici Annui,  Pulv. Zin-
fectionis  Senns,
3J-3ij> Pro dose.
         Form. 46.  Conserva Acetosell*.
R  Fol. Acetosells, f iv. ; Sacchari  Purificati, Jxij.  Con-
    tunde probe simul,  et fiat Conserva.
           Form. 47.   Decoctum ALTH.E.iE.
R Althsae Radicis exsiccats inc>s., f ij.; Rad. Glycyrrhizae
    contus., 3iij.; Aqus Destillatas, Ojss.  Coque leni igue
    ad Oj., et cola.

         Form. 48.  Decoctum Arctii Lappje.
R  Rad. Arctii Lapps,  f jss.-f ij.; Aqus, Jxvj.  Coque ad
    § xij., et cola.

     Form. 49.  Decoctum Arctii Lapp* Compos.
R  Rad. Arctii  Lap. recent., fij.; Lign. Sassafras, Dulca-
    mars,  55,  3iij.; Rad. Glycyrrh.,  3jss.; Aqus, Ojss.
    Coque ad Oj., et exprime.

   Form. 50.   Decoctum et Infusum Beccabunce.
R  Herbs Veronics Beccabungs recentis, f iij.;  Aqus Fer-
    ventis, Oj.  Macera per horas binas, vel coque perquar-
    tam horas partem, et exprime.  Capiat § ij. ter quaterve
    quotidie ;  vel utatur externe pro  embrocatione, super
    Ulcerationes Strumosas applicata.

        Form. 51.  Decoctum Calumb* Comp.
R Rad. Calumhs,  Lign.  Quassis ras., 55, 3ij. * Corticia
    Aurantii  exsic, 3j. ;  Rhei  Pulv., 3j.  ; Potasss Carb.,
     3j.; Aqus, fxx.   Coque ad Jxv., et cola; dein addo
     Tinct. Lavandul. Comp., J j.  (Niemann.)

 Form. 52.  Decoctum Cacuminum  Pini  Compositum.
R Cacum. Pini Sylvesi., fij.;  Radicis Symphyti Majoris,
     Jj. ; Aqus, foij.   Coque per hors partem quartam;
     exprime, et cola.

      Form. 53.  Decoctum Cinchona Aperiens.
R  Corticis Cinchonas  Pulv., ?j. ; Aqus,  foij.  Coque per
     partem horse quartam, et adjice Fol. Senns, Jss.; Rad.
     Zingiberis cont., 3j.; Sods Sulphatis, fss.; Hydrochlor.
     Ammonis, 3j.  Macera per horas  binas, et  adde Tinct.
     Senns Comp., J j.  M.

     Form. 54.  Decoctum Cinchona Compositum
R Cinchons Lancifol.  Cort. contus., fss.  Coque ex Aquaa
     Purs, pxvj., ad  consumpt.  dimid., adjectis sub finem
     coctionis Serpentariae Radicis contuss,  3ij.  Stent per
     horam, et  cola; dein adde Spirit. Cinnamom. Comp.,
     §jss.;  Acidi Sulphur, dilut., 3jss.  M.  Sumantur f ij.,
     sexta quaque hora.

       Form. 55.  Decoctum Cinchon* et Rhei.
R  Cortinis Cinchons  Oblongifol. c,ontuss, 3iij.;  Radicis
     Gentians inciss, 3ss.; Radicis Rhei Palmati, 3ijss. ;
     Carbonatis Potasss, 3j.; Aqus Fontans, s. q.   Coque
     per horam unam ut obtineantur colaturs uncis duode-
     cim, et cola.
R Liquoris Colati, fvss. ;  Tincturs Canellas, Spirit. Anisi,
     ia, 3jss.;  Sirupi Aurantii, §ss.  M.   Capiat Cochlear
    ]. vel ij. ampla.

  Form. 56.  Decoctum Cinchona et Serpentari/E.
R Cort. Cinchons pulveriz., 3vj.; Rad. Serpentaris, ?ss ;
     Corticis Aurantii sic, 31J. ; Aqus, tbjss.  Coque ad" foi.,
     et adde liq. colato, Tinct. Cinnamom.  fj.

         Form. 57.  Decoctum Cydoni* Comp.
R  Semin. Cydon. contus., 3ij. ; Raii. Glvcvrrh  contus
     Fici Caries  Fruct.,  55, J j.,  Aqus BuY  Oj'   C ,u ue
     cum igne leni per partem hois quartam, deinde cola.
R  Hujus Decocti, fvjss. ;  Bi-boratis Sod
*; 3j- ; Potasss
Tart.,3ij. ; Spirit. Ether. Nit., *ii •  Sirnt'm    ^
Sue. Inspiss.  Samb. N.g., ?ss.  ftJ''Fiit S-Mon vel
capt. Cochlearia, ij., larga, secund'is vel tertf'"'•C°]M
(In  the irritative Inflammation of the  Mueni.*'«
s horis.
(in  trie irritative inflammation of the Murr>.,« o  V
of the Digestive Organs, Dropsy, &c.)        Surface 
APPENDIX OF FORMULAE—Decoctum—Electuarium.
vn
        Form. 58.  Decoctum Deobstruens.
R  Radicis Taraxaci, Herbs Fumaris, Fol. Sisymbrii Nas-
    turt., Fol. Chsrophylli Sylvest., 55, Jj.  Omnibus bene
    concisis, adde Seri Lactfs, Jxxxij.   Coque per minuta
    hors, vj.;  et posteam acera  ad refrigerationem ; dein
    cola. Colaturs adde Sods Potassio-Tartrat., Jss.~3vj. ;
    Mellis  Optimi, Jj.  M.  Capiat Cyathos  Vin. ij., vel
    iij., vel iv., in die.  (Van Swieten.)

           Form. 59.  Decoctum Depurans.
R  Caul. Dulcamaras, Herbs Fumaris  Officin., Cort. Ulmi
    contusi, Rad. Arctii  Lapps cone, Rad. Rumicis  Pa-
    rentis concis., 55, Jss. ; Aqus Font., foijss.  Coque ad
    Ojss., et cola.  Liq. colato adde Sirupi Sarzs, Jij.  M.
    Capiat Jj.-Jjss., ter quaterve quotidiis.

         Form. 60.  Decoctum Dulcamara
R Stipitum Dulcamars, Jj.; Corticis Aurantii, 31J.; Aqus
    fojss.   Coque ad foj., et cola.

       Form. 61.  Decoctum Dulcamara Comp.
R Caul. Dulcamars, Radicis Arctii Lapps, 55, 3vj.; Ra-
    dicis Glycyrrh., Lign. Sassafras ras., Lign. Guaiaci ras.,
    55, 3ij.; Aqus Font., foij.  Coque ad colaturs, Jxx.
    (Augustin, Rheumatism, Syphilis, Cutaneous  Affec-
    tions, &c.)
      Form. 62.   Decoctum Filicis Compositum.
R Radicis Filicis Maris, Jj.; Rad. Inuls Helenii, 31J. ; Fo-
    lior. Absinthii, Jss.; Seminum Santonics cont., 3iij.;
    Aqus, Ojss.   Coque  ad Oj., et cola.  Liq. colato adde
    Sirupi Rhamni, Jj.   M.
            Form. 63.  Decoctum Gai.L£.
R  Gallarum contusarum, Jss.; Aqus Destillats, Oijss.
    Decoque ad oct. ij., et liquorem cola.  Turn adde Tinc-
    turs Galls, Jj.  (This decoction, used as  a fomenta-
    tion, enema, or injection, is of considerable use in the
    treatment of Prolapsus Ani, Hsmorrhoids, and in Leu-
    corrhosa.)
        Form. 64.  Decoctum Gentian* Comp.
R  Radicis Gentians Lutes inciss, Jss. ;  Aqus Fontans,
    foij.  Coque  per semihoram, deinde infunde quantum
    sufneit super Radicis Calami Arom., jiij.: cola,  et post
    refrigerationem adde Etheris Sulph., 31J.; Sirupi Au-
    rantii, Jss.  Misce.

 Form. 65.  Decoctum Guaiaci  et Dulcamara Comp.
 R  Rasur.  Ligni Guaiaci, Jjss. ; Stipit. Dulcamars, Jjss. ;
    Rad.  Lauri Sassafras concis.,  Flor. Amies, Rad. Cala-
    mi Arom., Rad. Glycyrrh., 55, Jss. \ Semin. Fosniculi,
    3ij.;  Aqus,  foiij.  Coque  ad foij., et cola.   Capiat
    Jj.-Jiij., ter quarterve quotidie.

         Form. 66.  Decoctum Helenii Comp
 R  Rad. Inuls Helenii, Jj. ; Summit. Hyssopi Officin., 3iij.;
    Fol. Heder- Terrest., 3ij. ; Aqus, q. s., ut sint Colaturs,
    Jxij.   Coque per partem hors quartam, et cola:  adde
    liq. colato, Potasss Carbon., 3J.;  Sirupi Tolutani, Si-
    rupi Althss, 55. fj.   M.  Capiat  Jj.-Jij-, ter quaterve
    quotidie.  (In Chronic  Catarrhs,  the  Pectoral Affec-
    tions of Debility, Asthma, Chlorosis, Amenorrhea, &c.)

       Form. 67.  Decoctum Inulje Compositum.
 R  Rad. Inuls Helen., J jss.; Hyssopi Officinalis, Flor. Tilis
    Europss, 55, 3iij.;  Fol. Heder. Terrest., 31J.; Aqus,
     foij.   Coque ad  fojss. ;  exprime,  et cola.  Colaturs
     adde  Spirit.  Ether. Nit., J ss.; Potasss Nitratis, 3j. ;
     Sirupi Scills, 3ij. ; Sirupi Althsae, Jss.  M.

       Form. 68.   Decoctum Pectorale Elsneri.
 R Rad. Glycyrrh., Croci Stig., Rad.  Inuls  Helenii, Rad.
     Iridis  Flor., Semin. Anisi, Hyssopi Officin., 55, Jss.;
     Aqus, foij.   Coque ad fojss.; cola, et adde Tinct. Bals.
     Tolutani, Jj. ;  Sirupi Tolutani,  Jj.;  Mellis, Jj.  M.
     Capiat Jj.-fij-, 4tis vel 6tis horis.

        Form. 69.  Decoctum Punice Granati.
 R Corticis Radicis Punics Granati recent, et exsic, Jij.;
     Aqus Com., Oij.  Macera sine calore per horas, xxiv.;
     dein coque ad Oj., et cola.   (The whole to be taken in
     three  doses within two hours.)

         Form. 70.  Decoctum Quassi/E Comp.
 R Ligni Quassis rasi, J ss. ; Flor. Anthemid., 3vj. ; Potasss
     Carbon., 3ijss.; Aq. Fontan., foij.   Coque ad dimidium,
     et cola.
            Form. 71.  Decoctum Santonici.
 R Santonici  Semin.  contus., Jij. ; Aqus  Destillats, J xx.
     Coque lento igne ad Oj., et cola.  (In Ascarides.)

       Form. 72.  Decoctum Sarz^  Compositum.
 R Sarzs Radicis, conciss et contuss, Jjss. ;  Glycyrrhizs
     Radicis contuss, J ss.; Coriandri Seminum contus., 31J.;
    Liquoiis Potasss, 3J. (vel sine); Aqus Ferventis, Oj.
    Macera per  horas, xxiv., in vase leviter clauso,  et
    cola: liquoris colati sumat partem 3tiam ter quotidie.
    (Sprague.)

       Form. 73. Decoctum Secalis Cornuti
R Secalis Cornuti, 3ij. ; Aqus, Jvij.  Decoque ad J iv.  Ab
    igne remove, et paulo post e fscibus effunde.

           Form. 74.  Decoctum Senegje.
R  Senegs Radicis cont., 3vj. ; Aqus, Oij.  Coque ad Oj. ;
    et sub finem coctionis adde Glycyrrh. Rad. contuss,
    Jss.  Exprime, et cola.

     Form. 75.  Decoctum Scoparii Cacuminum.
R  Scoparii Cacuminum concisi, Jj.; Aqus Destillats, Oj.
    Decoque ad octarium dimidium, et cola.

       Form. 76.  Decoctum Taraxaci Comp.
R Radicis Taraxaci, Jiv.; Bitart. Potasss, Bi-boratis Sods,
    55, Jss.; Aq., foiij.  Coque ad foij. ; et adde, ut sit oc-
    casio, vel  Spirit. Ether. Nit., vel Tinct. Scills, vel
    Spirit. Juniperi  Comp., vel Oxymel Scills.
Form. '
Decoctum Taraxaci Comp. Stollii.
R  Rad. Taraxaci,  Rad. Tritici  Rep.. 5a, Jij.; Aq, foiij.
    Coque ad foij. : cola, et adde colaturs, Potasss Sulph.,
    Jss.; Oxymel, Jj.  M.  (In Visceral Obstructions.)

        Form. 78.  Decoctum TormentilljE.
R Tormentills Radicis contuss, Jj.; Aqus Destillats, Ojss.
    Coque ad octarium, et cola.


    Form. 79.  Electuarium Alkalino-ijerratum.
R  Sesquioxidi Ferri, Jss.;  Potasss Carbonatis, 3j.; Car-
    bonat. Calcis, 3ij.;  Pulv. Zingiberis, 3jss. ; Sirupi Au-
    rantii, Jiijss.   M.  Fiat Elect, cujus capiat Coch., j.,
    minim, mane nocteque.   (Chlorosis, Chorea, <fec.)

     Form. 80.  Electuarium Anthelminticum.
R  Pulv. Valerians, Semin.  Santonics contus., 55, Jss.;
    Potasss Sulphatis, 3iij.; Pulv. Jalap., 3iv.; Oxymel.
    Scills, Jiv.;  Pulv. Glycyrrh.  (vel  Extr. Glycyrrh.),
    Jij.  M.  ut fiat  Electuarium.  (For  children, one to
    two drachms; and for adults, Jss., three or four times
    daily.)

     Form. 81.  Electuarium Antispasmodicum.
R Pulv. Cinchons, Jj. ; Pulv. Valerians, Jss.;  Confect.
    Ruts, Jj.; Confect. Ros. Gall., Jss.; Confect. Aurantii,
    31'ij.; Olei Cajeputi, 3ss. ; Sirupi Aurantii, Jijss.; vel
    q. s., ut fiat Electuarium molle.  Capiat 3j.-3iij., mane
    nocteque.  (In Epilepsy,  Chorea, Hysteria, Flatulen-
    cy, &c.)
         Form. 82.  Electuarium Aperiens.
R Magnesis, Potasss Bitart., Flor.  Sulphuris, Pulv. Rad.
    Rhei, Pulv. Flor. Anthemidis, 55, gr. vj. ; Sirupi Au-
    rantii, 3iij.; Olei Piments, tfl,ij.  M.   Sit Electuarium
    pro dose.  (Hecker.)

         Form. 83.  Electuarium Aperiens.
R Manns, 3vj.; Sirupi Senns, 3iij.; Olei Amygdal.  Dulc,
    3ij.  Tere bene, et adde Aqus Fosniculi, 31J. ; Sacchari
    Albi, 3jss. Sit Electuarium, cujus capiat infans, 3j.-3ij.,
    pro dose.
     Form.  84.  Electuarium Arnica Composit.
R Pulv. Flor.  Amies,  3iij.;  Pulv. Cinchons, Jss.; Pulv.
    Rad. Serpentariae, 3iij.; Confect. Aromat., 3J. ;  Sirupi
    Aurantii, Jiij.  Misce.  Capiat 3j.~3ij., 2 (lis horis.

         Form. 85.  Electuarium Bechicum.
R Manns Optims, Jj.; tere cum Aq. Flor. Aurantii, q. s.,
    et adde gradatim Pulv. Acacis, Jss.; Extr. Glycyrrh.,
    3j. ; Sirupi Tolutani, q. s.  Sit Electuarium molle, cu-
    jus capiat  pauxillum urgenti Tusse.  Interdum adde
    Pulv. Ipecacuanhs, Extract. Conii, vel Extr. Lactucs.

    Form. 86.  Electuarium Cinchona Aperiens.
R Cinchons Lancifol. Cort. in Pulv., Jj.; Valerians Rad.
    Pulv., 3iij. ; Confectionis Senns, Jjss.; Confect. Aro-
    mat., 3ij. (vel Confect. Piperis Nigri, 3iij.) ;  Sirupi
    Senns, Jijss., vel q. s., ut fiat Electuarium molle, cu-
    jus devoret Cochlear., j., vel ij., minima mane, meridie,
    ct nocte.  (In Ague, Diseases of Debility, &c.)

   Form. 87.  Electuarium Cinchona Compositum.
 R Cinchons Cordif.  Corticis Pulv., Jj.; Confectionis Ross
    Gallics, Jss.; Acidi Sulphurici diluti, 3j.; Sirupi Zin-
    giberis, Jjss.  M.   Fiat Electuarium.  Dosis 3J.-31J ,
    ter quaterve in die.

    Form. 88.  Electuarium Cinchonje dum Ferro.
 R Cinchons Cort. Pulv., Jj. ; Ferri Sesquioxidi, 3ij.—3'j- : 
APPENDIX OF  FORMULAE.—Electuarium—Emplastrum.
    Sirup. Zingiberis,  q. s., ut fiat Electuarium.  Dosis
    3j~3ij., bis terve quotidie.

       Form. 89.  Electuarium Deobstruens.
R  Potasss Bitart.. Jjss. ; Sulph. Prscip., Jj. ;  Sodas Bibo-
    ratis, 3ijss.; Sirupi Zingiberis, q. s., ut hat Electuar.
    Cochlear, j. vel ij.,  minima h. s.

       Form. 90.   Electuarium Febrifugum.
R  Pulv.  Cinchons, Jij.;  Pulv. Rad.  Serpentaris, Pulv.
    Cort. Canells,  aa, 3ij. ; Camphors rass, 3ij.; Opii
    Puri  gr. iv.;  Sirupi  Zingiberis, et Sirupi Aurantii,
    55, q. s.', ut fiat. Electuarium, cujus capiat 3SS.-3JSS.
    pro dose.
 Form. 91.  Electuarium Febrifugum Hoffmanni.
R  Pulv. Cinchons, 3»J-; Pulv Flor- Anthemid., 3'j-; Ca-
    ryoph. in  Pulv., Ext.  Centaurn Mm., aa,  3ss.  (vel
    Pulv.  Centaurii, 3jss.) ; Succi Inspiss. Sambuci Nig.,
    Jss. ; Sirupi Limonis, Jjss.  M.  Capiat 3j., 4tis horis.

   Form. 92. Electuarium Febrifugum Trilleri.
R  Cinchons Pulv.,  Jj.; Pulv. Flor. Anthem., 3'j-.5 Potasss
    Nitratis, Ferri  Ammonio-Chloridi, 55, 3j.; Sirupi  Au-
    rantii, Jijss. M. Fiat Electuarium, cujus capiat Coch-
    lear., j.-ij., min. pro dose.

 Form. 93.  Electuarium Ferri Ammonio-Chloridi
                   Compositum.
R  Myrrhs Pulv., 3jss.; Ferri Ammonio-Chloridi.gr. xxxv.  ;
    tere simul, et adde Pulv. Radicis Rubis, 3jss. ; Pulv.
    Castorei, 3ij.;  Sir. Zingiberis, Jjss., vel q. s., ut fiat
    Electuarium ;  de quo sumatur, bis quotidie, ad Myris-
    tics Nuclei magnitudinem.

Form. 94.   Electuarium Ferri Potassio-Tartratis.
R  Potasss Bitart., Jij.: Ferri Potassio-Tartratis, 3iij.;  Zin-
    giberis, 3j.; Sirupi Aurantii, q. s., ut fiat Electuarium
    molle, cujus capiat, 3J.-31J-. "is terve in die.

    Form. 95.  Electuarium Nitri Camphoratum.
R  Camphors rass et ope Alcoholis pulverizat., gr. vj.-xij. ;
    Potasss Nitratis, |jss. ; Confect. Ross Gallics, Jjss. ;
    Sirupi Simp., q. s., ut fiat Electuarium.  Dosis, moles
    Myristics Nuclei subinde capiatur.

          Form. 96. Electuarium Purgans.
R  Confectionis Se*ins, Jij. ; Pulver. Jalaps, 3j.; Potass.
    Bitart. pulv.,  Jss.; Sirupi  Zingiber., Jj.  M.   Sumat
    Cochl., j., min. bis vel ter die.

    Form. 97.  Electuarium Scills Compositum.
R  Potasses Bitart. contrit., Jiij.; Juniperi Bac.et Cacumin.
    pulv., Jj. ;  tere bene simul, et adde terendo Pulv. Ja-
    laps,  31J. ; Oxymellis Scills, Jij.; Sirupi Zingiberis,
    q. s., ut fiat Electuarium.  Dosis 3j.~3iij., bis, ter, qua-
    terve in die.
    Form. 98.  Electuarium Senn.e Compositum.
R Senns Fol.  pulver., Jss.;  Potasss  Bitart. pulv.,  3vj. ;
    Pulv. Jalaps  Rad., 3ij.; Sods Bi-boratis, 3j.; Sirupi
    Zingiberis, Jij.  Misce.  Dosis a 3J.-3ij., pro re nata.

       Form. 99.  Electuarium Terebinthins.
R Pulv. Tragacanth.,  3iv. ; Aq. Purs. Jj.  M.  Fiat mu-
    cilago ; tunc gradatim adde 01. Terebinth., Jj.; et con-
    tere cum Sacch, Purif., 3ij.; Pulv.  Curcums, gr. x., ut
    fiat Electuarium.

    Form. 100.  Electuarium Terebinthinatum.
R Olei Terebinthins, Jij. ; Mellis Despumati, Jij.; Pulv.
    Rad. Glycyrrh., q. s., ut fiat Electuarium.

  Form. 101.  Electuarium Valeriana Compositum.
R Pulv. Rad. Valerian. Minor., 3j. ; Pulv. Sem. Santonics,
    3ij.; Pulv. Rad. Jalap., gr. xxx.-xl.;  Oxymel. Scills,
    q. s., ut fiat Electuarium.

       Form. 102.  Electuarium Vermifugum.
R Potasss Bisulphatis, Pulveris  Radicis Jalaps,  Pulveris
    Radicis Valerians, 55, 3j. ;  Oxymellis Scillitici, Jiv.
    M.  Sumantur adulti,  Jss., quatuor  vices  de die, et
    pueri, 3j. ad 31J.   (Stoerk.)


        Form.  103.  Elixir Aloes Compositum.
 R Croci Stig., part. j.; Potasss Acet., Aloes,  Fellis Tauri
    Inspiss., 55, part. ij. ;  Myrrhs,  part.  ij. ; Spirit. Vini
    (vulgo  Brandy diet.), part. xxiv.   Infunde et macera
    secundum artem,  et cola. 3j-~3'jss.  pro dose.

      Form. 104.   Elixir Pectoralis Wedellii.
 R Asafcetids, 31J-; Acidi Benzoici, Opii Purif. Camphors,
    Croci Stig., Rad.  Scills, Olei Anisi, 55, 3ij.; Balsami
    Peruv., Jss.;  Spirit.  Vini Rect., ftijss.  Macera, et
    cola.
Form. 105.  Elixir Proprietatis Rhubarbabinum
            Form. 106.  Elixir Roborans.

R Aloes, Myrrhs, 55, 3ij-;  Summ^AbSJ?th*''sS.U Cort?™
    taurii Minoris, Cinchons in  Pulv., la, Jss.,  Cort,ciS
    Aurantii  Amari, 3*U-; Croci, 3U- !  V11..  Albijh-imnj,
    foij.   Macera in sole per horas, xlvuj., dein aaue sac
    char. Alb., Jviij., et cola.


         Form. 107.  Emplastrum Ammonia.
R Ammonis Hydrochloratis, 3J. ; Saponis Duri, 3'j-; Em-
    plastri Plumbi, Jss.: Emplastrum  et Saponem sirnul
    liqua, et  paulo antequam concrescant imimsce Salem
    in pulverem tenuem tritum.   Extensum super alutam
    parti  affects  quamprimum applicatur, et pro re nata
    repetatur.

    Form. 108.   Emplastrum Anodynum Fortius.
                      (Richter).
R Emplastri Galban. Comp. (vel.  Emp. Cumini), Jj.; Cam-
    phors, 3J. ;  Ammon. Sesquicarbon., Opii Puri, 55, 3ss.;
    Olei  Cajepul., gtt. xl.   Fiat Emplastrum secundum
    artem.

       Form. 109.  Emplastrum Awticolicum.
R Gum. Ammoniac., Gum. Galbani, 55, Jj.; Terebinthin.
    Venet., et Terebinthin. Commun., 55, 3x.: lento igne
    liquefactis, adjice Asafcetids, Jjss.; Croci Stigm.,3iij.;
    Olei Menths Pip., et Olei Ruts, 55, 3SS.-3J., et omnia
    misce.

      Form. 110.  Emplastrum Antihystericum
R Galbani, Sagapeni, 55, Jj.; Asafcetids, Jss.; Olei Ruts,
    3SS.-3J.; Aceti Vini, q. s.,  ad Gum. Resin, liquefacien-
    dum: dein  adde Terebinthins Commun., Jj.;  Cera
    Flavas, Jiij. ; Pulv. Myrrhs, Jss. ; Pulv. Castorei, 3jss.;
    Olei  Succini, 3ss.   Misce.   (The  Wurtemberg and
    Manheim Pharm.)

  Form. 111.  Emplastrum Aromaticum Compositum.
 R Emplast. Arom. (Ph. Dub.) vel Emp. Cumini, Jss.;  Sul-
    phuris Sublimati, 3ij.;  Olei Macis, fllxxxv.  Fiat Em-
    plastrum.

        Form. 112.   Emplastrum Belladonna.
 R Extr. Belladonna, part. iij.; Ammon. Sesquicarbon. Pulv.,
    part. j.   Misce, et fiat  Emplastrum.  (To very painful
    parts.)

         Form. 113.  Emplastrum Camphors.
 R Olei  Olivs, Jxij.; Plumbi Binoxidi, Jviij.  Liqua,  et
     masss refrigerats adjice  Camphors, Jijss., soluts  in
     pauxillo Olei.  Misce bene.   (Stahl.)

         Form.  114.  Emplastrum Defensivum.
 R Plumbi Binoxidi,  Jviij.; Aceti, Jiv.; Olei Olivs, foj.
     Liqua,  et  adde  Cerse  Flavs,  Jij.; Camphors, Jss.
     Misce bene.

        Form. 115.   Emplastrum Deobstruens.
 R Potassii  Sulphureti, Pulv.  Conii, 55, 3ijss. ; Camphorae
     Pulveris, Terebinthins Vulg., 55, 3iv. ; Saponis Albi,
     3ss.; Cers Flavs, Jj.;  Emplast. Simp., Jiv.   M.

            Form. 116.  Emplastrum Picis.
 R Picis Abietins vel Nigrs, Jvj.; Cers Flavs, Jj. ;  Tere-
     binthins Vulg., 3iij. ; Liquefac simul, et fiat Emplas-
     trum.

         Form. 117.  Emplastrum Resolvens.
 R Emplastri Ammoniaci  cum  Hydrarg., Emplast. Picis,
     Emplast. Galbani Comp., 55,  partes asquales.   Fiat
     Emplastrum.

          Form. 118.  Emplastrum Roborans.
 R Emplastri Picis, Empl.  Galban.  Comp.,  Empl.  Cumini,
     5a, partes binas; Ferri Sesquioxidi, Thuris, 55, partem
     unam;  Olei Piments, q. s., ut fiat Emplastrum.

        Form. 119.   Emplastrum Rubefaciens.
 R Emplast.  Aromat. Comp. (F. Ill), Jss.   Forma in Em-
     plast., dein  asperge cum Antimonii Potassio-Tartratis
     3j.;  Camphors  Pulveriz., 3j.; Sulphur. Sublimati!
     3ss., in unum admixtis.                           '

          Form. 120.  Emplastrum Stibiatum.
 R Emplast. Picis, part. xj. ; Terebinth. Venet., part iv •
     Antimon. Potassio-Tartratis in Pulv., part, j   Lioi  f''
     Emplastrum et Terebinthinam, et adde Antimonin^f
I     (Niemann and Augustin.)                    ™' 
                      APPENDIX  OF  FORMULAE

    Form. 121.  Emulsio Amyodalo-Camphorata.
R Amygdal. Dulc. decortic, Jss.; Amygdal. Amar. No.,
    iij. ; Aqus Fontans, Jvijss.  Fiat Emulsio, cui adjice
    Pulv. Gummi Arabici, 3ij- ;  Camphors (cum paux. Al-
    cohol, subacts), 3j. ; Sirupi Papaveris Albi, 3ss.   M.
    Et sit Emulsio, de qua  sumat quovis bihorio Cochleare
    unum, prsgressa phials commotione.

       Form. 122.   Emulsio Anticatarrhalis.
R Sem. Phelland. Aquat. con., Jj. ; Gum. Acacis, Jj. ; Aq.
    Ferv., Jix.  Macera, et cola.  Colats adde Sirupi Al-
    thass, Jss.; Vini Ipecac, 3ij.  M.   Capiat Coch., ij.,
    larga 3tiis vel 4tis horis.

          Form. 123. Emulsio Camphorata.
R Olei Amygdal. Dulc, Jss. ; Gum. Acacis, q. s.; Cam-
    phors, gr. x.-3j.; tere bene simul, et adde Aqus Fos-
    niculi et Aqus Laurocerasi, Jij.; Sirupi Althsae, Jss.
    M.  Fiat Emulsio.

    Form. 124.  Emulsio Camphorata Anodyna.
R Camphors Subacts, gr. xvj. ; Amygdal. Dulc, Jss.; Acidi
    Hydrocyanici, 1fl,xii.; Aqus Flor. Sambuci, Jvj.

    Form. 125.  Emulsio Camphorata Composita.
R Camphors, gr. x.-3j.:  subige in Alcoholis, 3ss.; et
    adde  terendo  Mucilag.  Acacis,  3;j. ; Olei Amygdal.
    Dulc, Jss.; Sirupi  Althss, Jss. ; Aqus Laurocerasi,
    Aqus Fosniculi, 55,  Jijss.  M.  Capiat Coch., j. vel ij.,
    3tiis vel 4tis horis.
Interdum  adjiciatur vel Vinum  Ipecacuanhs, vel Vinum
    Antimonii, vel Potasss Nitras, vel Sirupus Papaveris
    Albi.

      Form. 126.  Emulsio Nitbo-Camphorata,
R Camphors Subacts, Potasss Nitratis, 55,  3j.; Pulv.
    Gum. Acacis,  3J.;  Infnsi Pectoralis vel  Aqus Flor.
    Aurantii, Jvjss. ;  Sirupi Althss, Jj.   M.

          Form. 127.  Emulsio Pectoralis
R Spermaceti, 3j.; Gum. Acacis, 3ij. ;  Olei Amygdal. Dulc,
    Jss. ;  Acidi  Hydrocyanici, nix.;  Sirupi  Simp., Sirupi
    Tolutani, 55, Jss.; Aq. Fosniculi, Jivss.   M.

           Form. 128.  Emulsio pro Tussi.
R Olei Amygdal. Dulc, Jss.; Vitellum Ovi unius ; Aqus
    Flor. Aurantii, Jvj.; Mucilag. Acacis, Jss.; Vini  Ipe-
    cacuanhs, 3jss.;  Sirupi Althss, Jss. M.

           Form. 129.  Emulsio Sedativa.
R Mist. Amygdal.  Dulc, Mist. Camphors, 55, Jiijss.; Mu-
    cilag. Acacis, Jss. ;  Morphis Acetatis, gr. j.-ij.; Sirupi
    Tolutani, Jss.   Solve Morph. Acetat. in Olei Amygdal.,
    1t[xx.; deinde adde  alia.


   Form.  130.  Enema Alces et Asafcetids Comp.
R Extr. Aloes, 3ss. ; Asafcetids, 3jss.; Camphors rass, gr.
    xij. ;  Olei Olivs, Jjss. ; Decocti  Avens, Jxij.   Misce.
    (In Flatulent Colic, Ascarides, <fec.)

        Form. 131.   Enema Antihysteeicum.
R Fol. Ruts, Fol. Sabins, 55,  3ss. ; Aqus Fervid., q. s.
    Coque ad Jxvj. ; et adde Asafcetids, 31J.; Olei Olivs,
    Jij.  Misce.

     Form. 132.  Enema Antispasmodicum. (1.)
R Tinct.  Opii, 31.; Infusi Valer., Jxv.;  Mucilag. Acacis,
    Si.  M.

     Form. 133.   Enema Antispasmodicum. (2.)
R Tinct. Opii, 3SS.-3J.; Infusi Cusparis, Decocti  Althss
    Officin., 55. Jvij.  M.  Pro  Decocto Alth. interdum
    utatur vel Decocto Malvs, vel Decocto Hordei, vel In-
    fuso Ipecacuanhs.

    Form. 134.  Enema Asafcetids, vel Fcetidum.
R Asafcetids Gummi Resins, 31J.; Decocti Malvs Compo-
    site  Jxv.; Spiritus Ammonis Compos.,  3jss.; Tinc-
    turs Opii, 3ss.  Misce pro Enemate.

  Form. 135.  Enema Asafcetids et Terebinthins.
R Asafcetids, 3J.-31J. ; Camphors rass, gr.  xij.; tere  cum
    Decocti Avens, Jxiij.;  dein adde Olei Terebinth., Jss.
    ad Jjss.  Misce, et fiat Enema.

    Form. 136.   Enema Asafcetids Compositum.
R Asafcetids, 3j-3>j. i  Camphors rass, gr.  x. ;  Decocti
    Avens,  Jxvij.   Misce  pro  Enemate.  Interdum adde
    Olei   Terebinth.,  3iij.-Jjss.  (In  Flatulent Colic,
    Worms, <fec.)

          Form. 137.  Enema Belladonns.
R Fol. Belladonns exsic.gr. xij. (vel Extr. Belladonns, gr.
  ,—Emulsio—Extractum.                    ix

    ss. ad gr. j.); Aq. Fervid., Jxij.  (For Retention of the
    Urine from Spasm of the Sphincter Vesics, or Spasm
    of the Rectum.)

         Form. 138.   Enema Camphors Comp.
R Camphors rass, gr. xij. ;  Olei Juniperi Angl., 3-ss.; In-
    fusi Valerians, 3xv.; Mucilag. Acacis, Jj.  M.  Fiat
    Enema.

         Form. 139.  Enema Camphoratum.
R Acidi Acetici Camphorati (F. 2), Jss.-Jj.; Infusi Vale-
    rians, Jxiij.  M.  (Augustin.)

          Form. 140.  Enema Catharticum.
R Decocti Malvs Composit., Jxij.; Magnesis Sulphatis,
    Jj.; Olei Olivs, Jij.  Misce.   Fiat Enema.

   Form. 141.  Enema Colocynthidis Compositum.
R Colocynthidis Pulps incis., 3). ; Aqus, Jxij.  Coque pau-
    lisper, et cola; dein adde Sodii Chloridi (vel Sods Sul-
    phatis) Jss. ; Sirupi Rhamni Cath., Jss.  Misce.

         Form. 142.   Enema contra Spasmos.
R Camphors rass, gr. v.-x.; Potasss Nitratis, 3ss.; Olei
    Olivs, Jj. ;  tere simul, et adde Infusi Valerians, Decocti
    Malvs Comp., 55, Jvij.   M.

           Form. 143.  Enema Emolliens.
R Flor. Anthemidis, Seinin. Lini contus., 55,  Jss.;  Aqus
    Fervid.,  Jxvj.  Macera et cola;  dein adde  Opii, gr.
    vj.-xvj.   M.  Fiat Enema.

        Form.  144.  Enema Emollio-Aperiens.
R Decocti Malvs  Comp., Jxij. ;  Sods Potassio-Tartratis,
    Jss. ; Olei  Olivs, Jij.  M.  Fiat Enema.

            Form. 145.  Enema Opiatum.
R Tincturs Opii, 3J.  ; Mucilag. Arnyli, Jvj.; Decocti  Hor-
    dei, Jx.  Misce.   Fiat Enema, tepidum injiciendum.

            Form.  146.   Enema Saponis.
R Saponis Mollis, Jj.; Aqus Ferventis, Oj.  Solve, et te-
    pidum exhibe.

           Form. 147.  Enema Sedativum.
R Seminum Lini contus., Jj.; Aqus Ferventis, Jviij.  Ma-
    cera per horam: dein cola, et solve in Liq. colato Bi-
    boratis  Sods,  3j.;  Opii Extr.,  gr.  ij.-iij.   M.  Fiat
    Enema.

    Form. 148. Enema Sedativum Camphoratum.
R Infusi Lini  Comp., Jxij.; Tinct.  Opii, 3ss.; Bi-boratis
    Sods, 3ss.; Camphors rass, gr. x.  M. Fiat Enema,
    bis terve in die injiciendum.

        Form.  149.  Enema Terebinthinatum.
R Camphors rass, 3j. ;  Olei Terebinth., Jss.-Jjss. ; Olei
    Olivs, Jjss.; Decocti Avens, Jxiij.  Fiat Enema.

         Form. 150. Enema Terebinthins.
R Terebinthins Vulgaris, Jj. (vel Olei Terebinthins, Jss.
    ad Jjss.);  Ovi unius Vitellum.  Tere simul, et grada-
    tim adde Decocti Avens tepid., Jxv.   Injiciatur pro
    Enemate semel  in die, pro re nata.  (When it is re-
    quired to  evacuate the lower bowels, 01. Ricini, Jj.,
    will be found a useful addition.)

   Form. 151.   Enema Terebinthino-Camphoratum.
R Olei Terebinth., Jj. ; Olei Olivs, Jjss. ; Camphors rass,
    gT. xv.;  Decocti Avens, Jxvj.  M.  Fiat Enema.

          Form. 152. Enema Thebaiacum.
R Opii Puri, gr. j.-iij.; Mucilag. Acacis, Jss.; Lactis Te-
    pefact., Jxvj.  Misce pro Enemate.

          Form. 153. Enema Vermifugum.
R Rad. Valerians, Herbs Absinthii, Herbs Tanaceti Ca-
    cum. (vel Sem.)  Santonic, 55, 3iij.; Aq. Fervids, sxvij.
    Macera per horas binas, et cola.  Liq. colato adde Sodii
    Chloridi, Jss.  Fiat Enema.


   Form. 154.  Extractum Aloes Alkalinum Comp.
   Aloes Spicati Extr. contrit., Jiij.; Zingiberis Radicis
    concis., Jss. ;  Myrrhs Pulv., Croci Stigtnat., 55, 3vj.;
    Potasss Carbon, (vel Sods Carbon.), Jss.  Macera per
    triduum leni cum calore, dein cola.  Liquorem defs-
    catnm consume, donee idoneam habeat crassitudinem.
    (Dosis gr.  x. ad xxx.)

         Form. 155.   Extractum Dulcamars.
   Stipit. Dulcamars, part. j.; Aqus Bullient., part. viij.
    (Split the  shoots of dulcamara longitudinally, and ma-
    cerate them in  the water for twelve hours ; boil for a
    quarter  of an hour, and express the fluid.   Afterward
    boil the residue with four parts  of water, and finally 
APPENDIX OF  FORMUL/E.—Extractum—Haustus.
    express.  Mix the two  liquors, and evaporate with a
    gentle heat to a proper consistence.)

  Form. 156.  Extractum Hellebori Nigbi Backeri.
R Radicis  Hellebori  Nig. exsic, foij. ; Potasss  Carbon.,
    foss. ; Alcohol. (22 grad.), fbviij.
      (Backer directs the above to be digested in a sand-
    bath for twelve hours, shaking it frequently, and after-
    ward to be expressed and strained.  Eight pounds of
    white wine are to be poured upon the residue, and di-
    gested with it for twenty-four hours in a sand-bath, and
    afterward  to be expressed and  strained.  After a few
    hours both these  tinctures are to be mixed together,
    and evaporated with a gentle heat to the consistence of
    an extract.  This is the best preparation of Hellebore.
    Dose from x. to xv. grains.)


        Form. 157. Fomentum Camphobatum.
R Camphors, Jss.; Acidi Acetici, Jij.; Aceti Commun.,
    Jx.  M.  (Augustin.)


   Form. 158. Gabgarisma Acidi Hydrochlorici.
R Infusi Cinchons, Jvj. j Acidi Hydrochlorici, Tllxx.; Mel-
    lis, Jss.  M.

  Form. 159. Gabgarisma Acidi Hydrochlobici Com-
                     positum.
R Acidi Hydrochlorici,  3jss.; Decocti  Cinchons, Infusi
    Ross Compos.., 55,3i.jss.; Mellis Ross, Jj.  M.  Fiat
    Gargarisma.

       Form. 160.  Gargarisma Antisepticum.
R Decocti Cinchons, Jvj. ; Camphors, gr. xx.; Ammonis
    Hydrochloratis, gr. xv.  M.

        Form. 161.  Gabgarisma Astringens.
R Infusus Krameris, Jvjss.; Acidi Sulph. Diluti, 3ss.: Si-
    rupi Mori, Jj.  M.   Fiat Gargarisma.  (For Relaxa-
    tion of the Uvula and Fauces.)

   Form. 162. Gargarisma Astringens  Zobellii.
R Aluminis Crudi, Potasss Nitrat., 55, 3ss.; Potasss  Bi-
    tart., 3ij.; Aceti Destil., Jij.  Solve, et  adde Aqus
    Ross, Jvj. M.  Fiat Gargarisma.

      Form. 163.   Gargarisma Bi-boratis Sods.
R Bi-boratis Sods, 3ij.;  Aqus Ross, Jvij. ;  Mellis Despi>
    mati, Tincturs Myrrhs, 55, f. Jss.  M.

   Form. 164.  Gargarisma Catechu Thebaiacum.
R Infusi Ross, Jvij. ; Tincturs Catechu, 3vj.; Acidi  Sul-
    phurici Diluti, 3j.;  Tincturs Opii, 3jss.  Sit Garga-
    risma sspe utendum.  (A. T. Thomson.)

         Form. 165.  Gargarisma Commune.
R Aqus Purs, Jxxij.; Bi-boratis Sods, 3x. ; Tinct. Cate-
    chu, Jj.-Jiij.; Tinct. Capsici Annui, 3j.-3iij.; Mellis
    Ross, Jjss.-Jiij.  Interdum adde, loco Bi-boratis Sods
    et Tinct. Catechu, Acidum Hydrochloricum vel Acidum
    Sulphuricum.

   Form. 166.  Gargarisma Potasss Nitratis.  (1.)
R Potasss  Nitratis, 3jss. ; Mellis Despumati, Jij. ; Aqus
    Ross, Jvj.  M.  Fiat Gargarisma.

   Form. 167.  Gargarisma Potasss Nitratis.  (2.)
R Potasss Nitratis, 3ij.;  Decocti Hordei, Jvij. ; Oxymellis
    Simplicis, Jj.  M.  (Brande.)


       Form. 168.  Gutts Acetatis Morphis.
R Morphis Acetatis,  gr.  xvj.;  Aqus Destillats, 3vj.;
    Acidi Acetici Diluti, 3ij.: Tinct.  Cardamom. Comp.,
    Jss.  M.

   Form. 169.  Gutts Etheris Terebinthinats.
R Olei Terebinthins, part. j. ;  Ether. Sulphurici  (vel
    Ether. Nitrici), part. iij.  M.  (Nearly the  same as
    that recommended by M. Durande in  Jaundice  and
    Biliary  Calculi.)

            Form. 170.   Gutts Anodyns.
R Morphis Hydrochloratis, gr. xvj. ; Aqus Destillats,  Jj. :
    Tinct. Lavandul.  Comp., Jss.  M.   (In  doses of from
    v. to xxx. drops.)

          Form. 171.  Gutts Antiloimics.
R Pulv. Camphors, Jij.;  Spirit. Rect., Jviij.;  Liquoris
    Amnion., Jij. ; Ol. Lavandul , 31J.  M.  Finnt Gutts,
    quarum capiat xx. ad 3j., quovis in idoneo vehiculo.

         Form. 172.  Gutts contra Spasmos.
R Olei  Cajeputi,  Tinct.  Ether. Valerians  (vide Form.),
    Tinct. Ammon.  Comp., 55, Jj.;  Olei Anisi, 3«-  M"
    (V[\. ad xxxv.)
   Form. 173.  Gutts contra Spasmos.   (Stoll.)
R Liquoris Ammonis Sesquicarbon., Tinct. Castorei, Tinct
    Succini,  Tinct.  Asafcetids, 55, 3"J- M'  ™ L" bla
    terve in die.)
           Form. 174.  Gutts Nervins.
R Camphors, Croci, 55, 3jss.; Moschi, Myrrhs, 55 3ijr. ;
    tere cum Sacchar.  Albi, Jss. ; et Spirit  V,n. Rect.fic
    3ij. ; dein adde terendo Olei Lavand., Ol. Juniper., 01.
    Rorismarini, Olei Origam, 55, 3»j.; <Olei;Suc<;»». 9lel
    Cajeputi, 55,3j.; Olei Limonis, Jss. ; Ole. Terebinthins,
    Jij.; Sacch. Albi, Jss. ; Spirit. Vim Rect., Jij.  Ma-
    cera et serva in vase bene obturato.


     Form. 175.  Haustus Acidi Nitbici et Opii.
R  Tinct. Opii, 1TLxx.-xxx.;  Tinct.  Caryoph. (vide  Form.),
    3j.-3ij.;  Acidi Nitrici, Tftxx.;  Aqus Piments, Jj.  M
    Fiat Haustus.

     Form. 176.  Haustus Acidi Nitbici et Opii.
R Acidi  Nitrici Diluti, 3ss.; Tinct. Opii, 3ss.;  Infusi Ca-
    lumbas, 3xj.  Misce.  Fiat Haustus, ter in die capi-
    endus.

           Form. 177. Haustus Anodynus.
R  Mist. Camphors,  3ix.; Potasss  Nitratis,  gr. vj.; Spirit.
    Etheris Sulph. Compos., 3j. ; Tinct. Opii, Hlx.-xij.;
    Sirupi Papaveris,  3ij.  Fiat Haustus, hora decubitus
    sumendus.

        Form. 178.  Haustus Contba Emesin.
R  Infusi Aurantii Comp., 3x.; Spirit. Menths Virid., 3j. ,
    Liq. Potasss,  ulx.  ; Magnes. Carbon., 3j. ; Tinct. Hy-
    oscyami, 3ss. ; Extracti Humuli, gr. viij. ; Sirupi Zin-
    gib., 3J.   M.  Fiat Haustus.

        Form.  179.  Haustus Anti-emeticus.
R  Magnes. Carbon., 3j. ; Extr. Humuli, gr. vj.; Liq. Po-
    tasss, TfLviij. ;  Tinct. Hyoscyami, 3ss.;  Spirit.  Menths
    Virid., 3J. ;  Infusi  Aurantii Comp. (vel Infusi Caryoph.
    Comp.), 3X. ;  Sirupi Zingiberis,  3J. M.

           Form. 180.  Haustus Aperiens.
R  Extracti Rad. Jalaps, gr. xx.;  tere cum  Amygdal. Dul-
    cibus Num., iv.  ; Aqus Cinnam., Jjss.  Fiat Haustus.

 Form.  181.  Haustus Apeeiens ex Jalapa et Aloe.
R  Pulv. Rad. Jalaps, gr. xvj.; Aloes Socot., gr. x.; tere
    probe cum  Extract. Glycyrrh., 35s. ; Tinct. Rhei, 3j.;
    Ol.   Carui, TTLij. ; Aqus Cinnam.,  Jjss.   M.   Fiat
    Haustus.

    Form. 182. Haustus Apebiens ex Scammonia
R  G. R. Scammon., °r. xij.; tere cum Glycyrrh. Extracti,
    gr. xx.; Tinct.  Rhei, 3ij.; Sirupi Zingiberis, 3J., Aq.
    Cinnam., Jjss.  M. Fiat Haustus.

          Form. 183.   Haustus Astringens.
R  QuercOs  Corticis cont., Jss. ;  Aqus Ferventis; Jxiij.
    Macera per horam, et cola.
R Liquoris Colati, 3xj.; Tinct. Catechu, 3ss.;  Tinct. Car-
    damom.  Comp., 3ij ; Sirupi Aurantii Cort., 3j.  Fiat
    Haustus.

          Form.  184.  Haustus Boraciccs.
R  Infusi Lini Co., vel Infusi Althss Co., Jjss.; Bi-boratis
    Sods, 3ss.; Spirit. Ether. Nit., 3ss.;  Sirupi Papave-
    ris,  Sirupi  Aurantii, 55, 3ss.   M.  Fiat Haustus, ter
    tiis  vel quartis horis capiendus.

    Form. 185.  Haustus cum Calumba et Ferro.
R  Infusi Calumbs, 3xj.;  Tincturs  Ferri  Sesquichloridi,
    lllxv.; Tincturs Calumbs, 3j.   Fiat Haustus, bis die
    sumendus.

       Form. 186.  Haustus Camphors  Comp.
R  Camphors, gr.  ii.—vij.; Tinct. Calumbs, Spirit. Anisi
    5a, 3jss. ;  Aqus  Piments, Aqus Menth. Virid., 55  3v
    Tere Camphorain cum Tinctura et Spiritu •  dein adde
    gradatim  Aquas.  Fiat  Haustus, hora  somni  vel  ur-
    genti vomitu,  sumendus.  Si sit occasio, adde  Tinct
    Opii, 1tlx.-xx., vel Tinct. Hyoscyami, Tllxv.-xxv.

         Form.  187.  Haustus Carminativus.
R Magnesias Carbon.,  3j. ;  Pulv.  Rhei, »r. x _l„ . 0,_j
    Anisi, llli j-; Liq. Potasss, mxii  • 1 in..nri= i   '
    mxx.; AqUAnerh,, Jij.  ti^I^Zll^™™'

          Form. 188.  Haustus  Colchici.
R Vini Colchici min  xxv.-xxxv. ; Magnes. Carbon  w  •
    Aqus Cinnam , Aqus, aa, 3VJ.   m.     v""uon-, ■&)■, 
APPENDIX OF FORMULAE.—Haustus—Infusum.
XI
         Form. 189.  Haustus cum Colchico.
R Potasss Sulphatis, 3ss.;  Sods Sesquicarbonatis, 3ij.;
    Aqus Anethi, Jjss.; Tinct. Calumbs, jjss.; Vini Col-
    chici, Itlxxv.  Fiat Haustus cum Acidi Tartarici granis
    quindecem in Aqus semifluid-uncia solutis, et in impe-
    tu effervescentias sumendus.

             Form. 190.  Haustus Conii.
R Infusi Conii (F. 230), Jj.; Liq. Ammon. Acet., 3ij.-3.ij.;
    Tinct. Hyoscyami vel  Conii, Tfl,xv.; Sirupi Papaveris,
    3ss. M.  Fiat Haustus.

      Form. 191.  Haustus Conii et Hyoscyami.
R Extracti Conii, Extracti Hyoscyami, 55, gr. v.;  Mucila-
    ginis Acacis, 3ij.  Tere simul donee quam optime mis-
    ceantur, et deinde adde  Liquoris Ammonis Acetatis,
    Aqus Purs, 55, Jss.; Sirupi Rhsados, 3J.  Fiat  Haus-
    tus, quarta quaque hora sumendus.   (Paris.)

  Form. 192.   Haustus Deobstruens et Robobans.
R Rad. Angelics contuss, 3ijss.-Jss.; Rad. Calumbs con-
    riss, 3jss. ; Rad.  Rhei cont., 3ij.; Baccarum Capsici
    cont., gr. xxv.; Aqus Ferventis octarium dimidium.
    Macera per horas duas, deinde cola.
R Hujus Infusi,  3x.; Tinct.  Calumbs, 3j.; Potasss Sul-
    phatis. gr. xxv.  ; Sirupi Aurantii, 3j.  M.  Fiat Haus-
    tus, bis quotidie sumendus.

         Form. 193.  Haustus Diaphoreticus.
R Infusi Serpentaris Comp.  (F. 262), Jj.; Liq. Ammon.
    Acet., 3iij. ; Sirupi  Aurantii, 3j.  M.  Fiat Haustus,
    bis terve  in die  sumendus.   (Dyspepsia, with dry,
    harsh skin, languor, and debility of pulse.)

        Form. 194.  Haustus Diureticus.   (1.)
R Potasss Acetatis, 3J.; Oxymel.  Colchici, 3ij.; tere cum
    Aqus Fosniculi  Dulcis, jj. ; Spirit. Juniperi Comp., 31J.
    M.  Fiat Haustus, bis terve in die sumendus.

        Form. 195.   Haustus Diureticus.  (2.)
R Acidi Nitrici Diluti, 3ss.; SpirilOs Etheris Nitrici, 3j. ;
    Infusi  Digitalis,  3iij. Aqus  Destillats, 3ix. ;  Sirupi
    Zingiberis, 3ij.   M.  Fiat Haustus, ter in die sumen-
    dus.

        Form. 196.   Haustus Diureticus.  (3.)
R Potasss Acetatis, 3ss.;  Infusi Quassis, Aq.  Cinnamomi,
    55, 3vj.; Aceti  Scills,  Spirittls Etheris  Nitrici, 55,
    3ss.  M.  Fiat Haustus, ter in die capiendus.

        Form. 197.   Haustus Diureticus.  (4.)
 R Tincturs Jalaps, 3ij.;  Aceti Scills, 3j.; Aqus Menths
    Viridis, Jjss.  Fiat Haustus.

       Form. 198.  Haustus Emeticus excitans.
 R Pulv. Radicis Ipecacuanhs, 3ss.; Ammonis Sesquicar-
    bon., 3j.; Aqus Menths Piper., Jijss.; Tinct. Capsici,
    3j.; Olei Anthemidis, V[x.  M. Fiat Haustus emeti-
    cus.  (In Poisoning from Narcotics, &c.)

       Form.  199.  Haustus Guaiaci Compositus.
 R Tincturs  Guaiaci, 3j.; Mellis, 3j.; tere simul, et adde
    Decoct. Senegs, Jss.; Aqus  Piments, Jj. ; Ammonis
    Sesquicarbonatis, gr. vj.   Fiat Haustus, sexta quaque
    hora sumendus.

   Form. 200.  Haustus Infusi Cinchons cum Acido
                   Hydrochlorico.
 R Pulveris Cinchons, Jj.; Confectionis Ross,  Jjss.; Aqus
    Ferventis, Oj. ; tere ben6, et per horam, in vase clause,
    infunde.
 R Liquoris Colati,  3xj.; Tinct. Cinchons, 3j.; Acidi Hy-
    drochlorici Diluti, TUviij.  M.  Fiat Haustus, ter quo-
    tidie sumendus.

  Form. 201.   Haustus Infusi Cusparis Compositus.
 R Corticis Cusparis contus., 3ij.; Rad. Calumbs contuss,
     3jss. ; Rad.  Rhei,  3j.;  Sem. Cardan., contrit., 3ss. ;
    Sem. Anisi cont., 3ss.; Aqus Ferventis, Jxv.  Macera
    per horas duas,  et cola.—R Hujus Infusionis, Jj.; Tinct.
    Cinnam., 3Jss.; Spirit.  Ammon. Aromat., fllxxv. ; Si-
    rupi Aurantii,  3j.   Fiat Haustus, ter quotidie sumen-
    d us.  (In all diseases of Debility, excepting Hectic Fe-
    ver, and in Relaxation of Mucous Surfaces.)

  Form. 202.  Haustus Infusi Uvs Ursi Alkalinus.
 R Infusi Uvs Ursi, Jjss.-Jij.; Potasss vel Sods Carbon.,
    gr. xv. ;  Tinct. Hyoscyami, 3ss. (vel Tinct. Opii Cam-
    phor., vel Extr.  Conii)  ; Sirupi Papaveris, 3ss.  Fiat
    Haustus, ter quaterve quotidie sumendus.  (In Affec-
    tions of the Urinary Organs, and of the Air Passages.)

   Form. 203.  Haustus Infusi Uvs Ursi Compositus.
 R Infusi Uvas Ursi (F. 267), 3xiv. ; Acidi Sulphur. Dil.,
    Ulxx.; Tinct. Digitalis, 1\[xv. ; Sirupi Papaveris Veri,
    3jss. M.  Fiat Haustus, ter quaterve quotidie sumen-
    dus. (In Chronic Laryngitis, Bronchitis, &c)

         Form. 204.  Haustus cum Iodinio.
R Liquoris Potassii Iodidi lodiur. Concent. (F. 328), V[vj.-
    xv. ; Aqus Destillats, Jj.;  Sirupi Althss, 31J.  M.
    Fiat Haustus.

            Form. 205.  Haustus Laxans.
R  Potasss  Tartratis, 3j.; Infusi Senns Compos., Aqus
    Pimentas,  55,  3vj. ;  Tinct. Jalaps,  3j.   M.   Fiat
    Haustus.

     Form. 206.  Haustus cum Plumbi Acetate.
R  Plumbi Acetatis, gr. j.  Solve in Aqus Ross, Jj.;  et
    adde Oxymellis Simplicis, 3J.; Tinct. Opii, Ttlv. ; Tinct.
    Digitalis, m*-  Fiat Haustus, quartis vel sextis  horis
    sumendus.

        Form. 207.  Haustus Quins et Zinci.
R  Zinci Sulphatis, gr. $-j.;  Quins Sulphatis, gr. ij.; In-
    fusi Ross  Compos., 3x. ; Tincturs Aurantii, Sirupi
    Aurantii, 55, f. 3J.  M.  Fiat Haustus, quarta quaque
    hora sumendus.

          Form. 208.  Haustus Sedativus.
R  Extr. Conii,  Extr. Hyoscyami, 55, gr. iv. ;  Mucilag.
    Acacis,  3ij. ; tere simul, deinde adde Liquoris Ammon.
    Acet., 3iij.  ; Mist. Camphors, 3V.; Sirupi Rhsados, 3j.
    M.  Fiat Haustus, quarta vel cjuinta quaque hora su-
    mendus.

     Form. 209.  Haustus Sedativus Emolliens.
R  Infusi Lini Co., vel Infusi Althss Co., Jjss.; Bi-boratis
    Sods, 3ss.; Spirit. Ether. Nit.,3ss. ; Sirupi Papave-
    ris, Sirupi Aurantii, 55, 3&s.   M. Fiat Haustus, tertiis
    vel quartis horis capiendus.

     Form.  210.  Haustus contra Spasmos.   (1.)
R  Aqus Menths  Virid.,  Jj. ; Liq. Ammon. Acet., 3ij.;
    Spirit.  Amnion.  Arom.,  Spirit. Ether.  Sulph.  Co.,
    Tinct. Lavand. Co., 55,  3ss.; Tinct. Opii,  Ulxx.  M.
    Fiat Haustus, statim  sumendus, et pro re nata repe-
    tendus.

     Form.  211.  Haustus contra Spasmos.   (2.)
R  Infusi Caryophyl., Jjss. ; Spirit. Piments. Spirit. Roris-
    marini,  5a,  3ss. ; Tinct.  Opii, fllxx.;  Olei  Cajeputi,
    Itlx. M.  Fiat Haustus, ut supra sumendus.

  Form. 212. Haustus contra Spasmos cum  Pilula
                     Camphors.
R  Mist. Camphors, Jj. ; Spirit. Etheris Sulphur. Coinp..
    Tinct.  Camphors Comp., 55, 3j. ; Tinct. Hyoscyami,
    3ss. ; Sirupi  Papaveris,  3jss.  M.   Fiat Haustus, in-
    terdum  cum Pilula sequenti sumendus.
R  Camphors rass, gr. j.-iij.; Ammon. Sesquicarbon., gr.
    iij.-vj.;  Mucilag. Acacis, q. s. M. et fiat Pil. j. vel ij.

          Form. 213.  Haustus Stimulans.
R Aq. Cinnam., Jjss. ; Magnes.  Carbon., 3ss.;  Spirit. Am-
    nion. Arom., 3ss. ; Spirit. Ether. Arom., 3j.; Olei Ro-
    rismarini, TqVvij.  M.   Fiat Haustus.

         Form. 214.  Haustus Stomachicus.
R Calumbs Rad. conciss, 3j. ; Acori Calami Rad. contuss,
    Jss. ; Rhei Rad.  contuss, 3jss.; Cardam.  Sem. con-
    trit., 3ss.; Aqus ferventis octarium dimidium. Macera
    per horam, et cola.—R Hujus Infusionis, 3xij. ; Tinct.
    Aurantii, 3j.; Potasss Carbon, (vel Sods  Sesquicar-
    bonat.), gr. xij.  Misce.  Fiat Haustus, bis  terve quo-
    tidie sumendus.

    Form. 215.  Haustus Stomachicus Aperiens
R  Sods Pot.-Tartratis, 3ij.; Sods Sesquicarbonatis, 3ij.;
    Aqus Anethi, Jss. ; Infusi Anthemidis, Jj. ; Tinct. Ca-
    lumbs,  Tinct. Aurantii Co., 5a, 3J.  M.  Fiat Haustus
    cum Acidi  Tartarici granis  quindecim, in Aqus semi-
    fiuid-uncia solutis, in impetu effervescentis sumendus.

  Form. 216.  Haustus Terebinthinatus Aperiens.
R  Olei Terebinth., 3ij.-3v. ;  Olei Ricini,  3jss.-Jjss. ; Olei
    Limonis, et Olei Cajeputi, 55, fll'v. ad xij.; Magnesis,
    3ss. ; Aqus Menths Virid., Jj.-Jij.  M.  Fiat Haustus,
    pro re nata capiendus.  (In Puerperal, Infectious, and
    Malignant  Fevers.)

         Form. 217.  Haustus cum Uva Ursi.
R  Pulv. Fol. Uvs Ursi, gr. xv.-3j.; Potasss Nitratis, gr.
    xij. ;  Pulv.  Tragacanth. Comp ,  3j. ;  Aq. Anethi;
    Jjss.  M.


            Form. 218.  Infusum Amarum.
 R  Summit. Absinthii Artem., Jj.; Corticis Aurantii, Jss., 
XII
APPENDIX OF FORMULAE.—Infusum.
    Rhei, 3ij.; Rad. Gentians, 3j.; Aqus Ferventis, Jxij.
    Macera per horam, et cola.
R Liq. Colati, Jjss. ; Potasss Carbon., gr. xij. (vel Liq. Po-
    tasss, fllxxij.) ; Tinct.  Aurantii Co., 3j. ; Spirit. Anisi,
    3j.; Sirupi Zingib., 3ss. M.  Fiat Haustus, bis terve
    quotidie sumendus.

     Form. 219.  Infusum Angelics Compositum.
R  Fol. vel  Rad.  Angelics Arch.,  Jij. ; Rad.  Serpentar.,
    Jss.; Florum  Sambuci  Nig., Jj- ; Potasss Carbonat.,
    3iij.; Aqus, foij.  Macera per horas tres, et cola.
R  Liq.  Colati, Jjss.; Spirit. Juniper. Comp.,  3j.; Tinct.
    Opii Co., ItU-  Fiat Haustus. (In Atonic Dropsy, <fcc.)

    Form. 220.  Infusum Anthemidis Compositum.
R  Flor. Anthemidis, Jss.; Semin.  Anisi cont., 3iij. ; Fol.
    Menth.  Virid., Jss.  ;  Caryoph. cont., 3j. ;  Aurantii
    Cort. Sic, 3ij. ; Aqus  Fervid., fojss.   Macera per ho-
    ram, et cola.

      Form. 221.  Infusum Armoracis  Compos.
ft Sinapeos Semin. contus., Armoracis Radicis conciss, 55,
    3iij.; Aqus Ferventis, Oj.  Macera per horam, et cola.
R  Liq. Colati, Jvij. ; Spirit. Ammon. Arom., 3jss.; Spirit.
    Piments, 3iij.  M.   Capiat  Coch., ij., ampla, ter quo-
    tidie.

    Form. 222.  Infusum Arnics.  (Ph. Mil. Dan.)
R Flor. Amies, 3j. ; Flor. Anthemid., Jss. ; Herbs Menths
    Piper., 3ij.; Aqus Fervidae, Jx.   Macera,et cola.  (Do-
    sis Jj-Jjss.)

        Form. 223.   Infusum Arnics Compos.
R  Arnics  Montan. Herbs, Summit. Artemis. Vulg., 55,
    Jss. ; Herbs Centaures Benedict, Rad. Calami Arom.,
    55, 3ij. ; Aqus Fervids, Jxvj. Macera per horas binas,
    et cola.  Liq. colato adde Tinct. Aurantii, Spirit. Pi-
    ments, 55, Jss.; Spirit. Rorismarini, 3ij.   M.  (Dosis
    Jss.-Jjss., bis terve in  die.)

    Form. 224. Infusum  Artemisis Vulgaris Co.
R  Summit. Artemis. Vulgar., 3vj.;  Herbs Centaures  Be-
    lied., 3iij. ; Aqus Fervid., Jxvj.  Macera per  horas bi-
    nas, et cola.  Liq. colato adde  Spirit. Juniperi Comp.,
    Jj.; Olei Rorismarini,  fllxij.  M.  (In Epilepsy from
    Exhaustion, Chlorosis, &c)

            Form. 225.  Infusum Barberis.
R  Barberis Corticis  contusi, Jss.; Aqus Ferventis, Oss.
    Macera per horas binas in vase leviter clauso, et cola.
    (Dosis Jj.ad Jij., bis ter quotidie : interdum cum Sods
    Carbonate, vel  Potasss  Carbonate,  vel  Tinct.  Ca-
    lumbs.)

       Form. 226.  Infusum Calami Aromatici.
R  Calami  Radicis  contuss, 3iij. ;  Aqus  Ferventis, Oss.
    Macera per horas duas, et cola ; dein adde Tinct. Cal-
    ami, Jss.

Form. 227.  Infusum Calami Aromatici Compositum.
R  Rad.  Calami Arom.  conciss, 3jss. ;  Flor. Anthemid.,
    3j. ; Aurantii Cort.  exsic,  3j. ; Caryoph. cont., 3ss. ;
    Aqus Ferventis, Oss.   Macera  per quartam hors par-
    tem, et cola.  Liquori colato adde Potasss  Carbon.,
    3j--3"j-
       Form. 228.  Infusum Caryophylli Comp.
R  Caryoph. contus., 3j. ; Cort. Aurantii Sic, 3ij. ; Semin.
    Coriandri  et Sem. Anisi cont., 55, 3ss.; Aqus Ferven-
    tis, foj.  Macera per semi-horam, et cola.

 Form. 229  Infus.  Cinchons cum Quins Sulphate.
R  Cinchons Cordifol. Corticis in Pulv., 3vj. ; Confectionis
    Ross, Jjss.;  Aqus  Ferventis,  Oj.  Tere  bene, et  di-
    gere per horas duas in vase clauso ;  dein cola.
R  Liq. Colati, Jvj.; Sulphatis Quins, gr. viij.; Acidi Sul-
    phur. Diluti, fllxxiv.   Fiat Mist., cujus Coch. ij., larga
    tertiis vel quartis horis s'umenda.

              Form. 230.  Infusum Conii.
R  Conii Fol.  exsiccat., 3ij.; Anisi et Coriandri Semin.
    contus., 55, 3jss. ; Aqus Ferventis, Oss.   Macera per
    horas duas, et cola.   (Dosis 3j. ad Jij., bis,  ter, qua-
    terve in die.)

        Form. 231.  Infusum Diosms Crenats.
R  Fol. Diosms Crenats, Jss. . Aqus Ferventis, Oss.  Ma-
    cera per horas quatuor, et cola.   (Dose Jj.-Jjss.)

 Form. 232.  Infusum Gentians  Alkalinum Compos.
R  Radicis Gentians  conciss, 3ij.;  Corticis Aurantii Sic,
    3j.; Semin. Coriandr. contus., 3j.; Rorismarini  Cacu-
    min., 3j. ; Potasss Carbon, (vel Sodas Carb.), 3j. ; Aqus
    Ferventis, Jxij.   Macera per horas duas, et cola.
     Form. 233.  Infusum Guaiaci Compositum.



    Seminum contusorum, Jj.; *J,<lU0"fs  'mtXeeT oua-
    funde  per dies tres, de.n cola ;  ^us-mat .gerqa.
    tnor  sexve  unc.as  pro close,  ev i»= «     r
    (Sprague.)
  Form. 234.  Infusum Glechoms Hederaces, cum
                Acido Hydrocyanico.
R Glechoms Hederaces, vel Heder* Terrest™, fss.^;
    Radicis Glycyrrhizs, 3iij.  ; Aqus Ferventis, Oj.  Ma-
    cera per horas tres, et cola.
R  Liq. Colati, Jjss.; Acidi  Hydrocyanici, mj-"j;; Sirup
    Althss Officin, 3jss.  M.   Fiat Haustus, sexta vel oc
    tava quaque hora sumendus.
            Form. 235.  Infusum  Juniperi.
R  Juniperi Baccarum contusarum, Jij.; Aqus Ferventis,
    Oj.  Macera in vase leviter clauso per  horas duas, et
    cola; dein adde Spiritus Juniperi Compositi, Jj.; et in-
    super, pro re nata, Potasss Bitartratis, 31JSS.  (Dosis,
    fiuidunc. ij. ad iv., ter quaterve quotidie.)

Form. 236.  Infusum et Mistura Juniperi Composit.
R  Baccarum Junip. contus., Jijss. ; Semin. Anisi  contus.,
    Semin. Fosniculi cont., 55, 3jss. ; Aqus Ferventis, Oj.
    Macera per horas tres ;  dein cola.
R  Liq.  Colati,  Jxiij. ; Potasss Nitratis, 3jss.; Sods Car-
    bon.,  3jss.; Tinct.  Scills, 3jss. ; Spirit. Junip. Co.,
    3ijss. ; Tinct. Opii, T$,xx\.  Fiat Mist., cujus capiat
    Cyathum subinde\

           Form. 237.  Infusum Marrubii.
R  Marrubii Herbs exsic, Jss. ; Aqus Destillats Ferventis,
    Oss.  Macera per horam, et cola.
R  Liq.  Colati,  Jjss.; Tinct. Camphors  Comp., 3j.; Ext.
    Glycyrrh., gr. x. M.  Fiat Haustus, ter in die sumen-
    dus.  (Chronic Bronchitis, and  Catarrh with inordinate
    Secretion.)
      Form.  238.  Infusum Melisss Compositum.
R Melisss Officinalis exsic, Radicis Glycyrrh. contuss, 55,
    jijss. ; Sem. Anisi cont., Sem. Fosniculi, Sem. Coriand.
    cont., 55, 3ss.; Aqus Bullientis, foij.   Infunde per ho-
    ram, et cola.
    Form. 239.  Infusum Menths et Caryophylli.
R  Folior. Menths Virid. Sic, 3iij. ; Ross  Gallics Petal.
    Sic,  3jss. ; Caryophyllorum contus , 3jss. ;  Aurantii
    Cort. Sic, 3jss.;  Aqus  Ferventis,  Oj.  Macera per
    horam, et cola.

    Form. 240.  Infusum Menths Compositum. (I.)
R  Fol. Menth. Virid. exsic, Radicis  Glycyrrh. concis. e
    cont., 55,  Jss. ; Semin. Anisi et Semin. Coriand. con-
    tus., 55, 3j. ; Aqus Ferventis,  q. s., ut fiat  Colaturs
    Oj.  (Adde Magnes  et Sacch. Album pro tormi.nbus
    infantum;  aut interdum  Acidi Sulphurici Arom., 3J.,
    pro nausea vel vomitu.)

   Form. 241.   Infusum Menths Compositum. (2.)
R  Menths Viridis  exsiccat. contuss, Jjss. ; Ross Gallics
    Petalorum exsiccatorum,  3j. ;  Aqus Ferventis, Oj.;
    Acidi Sulphurici Diluti, 31J.; Sacchari Purificati, Jjss.
    Menths et Ross Petaiis superinfunde Aquam cum Acidi
    dimidio mistam.  Macera ; dein Liquorem effunde, et
    Saccharum, et  Acidum reman, adjice.   (Dosis a fiu-
    idunc j. ad ij., bis, ter, sspiusve quotidie.)

          Form. 242.  Infusum Menyanthis.
R Menyanthis Fdliorum, Jss.; Zingiberis Radicis concis.,
    3ij.; Aqus Ferventis, Oss. Macera in vase clauso per
    horas duas, et rola.  (In doses of Jj. to Jjss., with Spir-
    itus Etheris  Nitrici, 3J.  ad  3ij.,~in  Rheumatism, Ar-
    thritic Affections, and in Cachectic and Cutaneous Dis-
    eases.)
    Form. 243.  Infusum Millefolii Comtositum.
R Herbs Millefolii, 31'j.; Herbs Rorismarini, Herbs Thymi
    Vulg., aa,  3j. ; Semin. Coriand. cont., 3J. ;  Aq. Fer-
    ventis, foj.   Infunde per horam, et cola.
R  Liquoris  Colati,  Jjss. ; Spirit. Rorismarini, 35s.; Tinct.
    Aloes Comp., 3j.~3ij.  Fiat Haustus, primo mane quo-
    tidie capiendus. (In Chlorosis, Amenorrhasa, <fcc)

        Form. 244.  Infusum Pectorale.  (1.)
R  Herb. Malvs Off., Herb. Tussilag., Radicis Aithss  Rad
    Glycyrrh.,  55,  Jj.; Semin. Anisi, Jss.; Aq. Fervid.
    quantum velis.  Macera.

        Form. 245.   Infusum Pectorale.  (2.)
R Rad. Althaeas, Herb. Melisss, Herb. Menths Viridis "lor
    Sambuci, Flor. Arn.cs,  55, Jj. ; Semm. Anisi, J^ M
    Sint loco Thes.                          >:>-»• «« 
APPENDIX OF FORMULAE.—Infusum—Injectio.                     xiii
         Form. 246.  Infusum Quassis Comp.
R Radicis Calumbs concis., 3j.; Ligni Quassis, 3jss.; Aq.
    Ferventis, q.  s., ut sint Colaturs, Jvijss ; adde  Zinci
    Sulphatis, gr. iv.; Acidi  Sulphur. Arom., 3j.;  Tinct.
    Aurantii Co., 3iij.  M.

   Form. 247.  Infusum Quassis cum Aqua Calcis.
R Ras. Lign. Quassis, Jss.; Aq. Calcis Vivae, Jvij.   Stent
    in digestione per horas, xxiv. ;  cola, et adde Aq. Menth.
    Virid., Jij.; Sirupi Aurantii, Jss.  M.

           Form. 248.  Infusum  Rhatanis.
R Krameris Radicis contus.,  3iij.; Aqus Ferventis, Oss.
    Macera  per horas sex in  vase leviter clauso, et liquo-
    rem cola.

             Form. 249.  Infusum Rhei.
R Rhei Radicis concis., 3jss. ; Aqus Ferventis, Oss. Ma-
    cera Radicem per horas duas in vase leviter clauso, et
    cola; dein adde Sacchari Albissjmi, 3ij. ; Olei Menths
    Viridis, gtt. viij., solutas  in Spiritu Menths Piperita,
    Jj.  Tunc misceantur.

        Form. 250.  Infusum Rhei Alkalinum.
R Rhei Rad. concis. et contus., 3ij.; Potasss Carbon., 3j.;
    Aqus Fervid., Oss.  Macera per horas quatuor, cola,
    et adde Tinct. Cinnam., Jss.

        Form. 251.  Infusum Rhei Alkalinum.
R Infusi Rhei, Jvij.;  Potasss Carbon., jijss. ; Tinct. Sen-
    ns, et Sirupi  Senns, 55, 3iijss.  M.

           Form. 252.  Infusum  Rhei Comp.
R  Rhei Rad. concis. et contus., Jss. ; Cort. Canells Albs
    cont., 3ij. ; Flor. Anthemid., Corticis Aurantii, 55, 3iij.;
    Semin. Fosniculi cont., Sem. Coriandri  cont., aa, 3j. ;
    Aqus Ferventis, fojss.  Macera per horas quatuor, et
    cola. Liquori colato adde  Potasss Carbon., 3ij. ; Tinct.
    Cinnam., Jj.   M.

    Form. 253.  Infusum Ross et Aurantii Comp.
R  Ross Gallics  Petal. Sic, 3iij.; Aurantii Cort.  exsic,
    3ij.; Linionis  Cort. Recent., 3j.; Caryophyl. contus.,
    3jss. ; Aq. Ferventis, Ojss.  Macera per horam, et cola.
    Liquori colato adde Sacchar. Albi, Jj.

          Form. 254.   Infusum Ruts Comp.
R Herb. Ruts, Flor. Anthemid.,  Radicis Calami Arom.,
    55, 3iij.  Macera  cum Aqus  Fosniculi, Jx., per horas
    tres, et cola.   Liq. colato adde Camphors, 3j. ; prills
    in Mucilag. Acacis, q. s., soluts; Spirit. Ether. Nit.,
    Jss.  M.

       Form. 255.   Infusum Salvis Compositum.
R Herb. Salvis, Semin. Sinapeos, 55, Jss. ;  Aqus Fervid..
    foj.  Macera  per horam, et cola.  Liq. colato adde Spi-
    ralis Armoracis Comp., Jij.  M.   Capiat Coch. ij.-iij.,
    ter quaterve in die.

   Form. 256.  Infusum Sambuci cum Antim. Tart.
R Flor. Sambuci, Jj.; Aq. Fervid., q. s.,ut sit Colat., Jvj.;
    cui adde Oxymel. Simplicis, Oxym. Scillitici, 55, Jj.;
    Antimonii Pot.-Tart., gr.  ij.  M.   Capiat Coch.  j., om-
    nia hora.  (Augustin.)

    Form. 257.  Infusum Santonics Seminum Com-
                       positum.
R  Semin. Artem. Santonics  cont., Rad. Valerians Opt.,
    55, Jss.  Infunde  in vase  clauso cum Aq. Fervid., Jix.;
    cola, et adde Aq. IVLsnth. Virid., Jij.;  Extr. Ruts, 3J. ;
    Tinct. Valerians Composits, 3iij.  M.  Capiat Jss.-Jjss.,
    pro  dose.    (In  Hysteria,  Chlorosis,   Amenorrhcea,
    Worms, &c)

       Form. 258.  Infusum Sarz* Alkalinum.
R Sarzs Radicis concis. et contus., Jiv.; Glycyrrhizs Ra-
    dicis contus., Jj.  ; Liquoris Calcis, Oiv.  Macera  per
    horas xxiv., in vase bene clauso, sspe agitando.

Form. 259.  Infusum Senegs et Sertentaris Comp.
ft  Rad. Senegs,  Rad. Serpentaris, 55, Jss.; Aq Fervid.,
    Oj.  Macera  in vase clauso per horam,  et cola.  Liq.
    colato adde Camphors, 3ss. ;  prius soluts  in Etheris
    Sulphurici, 3iij.;  Aqus  Cinnam., Jj- ; Sirupi Althss,
    et Sirupi Papaveris, 55,  Jss.   M.  Capiat Cochlearia
    ij., larga, 4tis horis.  (Hecker.)

      Form. 260.   Infusum  Senns Compositum.
R Senns Foliorum, Jss.; Coriandri Seminum contus., 3J.;
    Zingiberis  Rad.  contus., 3J.; Extracti Glycyrrhizs,
    3jss?; Aq. Ferventis, Oss.  Macera per horam  in vase
    leviter clauso, et Liquorem cola.

       Form. 261.  Infusum Senns  cum Manna.
ft Manns, Jij.; Fol Senns,  Jjss.; Potasss  Bitart.. Semi-
    num Anisi  contus., 55, jijss.; Semin. Coriand. Sat.
    contus., 3jss.; Aq.  Ferventis, Oij.  Infunde per horas
    quatuor, et cola.

   Form. 262.  Infusum Serpentaris Compositum.
ft  Serpentaris Radicis, Contrayervs  Radicis, singulorum
    contus., 3ij. ; Aq. Ferventis, Oss.   Post macerationem
    in vase aperto per  horas duas, Liquorem cola, et adde
    Tinct.  Serpentaris, Jss. vel Jj.   (Cum Liq. Ammon.
    Acet., &c)
Form. 263.   Infusum et Haustus Scoparii Composit.
ft  Scoparii Cacum. concis., Jj.; Marrubii Vulgar. Fol.,
    Jss. ;  Aq. Ferventis,  Ojss.  Macera per horam,  et
    cola.
R Infusi Colati, 3xj".; Spirit. Ether. Nit., 3ss.; Spirit.  Ju-
    niperi Comp., 3J. Fiat Haustus, ter quaterve quotidie
    sumendus.
     Form. 264.  Infusum Spigelis Compositum.
ft Spigelis Radicis concis., Jss. ; Senns Folior., 31'j.; Au-
    rantii Corticis cone, Santonics Seminum contus., Fu-
    niculi Semin. contus., 55, 3j. ; Aq.  Ferventis, Jxij. Ma-
    cera per horas  duas in vase leviter  clauso, et cola.
    (Dosis, Cyathus Vinosus singulis  auroris,  jejuno ven-
    triculo.—In Lumbricis.  Sprague.)

      Form. 265.  Infusum Tilis Compositum.
R Florum Tilis Europ., Jss.; Rad. Althss Officin., 3iij. ;
    Flor. Auran., 3ij.;  Aq.  Ferventis, foij.  Macera  per
    horam ; exprime, et cola.

 Form. 266.  Infusum et Mistura Tonico-Aperiens.
ft Senns Foliorum,  Jijss.; Gentians Radicis concis., 3iij.;
    Aurantii  Corticis exsic, Jijss.; Limonis Corticis Re-
    centis,  Jiijss.; Semin. Coriandri  contus., Jijss. ; Zin-
    giberis Rad. concis., 3jss. ;  Aq. Ferventis, Oij.  Mace-
    ra bene in vase clauso per noctem integram (vel  per
    horas octo) ; exprime bene, et cola.  Liq. colato adde
    Magnesis Sulphatis, Tinct. Cardamom.  Coinp.,  55,
    Jiij. ;  Spirit. Vini Rect.,  31 ij. M.  (Dosis Jj.-jjss.,
    pro  re nata.)
           Form. 267.   Infusum Uvs Ursi.
ft Uvas Ursi Folior., 3ij. ; Aq. Ferventis, Oss.   Macera in
    vase clauso per horas  tres,  prope  ignem, et cola.
    (With  the  Alkaline Carbonates  in Nephritic Cases,
    &c.; and with  the Mineral Acids, <fcc, iu Affections
    of the Air Passages.)

           Form. 268.  Infusum Valerians.
ft  Valerians Radicis  contus., Jss.;  Aq.  Ferventis, Jxij
    Macera in vase  clauso per horas duas.  Liquori colato
    adde Tinct. Lavandul. Composils, Sirupi Aurantii, aa,
    Jss. (Dosis, fluidunC. ij , ter quaterve quotidie)

    Form. 269.   Infusum Valerians Compositum.
ft  Radicis Valerians, Rad. Calami Aromatici, 55, concis. et
    cont., Jss. ; Flor. Arnics Montans, 3ij. j  Aq. Ferven-
    tis,  Jxvj. ; Liquoris Potasss, 3J.   Macera per horas bi-
    nas vel tres ; exprime, et adde Etheris Sulphur., 3iij. ;
    et interdum Tmct. Lavandul.  Comp., 3iij., vel Extr.
    Ruts vel Extr.  Taraxaci, 3iij.  M. (Dosis Jss.-Jjss.,
    ter  quaterve in die.)

  Form. 270.  Infusum Valerians  et Serpentaris
                        Comp.
ft  Rad. Valerians, Rad. Serpentaris,  Flor. Sambuci Nig.,
    55,  3ij. ; Aq. Fervid., Jix.  Macera per horas binas, et
    cola.  Liq. colato adde Acidi Sulph. Arom., 3jss. ; Si-
    rupi Papaveris,  Jss. M.  (Fevers, Hysteria, and oi1.pt
    Nervous Affections.)

           Form. 271.   Infusum Zingiberis.
R  Zingiberis Radicis concis., 3jss. ; Aqus Ferventis, Oss.
    Macera per  horas  duas in  vase leviter clauso, et cola ;
    turn adde Tinct. Zingiberis, Sirupi ejusdeni, aa,  5ss.
    (This is  the best vehicle for giving  the Liquor. Ferri
    Oxygenati, and  it is also a very  grateful  aromatic in
    cases of Flatulency.)


        Form. 272.   Injectio Aceti  Pyrolignei.
R  Acidi Pyrolignei, part, j.-ij.; Mist. Camphors, Aq. Ross,
    aa,  part, ij.-iij. ; Tinct. Camphors Co., part, ss.-j.

       Form. 273.   Injectio Argenti Nitratis.
                             No. 1.    No. 2.    No. 3.
R  Argenfi  Nitratis   .    .    . 3j.      3ij.     jj.
    Aq. Destillats   .    .    . Jiij.      Jiij.     Jnj.
      Solve.
          Form. 274.   Injectio Astringens.
R  Infusi Quercus, ut supra, Jiv.; Pulv, Gallarum, gr. xxx.;
    Tinct.  Catechu, 3ij. Fiat Mist., ex quo injicitur paux-
    illum, vel per vaginam vel per auum, pro Leucorrncea,
    vel  Sanguinis Fluxu. 
APPENDIX OF FORMULAE.—Injectio—Linimentum.
           Form. 275.  Injectio Boracica.
R  Aq. Ross, Jiv.;  Aq. Flor.  Aurantii, Jij.;  Bi-boratis
    Sods, 3j. ;  Tinct. Camphors  Comp.,  3ij.-Jss.  M.
    Fiat Injectio.

   Form. 276. Injectio Zinci Acetatis Composita.
R  Zinci Sulphatis, Plumbi Acet., 5a, 3ss. ; Camphors, 3ss.;
    Opii, 3ij.   Solve in Aq. Bullientis, Oj.; cola, et  fiat
    Injectio, ter quaterve in die  utenda; phiala agitata.


          Form. 277.  Iodidum Hydrargyri.
[Internally, in doses of from one grain to three, and exter-
    nally in ointments.—(Vide  Unguent. Iod. Hyd.)  For
    the best account of the preparations and  uses of Iodine,
    consult Dr. O'Shaughnessy's  translation of Lugol on
    Scrofula.)

            Form. 278. Iodidum Plumbi.
(Internally, in doses of from half a grain to five grains ; and
    externally.—Vide Ung. Iod. Plumbi.)
          Form. 279.  Julepus Sedativus.
R  Camphors, gr. vj. ; Spirit. Ether.  Sulphur.  Comp.,
    3jss.; Potasss Nitratis,, gr.  xij. ; Aq.  Flor. Aurantii,
    Jiij. ; Sirupi Althss, 3iij. ; Sirupi Papaveris, 3ij.   M.
    Fiat Mist., cujus capiat tertiam partem omni hora, vel
    bihorio.  (Pierquin.)


     Form. 280.  Linctus Acidi Hydrochlorici.
ft  Mellis Ross,  3x.; Acidi Hydrochlorici, fllxx. ; Sirupi
    Rhceados, 3ij.  M.  Simul agita, ut fiat Linctus.

           Form. 281.  Linctus Boracicus.
R  Cetacei, Jijss ; Pulv. Tragacanths Comp., 3iij.; Sirupi
    Tolutani, Jj.; Bi-boratis Sods, 3jss.;  Confect. Ross,
    3v.; Sirupi Althss, Jj., vel q. s.   Fiat  Linctus, de
    quo lambat pauxillum  sspe.  (Sore Throat, Oesopha-
    gitis, etc.)

        Form. 282.  Linctus Camphobaceus.
ft  Camphors, gr. xij.; Pulv. Gum. Acacis, 3J. ; Sirupi Al-
    thss, Jij.  Misce bene.  (Niemann.)

      Form. 283.  Linctus Chlobubeti Calcis.
R  Chlorureti Calcis, gr. iij.;  solve  in Aq. Destil., Jj.; et
    adde Mellis, Jjss.  M.  Capiat infans Cochleare unum
    minimum subinde.  (In Softening of the Digestive Mu-
    cous Surface.)

        Form. 284.  Linctus Demulcens.  (1.)
R  Olei Amygdal. Dul., Sirupi Althss, 55, Jij.; Sirupi Pa-
    paveris, 3xj. ; Vini Ipecacuanhs, 3jss.; Vitellum  Ovi
    unius.   M.  Fiat Linctus.

        Form. 285.  Linctus Demulcens.  (2.)
It  Cetacei, jijss.; Pulv. Tragacanths Comp., 3jss.; Sirupi
    Papaveris et Sirupi Tolutan., 55,  Jss.;  Potasss  Ni-
    tratis, 31j. ;  Confect. Rosar., 3vj.;  Sirupi Simp., q. s.,
    ut fiat Linctus, de quo  lambat pauxillum pro re nata.

    Form. 286.  Linctus  Demulcens et Aperiens.
R   Sirupi  Viols, Jijss.; Olei Amygd. Dul., Jj.: Sirupi
    Scills et Sirupi  Senns, 55, Jss.  M.  Fiat Linctus.
    (Infantibus.)

    Form. 287. Linctus Emolliens.  (Brendellii.)
It   Saponis  Venet., 3iv.; solve in  Olei  Amygdal. Dulcis,
    Jjss.; Manns Purif., Jss. ; Potasss Bitart., 3ij.; Sirupi
    Althss, Jj.  M.  Fiat Linctus.

    Form. 288. Linctus Myrrhs et Ipecacuanhs.
It  Myrrhs  G. R , 3J. ;  Pulv. Ipecacuan., gr. vj. ; Oxymel.
    Scills,  Mucilag. Acacis, Sirupi Althss, 55, 3vj.   Fiat
    Linctus, de quo lambat pauxillum sspe.

         Form. 289.   Linctus Oleosus.  (I.)
It   Olei Amygdalarum, Sirupi Mori, 55,  Jjss.;  Confect.
    Fruct.  Ross Canins, Jij. ; Pulv. Tragacanth. Comp.,
    3iij.  Misce.  Cochleare minim, subindfi deglutiatur.

         Form. 290.   Linctus Oleosus.  (2.)
H   Olei Olivs, Jjss. ; Oxymellis Scills, Sirupi Papaveris,
    5a, Jj.   Dosis, Cochleare parv. j., urgenti Tusse.   (In
    common Catarrhal Cough, with Sore Throat.)

            Form. 291.  Linctus Opiatus.
R  Sirupi Papaveris, Jij.; Mucil. Acacis Ver., Jjss.; Conf.
    Fruct.  Ross Canins,  Jj. ;  Acidi  Sulph.  Diluti,  3>j.
    Misce.   Dosis,  Cochleare minim, subinde

      Form. 292.  Linctus Opiatus cum Scills.
R  Sirupi Papaveris.  Jj.;  Sirupi Mori, 3vj.; Sirupi Limo-
    nis, Jss.; Oxymellis Scills, Jss-  Misce.   Dosis Coch-
    leare minim. Tusse urgenti.
          Form. 293.  Linctus Pectoralis.

ft Pulv.JBem. An^^^^f^NiS";
    S.^j'-r-s'SiiAiaW  M.  Fiat Line
    tus.  Capiat 3j., pro re nata.
       Form. 294.  Linctus Potasss Nitratis.
R  Potasss  Nitratis contr., ;jss. ;  Mellis Ross, Jj. ; Oxy-
    mellis Simplicis, Jjss.
    re nata.
M.  Capiat Coch. minim., pro
 Form. 295.  Linimentum Ammonis cum Oleo Tere-
                     binthins.
R  Liquoris Ammon., Jss. ;  Olei Olivs, Jj. ;  Olei Tere-
    binthins, Jss.; Olei Limonis, 3ss.  Agita simul donee
    misceantur.       ,

Form. 296.   Linimentum Ammonis et Terebinthin*
                       Comp.
R  Liquoris Ammon., Jj.; Olei Olivs, Jij.  Misce  bene, et
    adde Tinct.  Camphors,  Jij. ; Olei  Terebinth., Jiij.;
    Saponis Duri, 3v. Misce bents, dein adde, Olei Cajeputi,
    3j.; Olei Limonis, 3jss.   M.

      Form. 297. Linimentum Anodynum.  (1.)
R  Opii, Jj.;  Camphors, Jij. ; Liq. Ammon., Jiv.; Saponis
    Duri, Jiv. ;  Olei Terebinth.,  Jviij. ;  Olei  Limonis,
    Jss. ; Spirit. Rorismarini et Spir. Lavandul.,  55, Jxij.
    Misce.

      Form. 298. Linimentum Anodynum.  (2.)
R  Linimenti Saponis Co.np., Jj.  Liquoris Ammonis, 3iij.;
    Olei Caryophylli, 3j.;  Tinct.  Opii,. Jss.  M.  Fiat
    Linimentum.

    Form. 299.  Linimentum Camphors Fortius.
R  Camphors rass, jijss. ; solve  in Tinct. Cantharidis, 3ij.,
    et Tinct.  Capsici Annui, 3jss.; dein adde Linimenti
    Saponis Comp., Jss. ; et gradatim,  miscendo, Liquoris
    Ammon., 3vj. ;  Olei Olivs,  3xj. M.  Fiat Linimen-
    tum, cum quo illinatur pars affecta bis terve quotidie.

    Form. 300.  Linimentum Canthabidum Comp.
R Tinct. Cantharid., 3iij.; Olei Terebinth., Jj. ; Ammonis
    Liq., 3jss.; Saponis Duri, 3j.; Olei  Cajeputi, 3ss.  M.
    Fiat Linimentum.  (Altered from Augustin.)

        Form. 301.   Linimentum Febrifugum.
 R Antimonii Potassio-Tartratis, gr. xxv.;  solve in Aquas
    Destil.,  3ij., vel  q. s. ;  deinde  tere  bene  cum Adipis
    Prspar., Jj., et fiat Linimentum.  (The  antimony is
    partially absorbed without producing any Phlogosis.)

           Form. 302.  Linimentum Iodinii.
 R  Linimenti  Saponis Co.,  Jj.;  Iodinii, gr. viij. vel x.
    Misce.

       Form. 303.   Linimentum Phosphoratum.
 R Olei Olivarum Optimi, Jviij. ;  Phosphori excisi, gr. xx.
    Solve cum calore, cola ex frigido, et fiat Linimentum.
    (In Paralyse locale, Marasmo, Rheumatismo, et Arthri-
    tide Chronico.

         Form. 304.  Linimentum Pyrethri.
R Tinct. Pyrethri, 3yj.; Linimenti Camphors, 3iv.; Li-
    quoris Amnion., 31J.  Misce. Fiat Linimentum.

        Form. 305.   Linimentum Rubefaciens.
ft Camphors, 3J.; Olei Olivs et  Liq. Amnion., 55,  Jj.; Olei
    Macis, 1H,xxxv.   Misce.   (Externally to parts  in deep-
    seated Inflammation.)

Form. 306.  Linimentum Saponis et Camphors Comp.
R Saponis Med., Jj. ; Alcoholis Rect., Jvj. ; Camphors et
    Aq. Destil., 55, Jj.  Solve leni cum calore, et adde Olei
    Rorismarini, 3iv.; Olei Thymi, 3j. ; Liquoris Ammo-
    nis, Jij.  Misce bene.

      Form. 307. Linimentum contra Spasmos.
R Olei Olivs,  Olei Terebinthins, Liquoris Ammon., Tinct.
    Opii, Linimenti Saponis Compositi,  55, Jss  Fiat Lin-
    imentum.

         Form. 308.  Linimentum Stimulans.
R Linimenti Camphors Compositi, Linimenti Saponis Com-
    positi, 55, Jjss. ;  Olei  Crotonis, 3J. ; Olei  Cajeputi,
    3jss.  Fiat Linimentum.

   Form. 309.  Linimentum Sulphuro-Saponaceum.
R Potassii Sulphureti, Jiij. ;  Saponis Albi, Olei Olivs 55
    Ibj.; Olei Volat. Thymi, 3j.   M.  (Jadelot.)    '  ' 
APPENDIX OF FORMULAE.—Linimentum—Mistura.
          Form. 310.  Linimentum Tabaci.
R Tabaci Foliorum, Jj.; Axungis Porcins, foj.   Simul li-
    quefac et macera prope ignem donee friabilia sint folia ;
    tunc exprime.   (Ph. Amst.)

    Form. 311.   Linimentum Tebebinthins Comp.
R  Linimenti Saponis Co., Linimenti  Camphors Co., aa,
    Jjss.; Olei  Terebinth., Jij.; Saponis Duri, 3ij. ;  Olei
    Limonis  et 01. Cajeputi,  3j~3'j-   M.   Fiat  Lini-
    mentum.

  Form. 312. Linimentum Terebinthino-Phospho-
                       ratum.
R  Olei Terebinth., Jij.; Camphors rass, 31J.; Linimenti
    Ammon. Fort., Jij. ; Saponis Medicin., 31J. ; Phosphori
    Puri, gr. x.-xij., prius soluti  in Olei Cajeputi, vel  in
    Olei Caryophyl., 3ij., vel q. s.  M.   (In Chronic Rheu-
    matism and Epidemic  Cholera.)

 Form. 313.  Linimentum Thebaiacum Compositum.
R  Opii Puri, 3ij.; Camphors, Succini, 55, 3ss.;  Spirit.
    Vini, Jvj.  Misce pro Linimento.

          Form. 314.  Linimentum Volatile.
R Olei Olivs, Jiv.; Camphors, 31J. ; Liquoris Ammon., Jij.
    Misce.
       Form. 315.  Liquor Acetatis Morphis.
R Morphis Acetatis, gr. xvj. ; Aq. Destillats, Jvij. ; Acidi
    Acetici, ttlx.; Spirit. Piments, 3v.  Solve.   (Dosis a
    1fl,v. ad Tfl,xxx.)

 Form. 316.  Liquor Antimonii Potassio-Tartratis.
ft Antimonii Potassio-Tartratis, gr. xxxij,;  Aq. Destillats,
    Jxiv.;  SpiritOs Rectificat., Jij.;  Uvarum  Passarum,
    demptis acinis, Jij.  Macera per hebdomadam, et cola.

 Form. 317.  Liquor Balsamico-Aromaticus.—Balsa-
                 rmim Vita Hoffmanni.
ft  Balsami Peruviani,  3j.;  Olei  Succini, Olei Ruts, Olei
    Rorismarini, Olei Lavand., Olei Caryoph., Olei Piments,
    55, 3ss.; Spirit. Vini Rectificati, Jxjss.  Misce bents.
    (In doses of from 10 to 30 drops on Sugar, or in a suita-
    ble vehicle.)

      Form. 318.  Liquor Bi-bobatis Sods  Comp.
R Bi-boratis Sods, Potasss Bitart., 55,  Jss. ; Aq. Destil.,
    Oj.  (Dosis 3J.~3iij., pro Infantibus ; et Jss.-Jiij., ter die
    pro Adultis.)

   Form. 319.   Liquoe Calcii Chloridi.  (Beddoes.)
R Acidi  Hydrochlorici, Aq. Destillats, 55, Jiv.;  Marmoris
    Albi Pulv., q. s., ad saturandum.

      Form. 320.  Liquor Camphors Ethereus.
 R  Camphors  rass, Jj.; Etheris Sulphurici, Jj. Solve.
    Capiat Hlxx.-xl., super Saccharum vel in Vini Hispan.
     Cyatho.  (Proposed by Bang, and adopted in most of
     the  Continental Pharm.)

  Form. 321.  Liquor Ferri  Oxygenati.  (Beddoes.)
 R  Ferri  Sulphatis, Jss. ; Acidi  Nitrici  Fortissimi (per
    pond.), Jss.  Tere probe simul in mortario vitreo donee
    effervescentia peracta ; dein adde gradatim Aq. Destil-
     lats, Jjss.  Postea per chartam cola.  Dosis  a quatuor
     ad decern guttas, ter  quaterve,  quotidie, in  Quassis,
     vel Zingiberis, vel Caryophylli, Infusione.   (In Worms,
     Haemorrhages, &c)

      Form. 322.  Liquor Hydrargyri Bichlobidi.
 R Hydrargyri Bichloridi, gr. iv. ; Acidi Hydrochlorici, 1Tlvj.;
     Aq. Destillats, Jj.; Spirit. Tenuioris, Jvj. ; Tincturs
     Croci, 3ij.  Tere  probe simul in mortario vitreo ut fiat
     Solutio.   Incip.  surnendo,  1fl,xx., nocte  maneque ex:
     haustu InfusOs Lini, vel Decocti Glychyrrhizas;  poste-
     aque pro re nata augeatur.   (Sprague.)

           Form. 323.   Liquor Potassii Iodidi.
 R Potassii Iodidi, gr.  xxiv.; Aq. Destillats, Jj.   Solve te-
      rendo in vase vitreo.   (Dosis 1Ux.-xxx.)

     Form. 324.  Liquor Potassii Iodidi Ioduretus.
 R Potassii Iodidi, gr.  xxxvj. ;  Iodinii, gr. x.; Aq. Destillats,
     3x.   Solve terendo in vase vitreo.  (In doses  of 10
     drops to 30, thrice daily.)

         Form. 325.  Liquor Mobphis Citbatis.
 R Morphis Purs, gr. xvj.; Acidi Citrici Crystal., gr. viij. ;
      Aq. Destillats, Jj. ; Tinct. Cocci, q. s.  Solve.  (Dosis
      IHv.-xxv.)
     Form. 326.  Liquor Plumbi Acetatis Dilutus.
 R Liquor Plumbi Acetatis, 3j. ad 31J.; Acidi Acetici Diluti,
    31 ij. ; Spirit. Rectificati, 3jss. ;  Aq. Destillats,  Jxiv.
    Misce.

       Form. 327.  Liquor Potasss Chloratis.
R Potasss Chloratis, 3j.; Aq. Destillat., Jxij.  (In indolent
    Sores as a Lotion, and internally in three times Us bulk
    of vehicle.)

 Form. 328.  Liquor Potassii Iodidi Ioduretus Con-
                centbatus.  (Lugol.)
ft  Iodinii, 3j.;  Potassii Iodidi, 3tj. ; Aq. Destillats, Jvij.
    Solve.  (This solution contains one twenty-fourth part
    of Iodine.  Dose for an Adult, six drops in sugared Wa-
    ter in the morning fasting, and six an hour before din-
    ner ; increasing the dose, every week, two drops, until
    it  reaches to thirty or thirty-six daily.)

 Form. 329. Liquoe Potassii Iodidi Iodubetus Dilu-
                   tus.  (Lugol.)
                          '   No.  1.    No. 2.   No. 3.
 R Iodinii.....gr. %     gr. j.    gr. ji
    Potassii Iodidi  .     .    . gr. jss.    gr. ij.   gr. ijss.
    Aq. Destillats  .     .    . Jviij.     Jviij.    Jviij.
       Solve.

         Form. 330.  Liquor Zinci Acetatis.
 R Zinci Sulphatis Purif., gr. xxiv.; Aqus Destillats, Jiv.
    Solve.
 R Plumbi Acetatis, gr. xxxij.;  Aq. Destillats, Jiv.  Solve.
    Misceantur Solutiones ; quiescant paulisper; dein co-
    letur Liquor.


        Form. 331.  Lotio Acidi Hydbocyanici.
 R  Acidi Hydrocyanici, Jss.; SpiritOs Rectificati, Jj.; Aq.
Destillats,
utenda.
|xss.   Misce,  et fiat  Lotio,  diligeuter
         Form. 332.  Lotio Antiphlogistica.
R Liquoris Plumbi Diacetatis, 3vj.; Liquoris Ammon. Ace-
    tatis, Jiv.; Aq. Purs, foij.  Misce.

           Form. 333.   Lotio Antipsorica.
R Potassii Sulphureti, Jiv.;  Aqus, Oj.; Acidi Sulphurici,
    3iv.   Misce.  Fiat  Lotio, bis terve  quotidie utenda.
    (Dupuytren.)

             Form. 334. Lotio Boracica.
R Bi-boratis  Sods.  3j.; Aq. Ross, Aq. Flor.  Aurantii, 55,
    Jiij.   M.  Fiat Lotio.

            Form. 335. Lotio E vapor ans.
R Etheris  Sulphur., Liquor. Ammon. Acet., Spirit. Vini
    Rect., 55, Jjss. ; Aq. Ross, Jiijss.  M.  Fiat Lotio.

      Form. 336.  Lotio Evapobans Astbingens.
R Ammonis Hydrochloratis, 3ij. ; Liquoris Ammon. Acet.,
    Jiij.; Aqus Purs, Jxij.   Misce.

               Form. 337.  Lotio Flava.
R  Hydrargyri Bichloridi, gr. xv. ; Liquoris Calcis, foj.
    Misce.

    Form. 338.  Lotio Hydrargyri Camphorata.
ft Hydrargyri, 3j.;  Acidi Nitrici, Jij. ; Aq. Destillats, Ov.
    Hydrargyrum digere cum Acido Nitrico, et Aquam De-
    stillatam adde,  dein Camphors, jss.  ad Jijss., adjice
    (In Chronic Cutaneous Affections, applied twice daily.)

             Form. 339.  Lotio Sedativa.
 ft  Acidi  Hydrocyanici, 3j.-3ij.;  Mist. Amydal.  Amaros,
    Jvijss.; Hydrarg. Bichloridi, gr. lij.-v.  Fiat Lotio, opu
    spongis partibus affectis applicanda.

   Form.  340.  Lotio Terebinthins et Camphors.
 ft  Camphors, 3iv. ;  Spirit. Vini Rect., Olei Terebinthins,
     55, Jiv.   M.  Fiat Lotio, in Morbis Cutaneis Chronics
     utenda.

          Form. 341.  Lotio Terebinthinata.
 ft  Olei Terebinthins, Alcoholis, 55, Jiv.; Camphors, 3vj.
     Fiat Lotio.  (In Pityriasis, &c)


       Form. 342.  Mistura Acetatis Morphis.
 ft  Morphis Acetatis, gr. ij.;  Acidi Acetici, 3ss.; Mist. Cam-
     phors, Jvss. ; Tinct. Humuli, 31 ij. ;  Sirupi Tolutani,
     3j.   M.   Fiat Mist., cujus capiat Cochleare unum am-
     plum tertia vel quarta quaque hora.

          Form. 343.  Mistura Acidi Boracici.
 ft Acidi  Boracici, 3j.;  Mist. Camphors, Jiv.: Sirupi Au-
     rantii,  Jj.  M. Capiat Cochlearia,  ij.,  2d5  vel 3tn\
     quaque hora.  (In Cerebral Affections.  Chaussier.j 
APPENDIX  OF FORMULAE.—Mistura.
    Form. 344.  Mistura Acidi Hydrocyanici Comp.
 R Acidi Hydrocyanici, 7fl,viij.-xx. ; Vini Ipecacuanhs, 31J. ;
     Spirit. Etheris Sulphurici Comp., jiij.; Mist. Cam-
     phors. Mist.  Amygdal. Dulc, 55,  Jiijss ;  Oxymellis
     Scills, 3ij.-Jss. M.  Capiat Cochlear, j., vel ij., vel iij.,
     ter quaterve quotidie.

      Form. 345.   Mistura Acidi Hydrochlorici.
 ft Acidi Hydrochlorici, 3j. ;  Decocti Hordei, Oj.; Sacchari
     Purificati, Jss.  Misce.   (Dosis a rluidunc, ij. ad iv.,
     bis, ter, sspiusve quotidie.)

       Form. 346.   Mistura Acidi Nitrici Comp.
 ft Extracti Hyoscyami, 3ss.;  Acidi  Nitrici Diluti,  3j.;
     Aqus Destillats, Jvss.; Sirupi Zingiberis, 3iij.  M.
     Fiat  Mistura.  (Dosis unc. j., secundis horis, durante
     paroxysmo.)

       Form. 347.   Mistura Alkalina Anodyna.
 ft Tinct.  Opii, 31J.; Liquoris t>otasss, Jss.;  Spiritus Myris-
     tici, Jss. ; Aq. Purs, Jxjss.  Misce.  (Dosis 4 Jj. ad Jij.,
     bis terve in die.)

       Form. 348.   Mistura Alkalina Cardiaca.
 ft Mist. Camph., Jvjss., Sods Carbon., 3jss.; Ammon. Ses-
     quicarbon., 3j.; Tinct.  Calumbs,  Jss.; Spirit. Anisi,
     Tinct. Cardamom. Co., 55, Jss. M.  Capiat Cochlea-
     ria ij., magna, bis terve  quotidie.

     Form. 349. Mistura Aloes et Guaiaci Comp.
 R Tinct.  Aloes Comp., Tinct.  Guaiaci,  Spirit. Ammonis
     Aromat., 55, Jss.; Tinct. Ferri Ammonio-Chloridi, 3iij.
     M.  Capiat 3j. vel 3ij.,  ter de die, in vehiculo quovis
     idoneo.

      Form. 350.  Mistura  Ammoniaci Comp.   (I.)
 R Mist. Ammoniaci,  Jvjss.; Potasss Nitratis,  3j.; Aceti
     Scills, Jiij.; Spirit. Junip. Comp., Jj. ;  Tinct. Opii,
     Tllxij.   Fiat Mist., cujus capiat Cochleare amplum 3tiis
     vel 4tis horis.

      Form. 351.  Mistura  Ammoniaci Comp.  (2.)
 ft Gummi Ammoniaci, 3j. ; Oxymellis Scills, Jj.;  Vini Ip-
     ecacuanhs, 3J.; Aqus Flor. Sambuci,  Jivss.; Sirupi
     Papaveris, 3ij.  M.   Capiat sger  qualibet hora Coch-
     leare  unum.  (Chronic Pectoral Complaints.)

   Form. 352.   Mistura Ammonis Hydrochloratis.
 ft Hydrochloratis Ammonis, Extr. Glycyrrh., 55, 3j. ;  De-
     cocti  Althss,  Jvj.; Oxymel. Simp., Jj. (vel Oxymel.
     Scills.) M.   (Catarrhal Affections.)

            Form. 353.  Mistura Anodyna.
 R Magnesis Carbon., 3jss.; Tinct. Humuli, 3iij.; Aqus
     Menth. Virid., Jiij.;  Infusi Caryophyl., Jiijss.  M.
     Fiat Mist., cujus capiat Cochlearia ij., larga pro re nati,
     vel urgenti Nausea.

     Form. 354.  Mistura Anodyna..—(Infantilis.)
 R Testae Prsparats, jij.;  Sirupi Papaveris Alb., Jj.; Spiri-
     tds Ammon.  Fcetid., Jj. ; Olei Anethi, Olei Fcenicul.
     Dulc, aa, Ttliij.; Aqus Destillats, Jiij.  Fiat Mistura.

        Form. 355.  Mistura Anodyna Aoetosa.
 ft Mist. Camphors, Jiv.; Liquoris Ammon.  Acet., Jiij. ;
     Acidi  Acet., Jij.; Spirit. Ether. Nit., 31J.; Vini Ipe-
    cacuanhs,  3ij.; Extracti Conii, gr. xxx.; Sirupi Tolu-
    tani, 3ij.  M.   Fiat  Mist., cujus capiat Cochlearia ij.
    vel iij., larga, 4ta vel quinta  quaque hora.

      Form. 356.   Mistura Anodyna  cum Zinco.
 ft Zinci Sulphatis, gr. vj.;  Mist. Camphors, Jvij.; Acidi
    Sulphur. Arom., 3ss. ;  Tinct. Hyoscyami, 3jss.; Tinct.
    Camphors  Comp., 31 ij.; Sirupi Limonum, 3jj.   M.
    Capiat Cochlearia ij., larga, ter quaterve quotidie'.

          Form. 357.  Mistura Anti-emesis.
 ft  Magnes. Carbonat.,  3jss.;  Spirit. Ether.  Sulph. Comp.,
    3iij.;  Tinct. Cardamom. Co., Jss.; Spirit. Anisi, 3v.;
    Olei Carui, Itlx. ;  Sirupi Zingiberis, Jijss. ; Mist. Cam-
    phors, Jjss. ;  Aq.  Menths Viridis,  Jvss.  Fiat Mist.,
    cujus  sumantur Cochlearia  duo ampla, urgenti Flatu
    vel  Nause5.

     Form. 358. Mistura Antiphlogistica.  (1.)
R  Potasss Nitratis, Jss.; Liquoris Ammonis Acetatis, Jjss.;
    Vini Antimonii  Potassio-Tartratis, Jiij. ; Mist. Amyg-
    dalarum, Jvj.   Fiat Mistura, cujus sit dosis Cochlearia
    tria magna, quarta quaque hora.

     Form. 359.  Mistura Antiphlogistica.  (2.)
ft  Liquoris  Ammonias Acetatis,  Aq. Mentha  Viridis, 55,
    Jij.; Aq. Destillats, Jiijss.; Potasss Nitratis, 3ij. ;
    Vini Antimonii Potassio-Tartratis, jiij.  Fiat Mistura,
     cujus sit dosis Cochlearia tria ampla, tertift vel quarta
     quaque hora.
           Form. 360.  Mistura Antiseptica.
 R Acidi Hydrochlorici Dil. vel Acidi Acetic, Etheris Sul-
     phur., 55, 3ij.; Aq,  Piments,  5'vss'i  Aq. Ci.inam.,
     Jij. ; Sirupi  Aurantii, Jj.  M.   Sumantur  Coch. duo,
     omni b.horio.
            Form. 361.  Mistura Aperiens.
 R Magnesis Sulphatis, Jv. ;  Magnesis Carbonatis, 3iijss ;
     Aq.  Destillats, Oij.  ; Spiritus  Cmnamomi, Spiritus
     Anisi, 55, jij. ; Tinct. Cardam. Co., Jss.   Fiat Mistura.
     Dosis a Jj. ad Jij.

        Form. 362.  Mistura Aperiens Salina.
 R Florum Anthemidis, Jij.; Radicis Zingiberis concise,
     Jj. ; Aq. Ferventis, Oijss.   Macera  per noctem ; ex-
     prime, et adde Magnes. Sulphatis, Jij.; Sods Sulpha-
     tis, Jjss. ; Potasss  Sulphatis, 3v. M.  Capiat Cyathum
     primo mane.  (After  each dose take an hour's exercise
     in the open air, and breakfast afterward.)

           Form. 363.   Mistura Aromatica.
 R Infusi  Caryoph., Jiv.; Aq.  Cinnam.,  Jiij.; Tinct. Cin-
     nam., 3ij. ; Magnes.  Carbon., 3jss. ; Confect.  Arom.,
     3j.  M.  Fiat Mist., cujus sumat Coch.  ij.,  larga.

           Form. 364.  Mistura Arsenicalis.
 R Liquoris Potasss Arsenitis, 3jss. ; Tinct. Cardam. Comp.,
     3v.; Aqus Cinnam., Jiij  : Aq. Destillats, Jiv. M.
     Fiat Mistura.  Dosis Cochlearia ij.  (Jj.), 3t.is vel 4tis
     horis.

      Form. 365.   Mistura Arsenicalis cum  Opio.
 ft Liquoris Potasss Arsenitis, 1tlxl.;  Confectionis  Opii,
     3iv.; Aq. Menths  Viridis, Jiv.  M.   Capiat  partem
     4tam  post jentaculum,  prandium,  et  ccenam.   (Dr.
     Cleghorn.)

           Form. 366.   Mistura Asafcetids.
 ft Asafcetid-s, jj.; Liquoris Ammon.  Acet., Aq. Pulegii, 55,
     Jiijss.  M.   Cap.  Cochleare unum, vel duo, pro dose.

        Form. 367.  Mistura Asafcetids Comp.
 ft Asafcetids, 3J.;  tere cum Aqus Menth. Virid., Jv.; dein
     adde Tinct. Castorei, 3iij. ; Tinct. Valer. Comp., 31J.;
     Ether. Sulphur.,  3J.   Fiat Mist., cujus capiatur Coch-
     leare unum amplum,  secundis horis.

  Form. 368.  Mist. Asafcetids et Valerians Comp.
 ft Tinct. Asafcetids,  Tinct. Gentians  Compositie, Tinct.
     Valerians,  Spintds  Ammonis  Arom.,  55, Jss.  M.
     Sumatur Cochleare  unum minimum ex Aqus tostm
     cyatho.
       Form. 369.  Mistura Balsami Peruviani.
 R Balsami Peruviani, 3ij. vel iij.;  Mellis Despumati, Jj.
     Simul diligenter tere, et gradatim adde Aq.  Destillatse,
     Jvij.  Dosis a fluid. 3j. ad Jss., bis, ter, quaterve quo-
     tidied

        Form. 370.  Mistura Balsami Tolutani.
 R Tinct.  Balsami Tolutani, 3ij.;  Mucilaginis Acacis, Jj.
     Misce; adde gradatim,  Aq. Destillats, Jiv.; Tinct.
     Camphors Co.np., Sirupi Simplicis, 55,  3iij ; Ammon.
     Sesquicarbonatis,  3ss. (vel sine).  Misce. Fiat Mistu-
     ra, cujus capiat Coch. ampl. ij., ter in die.

            Form. 371.  Mistura Bechica.
 ft  Pulveris Tragacanths Compos.,  3ij.;  Aq. Destillats;,
     Jxij. ; Sirupi  Simplicis, 3vj.  Misce.   Interdum adde,
     vel Nitratis Potasss,  3iv., vel Tinct. Opii, Hxl., vel
     Tinct. Hyoscyami, 3jss., vel Tinct. Camphors Comp.,
     3ss., vel  Oxymellis Scills, 3vj., vel aliun. medicamen-
     tum idoneum.

           Form. 372.   Mistura Camphors.
 R« Camphors,  3J.; tere  cum  Spirit. Rectificati,  fllxx.;
     Magnesis Carbonatis, 3ij. ; et Sacchari  Purificati,
     3ij- ; dein adde gradatim, Aq. Destillats  Ferventis, Oi.
     M.  Fiat Mistura.

     Form. 373.  Mistura Camphors Composita.
 R Camphors rass, gr.  xij. ; Magnesis Carbon., 3j • Gum.
    Acacis in Pulv., 3j.; Mist. Amygdal. Dulc, 'jvjss.;
     I met.  Opii, 1TUxx.  (vel Tinct. Hyoscyami, 3j ) • Sirupi
    Papaveris Alb., 3iij.  M..  (In Affections of Mucous
    Surfaces, &c )

         Form. 374.  Mistura Camphorata.
R Camphors, gr. viij -xvj. ; Alcoholis,  Itlvj.; Sacchari Albi,
    Pulv.  Acacis,  Magnes. Calc, 55, 3ij.;  Aqu!8  PuraB'
    Jvijss.  M.

   Form. 375.  Mistura Camphorata.   (Ph.  Dan.)
R  Camphors Pulverizats, 38s.; Gum.  Acaciae, Sacchari 
APPENDIX  OF  FORMULAE.—Mistura.
xvii
    Albi, 55, 31J. ; Magnesis, 3ss. ; Decocti Althss Offi-
    cinalis,  Jvijss.  M.  (Interdum adde Tinct. Opii, vel  ]
    Tinct. Hyoscyami, vel Vinum Ipecacuanhs, vel Spirit.
    Ether.  Nit., vel Ether. Sulphur., vel  Extr.  Conii,
    «fcc, etc.)

         Form. 376.  Mistura Carminativa.
R Magnesis Sulphatis, Jjss.; Magnesis Carbonatis, 3ijss.;  ]
    Tinct. Cardamomi Comp., 3jss.; Tinct. Castorei, Itlxl. ">
    Olei Anisi, TIlx. ;  Aq. Anethi. Jxij. ; Aqus Purs, Jviij.
    Misce.  Dosis a jij. ad Jjss., 4tis vel 6tis horis.

  Form. 377.  Mistura Carminativa Deobstruens.
R Infusi Menths Caryophyl. (F. 239), Jvij.; Potasss Bi-
    sulphatis, Jijss.; Acidi Sulphur.  Dil., 3j. ;  Spirit. Pi-
    ments,  Spirit. Carui, 55, 3jss.; Spirit. Myristics, 3ij. ;
    Sacchari Albi, 3ij.   Fiat Mist.  Capiat Cochlearia duo
    larga, 3tiis vel 4tis horis.

          Form. 378.  Mistura Cathartica.
R Olei Cinnamomi, fllviij.; Sacchari Purificati, Jss. Misce.
    Adde gradatim Infusi Senns  Comp., Jx. ; Sods Sul-
    phatis,  Jjss. ;  Magnes. Sulphatis, Jj. ;  Tinct. Jalaps,
    Jj. ; Tinct. Senns Comp., Jjss.  Misce.   Fiat Mistura,
    et per chartam cola.  Dosis Jjss. ad Jij.

    Form. 379.  Mistura Cathartica Ammoniata.
R Olei  Menths Viridis, ttlx. ; Olei Menths Piperits, fllv.;
    Sacchari  Purificati, 3iij.   Misce; turn  adde  Infusi
    Senns Comp., Jvij.; Sods Sulphatis, Jj. ; Tinct. Senns,
    3v. ;  SpiritOs Amnion. Aromat.,  3iij.    Misce.   Fiat
    Mistura, cujus sumat  partem 4tam, 3tirs horis, donee
    alvus responderit.

            Form. 380.   Mistura Cinchons.
R  Cinchons  Flavs in Pulv. subacts, jvj. ; Confectionis
    Opii, 3ij. ;  Pulv. Cinnam. Comp., 3J.;  Ammon.  Ses-
    quicarbon., gr. xij. ; Vini Rubri Op., Jxij.  M.

      Form. 381.  Mistura Cinchons Alkalina.
ft Myrrhs in Pulv., 3jss. ; Liquoris Potasss Carbon., 3x1 j.;
    Decocti Cinchons,  Jvss. ; Tinct.  Cascarills, 3iij.  Fiat
    Mist., de qua sumantur Cochlearia duo  ampla, bis de
    die.

      Form. 382.  Mistura Cinchons Aperiens.
 R  Confectionis Ross Gallics, Jj. ; contere  cum Decocti
     Cinchons Ferventis, Jviij.;  stent simul  per  partem
     hors sextam, et cola.
 R  Liquoris Colati, Jvij.;  Acidi Sulphurici Diluti, 3J. ;
     Magnes.  Sulphatis, 3iv.; Spiritus Myristics, Jss.  M.
     Fiat Mistura, cujus sumat Coch.  ampl. iij., ter in die.

         Form. 383.  Mistura Conii Composita.
 R  Extracti Conii, 3ss.; Sods Carbonatis, 3ss -•. ; Decocti
     Glycyrrh., Jvss. ; Spirit. Piments, 3iij.  M.  Dosis Jss.
     ad Jij., ter quaterve quotidie.

           Form. 384.   Mistura Crets Comp.
 R  Crets Prsparat., Gum. Acacis, Sacchar. Purif., 55, Jss.;
     Olei Fosniculi, ULviij. ; Aq. Piments et  Aq. Cinnam.,
     5a, Jviij. ; Tinct. Aurantii, Jj.  M.

 Form.  385.   Mistura Decocti Cinchons Ammoniata.
 R  Decocti Cinchons, Jiv.;  Liq.  Ammon. Acet., Jjss. ;
     Spirit. Ainmon. Aromat.  (vel Fostid., vel Tinct. Amnion.
     Compos.),  3iij. ;  Spirit. Rorismarini,  3ij.  M.  Fiat
     Mistura.

    Form. 386.  Mistura Decocti Cinchons Compo-
                       sita.  (1.)
 R  Decocti Cinchons, Jiv.;  Liq. Ammon.  Acetatis, Jij.;
     Spirit. Ether. Nit., 3ij.   M.  Fiat Mistura.

    Form. 387.  Mistura Decocti Cinchons Compo-
                       sita.  (2.)
 ft  Pulv. Cort. Cinchons, 3vj.; decoque  cum Aq. Fontan.,
     Jxvj., ad uncias octo ; et sub finem coctionis adde Pulv.
     Radicis  Serpentaris,  3iij. ; Pulv. Radicis Rhei  Opt.,
     3jss.   Cola cum express. ; deinde admisce Liquoris Am-
     nion.  Acet.,  J.j. ;  Sirupi Cort. Aurantii, Jj.  Misce.
     Capiat sger, altera quaque hora, Cochleare unum.

  Form. 388.  Mistura Decocti Cinchons cum  Aceto
                      Pyroligneo.
 R  Decocti Cinchonae, Jvjss. ;  Acidi Acetici  Fortior. (vel e
     Ligno  destil),  3 i j - ;  Spirit. Rorismarini, Spirit.  Pi-
     ments, 55, 3ij.  M.   Fiat Mistura.

            Form. 389.   Mistura Demulcens.
 R Pulveris  Tragacanth., gr. xv. ;  Sacchari Albi, gr.  xij.
     Tere,  et paulatim adde  Mist. Amygdal. Dulc, Jij.;
     Mist.  Camphors, Jiijss.;  Sirupi AlthsiE, Jss   M.
     Fiat Mist,                                         '
      Form. 390.  Mistura Deobstruens.  (1.)
  Extr. Taraxaci, Extr. Humuli, 55, jij. ;  Potasss Tarta
   rizats, jj. ; Aq. Fosniculi, Jvj.;  Vini Antimonii Potas
   sio-Tartratis, 31J.; Oxymel. Scills, Jss.  M. Fiat Mist.,
   cujus capiat Coch. j. vel ij., 3tiis vel 4tis horis.

      Form. 391.  Mistura Deobstruens.  (2.)
  Radicis Rhei,  Jss.; Fol. Senns, 3iij.; Aq.  Ferv., Jxij.
   Infunde per horas iij., et cola.
  Hujus  Infusi, Jx.; Extracti Taraxaci, Ext. Chelid., 55,
   3iij. ; Ext. Flor.  Calendul., 3ij. ; Acet. Potasss,  Jvj. ;
   Tinct. Calumbs, Jss.; Spirit. Junip. Co., Jj.; Etheris
   Hydrochlorici,  3jss.  M.  Capiat Cochlear, j.  vel ij.,
   larsa, ter de  die.  (In Glandular Enlargements, par-
   ticularly those of the Abdomen.)

      Form.  392.  Mistura Deobstruens.  (3.)
  Extr.  Taraxaci, jijss.; Ext. Sarzs vel Scoparii, Jij.;
   Potasss  Tart., Jjss.  ; Bi-boratis Sods, Jss.; Aq. Fos-
   niculi Dul., Jvj. ; Vini Antimon. Pot.-Tart., 3ij. ;  Oxy-
   Scills,  Jj.   M.  Capiat Coch. ij.-iij.,  3tiis  vel 4tis
   horis.

         Form. 393.  Mistura Diaphoretica.
  Liquoris Ammon. Acetatis, Jiv. ; Vini Antimonii  Pot.-
   Tart., Jss. ; Vini Ipecac, 3 i j. ; Sirupi Papaveris,  Jss.;
   Aq. Destil.,  Jxv.  Misce.   (Dosis  a 3J. ad Jj.,  3tiis,
   4tis, vel 6tis  horis. Interdum adde, vel Spiritum Ethe-
   ris Nitrici, vel Tincturam Opii.)

   Form. 394.   Mistura Diaphoretica Anodyna.
R Liquoris Ammon. Acetatis, Jiv.; Vini  Antimonii  Pot.-
   Tart., Vini Ipecac, 55, 3ij.; SpiritOs Etheris Nitrici,
   Jss.; Sirupi Papaveris, Jj.; Extracti Conii, gr. xiv. ;
   Aq. Destil., Jxij.  Misce.

 Form. 395.   Mistura Digitalis et Colchici Comp.
R  Infusi Digitalis, Liq. Ammon. Acetatis, 55, Jijss.; Po-
    tasss Acetatis, 3ij.;  Aceti  Colchici, 3ij.;  Opii Tinct.,
    flLxx.  Fiat  Mist., cujus sumantur Coch. ij., larga, bis
    terve in die.

       Form. 396.  Mistura Diosms Crenats.
R  Infusi Diosmse Crenatas, Jvjss.  (F. 231) ; Pulv. Traga-
    canth., 3ij.  ; Tinct. Diosms  Crenatas, Jss.  M.  (In
    Rheumatism, and Affections of the Mucous Surfaces,
    particularly  those of the Urinary Organs.)

        Form. 397.  Mistura Diuretica.  (1.)
ft  Antimon. Pot.-Tart.,  gr. j.:  Potassas Bitart., 3jss.;  Bi-
    boratis Sodas, 3ss.;  Infusi Juniperi, Jxijss. ;  Spirit.
    Ether.  Nit., 3iij.;  Tinct.  Opii Comp., njxxvj.  ad  L.
    M.   Capiat  Coch. j. larg. 2da quaque hora.  (Altered
    from Augustin.)

        Form. 398.  Mistura  Diuretica.  (2.)
ft Potassae Bitart., 31J.; Bi-boratis Sodas, 3j. ; Aq. Fosniculi,
    Jviij. ; Spirit. Junip. Comp. et Spirit. Ether. Nit., 55,
    3iij.; Sirup. Papaveris, Jss.

        Form. 399.  Mistura  Diuretica.   (3.)
ft  Baccarum Juniperi contus., 3yj. ; Carui Semin. contus.,
    3.ijss.; Anisi  Semin. cont., 3jss.;  Aq. Ferventis, Oj.
    Macera per  horas tres, et cola.
ft Liquoris Colati, Jxij.; Spiritus Juniperi Compositi. Jij.;
    Potassas  Nitratis, 3ij- : Sirupi  Scillre, Jss.  Fiat Mis-
    tura, de qua sumatur Cyathus  subindts.

        Form. 400.  Mistura Diuretica.  (4.)
ft Infusi Digitalis, Aq. Anethi, 55, Jiijss.; Potassas Acetatis,
    3ijss.; Scillas Aceti (vel Acet. Colchici), 3iij. ;  Tinct.
    Opii, Tllx.   Fiat Mist.,cujus capiat Cochlear, ij., larga,
    bis terve quotidie.

         Form. 401.  Mistura Diuretica.  (5.)
ft Gum. Acacias. 3v.; Saponis  Med., Jss.; Carbonatis  Po-
    tasss, 31J.;  Potasss  Nitratis,  3ij. ; Infusi  Juniperi,
    foii.  (In Gout, with double its quantity of Potash, and
    a stomachic Tincture, and the Wine or Tincture of
    Colchicum.)

    Form. 402.   Mistura Emetica Excitans.   (1.)
R Zinci Sulphatis, 3ij.; Aq. Menth. Pip., Jivss.  Solve, et
    adde Vini Ipecac, Tinct. Serpentaris, 55, Jss.;  Tinct.
    Capsici, 3ij.; Olei  Anthemidis, Itlxii.  Misce;  et fiat
    Mist., cujus capiat  partem  tertiam vel quartam, inter-
    vals brevibus.

    Form. 403.   Mistura Emetica excitans.   (2.)
ft Antimon. Pot.-Tart , gr. xij. ; solve in Aq. Menth. Piper.,
    Jivss. ; et adde Vin. Ipecacuanhs, Tinct. Serpentaris,
    5a, Jss. ; Tinct. Capsici, 3ij.;  Olei Anthemidis, fllxij.
    M.  Capiat partem quartam vel tertiam, intervallis  bre-
     vibus, ad affectum plenum. 
XV111
APPENDIX  OF  FORMULAE.—Mistura.
         Form. 404.  Mistura Expectorans.
ft Misturas Amygdal.  Dulc, Jv. ;  Vini  Ipecacuan., Tinct.
    Scills, 55, 3j.; Sirupi Tolutani, 3vj.   Misce.  Sumat
    Cochleare magnum, urgente Tussi.  (In Humoral Asth-
    ma, and the latter Stage of Catarrh.)

        Form. 405.  Mistura Febrifuga.  (1.)
B Camphors, 3j.;  Pulv. Gum. Acacis, 3j. ; Mist. Amyg-
    dal. Dulc, Jiij.;  Potasss Nitratis, 3j. ad 31J. ; Aq.
    Flor.  Sambuci  Nig., Jiv. ;  Sirupi Papav.  Albi  (vel
    Sir. Limonis), Jss.  M.  Capiat Jss.-Jj., 3tiis vel 4tis
    horis.
        Form. 406.  Mistura Febrifuga.  (2.)
ft Mist. Camphors, Jxxiij.;  Antimonii Pot.-Tart., gr. iij. ;
    Potasss Nitratis, 3vj.; SpiritOs Etheris Nitrici, Jss. ;
    Sirupi  Limonum,  Jss.   Misce.  Interdum  adde, vei
    Vinum Ipecac, vel Tincturam Digitalis, vel Tincturam
    Opii, vel Sirupum Papaveris.

        Form. 407.  Mistura Febrifuga.  (3.)
R Ammon. Hydrochlor., Succi Glycyrrh. Inspiss., aa, 3j.;
    Aq. Font , Jv.  Solve,  et adde Vini Antimonii  Pot.-
    Tart., Jij.;  Oxymel. Scills, Jss.  M.   (Heckeb.)

    Form. 408.   Mistura Febrifuga.  (Peysson.)
ft Antimonii  Potassio-Tartratis, gr. j. ; Gum. Tragacanth.,
    3j. ; Aq. Communis, Jvij.; Tinct. Opii, Hlxx.; Sirupi
    Papaveris, Jvij.  M.

      Form.  409.  Mistura Febrifuga Nervina.
ft Camphors rass, 3j.-3ij. ; Vitel. Ovor., q. s. Subige,
    et adde Decocti Cinchons, Jvijss. ;  Tinct.  Opii Comp.
    (vide Form.), jss.; Ether. Sulphur., 3iij.  M. Capiat
    Jss.-Jjss., 5tis vel 6tis horis.

      Form.  410.  Mistura Guaiaci Ammoniata.
ft Guaiaci Gummi Resins, Pulveris Acacis, 55, jij. ; De-
    cocti Glycyrrh., Oss.; Liquoris Ammon. Sesquicarbo-
    natis, jijss.  Tere Guaiacum  et Pulv. Acacis cum Li-
    quore Ammon., et gradatim adde Decoctum.

         Form. 411.  Mistura Guaiaci Comp.
R Gum. Guaiaci, Gum. Ammoniaci, Gum. Acacis, 55, jij.;
    solve terendo in Aq. Fosniculi, Jvjss., et adde Vini An-
    timonii  Potassio-Tartratis, Jss.; Sirupi Althss, jvj.
    M.  Capiat Cochleare unum amplum tertiis vel quartis
    horis.

  Form. 412.  Mistura cum Hydrargyri Bichlorido.
R Decocti Glycyrrh., Jv.; Aq. Cinnamomi, Jij. ; Liquoris
    Hydrargyri Bichloridi (Form. 322), Sirupi Aurantii, 55,
    Jss.  Misce.   Fiat  Mistura, cujus  sumat  Coch.  ampl.
    ij.  vel  iij., statim  post cibum,  bis  terve in die.
    (Sprague.)

  Form. 413.  Mistura Infusi Cusparis Composita.
R Cusparis Corticis  contus., Jj.; Aurantii Corticis  exsic-
    ca.i, Jss. ; Aq. Ferventis Octarium, j.  Macera par ho-
    ras quatuor in vase  clauso, et cola.
ft Infusi Colati, Jvij.  ; Tinct. Cinnamomi, Sirupi Auranti-
    orum, 5a, Jss. ; Crets  Prsparats, jj.   M.  Fiat Mis-
    tura, de  qua sumatur Cyathus (Cochlearia iij.-iv.), ter
    vel quater quotidie.

      Form.  414.  Mistura Infusi Salicis Comp.
R Cort. Salicis contusi, Jiij.; Aqus, Oij.  Decoque ad oc-
    tarium, j.; dein adde Caryophyl. contus.,  Jss., et cola.
R Liquoris Colati, Jvij. ; Tinct. Aurantii, 3vj.;  Sirupi Au-
    rantii, 3ij.  M.  Sumat  quartam partem ter die.

      Form. 415.  Mistura Infusi Senegs  Comp.
R Rad. Polyg.  Senegs cone. ;  Rad.  Glycyrrh., 55, Jss.
    Decoque cum  Aq. Fontans,  xvj.,  a-1 uncias octo.  In
    r.olat. dissolve  Ammon. Hydrochlor., 3ij.;  Pulps Ta-
    marind., 3j.; Antimonii Potassio-Tart., gr. j. ; Sirupi
    Althss,  Jj.  M.  Capiat sger, altera quaque  hora,
    Cochleare unum.

Form. 416.  Mistura Infusi Serpentaris Comp.  (1.)
R Olei Cinnamomi, Ttlvj. ; Sacchari Purif., 3iij. ; terantur
    bene,et adde Infusi  Serpentaris (F. 262), Jvij. ; Spirit.
    Etheris Hydrochlorici,  Jss. ;  Tinct Capsici, 3SS.  M.
    Fiat Mist., cujus capiat  Coch. ij.—iv., tertiis vel quartis
    horis.

Form. 417.  Mistura Infusi Serpentaris Comp.  (2.)
R Infusi  Serpentaris, Jvj.; Tinct. Camph. Comp-,  3v. ;
    Spirit. Ammon. Arom.,  3ij. ;  Sirupi Aurantii, Jj. M.
    Cupiat partem quartam tertiis vel quartis horis.

        Form. 418.  Mistura Infusi Uvs Ursi.
R Infusi Uvs Ursi, 3xiv.; Potasss Bicarbon., gr. xx. ; Ex-
    tracti Conii, gr. iij.  ad gr. vj.; Extracti Papaveris, gr.,
M.   Fiat Haustus,
    v. ad viij.; Sirupi Zingiberis, 3>J-
    ter in die sumendus.
  Form. 419.  M.stura Infusi Uvs Ursi Composita.

ft Uvs Urs. Fol., Jijss. ;  Radicis Rh^^orasli^hrv^e
    Aq. Ferventis,  Jxij.  Macera per horas Jj.,  111  vase
    clauso, deinde cola.
R  Liquoris Colati,  Jvijss.;  Sods  Carbon.,  jjss ; Tinct;
    Opii, 1H*lv. (vel  Hyoscyami, 3J«:) i  Ttf^'HwT
    Comp.,3iij.   Sirupi Tolutani, 3Jm.   M.  Fiat Mist.,
    cujus capiat Cochlearia duo magna, quatuor  vices  in
    die.
            Form. 420.  Mistura Laxans.
ft  Infusi Ross Com., Jvjss. ; Acidi  Sulphur. Dil., Itlxx.,
    Potasss Sulphatis, 3113- ; Tinct. Aurantii Comp., 311J.
    M.   Fiat Mist., cujus  capiat Cochlearia ij., larga, ter-
    tiis vel quartis horis.

     Form. 421.  Mistura Mucilaginis Anodyna.
R Mucilaginis Tragacanth., Jijss.; Oxymellis Scills, Jss.;
    Sirupi Papaveris, Jj.   Misce.  Fiat Mistura.  Coch-
    leare amplum, urgenti Tusse, gradatim deglutiendum.
      (If the mucilage of Tragacanth should not be  at hand,
    its place may be supplied by Pulvis Tragacanth. Comp.,
    3jss.; Aq. Destil., Jijss.  Sprague.)

            Form. 422.  Mistura Myrrhs.
ft Myrrhs, 3jss. ;  Decocti Glycyrrh. Ferventis,  Jvss.  Si-
    mul tere, et cola. Dosis Jj., bis vel ter quotidie.  Sin-
    gulis dosibus interdum adde, Sods Carbonatis, gr. xij.,
    vel Acidi Sulphurici Aromatici minim, xv., vel Tinct.
    Camphors Comp., 3ss.  Misce.  (In the latter stages
    of Phthisis Pulmonalis, when languor or debility is a
    very prominent symptom, the above mixture, combined
    according to circumstances, is an excellent medicine.).

         Form. 423.  Mistura Nervina.  (1.)
ft  Mist. Camphors,  Jiij. ;  Mist. Asafcetids, Jij.; Tinct.
    Valerians, Tinct. Amnion. Compos., Spiritus Etheris
    Sulph. Compos., 55, 3ij.  M.  Fiat Mistura, cujus su_-
    mantur Cochlearia duo ampla subinde\

         Form. 424.  Mistura Nervina.  (2.)
ft  Mist. Camphors,  Jvij.;  Spiritfis Etheris Sulphurici
    Comp., Tinct. Ammon. Compos.,  5a, Jijss.  ; Sirupi
    Croci, Jss.  Fiat Mistura, de qua sumantur Cochlearia
    duo vel tria magna, urgente Agitatione.

             Form. 425.  Mistura Oleosa.
 ft  Olei Olivs (vel Olei  Lini), Aq. Piments, 55,  Ojss.; Po-
     tasss Carbonatis, 3vj.  Misce.  Dosis  Jj. ad Jjss.  An-
     tiphlogisla fit  addendo  Liquoris Antimonii Pot.-Tart.,
     Jss ad Jij.  Anodyna fit addendo Tinct. Opii, 3j- ad Jj.
     Volatilis fit usu Spiritus Ammon. Aromatici  loco Po-
     tasss Carbonatis.

         Form. 426.   Mistura Pectoralis.  (1.)
 ft  Rad. Althss, Jjss. ;  Semin.  Anisi cont., 3iij.; Aq. Fer-
     vent., q. s., ut  sit Colat., Jxij.   Adde Amnion. Hydro-
     chlor.,  31J.; Succi  Insp. Glycyrrh., Jss.  M.  (Aust.
    Phar.)

         Form. 427.   Mistura Pectoralis.  (2.)
 R  Decocti Cetraris, Jxj. ; Vini Ipecac, 31'j.; Extr. Conii,
    3j. ; Olei Anisi, Tllxij.:  Sirupi Althss  et Sirupi P»-
    paveris, 55, 3iij.  M.   Capiat Coch. iij. vel  iv., quater
    in die.

          Form. 428. Mistura Phosphorata.
R  Phosphori, gr. ij.; Olei Terebinth.,  35s.; Olei OIiva>,
    Jijss.; Mucilag. Acacis, Jj.;  Aq. Anethi, Jiv.; Sirupi
    Zingiberis, Jj.; Olei Caryophyl., Tfl,vj.

         Form. 429.  Mistura Purgans.  (1.)
ft  Infusi Senns  Comp., Jivss.;  Magnes. Sulphatis, Jj.,
    Aq. Menth. Sativ., Jijss. ;  Tinct. Senns Comp., jss.
    M.  Sumantur Cochlearia iv., primo mane, et  repetaa-
    tur post horas tres,  si  opus sit.

         Form. 430.  Mistura Purgans.  (2.)
ft  Fol. Senns, Conservs Menth. Viridis (F. 49), 5a, Jss.;
    Sem. Coriand. contus., 3ij. ; Aq. Ferventis, Jviij. Ma
    cera per horas duas, et cola.
ft Infusi supraprsscripti, Jvij. ; Sods Sulphatis, Jj. ; Tinct
    Senns Comp., 3vj.;  Tinct.  Cardam. Co., jij.; Sp.
    Ammon. Arom., 3ij.  M. Ft. Mistura.   Capiat partem
    4tam secundis horis, donee bene solutus sit alvus, el
    pro re nata repetatur.

         Form. 431.  Mistura Refrigerans.
R  Camphone rass, gr. x.-3j. ;  tere  cum  Mucilaginis
    Acacias, 3iij.;  Ammon. Hydrochlor., 3j.-jjss. ;  Aq
    Flor. Aurantii, Aq.  Com., 55, Jiij.; Sirupi Aurantii,
    Jss. M. 
APPENDIX  OF FORMULAE.—Mistura—Pilulje.
XIX
           Form. 432.  Mistura Resolvens.
R Flor. Amies, 3jss. ;  Aq. Fervid., q. s., ut sint Colaturs,
    Jvijss.   Adde  Potasss Carbon., 3J.; Tinct. Lavandul.
    Co., 3jss.  M.  (In Engorgements of Glands, &c.)

        Form. 433.  Mistura Rhei Composita.
R  Rhei Radicis contrit., 3ss. ; Sodae Carbonatis, 3j. ; De-
    cocti Glycyrrh., Jv. et 3ij.; Tinct. Aurantii, 3vj.  Misce.
    Dosis 5 Jss. ad Jj., semel, bis, vel ter quotidii.   (This
    is  a pleasant and efficacious  method of administering
    small doses of Rhubarb in Dyspepsia.—Sprague.)

        Form. 434.  Mistura Rhodii Comp.  (1.)
R Tinct. Rhodii, 3iij.; Mucil. Acacis, 3vj.  Terantur probe
    simul;  adde  gradatim, Infusi  Caryophyllorum, Jiv. ;
    Sirupi  Zingiberis, Jss.  M.  Fiat Mistura.  Sumat par-
    tem 4tam ter in die, urgente  Flatu.

        Form. 435.  Mistura Rhodii Comp.  (2.)
R  Tinct. Rhodii,  Jss.; Mucil. Acacis, 3vj.  Tere bene, et
    adde gradatim, Infusi Uvs Ursi, Jvj. ; Sirupi  Papave-
    ris, 3vj.  M.   Fiat Mistura.   Dosis partem 4tam, ter
    quaterve in  die.  (In Asthma, and in  Chronic  Ca-
    tarrhs, <fcc)

             Form. 436.   Mistura Salina.
R  Mist. Camphors.,  Jivss.; Liq. Ammon.  Acet., Jiij.;
    Spirit. Ether. Nit., 3iij.;.Potasss Nit.,  3ij.;  Sirupi
    Limonis, 3ij.  M.  Fiat Mist., cujus capiat Cochlearia
    ij., larga, quarta quaque hora.

    Form. 437.   Mistura Salina Antiseptica.   (1.)
R  Infusi  (vel Decocti) Cinchons, Jvij.; Sodii  Chloridi,
    3j.~3'j. i Potasss  Chloratis, 3SS.-3J.  Solve,  et adde
    Tinct. Serpentaris, Jss.  M.

    Form. 438.   Mistura Salina Antiseptica.  (2.)
R Infusi (velDecocti) Cinchons,Mist. Camphor., 55, Jiijss.;
    Potasss Nitratis,  Potasss  Chloratis, 55, 3.j.;  Tinct.
    Serpentaris, Jss.  M.

    Form. 439.  Mistura Salina Antiseptica.  (3.)
R  Mist. Camphor., Jvij.; Potasss Chloratis, 3ij.; Sodii
    Chlorid., 3j.;  Tinct. Serpentaris, Jss.; Spirit. Lavand.,
    3ij- M.

    Form. 440.   Mistura Salina Febrifuga.  (1.)
 R  Mist. Camphors, Jivss.; Liq.  Ammon.  Acet.,  Jijss.;
    Magnes. Sulphatis, Jss.-Jj. (vel Potasss Sulph., 3ijss.);
     Spirit. Ether. Nit., 3iij.  M.

     Form. 441.   Mistura Salina Febrifuga.  (2.)
 R  Mist. Camphors, Jivss. ; Liq. Ammon. Acet., Jiij. ; Sods
     Sulphatis (vel Sods Phosphatis), 3vj. ; Spirit. Ether.
    Nitrici, 3iij.   M.

            Form. 442.  Mistura Sedativa.
 R  Magnes. Carbonatis, Crets Prsparats, Pulv. Acacis, 55,
     31 j.;  Spiritils Ammon.  Aromat.,  Jijss. ;  Tinct. Asafce-
     tids,  Jiij.; Sirupi Papaveris,  Jss.; Aq. Destil.,  Oj.
    Misce.  Dosis a Jss. ad Jjss., 3tiis, vel 4tis, vel 6tis
    horis.   Interdum adde Tinct. Catechu, &c, &c.

           Form. 443.   Mistura Strychnis.
 R  Strychnis Purissims, gr. j.;  Sacchari Purif., 3jss.; Aq.
     Destil., Jij.;  Acidi Acetici,  gtt. ij.  M.   Capiat Coch-
     learia minima ij.,  mane nocteque.

 Form. 444. Mist. Terebinthins Venets.  (Clossius.)
 ft  Terebinth. Venet., Jj.-Jjss.; Vitelli Ovorum,  q. s.;  et
     adde Aq. Menth. Piperitas, Jivss.  Capiat Cochleare j.
     vel ij., pro re nata.   (Against Worms and Chronic Af-
     fections of the Mucous Surfaces.)

           Form. 445.  Mistura Tonica.  (I.)
 ft  Infusi Cascarillas (vel  Gentianas Comp.), Jvij. ; Potassas
     Carb., Jj.-Jjss.;  Tinct. Aurantii Comp., Spirit.  Pi-
     mentos, 55, Jiij.  M.

           Form. 446.   Mistura Tonica.  (2.)
 R  Infusi Cascarills, Ojss.;  Acidi Sulphurici Aromat., 31J.
     Misce.  Dosis 5 Cochlear, ij., parv. ad Cochl. iij., mag-
     na, bis die.

           Form. 447.  Mistura Vermifuga.
 R  Rad. Valer. Min., Semin.  Santon., 5a, Jss.  Infunde Aq.
     Font.  Fervid.,  Jviij. ;  digere  per horam, dein cola.
     Liq. colato  adde Asafcetids, 3j., in Vitell. Ovi  soluts.
     Fiat Mistura.

              Form. 448.  Mistura Vinosa.
 R  Vini,  Jvj. ;  Ovorum duorum Vitellos ; Sacchari Puri-
     ficat.,  Jss. ; Olei Cinnamom., 1fl,iv.;  Tinct.  Capsici,
     3j.  M.  Dosis Jjss., ter  quaterve, aut saspius, quo-
     tidie,  urgentibus Languoribus.

       II                  B
           Form. 449.  Oleum Camphors.
R  Acidi Nitrici quantum velis; Camphorae, q. s., ad Aci-
    dum saturandum.  Serva in vase bene obturato.  (Fee.)
        Form. 450.  Piluls Aloes cum Ferro.
R  Aloes Spicati Extracti, 3jss.; Myrrhas Gummi Resin.
    pulv., 31J.; Extracti Gentianas, 3iv.; Ferri  Sulphatis,
    3ij. ; Theriacs Purificat., q. s.  Simul contunde, et
    in Pilulas cxx., divide.  Dosis 5 ij. ad iv., semel vel bis
    quotidie.

  Form. 451.  Piluls Aloes cum Ferro Composits.
R Massas Pilul. Aloes cum Myrrha, Pilul. Ferri Comp., Pi-
    lul. Galban. Comp..  55, 3ij.; Sodas  Carbon, exsic,
    3j.; Olei Junip. Sabin., Ttliv.  Contunde simul, et fiat
    massa squalis, in  Pilulas xxx., distribuenda.  Capiat
    asgra binas, mane nocteque.

         Form. 452.  Piluls Aloes et Ferri.
ft  Ferri Sulphatis,  Potasss Carbonat., 55, 3j.; Myrrhae
    pulver., 3J. ; Aloes pulver., 3ss.  M., et divide  in Pi-
    lulas xxx.  Capiat ij. vel iij., nocte maneque.

  Form. 453.  Piluls Aloes et Moschi Composits.
ft  Pilul. Aloes cum Myrrha,  3j. ; Camph. rass, gr. xij.;
    Moschi, gr. xxviij.; Balsam. Peruvian., q. s. M. Fiant
    Pilul. xxiv., quarum capiat binas omni nocte.

   Form. 454.  Piluls Aloes et Scammonis Comp.
R Aloes Spicat., 3j. ; Scammon.,  gr. xij. ; Extr. Rhei,
    3ijss.; Baccar. Capsici pulv., gr. viij.; Olei Caryoph.,
    111 vj.  M. Fiant Pilul. xviij.,  quarum  sumantur bins
    hora decubitus.

        Form. 455.  Piluls Alterativs.  (1.)
R Masss Pilul. Hydrarg.  Chloridi  Comp., 3ij.; Saponis
    Castil., 3ss. ; Extr. Sarzas  et Extr. Taraxaci, 35,  3jss.
    Misce bene, et divide in Pilulas lx., quarum capiat bi-
    nas vel tres, ter quotidie.

        Form. 456.  Piluls Alterativs.  (2.)
R Scills Radicis exsic, gr. vj. ; Pulv. Fol. Digitalis, gr.
    xij. ;  Hydrarg.  Chloridi, gr. vj.; Myrrhs Pulv., 3j.
    Tere simul, et  adde Asafostid., 3ss. ;  Extr. Gentian.,
    q. s.  Fiat massa squalis, et divide in Fil. xviij., qua-
    rum capiat unam mane, meridie, et nocte.

      Form. 457.  Piluls Ammoniaci Composits
ft Gummi Ammoniaci, 3JI; Saponis Castil., Fellis Bov. In-
    spissat., Pilul. Hydrarg., Pulv. Folior. Conii, Extracti
    Conii, 55, 3ss. ; Ext. Taraxaci, 3ij.; Antimonii Oxy-
    sulphureti, 3j.; Theriacs Purif.,  q. s.  Contunde  in
    massam  squalem, et divide  in  Pilulas lxxx., quarum
    capiat binas vel tres, ter quotidie.  (De'ibstruent, dis-
    solvent, &c.)
    Form. 458.  Piluls Ammonis et Anthemidis.
ft Ammon. Sesquicarbonatis Pulver., Extracti  Anthemidis,
    55, 3ss.  Fiat massa, in Pilulas xij., dividenda, quarum
    sumatur una bis vel ter die.

Form. 459.  Piluls  Ammonio-Sulphatis Cupri Comp.
ft Cupri Ammonio-Sulphatis, Oxydi Zinci, 55, gr. vj.-xij.;
    Sacchari  Albi, Pulv. Tragacanth., 35, gr. xij.; Muci-
    lag. Acacis, q. s., ut fiant Pilul. xij., quarum capiat
    unam bis terve  quotidie.  (Epilepsy, Chorea, <fec.)

             Form. 460.  Piluls Anodyns.
 R  Camph. rass, gr. ij.—vij.; Potasss Nitratis, gr. v.-viij.;
    Extr. Hyoscyami,  gr. iij.-gr. viij.; Sir. Papaveris, q. s.
    Misce.   Fiant Pilul. iij.—vj., h. s. sumends.

      Form. 461.  Massa Pilularum Anodynarum.
 R Opii Crudi in Pulv. subtiliss., 3ss. ; Extracti Hyoscyami,
     3ijss. ;  Saponis Duri,  Iridis Flor. pulv., 55, 3J.   Con-
    tunde, ut fiat massa, in Pilulas sexaginla squales dis-
    tribuenda.
       (Ten grains of the mass contain one grain of opium
    and five of the extract of henbane.)

    Form. 462.  Piluls Anodyno-Aperientes.  (1.)
 R Pulv. Ipecac, gr. x. ; Extracti Colocynthidis Comp., 3j.;
    Extracti Hyoscyami, 3ss.; Pilul. Hydrarg., 3j. , Sa-
    ponis  Castil., gr. x.; Olei Caryoph., Itliij.  Contunde
    in  massam squalem, et divide in Pilulas xxx., quarum
    capiat unam, duas, vel tres pro dose.

    Form. 463.  Piluls Anodyno-Aperientes.  (2.)
 R Pulv. Ipecac, gr. viij. ; Extr. Colocynth.  Comp., 3ijss.;
    Extr.  Hyoscyami, 3ss.; Fellis  Taur.  Inspiss.  Con-
     tunde simul, et divide massam in Pilulas xxiv., quarum
     capiat unam, duas, vel tres pro dose.

      Form. 464.  Piluls  Antimonii Alterativs.
 R Antimonii Oxysulphureti, 3j.; Florum Sulphuris, 31J.; 
Camph. rass, 3j.;  Extracti Taraxaci (vel Extr. Sarzs),
Jjijss.  Fiat massa squalis,  et divide in Pilulas icv.
Capiat duas vel tres, ter quotidie.
Form. 465. Piluls Antimonii et Guaiaci Composits.
ft Antimonii Oxysulphureti, 3j.;  Florum Sulphur., jiij.;
    Resin. Guaiaci, Extr.  Conii, &a, 3ij.;  Sirupi Althss,
    q. s.  Fiat massa squalis,  et divide  in Pilulas cxx-.
    Capiat binas vel ires ter die.

Form. 466. Pil. Antimonii Oxysulphureti Comp. (1.)
R Antimonii Oxysulphureti, gr. v.; Pilul. Hydrarg,, Ex-
    tracti  Hyoscyami, aa, 3j.  Misce ut fiat massa squalis
    in Pilulas decern dividenda, quarum sumatur  una ter
    die.
Form. 467. Pil. Antimonii Oxysulphureti Comp. (2.)
R Antimonii Oxysulphureti, Hydrargyri  Chloridi, 55, gr.
    ss. ; Extracti  Conii, gr.  iv.  Fiat  Pilula ter  die  su-
    menda.

        Form. 468.  Piluls Antispasmodics.
R Gum. Ammoniaci, Jj.; Benzoini, Pulv. Myrrhs, aa, 3ij.;
    Asafcetids, 3ss. ; Camphors, 3j.;  Tinct. Opii,  Ttlxij.
    Misce.  Divide in  Pilulas lx., quarum capiat  sger,
    omni trihorio, duas vel  tres.

  Form. 469.   Piluls Antispasmodics Pierquinii.
R Camph., Potasss Nitratis, Pulv. Digitalis Purpur., 55,
    3ss.;  Pulv. Cinchons  Flav., jj. ; Extracti Gentians,
    jij. ; Sirup. Simp., q. s.  M.  Fiant Pilul. lxx.

        Form. 470.  Piluls Aperientes Comp.
ft Pilul. Hydrarg., Pilul. Aloes cum Myrrha, 55, 3j.;  Pi-
    lul. Cambog. Comp., gr. xvj. ; Pulv. Mastiches, gr. vj.;
    Olei Caryophyl., rfliij.  M.   Fiat massa squalis, et di-
    vide in Pilulas xxiv., quarum  capiat binas hora somni
    quotidie.
    Form. 471.  Piluls Aperientes Alterativs.
R Pilul. Hydrarg., 3j.; Antimonii Pot.-Tart., gr. jss.;
    Extr. Jalaps, 3jss. ; Fellis Tauri inspissati, 3ss. ;  Sa-
    ponis  Castil., gr. xv.  Contunde in massam squalem,
    et divide in Pilulas xl.;  quarum capiat binas vel tres
    omni nocte.

Form. 472.   Pil. Argenti  Nitratis et Belladonns.
ft Argenti Nitratis pulv., gr. ij.-iv. ; Pulv. Radicis Bella-
    donns, 3j.; Extr. Glycyrrh.,  3j.  Misce  bene, et di-
    vide in Pilulas xxxvj. ; quarum capiat unam  ad tres,
    bis terve quotidits.   (In  Pertussis  and Epilepsy.  M.
    Bories.)
  Form. 473.  Piluls Argenti Nitratis Composits.
R Nitratis Argenti pulv., gr. v. ; Opii Puri, gr. x. ;  Camph.
    rass, Nucis Myristics, 55, 3jss.; Pulv. Acacis, 3ss.;
    Sirupi Simp., q. s.  M.   Divide in Pilulas xxxvj., qua-
    rum capiat unam ad tres, bis terve quotidie.

Form. 474.  Piluls Argenti Nitratis et Gentians.
R Argenti Nitratis, gr. ix.  ; Opii Puri, gr. v.; Extr. Gen-
    tians, Extr. Glycyrrh., 55, 3jss.  Divide in Pilulas Iv.,
    quarum capiat unam ad tres vel quatuor, bis terve quo-
    tidie.   (Niemann.)

   Form. 475.  Piluls Argenti Nitratis Opiats.
R Argenti Nitratis pulv., gr. x.; Moschi,  3j.; Opii, Jjss. ;
    Camphors, Jij. ; Pulv. Acacis, Jss. ;  Sirupi Simp., q.
    s.  Misce  bene, et divide in Pilulas Ixxx., quarum ca-
    piat unam ad quatuor bis terve quotidie.  (Van Mons,
    Cadet de Gassicourt, et Ratier.)

        Form. 476.  Piluls Arsenicales.  (1.)
R Acidi Arseniosi, gr. ij.; Opii Puri, gr. viij.;  Saponis
    Medic, gr. xxxvj.  Divide in Pilulas xxiv., quarum ca-
    piat j.-iij., pro dose.

        Form. 477.  Piluls Arsenicales.  (2.)
R Acidi Arseniosi, gr. vj. ; Opii, gr. xij. ;  Ammon. Hydro-
    chlor., 3ss. ; Mucilag. Acacis,  3ij. ; Sirupi Simp.,q. s.
    M. Divide in Pilulas xxx., quarum capiat unam vel bi-
    nas ter die.

   Form.  478.  Piluls Arsenitis Ferri.  (Biett.)
R Proto-Arsenitis Ferri, gr. iij.; Extr. Humuli, 3ij.; Pulv.
    Althss, jss. ;  Sirupi Auran., q. s.  M. Divide in Pi-
    lulas xlviij., quarum capiat unam in die.

   Form. 479.   Piluls Asafcetids cum Cinchona.
R Asafcetids Gummi Resins, 3j. ; Extracti Cinchons Opt.,
    3ij. ; Saponis Duri, 3ss. ;  Olei Pulegii, UU'j- i Theriac.
    Purificat.,q. s.,ut fiat massa;  in Pilulas xlviij. divide ;
    quarum capiat iij. vel iv., nocte maneque.

     Form. 480.  Piluls  Asafcetids Composits.
R Asafcetid., Castorei, Valerians,  Succini, 55, pulveriz.,
APPENDIX OF FORMULAE—PriuL^r.

                            3*, • Camphors, gr. x.; Olei Cajeputi, q. 5. M. Fianl
                            pLi. »«?j,cjuafum capiat binas pro dose.

                             Form. 481.  Pilvls Asafcetids cum Felle.
                        ft Asafcetids, Fellis Tauri inspissati, to,  3)- i ™v- Rhe'-
                            3j.; Sirupi, q.s.  M. Fiant Pilul. *'•
                        Form. 482.  Pilvls Asafcet^s et Vale.ian* Comp.
                        ft Gum. Asafcetid., Pulv. Valerians, 55, Jj. }  Extr. Aconiti,
    gr. vi,; Pulv. Scills, gr. viij.; Castorei, 3m.; Ammon.
    Sesquicarbon., gr. Xvj. ; Sirupi  Papaveris  q  ..  M
    Fiant Piluls xlviij., quarum capiat duas ad qoatuorpra
    dose.  (In Spasmodic Affections of the Respiratory Or-
    gans.  Richter.)
         Form. 483-  Piluls AsTRINGENTES.
ft  Extr. Cinchons,  Ferri  Ammonio-Chloridi,  Aluminas
    Sulph., Pulv. Aromat., 5a, 3jss. ; Olei Caryoph., q. s.
    M.  Fiant Piluls lxxxiv., quarum capiat j.-.j., pro
    dose.

         Form. 484.  Piluls Balsams  Comp.

ft Myrrhs Gummi Resins pulv., 3ij. ; Galbani, Asafcetids,
    5a, 3j.; Capsici Annui  pulv., gr. xv. ; Balsami Peru-
    viani, 3j.   M.  Fiant Piluls xxx.; e quibus sumantur
    bins vel tres, bis terve de  die.

        Form. 485.  Piluls Balsamics.   (1.)
ft  Extr. Aloes, 31'j.; Extr.  Rhei,  3j.; Balsami Peruv. et
    Benzoini, 55, Jss.; Croci Stigmat. et Myrrhs, 55, 3j.;
    Extr. Opii, gr. v.; Spirit. Vini et Sirupi, q. s.   Fiant
    Piluls lxxx., quarum capiat unam ad quatuor pro dose.

        Form. 486.  Piluls Balsamics.   (2.)
ft  Terebinthins  Chiensis,  Spermaceti, aa,  3ij. ;  Pulv.
    Myrrhs, 3J. ; Olibani Pulver., q. s., ut  fiant Pilul. lxx.,
    quarum capiat unam vel  duas omni tertia vel quarta
    hora.

    Form. 487.  Piluls Balsamics Camphorats.
ft Acidi Benzoici, 3j. ; Camphors, Croci Stig., Balsami Pe-
    ruviani, G. Ammoniaci,  55, 3j. ; Mucilag. Acacis, q. s.
    M.  Fiat massa, quam divide in Pilulas xxxvj., quarum
    capiat binas pro dose.

          Form. 488.  Piluls Belladonns.
ft  Extr. Belladonns, gr. vj.;  Pulv.  Rad.  Glycyrrh., 3ss.,
    Succi Inspissati Sambuci Nig., q. s., ut fiant Pilul. xij.
    Capiat unam ad tres pro dose.

Form. 489.  Piluls Benzoini et Terebinthins Comp.
R  Myrrhs, G. Ammoniaci,  55, 3jss.; Benzoini, 3j.; Extr.
    Gentians, 3ij.; Terebinth. Venet., 3jss.  ; Pulv. Rhei,
    q. s.  Fiat Massa squalis, et divide in Pilulas, gr. iv.,
    pond.  (In Hypochondriasis, Habitual Coustipation,<fcc.)

            Form. 490.  Piluls Bismuthi,
R  Bismuthi Tris-nit., Castorei, 55, gr.  j.-iij.; Pulv. Gly-
    cyrrh. et Mellis, q. s., ut fiant Pilul.  ij., tertiis vel quar-
    tis horis sumends.

             Form. 491.  Piluls Brucis.
ft Brucis Purs, gr. xij.;  Conserv. Rosar., 3ij. Misce bene,
    et  divide in Pilulas xxiv. squales..  Capiat unam ad
    quatuor pro dose.

     Form. 492.  Piluls Cambogis Composits.
R  Cambogis, 3j. ;  solve in  Olei Ricini pauxillo, et adde
    Pilul.  Aloes cum Myrrha, Pilul. Galban.  Comp., Pilul.
    Hydrarg., 53, 3ij.  Contunde  bents  simul, et divide in
    Pilulas xlviij.  Capiat unam ad tres pro dose.

 Form. 493.  Piluls Camphors et Antimonii The
                       baiacs.
ft  Camph. rass, gr. iv,; Pulv.  Jacobi  Veri,  gr. iij.; Opii
    Pun, gr. ss.;  Sirupi Simp.,q. s. Fiant Pilul.ij.,quar
    la vel sexta quaque hora sumends.

   Form. 494.  Piluls  Camphors Comp.   (Brera.)
ft  Camphors, 3j.; Potasss Nitratis, 3ij.; Kermis Mine-
    ralis, gr.  vj. ; Pulv.  Glycyrrh. et Mellis,  55, q. s.  M.
    Divide  in Pilulas xviij.,  quarum capiat  duas, tertia
    quaque hora.

  Form. 495.   Piluls Camphors et Ipecacuanhs.
ft  Pulv. Ipecac  Comp.,  gr.  iv. ; Camph.  rass, gr. j -iij.;
    Sirupi Papaveris, q  s.  M.  Fiant  Pilul. iij.,  quarta
    quaque hora sumends.

     Form. 496.   Piluls  Camphors et Nitri.
ft  Camph.  Subacts, Potasss  Nitratis, 55,  gr  ij -v  •  Con-
    serv. Rosar., q. s.  M.   Fiant Pilul. ij. vel .ij. ''

     Form. 497.  Piluls Castorei Thebaiacs.
ft Opii, gr. ss. ; Castorei Rossici, gr. vjss.; Pulveris Digi- 
APPENDIX OF FORMULAE.—Pilot..*.
xxi
    talis, gr. j.;  Sirupi, q. s.  Fiant Pilul. dues, bis vel ter
    die sumends.   (In Spasmodic Asthma, and Dyspnosa.)

        Form. 498.  Piluls Cathartics.  (1.)
R Hydrarg. Chloridi, gr. viij.; Extr. Res. Jalap., gr. xvj. ;
    Gum. Guaiaci, gr. xxiv.; Mucilag.  Acacis, q. s.  M.
    Divide  in Pilulas xij.  Capiat binas vel ties pro re
    nata.

        Form. 499.  Piluls Cathartics.  (2.)
R Cambogis Cum., 3jss. ; Scammon., 3j.; solve terendo in
    pauxillo Olei  Junip.  ; dein adde Alogs Socot., jijss. ;
    Gum. Ammoniaci, 3jss. ; Potasss Sulphatis, 3j.;  Oxy-
    mellis Scills,  q. s., ut fiat massa squalis.  Capiat pro
    dose, gr. x. ad gr. xxx.

   Form. 500.   Piluls Colocynthidis Composits.
R Colocynthidis Pulps,  Jss. ;  Aloe's  Spicats  Extracti,
    Scammon. Gummi Resins, 55, Jj. ; Saponis Duri, 31 j.;
    Olei Caryophylli, 3j.  Alo£, Scammonia, et  Colocyn-
    thidis pulpa in pulverem redigautur ; turn cum Sapone
    atque Oleo conterantur; denique cum Mucilagine Aca-
    cis subigantur in massam.

Form. 501.  Piluls Colocynthidis cum Hydrargyro.
R Masss Pil. Colocynth. Coniposit., 3iv.; Hydrargyri  Chlo-
    ridi (Calomel), 3J.  Simul contunde in mortario lapideo,
    donee massa squalis sit; et in  Pilulas lx., squales dis-
    tribuenda.   Dosis, ab j. ad iv.,  pro re nata.

   Form. 502.   Piluls Cupri Sulphatis cum Opio.
R Cupri Sulphatis, gr. vj.. Opii Puri, gr. iv. ; Pulv. Tra-
    gacanth. Comp., 3j.; Mucilag. Acacis, q. s.,  ut fiant
    Pilul. xij. ; quarum capiat unam ter die, postea quater
    quotidie, vel tertiis aut quartis horis.  (Chronic  Diar-
    rhosa and Dysentery.)

      Form. 503.  Piluls Deobstruentes.  (1.)
R Antimonii Potassio-Tartratis, gr. iv. ; Pilul. Hydrarg.,
    3j.;  Saponis  Castil.,  Gum. Ammoniaci, Asafcetids,
    Extr. Alogs  Purif., 55, 3ss.  Misce  bene, et divide in
    Pilulas Ixxv., quarum capiat binas ter die.

      Form. 504.  Piluls Deobstruentes.  (2.)
R Extr. Aquosi Aloes, Jij.; Gum. Ammoniaci, 3ij.; Myrrhs,
    Mastiches, Benzoini,  Rhei, 55, 3j.;  Croci Stigm., gr.
    xvj.; Potasss Carbon., 3ijss.; Mellis, q.  s., ut fiat mas-
    sa squalis.  Capiat gr. x. ad xx., pro re  nata.

Form. 505.   Piluls Deobstruentes.  (Barthez.) (3.)
R Kermis Mineral., gr. j. ; Hydrarg. Chloridi. gr. ij. ;  Extr.
    Fumaris (vel Extr. Taraxaci),  gr. x.  Fiant Pilul. iij.,
    pro dose.

Form.506.  Piluls Deobstruentes.  (Recamier.) (4.)
R Saponis Castil., Jijss.; Gum. Ammoniaci, jj.;  Aloes
    Extr. Purif., gr. xv.; Asafcetids, Jss. ; Pulv. Rhei, 3j. ;
    Croci Sativi, jss. ;  Sirupi, q.  s.   M.   Fiant Piluls
    lxxxiv., quarum capiat binas bis quotidie.

      Form. 507.  Piluls Deobstruentes.  (5.)
R Saponis Hisp., Jiij.; Gum. Ammoniaci, 3j. ; Aloe's, Jj.;
    Rhei Pulv., Jj. ; Asafcetids, Croci, 5a, Jss.; Sirupi,
    q. s. M.  Divide in  Pilulas c.   Capiat binas  ad qua-
    tuor, bis terve  in die.

      Form. 508.  Piluls Deobstruentes.  (-6.)
R Saponis  Medicinalis, jiv.; Gum. Ammoniaci, 31'j. ; Ex-
    tracti Conii, Extr. Aconiti Paniculati, 55, 3jss.  ; Massas
    Pilul. Alogs cum Myrrha, 3j.   Contunde in  massam
    squalem, et divide in Pilulas granarum quatuor.   Ca-
    piat binas mane nocteque, augendo unam quotidie donee
    xv. vel xx., sumantur in die.  (Dr. Lowassy, in Gland-
    ular Tumours  and Scirrous Formations.)

 Form. 509.  Piluls Deobstruentes.  (Stoll.)   (7.)
R Antimonii Oxysulphureti, 3j. ; Saponis Venetii,   Jij.;
    Gummi Acacias, Jj. ;  Mucilag.  Gum. Tragacanth., q. s.
    Fiant Pilul.  L.  Sumat tres mane et nocte.  (For Cu-
    taneous Eruptions, Rheumatism, <fec.)

      Form. 510.  Piluls Deobstruentes.  (8.)
R Hydrarg. cum Creta, gr. xvj. ; Sodas Carbon, exsic, 3j.;
    Extracti Taraxaci, Jj.  M.  Fiant  Pilul. xx., quarum
    capiat duas vel tres omni nocte.

     Form. 511.  Piluls Biniodidi Hydrargyri.
R Hydrarg. Biniodidi, gr.  ij. ;  Extr. Humuli, 3ij. ;  Pulv.
    Glycyr., q. s.  Misce bene, et  divide in Pilulas xvj.,
    quarum capiat  binas mane nocteque, et augeat dosin ad
    tres vel quatuor.

         Form.  512.  Piluls Diaphoretics.
R Oxydi Zinci,  Extracti  Aconiti,  SS, gr.  xij ;  Antimonii
    Oxysulphureti, gr. vj.;  Extracti Humuli, 3j.; Sirupi
    Papaveris, q.  s.  Contunde  bene simul,  et divide  in
    tertia quaque  hora.  (In Chorea, Sciatica, Hysteria,
    and Rheumatism.)

    Form. 513.  Piluls Diaphoretics Sedativs.
R Kermis Mineral., Extr. Opii, 55, gr. ij. ; Potasss Nitra
    tis, gr. v.; Sirupi, q. s.   Fiant Pilul. ij., pro dose.

 Form. 514.  Piluls Digitalis  et Camphors Comp.
ft Pulveris Digitalis, gr. vj.; Camphoras, gr. xv.; Extracti
    Hyoscyami, 3jss.  Fiant Pilul. duodecim.   Sumat tres
    omni nocte.  (In Maniacal and Spasmodic Affections.)

  Form. 515.   Piluls Digitalis et Myrrhs Comp.
ft Myrrhas G. R., gr. ij.-iv.; Pulv. Digitalis, gr. j.;  Extr.
    Hyoscyami, gr. iij -v. ;  Sirupi, q. s. Fiant Pilul. ij.,
    bis terve quotidie sumends.

           Form. 516.  Piluls Diuretics.
ft Scills Rad. pulver., gr. ij.; Pulv. Foliorum Digitalis, gr.
    j.; Pilul. Hydrargyri, gr. vj.; Olibani pulver., 3ss ;
    Oiei Juniperi, 1lliv.  Fiat massa  in Pilulas quatuor di-
    videnda, & quibus capiat ij., hora somni, superbibendc
    haustulum Misturs Diuretics, No. 398, vel 399.

    Form. 517.  Piluls Diuretics Alterativs.
R Potasss  Bitart., 3j.;  Biboratis Sodse, 3jss.; Pulv. Rad.
    Polygals  Senegs, 3J. ; Pulv. Radicis Colchici exsic,
    3ij. ; Pulv. Scills, gr. xvj.; Extr. Taraxaci, 3iij-  Fiat
    massa  asqualis, et  divide in Pilulas c, quarum capiat
    tres, ter quotidie.

    Form. 518.  Piluls Dulcamars et Antimonii.
R Antimonii Sesquisulphureti, Pulv.  Stip. Dulcamars, 55,
    3j. ; Extr. Dulcamars, 3ij. ;  Sirupi Tolutani, q. s.  Mi
    Fiant Pilul. lx.  (Richter, in Scrofula.  Also in Cu-
    taneous Diseases.)

         Form. 519.  Piluls Emmenagogs.
R Alogs Socot., Myrrhs, 55,  3jss.; Galbani, Gum. Ammo-
    niaci, 55,  3ij.; Biboratis Sods, 3jss. ; Ferri Sulphatis,
    3ss.; Ferri Sesquioxidi,  3j. ;  Pulv. Rhei, 3ij.; Olei
    Ruts et Olei  Sabins, 55,/ntxij. ;  Saponis, q.  s.  Fiat
    massa squalis, et divide  in Pilulas cxx., quarum capiat
    duas vel ires, bis terve quotidie.

  Form. 520.  Piluls Eytr. Gentians et Humuli
                       Comp.
ft Extracti Gentians,  3ij.;  Saponis  Medicin., 3jss.;  Fell.
    Bovini  inspiss., Ext. Alofis Purif., 55, 3J.; Ext. Humuli,
    3jss.  Misce, et divide in Pilulas  pond. gr. iij., quarum
    capiat binas vel tres mane nocteque.

    Form. 521.  Piluls Ferri Ammonio-Chloridi.
ft Ferri Ammonio-Chloridi,  3j.; Extracti Aloes,  Extracti
    Gentians. 55, jss.  Contunde  simul, et divide  massam
    in  Pilulas  triginta, quarum sumat duas  ter quotidie.
    (In Dyspepsia, Hysteria,  Scrofula, and Mesenteric Ob-
    structions.)

    Form. 522.  Piluls Ferri Ammonio-Chloridi.
ft Ferri Ammonio-Chloridi,  3j.  ; Extr. Gentian,  et  Extr.
    Alogs, 55, 3ij.  Contunde simul, et divide massam  in
    Pil. xxxvj. ;  e  quibus  bins,  bis terve  quotidie, su-
    mantur.

    Form.  523.  Piluls Ferri Aperientes.  (1.)
R Ferri Sulphatis, Potasss Sulphatis, 55, 3J.;  Galbani,
    Asafcetids, 55,  Jjss. ;  Ammon.  Hydrochlorat.,  3ij. ;
    Masss  Pilul. Alogs cum  Myrrha, Jiij.; Theriacs Pu-
    rif., q. s.   Contunde in  massam  squalem, et divide in
    Pilulas cl., quarum capiat binas bis terve quotidics.

    Form. 524.  Piluls Ferri Apfrientes.  (2.)
R Ferri Sulphatis, Potasss Sulphatis, 55, 3j.;  Galbani,
    Asafcetids, 55, 3jss. ; Extr. Gentians, 31J. ; Masss Pi-
    lul. Aioes  cum  Myrrha, 3iij.; Theriacs  Purif., q. s.
    Contunde in massam squalem, et divide in Pilulas cl.

       Form. 525.  Piluls Guaiaci Comp.  (1.)
ft Gum. Guaiaci, 3ij.; Saponis  Venet., 3j.;  Calomelanos,
    Antimonii  Oxysulphureti, Pulv. Rad. Senegs,  Cam-
    phors, 55, gr. xvj. ; Aceti  Scills,  q. s.  Fiat massa
    squalis, et divide in Pilulas lxxx., quarum capiat duas
    vel tres bis terve quotidics.

       Form. 526.  Piluls Guaiaci Comp.   (2.)
ft Gum. Guaiaci, 31J.; Calomel., Antimonii Oxysulphureti,
    55, 3ss. ;  Mucilag. Acacis, q. s.   M. Fiant Pilul. lx.
    Capiat ij.-iv., pro dose.   (In Cutaneous Affections.)

       Form. 527.  Piluls Guaiaci Comp.  (3.)
ft Guaiaci Gummi Resins  pulv., 31J.; Pulv. Opii Crutli,
    gr. vj. ; Hydrargyri Chloridi (Calomel), gr. xij.,  Anti
    monii Potassio-Tartratis, gr. iv.;  Tinct. Myrrhs, q. s, 
APPENDIX OF FORMULA.—Pilule.
     ut fiat massa, in Pilulas xxxvj. dividenda.  Dosis, ij.
     vel iij., nocte maneque.

   Form. 528.   Piluls Guaiaci et Antimonii Comp.
 R Pulv. Jacobi Veri, 3j.; Resin. Guaiaci  in Pulv., Masss
     Pilul. Aloe's cum Myrrha, 55, 3jss. ; Sirupi Simp.,q. s.
     Fiat massa squalis, et divide in Pilulas xlviij.  Capiat
     binas ad quatuor pro dose. (Emmenagogue, Stomachic,
     Aperient, and Antirheumatic.)

   Form. 529.  Piluls Hellebori et Aloes Comp.
 R Extr. Rad. Hellebor. Nig., Alogs Ext. Purif., Ferri Am-
     monio-Chloridi, 55, 3J.  ;  Croci  Stigmat.,  3ss.;  Opii
     Puri, gr. v. ; Sirupi, q. s.  M.  Fiant  Pilul. 1.,quarum
     capiat binas vel tres.
     Form. 530. Piluls Hydrargyri Anodyns.'
 R Pilul. Hydrargyri,  Pulveris Ipecac. Compos.,  Extracti
    Hyoscyami, 55, gr. v.  Fiat  massa, in Pilulas iij. divi-
    denda.'  Sumantur hora somni.

    Form. 531.  Piluls Hydrargyri Bichloridi.
 R Hydrargyri Bichloridi, Ammon. Hydrochlorat., 55, gr. v. ;
    Aq. Destillats, 3ss. ; Glycyrrh. Radicis Pulveris, 3iv. ;
    Mellis Opt., 3ss.;  Pulv. Acacis, q. s., ut  fiat massa,
    quam divide in Pil. xl.;  e quibus sumatur una ter die.

 Form. 532.  Pil. Hydrargyri Phospiiatis Composits.
 R Hydrargyri Phosphatis, gr. ix.; Antimonii Pot.-Tartratis,
    gr. j.; Opii Crudi  in pulv. subtiliss., gr. vj.; Confecti-
    onis Fructus Ross Canins, q. s., ut fiat massa, in Pi-
    lulas sex squales distribuenda, quarum una hora decu-
    bitus sumenda.

     Form. 533.  Piluls Hydrargyri et Scills.
 R Sods  Carbon,  exsic, 35s.; Saponis  Duri, 3ij.; Pilul.
    Hydrarg., gr. xxiv.; Pulv. Scills Rad. exsic, gr. xij.;
    Olei  Juniperi,  q.  s.  M.  Fiant Pilul. xxiv., quarum
    capiat unam ter die.

  Form. 534.  Piluls Hydrargyri Chloridi Compo-
            sits, seu Piluls Plummeri.
 R Hydrargyri  Chloridi,  3ss.; Antimonii Oxysulphureti,
    3j.;  Guaiaci Gummi Resins contrit., 31'j. ;   Saponis,
    3ss.;  Olei  Juniperi,  fllxxx. ;  Theriacs Purificatos
    (Treacle), q. s., ut fiat massa, in Pilulas sexaginta di-
    videnda.
          Form. 535.   Piluls Ferri Iodidi.
R Ferri Iodidi,  gr. xxx. ;  Croci Stigm.  pulveriz., 3J.; Sac-
    chari Albi,  jiij.; Mucilag. Tragacanth., q. s.  Misce.
    Contunde in massam squalem, et divide in Pilulas xo.;
    quarum capiat unam, binas, vel tres, bis terve quotidie.
    (In Chlorosis, Amenorrhcea,  Scrofula,  <fcc.)

        Form. 536.  Piluls Kino Composits.
ft Kino, 3ij.; Camph. rass et subactas, 3ss.;  Oxidi Zinci,
    3ss.  ; Confect. Aromat., 3j.  M.  Divide in  Pilulas
    xx.  Capiat binas mane  nocteque.  (Augustin, in Di-
    abetes.  Also in Affections of Mucous  Surfaces.)

     Form. 537.  Piluls Morphis cum  Digitale.
ft Morphis Acetatis,  gr. j.; Pulv.  Fol. Digitalis, gr. vj. ;
    Camph. rasas, gr.  x.; Pulv. Acacis,  gr. viij. ; Sirupi
    Tolutani, q. s.  Fiat massa squalis. Divide in Pilulas
    vj., quarum capiat unain tertiis horis.

   Form. 538.   Piluls Myrrhs et Balsami Comp.
ft Myrrhas, 3jss.;  Benzoini, 3ij. ; Balsami Copaibas, 3j. ;
    Extr. Glycyrrh., 3iv. Fiant Pilul. lxiv., secundtun ar-
    tem.  Capiat sger binas bis terve quotidie.  (For Asth-
    ma, Chronic Bronchitis, &e.)

       Form. 539.  Piluls Nervins.  (Stoll.)
ft Gummi Ammoniaci, Gummi Asafcetids,  5a, 3jss.; Sapo-
    nis Venet.,  3ss. ; Pulv.  Castorei, Ammon. Sesquicar-
    bon., 5a, gr. xxv.;  Mucilag. Acacis, q. s.  M.  Fiant
    Pilul. lxxx.  ; e quibus sumantur bins tertiis vel quartis
    horis, vel ter die.

     Form. 540.  Piluls Nervins Antimoniats.
ft Gummi Galbani, 3jss.; Gummi Sagapeni, Saponis Ve-
    netian, 55,  3j. ; Pulv. Rhei, 3ss. ;  Antimon. Potassio-
    Tart. in Aqua Font., q. s., sol. gr. vj.-x.; Ext. Glycyrrh.,
    3j.  Misce.  Fiant Pilul. gr. iij.; sumat unam ad tres
    ter quotidie.

         Form. 541.  Piluls Nucis  Vomics.
R Extr.  Res. Nucis Vomics, 3ss.; G. R. Asafcetids, gr.
    3jss.  ; Sirupi, q. s.  Fiat massa squalis, et divide in
    Pilulas xxx. Capiat unam bis terve in die. (Cardialgia
    Spasmodica, <fec.)

   Form. 542.  Piluls Nucis Vomics Composits.
 R* Morphis Acetatis,  gr. j.; Ext.  Nucis Vomics, gr. ij.;
    Olei Olivs,  gr. x.  Solve ; et adde Extr. Rad. Hellebori
     Nio- iFd  Ph) ^i • Pulv. Glycyrrh., gr. viij.; Mellis,
     q^ ^t Squalis et cliLein P.lulas x,. ^u,
     rum capiat unam bis terve  in cue.   tin
     Amenorrhcea, <fcc.)
       Form. 543.   Piluls cum  Oleo Crotonis.

 R Pilul. Alogs cum Myrrha, 3J«-; S"C™h  a s \'
     Olei Protonis  Tielii. Tllvj.; Pulv. Glycyrrh., q. s.  m.
     Fitt Pilul. xxxg Capiat'duas vel  tres omn. nocte
     (In Amenorrhcea.)
  Form. 544.  Piluls Plumbi Acetatis et Digitalis.
 ft Plumbi  Acetatis, gr.  iv. ;  Pulveris Digitalis,  gr. vj.,
     Pulveris Opii,  gr. iij.  ; Confection* Ross Canins, q. s.
     Misce, et divide in Pilulas sex squales, quarum suma-
     tur una ter in die.
  Form. 545. Piluls Plumbi Acetatis et Colchici.
 R Plumbi Acetatis, gr. xij.; Pulveris Colchici, gr. xxv.,
     Pulveris Opii, gr. iij.; Mucilaginis Acacis, q. s. Misce
     optime, et divide in Pilulas squales duodecim.  (In act-
     ive Hsmorrhages, in  Phthisis, <fcc)

        Form. 546.  Piluls Plumbi Acetatis,
 R Plumbi  Acetatis, gr. viij.-xvj.; Opii Crudi pulver., gr.
     iv.; Confect. Fruct.  Rosas Canins, q. s.   In Pilulas
     viij. divide.  Dosis j., ij., vel iij., semel, bis, sspiusve
     in die.
           Form. 547.  Piluls Purgantes.
 R Fel. Tauri inspissati,  Alogs Extr. Purificati,  55, 3j.;
     Extr.  Colocynth.  Comp., Saponis Castil., 55, 3j. M,
     Fiant Pilul. xxxvj.

       Form. 548.   Piluls Rhei Resolventes.
 R Pulv. Rhei, Sods Acetatis, Fellis Bovini inspiss., 55,
     3ij. ; Pulv. Gum. Acacis, q. s.  Fiat massa Pilularis.
     (PA. Dan.)

        Form. 549.   Piluls Rhei Balsamics.

 R Pulv. Rhei, Pulv. Gum. Acacis, 55, partes squales;
    Balsam. Copaibs, q. s., ut fiat  massa pilularis.

           Form. 550. Piluls Scammonis.
 R G. R. Scammon., gr.  xv. ;  Sacchar. Albi, gr. x.  Tere
    probe ; deinde  adde Ol. Carui, Itliv.  Fiant  Pilul. vj.,
     quarum sumat ij. omni hora.

        Form. 551.   Piluls Scills Co'mposits.
 R Rad. Scills recent , 3ss. ; Gum. Ammoniaci, Succi Gly-
     cyrrh., 55,  3j. ; Antimonii  Oxysulphureti, Pulv. Nucis
     Myristrcs,  55,  3j.; Sirupi Papaveris, q. s.   M. Fiant
     Piluls 1., quarum capiat  binas ad tres, ter quaterve
     in die.
    Form. 552.   Piluls Scills  cum Ipecacuanha.
 R Scills Radicis Pulveris, Zingiberis Radicis Pulveris, 55,
     3j. ; Ipecacuanhs Radicis Pulv., 3ss.;  Saponis Duri,
     3jss. ; Olei Juniperi,  tllxxx.   Contunde, ut fiat massa
     in Pilulas lx. dividenda.

         Form. 553.  Piluls Sedativs.   (1.)
 R Extr. Opii, gr. j. ;  Nitratis  Potasss, gr. vj.; Camphors
     rass. gr. v. ; Sirupi Papaveris, q. s., ut fiant Pilul. iij.,
     pro dose.

         Form. 554.  Piluls Sedativs.   (2.)
 ft Camph.  Subacts,  3j. ; Potasss Nitratis, 33s.; Extr.
    Hyoscyami,  Extr. Anthemidis, 5a, 3ij. ; Sirupi Papa-
    veris, q. s.  M.  Fiant Pilul. xxxvj., quarum capiat duas
    4tis vel 6tis horis.

         Form. 555.  Piluls Sedativs.   (3.)
ft Camph. rass et  subacts, gr.x.; Extr. Hyoscyami, 3J.,
    Extr. Papaveris Albi, gr. xij.   M.  Divide  in Pilulas
    xij., quarum capiat binas vel tres hora somni.

 Form. 556.  Pil. Sods Sesquicarbonatis cum Hyos-
                       cyamo.
ft Camphors, 3ss.; (Sp.  Rect., q. s.,  ft. terendo pulv.)
    Sods  Sesquicarbonatis, 3jss.  ;  Extracti Hyoscyami,
    3ij.: Saponis  Dun,  3j.; Olei  Juniperi, tflxxx. • Pul-
    verisInd. Flor., q. s., ut ft. massa, in Pil. lx. squales
    (listnbuenda; quarum sumat iij. nocte maneque, cum
    lufuso Lini  vel  Decocto Althss.

            Form. 557.  Piluls Stahlii.
ft Antimonii Sesquioxidi, Aloes Socot., Resin. Guaiaci, 51,
    3J. ; Croc. Stig  Myrrhs, 3ss.;  Bals. Peruv., q. s., ut
    fiat massa squalis.  Divide in Pilulas  1.

        Form. 558.   Piluls Stomachics.  (1.)
     (Grana  Vita Mesne.-Frank's Grains of Health.)
ft Alogs. 3iij. ; Mastiches, Petal. Ross Rub   5a  7;  - F„l
    lis Tauri inspissati, 3J3S.  Misce bene ; divide  in PiIuIm
    c, quarum capiat ij. vel iij., ante prandium     ™ulaa 
APPENDIX OF FORMU
        Form. 559.  Piluls Stomachics.   (2.)
R Extr. Gentians, 31J.; Fellis Bovini inspiss., 3jss.; Scam-
    mon., 3j.  Contunde  in massam squalem, et divide in
    Pilulas lxxx.; quarum capiat binas quotidig, vel primo
    mane, vel ante prandium.

        Form. 560.  Piluls Stomachics.   (3.)
R Limat. Ferri, 3ij. ; Pulv. Canells, 3J. ; Fellis Bov. insp.,
    3ss.; Sirup., q. s.  M.  Fiat massa Pilularis. (Chloro-
    sis, <fec)

        Form. 561.  Piluls Stomachics.   (4.)
R Limat. Ferri, Jj.; Pulv.  Rhei,  Extr. Gentians, Fellis
    Tauri insp., 5a, jiij.  M.  Fiat massa Pilularis.

        Form. 562.  Piluls Stomachics.   (5.)
R Fellis Tauri  inspissat., Extr. Alogs  Purif., Extr. Gen-
    tians, Saponis Venet., aa, Jss.   M.  Fiant Pilul. xxx.,
    quarum capiat binas bis in die.

    Form. 563.  Piluls Stomachics Aperientes.
R Ext. Fumaris Officinalis,  Extr.  Jalaps, 55, 3J.; Pulv.
    Capsici  Annui, gr.  xvj.; Sods Carbon,  exsic,  3ss.
    Misce secundum  artem,  et divide  in  Pilulas  xxxvj.,
    quarum capiat duas vel tres hora et semisse ante pran-
    dium.

            Form. 564.  Piluls Stramonii.
R Extracti Stramonii, 3J. ; Saponis Duri, jij.; Acacia Gum-
    mi Pulv., 3j. ; Glycyrrh. Radicis Pulv., 3ij.; Mucilag.
    Tragacanth., q. s., ut ft. massa, in Pilulas lx. dividenda.
    Dosis, j. nocte maneque, vel ter die.

          Form. 565.  Piluls Strychnis.
R Strychnis Purif., gr. ij.; Conserv. Rosarum, jj.   Misce
    bene1, et divide in Pilulas  xxiv.

      Form. 566.  Piluls Styracis  Composits.
R Styracis, Jjss.; Olibani, Benzoini, Croci, Extr. Glycyrrh.,
    Mastiches, aa, Jss. ;  Opii Puri, 3ij.; Myrrhs, 3ij.  ;
    Balsami Tolutani, 3j.  Tere bene simul,  ut sit massa
    squalis. ,Divide in Pilulas lxxx., quarum capiat unam,
    binas, vel tres pro dose.  (Each pill contains half a grain
    of opium.)

        Form. 567.   Piluls Sudorifics.  (1.)
ft Hydrargyri Chloridi (Calomel), gr. xij. ; Antimonii Po-
    tassio-Tart., gr. jss. ad gr. iij.; Opii  Crudi in  pulv.
    subtiliss., gr.  vj. Misce ; turn  adde Confect. Fruct.
    Ross Canins, q. s., ut ft. massa.  In Pilulas vj. squales
    divide, quarum capiat j. hora  somni.

  Form. 568.  Piluls Sudorifics.  (Dumeril.)  (2.)
R Kermis Mineral. (F. 637), Antimonii Oxysulph., 55, 3j.;
    Extr. Opii, gr. xij. ; Extr. Hyoscyami, Jij.  Divide in
    Pilulas lx.   Capiat j.-ij.,  bis terve in die.

     Form. 569.  Piluls Sulphatis Strychnis.
ft Strychnis Sulphatis, gr. ij. ; Confect. Rosar., 3j.  Misce
    probe, et divide in Pilulas xxiv. squales.  Capiat unam
    pro dose.

        Form. 570. Piluls  Terebinthinats.
ft Gum. Guaiaci, 3j. ; Terebinth. Vulg., 3jss.  ; Pulv. Gly-
    cyrrh., q. s., ut fiant Pilul. xxxvj., quarum capiat binas
    vel tres, ter quotidie*.

   Form. 571.  Piluls Terebinthins et Camphors
                      cum Opio.
   Extr. Opii, 3j.; Pulv. Rad. Glycyrrh., 3jss. ; tere cum
    Aqus pauxillo, et adde Terebinth.  Venet., 3ij. ; Cam-
    phors rass, gr. xv.;  Croci Stigmatis, 3j.; Mastiches,
    gr. x.; Pulv. Acaciae, gr.  x.;  Olei Juniperi, q. s.  Tere
    bene  simul, et  fiat massa squalis.  Divide in Pilulas
    lx., quarum capiat duas ad tres,  bis terve quotidie.

    Form. 572.  Piluls Tonics Aperientes. (1.)
ft Quins Sulphatis, 3SS.-3J.; Potasss Sulphatis, 3jss.; Gum.
    Galbani. 3iv.; Extr. Gentians, vel Anthemidis, 3J.  ;
    Masss Pilul. Alogs cum  Myrrha,  3»j.; Thenacas Pu-
    rif., q. s.  Contunde  in massam squalem, et divide in
    Pilulas cxx., quarum sumantur  bins vel tres, bis terve
    quotidus.

    Form. 573.  Piluls Tonico-Aperientes.  (2.)
ft Quinffi Sulphatis,  3j. ; Alogs Extr. Purif., 3ss.; Extr.
    Gentians, 3j.   M.  Fiant Pilul. xxiv., quarum sumat
    unam vel biuas, omni meridie.

    Form. 574.  Piluls Tonics Aperientes. (3.)
ft Ferri Sulphatis, 3j. ; Extracti Absinthii  (vel Gentians),
    Extr. Alogs Purif., 55,  3jss.; Sirupi  Croci, q. s.  M.
    Divide in Pilulas lxxxv., quarum capiat binas, tres, qua-
    tuorve pro dose.
LiE.—Pilule—Potus.                     xxiii

    Form. 575.  Piluls Tonico-Aperientes.  (4.)
R  Quins  Sulphatis, Extr. Alogs Purif., 55, 3ij. ; Extr.
    Gentians, 3jss.; Sirupi Simp., q. s.  Divide in Pilulas
    xlviij. ; quarum capiat duas vel tics pro dose.

    Form. 576.  Piluls Tonico-Aperientes.  (5.)
ft Quinas Sulphatis, 3j.; Masss Pilul. Aloes cum Myrrha,
    3ij. ; Extr. Gentianas, 3j.  M.  Fiant Pilul. xxx.,qua
    rum capiat binas bis quotidie.

       Form. 577.   Piluls Tonics cum Cupro.
ft  Cupri  Sulphatis, gr. x. ;  Pulv. Rhei, 3J. ; Extr. Anthi
    midis, 3ij.; Sirupi Simp., q. s.   M.   Fiant Pilul. xl
    quarum capiat j. ad iij.  (In Leucorrhosa, <fcc, by Ai
    gustin;  and in Gleet, Chorea,  &c  The Ammonii
    Sulphate  of Copper is substituted for the Sulphate  i
    Chorea by Niemann.)

  Form. 578.  Piluls Tonics cum Sulphate Zinci.
ft  Zinci  Sulphatis, 3j. ; Extracti  Gentians, 3iv.; Extr.
    Anthemidis, 3ij.  Contunde massam, et divide in Pi-
    lulas xl., quarum sumantur dus  bis die, cum Haustv
    infra prsscripto.
ft  Infusi  Gentians Compositi, 3x.; Acidi Sulphurici Aro-
    mat., Itlxij.; Tinct. Zingiberis, 3j.  M.  Fiat Haustus

      Form. 579.  Piluls Tonico-Emmenagogs.
ft Quins Sulphatis, Masss Pilul. Galban. Comp., 55, 3ss.;
    Masss Pilul. Alogs cum Myrrha, 3j. ; Olei Junip. Sa-
    binae, q. s.  M.  Divide massam  in Pilulas xxx., qua-
    rum capiat binas mane nocteque.

       Form. 580.   Piluls Uvs Ursi et Rhei.
ft  Pulv. Uvos Ursi, Pulv. Rhei, 55, 3ss.; Saponis  Castil.,
    gr. xxv.; Mucilag. Acacis, q. s.  M.  Fiant Pilul. xx.
    Capiat duas bis quotidie.

       Form. 581.  Piluls Uvs Ursi et Sods.
ft Pulv. Fol. Uvs Ursi, Sods Carbon, exsic, Saponis Duri,
    55, 3j.; Mucilag.  Acacis, q. s.   M.   Fiant Pilul. xl.,
    quarum capiat binas bis terve quotidie.

     Form. 582.  Piluls Valerians Composits.
R Pulv. Valerians, gr. xxx.; Castorei, gr. xx.; Oxidi Zinci,
    gr. xx.; Sirupi Simp., q.  s.  M.  Fiant Pilul. xviij.,
    quarum capiat tres, ter quotidie.   (Dupuytren.)

      Form. 583.  Piluls Valerians et Zinci.
ft  Pulv. Valerians, 3ij.; Castorei, gr. xv. ; Oxidi  Zinci,
    3j.;  Olei Cajeputi, Tllv.;  Sirup.  Simp., q. s.  Divide
    in  Pilulas xviij.,  quarum capiat  tres,  quater in die.
    (Nearly the same as those used by Dupuytren.)

       Form. 584.   Piluls Zinci et Myrrhs.
ft  Zinci  Sulphatis, gr. xij. ;  Myrrhs in pulverem trits,
    3jss.; Confect. Ross, q. s., ut fiant Pilul. xxiv.; ts qui-
    bus sumantur bias, bis quotidid.

Form. 585.  Pil  Zinci cum Myrrha et Ipecacuanha.
R  Zinci  Sulphatis, gr. xij. ;  Myrrhs in pulv. trit.,  3j.;
    Pulv. Ipecac, gr. xviij. ; Extr. Hyoscyami, 3ij.; Sirupi
    Papaveris, q. s.   M.  Fiant Pilul. xxx.; e  quibus su-
    matur una, ter  quaterve quotidie.

Form. 586.  Piluls Zinci Sulphatis Composits.  (1.)
ft  Zinci Sulphatis, gr. xij.; Moschi, 3jss. ;  Camphors, 3ss.
    M. et divide  in Pilulas xxxvj., quarum sumantur dus,
    bis vel ter in die.

Form. 587.  Piluls Zinci Sulphatis Composits.  (2.)
ft  Zinci  Sulphatis, gr. xij. ; Pulv. Ipecac, gr. vj.; Pulv
    Myrrhs, 3ij. ;  Extr. Lactucs, 3ijss. ; Sirupi Tolutani,
    q. s.   Contunde in massam squalem, et divide in Pilu-
    las xxiv.


      Form. 588.  Potus Antiphlog. Diureticus.
ft Decocti Asparagi Officin., Ibij. ; Potasss Nit., 3ij. ; Spirit.
    Miher. Nit., 3iij.; Oxymel. Scills, Jss. Sit pro Potu
    communi.

Form. 589.  Potus Decocti Sarzs Comp. (Tisane de
                       Feltz.)
ft  Antimonii  Oxysulphureti,  Jiv. ;  Aqus  Com., ftxij. ;
    Rad. Sarzs,  Jiij.; Radicis Chins Orientalis, Corticis
    Lig.  Buxi, Ichthyocolls,  55, Jjss. ;  Hydrarg. Bichlo-
    ridi, gr. iij.  (Enclose the  Antimony in  a muslin bag;
    and boil the  whole, excepting the Bichloride of Mer-
    cury, until the water is reduced to  one half; strain
    the decoction, and add the Bichloride.   The properties
    of this decoction will not be materially affected by
    omitting the  Radix Chins  and Cort. Buxi; or Sassafras
    or Guaiacnm may be substituted, and Extractum Ta-
    raxaci added.) 
XXIV
APPENDIX OF FORMULA.—Potus—Pulvis.

                                Form. 608.
         Form. 590.  Potus Diureticus.  (1.)
R  Decocti Tritici Repen., lbijss.;  Potasss Acetat., Jjss. ;
    Spirit, .fither. Nit., Jiij.; Aceti Colchici, Jss.; Vim
    Xers, Jvj.; Oxymel. Scills, Jjss.   Sit pro Potu com-
    muni.
         Form. 591.  Potus Diureticus.  (2.)
R  Decocti Tritici  Repentis, Oijss. ;  Potasss Bitart., Jj.;
    Potasss  Nit.,3iij.; Sods Biboratis,  3ij.; Sacchari, 3iv.
    Sit pro Potu ordinario.

        Form. 592.  Potus Febrifugus.  (1.)
ft Potasss Nitratis, 3iij.; Seri Lactis, Oiij.; Succi Limonis,
    Jijss.  M.  Sumat pro Potu ordmano.

    Form. 593.  Potus Febrifugus.  (Stoll.) (2.)
ft  Pulps Tamarindorum, Jss. vel  3vj.; Potasss Nitratis,
    3ij. vel 3iij.; Seri Lactis, Oijss.  v
M.
                                     Omni bihorio su
    matur vasculum coffsanum

    Form. 594.  Potus Manns et Tamarindorum.
ft Manns, Conserv. Tamarindi Indici, 55, Jjss.; Seri Lac-
    tis, fojss.  Digcre et cola.  Capiat cyathum subinde.

          Form. 595.   Potus Refrigerans.
ft  Acidi  Hydrochlorici,  jj.; Spirit. JEther.  Nit., jiiijss.;
    Decocti Hordei  Comp., Jxxiv.  M.  Capiat  cyathum
    pro re nata.  (In Febrile Affections.)


  Form. 596.  Pulvis Acidi Benzoici et Camphors.
R  Acidi  Benzoici,  gr.  vj.; Camphoras, gr.  ij.;  Sacchari
    Albi, 3j.  M.   Fiat Pulvis.  Dispens. tales doses tres.
    Capiat sger altera  quaque hora unum.

       Form. 597.  Pulvis Almins et Quins.
R  Aluminas Sulphatis,  gr. viij.-xij.; Quinas  Sulphatis, gr.
    j.-iij.; Gum. Arab., Sacchar. Albi, aa,  gr. xij.  Fiat
    Pulvis.  Dispens. tales duodecim.  Capiat sger tertia
    quaque hora pulverem unum.   (In Adynamic Fevers,
    Hsmatemesis, Passive Hsmorrhages, <&c)

 Form. 598.  Pulvis Cupri Ammonio-Sulphatis cum
                       Zinco.
ft Cupri Ammon.-Sulphat., Oxydi Zinci, 55, gr. ss.-j.;  Sac-
    chari Albi, gr. x.  M.  Fiat Pulvis.  (In Epilepsy and
    Chorea.)

         Form. 599.  Pulvis  Antihydropicus.
ft  Potasss Bitart., Jj. ; Potasss Nitratis, Biboratis Sods,
    aa, 31J.; Pulv.  Fol. Digitalis, 3j.  Tere  bene simul, et
    divide in Chartulas xij., quarum capiat unam bis terve
    quotidie, in quovis decocto vel infuso.

    Form. 600.  Pulvis Antimonii et Camphors.
ft Antim. Oxysulphureti, Radicis Ipecac, 55, gr. j. ; Camph.
    rass, gr. j.-iij.; Sacchari  Albi, 3j.  M.   Fiat  Pulvis.
    Dispens. tales  doses sex; sumat sger  alter5 quaque
    hora Pulverem  unum.  (In Chronic Inflammations of
    the Respiratory Organs.)

    Form. 601.  Pulvis Antimonialis Compositus.
ft  Pulveris Antimonii  Comp., 3v.;  Antimonii Oxysulphu-
    reti,  3j.   M.  Dosis gr. v., pre state adulta.

        Form. 602.  Pulvis Antiphlogisticus.
ft Potasss Nitratis, Jiij. ; Potasss Tartratis, Jivss.; Acidi
    Boracici, Jj.  Tere  in pulv. subtiliss. (In doses of 3ss.
    in Cutaneous Affections, &c.)

  Form. 603.  Pulvis  Antispasmodics.  (Stahlii.)
ft  Kermis Mineral., gr. j.; Potasss Nitratis, Potasss Sul-
    phatis, 5a, gr. x. M.sce bene.

            Form. 604. Pulvis Aperiens.
ft Pulveris Jalaps, Jiij. ; Hydrargyri Chloridi, Jj. ; Pulve-
    ris Zingiberis, 3<j.  Misce.  Dosis, 5 gr. iv. ad gr. xx.

        Form. 605.  Pulvis Asari Compositus.
ft  Asari  Folior. exsiccat., Jiij.; Origani Folior. exsiccat.,
    Lavandul. Florum exsiccat., 5a, Jj.   Simul terantur, et
    fiat Pulvis.  (In Chronic Ophthalmia and Toothache, as
    a sternutatory, <fec ; to produce a secretion  from the
    Schneiderian membrane.)

          Form. 606.   Pulvis Belladonns.
ft Pulv. Rad. Belladonns, gr.  iv. ; Pulv. Rad. Glycyrrh. et
    Sacchari Albi,  55, gr. xxviij,  Tere bene1 simul. Dosis,
    gr. iv.-xx., bis  in die.

    Form. 607.  Pulvis Belladonns Compositus.
ft  Pnlv.  Rad. Belladonns, gr. vj. ; Pulv. Ipecac, gr.  vj.;
    Pulv. Rad.  Glycyrrh., Pulv. Sacchari Albi,  55, 3ss. ;
    Sulphuris Prscipit., 3ij.; Olei Anisi, Olei  Succini, 85,
    uliij.  Misce.   In dosis gr. v.-xx.
      M.  Fiat Pulvis,
"(Marcus.)
               Pulvis Belladonns Compositus.
                     (HECKER.)
                          ■  ;;; • Moschi, Camphors, aa,
R Pulv. Fol. Belladonns, gr.l.-i'J-.f*"^^.^ et\j,vlde ,„
    gr. v.; Sacchari  Albi, 3SS-   *    -   pertussiS)Asth-
    Chartulas viij.  (Antispasmodic.   *»'"
    ma, &c)
            Form. 609.  Pulvis Bismuth..

*  Wt^'JE- 'F^K'-rVef^
    quaque hora sumendus.  (ODIER.)
     Form. 610.  Pulvis Bismuthi Compositus.
R  Bismuthi Trisnitrat., Moschi, 5a  gr. ti-^i&Hjos^.
    ami, gr. iij.  ; Magnes. Carbon., BJ^^
    tertia quaque  hora sumendus.
       Form. 611.  Pulvis Boracis et Sabins.
ft  Pulveris FolioTum  Sabins, Pulv. Zingiberis, u5,gr.vij.;
    Sods  Biboratis, 3j.   Fiat Pulvis, b.s die  sumendus.
    (In Amenorrhcea  with a languid pulse.)

   Form. 612.  Pulvis Calomelanos cum Digitale.
ft  Hydrargyri Chloridi, Sacchari Albi,  55, Jj.;  Pulveris
    Digitalis, Jss.  Misce.  Dosis, a gr. j. ad gr. v.

      Form. 613.   Pulvis Calumbs Compositus.
ft  Pulveris  Calumbs, Jj.; Pulv. Rhei, Jss. ; Sods Carbo-
    natis exsic, 3iijss.  Misce.  Dosis, a gr. vj. ad 3ss.,bis
    de die.
            Form.  614.  Pulvis Camphors.
ft  Camphors,  3ss  ;  Sp. Rectif., q. s.  Ft. terendo pulv. ;
    dein adde, Sacchari Purificati, 3j.; Pulv. Acacis, Jjss.
    M.   Fiat  Pulvis.   In chart, x., squaliter  distnbu-
    endus.

       Form. 615.  Pulvis Camphors et Zinci.
ft  Camph. rass, 3j.; Zinci Oxidi, gr. xv.  M.   In Chartu-
    las  iv. distribue ; quarum  sumat unam hora somni.
    (In Epilepsy supervening about puberty, and connected
    with venereal desires and indulgences.)

       Form. 616.  Pulvis Carminativus.   (1.)
ft  Magnesis, gr. viij.; Seminum Anisi  contus., Seminum
    Fosniculi cont., 55, gr. ij. ; Croci, gr. j. ; Sacchari Albi,
    gr. vij.  Contunde bene  simul, et sit Pulvis. Capiat
    dimidium statim, et alterum post horam.  (For the Tor-
    mina of Infants,  &c)

        Form. 617.   Pulvis Carminativus.   (2.)
ft Magnes., Sacch.  Albi, 55, 3j. ; Pulv.  Corticis  Canelhe,
    Semin.  Fosniculi cont., 55,  gT. xx. ;  Olei Anisi, 1fl,viij.
    Tere  bents simul, et divide in Chartulas xij., quarum
    capiat unam  bis terve quotidie,  vel urgentibus tormi-
    nibus.

        Form. 618.   Pulvis Carminativus.  (3.)
ft Sem. Anisi, Sem.  Carui, Sem. Coriand., Sem. Fosniculi,
    5a, Jj.; Cort. Auran., Rad. Zingib., 55, 3vj ; Crete
    Prepar., Jjss.; Magnes., Jss.;  Macis, 3jss.;  Sacchari
    Albi, Jij.;  tere bene simul. Dosis, 3J.-31J.

           Form. 619.  Pulvis Catharticus.
ft  Hydrargyri  Chloridi, Pulveris Cambogis, Pulv. Jalaps,
Pulv. Rhei, Pulv. Cinnamomi, 55, 3ij.
5 gr. v. ad 3j.
Misce.  Dosis,
      Form. 620.  Pulvis Cinchons Compositus.
ft Pulv. Cinchons, Jjss.; Pulv. Moschi, gr. xv. ; Camphoras,
    3j. ; Ammon.  Sesquicarbon.,  gr. xxv.; Olei Succini
    et Olei  Menths, 55, 1t|,vj.  Misce probe, et divide in
    Pulv. viij.

       Form. 621.  Pulvis Cinchons cum Soda.
ft Pulveris  Cinchons, Sods Carbonatis, 55, partes squales.
    Dosis, 6 gr. v. ad 3ss., bis terve in die.

    Form. 622.  Pulvis  Corticis Cusparis Comp.
R Pulv. Cort. Cusparis, gr. x.; Pulv. Cinnam. Comp., gr.
vj.; Olei Piments, IHj.
capiendus.
M.  Fiat Pulvis,  ter in die
  Form. 623.  Pulvis Crets et Rhei Compositus.
R Crets Prspar., Jss. ; Saponis Amygdal., Pulv. Rhei, 55,
    31- ; Hydrarg. cum Creta, 3j. ; Olei Fosniculi, Ulviij.;
    Sacchari Albi,, 31J. ; tere  bene simul.  Capiat gr. vj.
    ad 3ss. pro dose  bis vel ter die.   (Pro Infantum Diar-
    rhoea.)

           Form. 624.   Pulvis Cretaceus.
ft Crets Preparole?,  Acacis  Gummi Ver. pulv  85 ?iv ■
    Sacchari Purificati contrili, J.ij.  Misce.  Ft. Pulvis.'

         Form.  625.   Pulvis Cyanidi Zinci.
R Zinci Cyanidi, gr. vj.; Magnes.  Calcinats, gr. ;v..  pul. 
APPENDIX OF FORMULA.—Pulvis.                           xxv
    ■vct'is Cinrmmami, gr. iv.  M.  Fiat Pulvis, quarta qua-
    que hora sumendus.  (In Gastrodynia, Dysiuenorrhasa,
    Dyspepsia.)

          Form. 626.  Pulvis Deobstruens.
ft Gum. Guaiaci, 3ij.; Flor. Sulphur., 3jss.; Calomelanos,
    3j.; Radicis Iridis Flor., Semin. Fosniculi, Sa, 3jss. ;
    Opii  Extr., gr. ij. ; Sacchar. Albi, Jss.  Tere bene si-
    mul, et divide in Pulv. vj.

        Form.627.  Pulvis Diureticus.  (1.)
ft Potasss Nit., Potasss Bitart.,aa, 3iv. ; Pulv. Scills, gr.
    viij. ;  Pulv. Zing., gr. xvj.   Misce  bene, et divide in
    Chartulas viij.

        Form. 628.  Pulvis Diureticus.  (2.)
ft Potasss Bitart., 3jss_ ; Pulv. Scills exsic, gr. ij. • Pulv.
    Digitalis, gr. j.;  Pulv. Zingiberis, gr. v.   Fiat  Pulvis,
    ter quaterve quotidie sumendus ex theriaca.

          Form. 629.  Pulvis Eccoproticus.
ft Potasss Bitart., Jj.; Magnes. Carbon., Flor. Sulphur.,
    55, Jss.; Potasss Nit_, 31J.   Misce, et divide m Chart.
    vj.  (In Haemorrhoids, &c.)

        Form.  630.  Pulvis Ecphraticus.   (1.)
ft Potasss Bitart., Jss". ;  SocUe Biboratis, Magnes. Carbon., ,
    ai, 3ij. ; Pulv. Flor. Anthemidis, Pulv.  Semin. Fosni-
    culi, aa, 31 j. ; Sacchari Albi, Jss. ; Olei Juniperi et Ol.
    Anisi, 52, Tlixv.  Tere bene simuL.  Capiat 3j.—3ij_, bis <
    terve quotidie.

   Form. 631.   Pu&vis Ecphracticus.  (Sellii.)  <2.)
ft Magnes. Carbon., Potasss  Bitart., Sulphuris Sublimati,
    Pulv.  Rhei,  Pulv.  Flor. Anthemid.,  Pulv. Seminum
    Fosniculi (vel potius  Sacchari Albi, Jss.; Olei Fosni-
    culi  DuL,  fllxxiv.), a4,  Jss.; Olei Juniperi,  Iqjcviij.
    Tere  bene simul.  Capiat 3J.—3 i j -, bis terve quotidie
    ex vehiculo quovic idoneo.  (in Obstructions, Jaundice, ■
    Piles, <fcc.)

            Form. 632.  Pulvis Excitans.
ft Biboratis Sods, gr. Jtv.-3j.: Pulv. Sabime, gr. vj.; Pulv.
    Castorei, Pulv. Rad. Zingib., 5a, gr. x.  M. Fiat Pul-
    vis.  Sumat sgra de die Pulveres binos in vino vel cum
    melle.   (Stimulaus et emmenagogus in Menstruorum
    defectu ex Leucuphlegtnasia.  Haetmann.)

            Form. 633.  Pulvis Infantilis.
ft  Rhei  Radicis Pulveris, Jij.; Magnes. Carbonatis, Jx. ;
    Zingiberis Rad. Pulv., 3SS.  M.  Fiat Pulvis.   Capiat
    gr. vij. ad Jss. pro dose.

  Form. 634.  Pclvis Ipecacuanhs cum Calomelane.
ft Hydrargyri Chloridi, 31 j.; Pulv. Ipecac, 3j. 4 Pulv. Cin-
    namomi, 3jss.; Sacchari Albi, 3ijss.  M.  Dosis, a gr.
    ij. ad gr. x.

       Form. 635. Pulvis Jalaps Compositus.
ft Jalapae  Radicis Pulveris, Jj.; Potasss  Bitartratis, Jij.;
    Capsici Baccarum Pulv., gr. xij.  Omnia, seorsini trita,
    permisce.  Dosis, a 3s*. ad 3j. mane.

    Form. 636.  Pulvis Jalaps et Calomelanos.    >
ft  Pulv. Rad.  Jalaps, gr. xv.-xx.; Hydrarg. Chloridi, gr.
    ij. ; tere probe cum Sacchar. Alb., 34s.; et adde Pulv.
    Acacis, 3j.',  Ol. Carui,  Tljij.  M.  Fiat Pulvis, statim
    sumendus.

        Form. 637.  Pulvis Kermis Mineralis.
      (Hydro-Sulphuret of Antimony.  Berzelius.)
ft Aqus Pluvial., part. 280;  Carbon. Sotbje, part. 128; Ses-
    quisulphuieti Antimonii  pulver., part. 6.   Dissolve the
    Soda in the water while boiling; and boil the Sulphu-
    ret in the solution /or half an hour, stirring it frequent-
    ly.  Filter the  boiling liquor  in a  vessel containing
    warm water  which bad been previously boiled.  De-
    cant  the water after it is cooled.  Wash the  precipi- ,
    tate which is formed, first with cold water, afterward .
    with  warm  water, until it passe* off quite  insipid. 1
    Lastly, press it, and dry  it in the shade.*  (Stimulant,
    Emetic, Diaphoretic, Alterative, Becchic, Expectorant.
    Dose j.-iv. gr.)
Form. 638.  Pulvis  Kermis Mineralis et Camphors.
ft Kermis Mineral., gr. ij. ; Camph. subact. in Pulv., gr. iij.;
    Potasss Nit., gr. v.-xij.  M.

Form. 639. Pulvis  Kermis Mineralis Camphoratus.
ft Kermis Mineral, gr. iij. ; Camph. pulverizats, gr. viij.;
    Potasss Nitratis, gr. xxiv.; Sacchari Albi, 3ss.  Tere
    bene, et divide in Pulv. iv.  Capiat unam, quater in die.
* I have given the directions for this preparation, and a few others,
1 F.oilkh, to prevent any mistake occurring io respect of them.
   Form. 640.  Pulvis Lenitivus Hypochondriacus.
                       (Klein.)
 R Flavedinis Cort. Aurant., Pulv. Radicis Rhei, Potasss
     Tartratis, 55, 3ss.; Olei Cajeputi, Tlliij.  M.  Ft. Pul-
     vis pro una dose.

           Form. 641. Pulvis Lientericus.
 R Pulveris Tragacanth. Comp., Pulv. Rhei, 55, 3iij.; Pulv.
     Ipecac. Comp., 3J. ; Hydrargyri cum Creta, jj.  Misce.
     Dosis, a gr. v. ad  35s., 3tiis, 4tis, vel 6tis horis.   Inter-
     dum adde Extractum Catechu, <fec.

 Form. 642.  Pulvis  Nitbo-Opiatus Ipecacuanhs, vel
                   Pulvis Doveri.
 ft Ipecac Radicis contrit., 3J.; Opii Crudi contriti, gr. xlv.,
     Potasss Nitratis, 3viij- et gr. xv.   Tere simul, et fiat
     Pulvis.  (A scruple of this powder  contains one grain
     and a half of opium, two grains of ipecacuanha, and
     sixteen grains and a half of nitrate of potass.)

             Form. 643.   Pulvis Purgans.
 ft Hydrarg. Chloridi, Cambog. G. R. pulveriz., Pulv. Zin-
     giberis, aa, 3ss.;  Sacchari Purif., 3j.  Tere bene si-
     mul;  et adde Olei Fosniculi Dulcis, lllxx.  Dosis, gr.
     v. ad xv.

        Form. 644.   Pulvis Refrigerans.  (1.)
 ft Acidi Boracici, Jss.; Potasss Nitratis, Jj.; Potasss Bi-
     tart., Jij.  Misce  bene.  Capiat 3J.-3J. pro dose.

        Form. 645.  Pulvis Refrigerans. (2.)
 ft  Potasss Bitartratis pulverizati uncias duas;  Nitratis
     drachmas tres.  Misce, et divide in paites xij. squales.

   Form. 646.  Pubvis ResOlvens, tie'Deobstruens.
 ft Potassas Bitartratis pulverizati, Jivss.; Sods Biboratis,
     Jjss. ; Antimonii  Potnssio-Tart., gr. iij.  Misce probe
     et divide in paries squales viginti.

        Form. 647.   Pulvis  Rhei Compositus.
 ft Pulveris Rhei, Jiijss.;  Hydrargyri cum Creta, Jj. ; Po-
     tasss  Carbon., 3jss. , Pulv.  Cinnamomi, 3ss.  Misce.
     Dosis, j! gr. v. ad 3j., bis vel ter die.

        Form. 648. Pulvis Rhei et Magnesis.
 R Pulv. Rhei, 3j.-jss. ; Magn. Carb., gr. xvj.-3ss.; Semin.
     Fosniculi, Sacchari Albi, 35, gr. x.; Olei Cassis Cin-
     nam., Ttlj.   M.  Fiat Pulvis.

     Form. 649.  Pulvis Rhei et Sulph. Potasss
 R  Pulv.  Rhei, gr. vj.-x. ;  Potassas Sulphatis, gr. x.-3j.,
     Pulv.  Sem. Anisi, gr. vj. ; Olei Fosniculi, IJ]j.  M.  Fiat
     Pulvis, bis terve quotidie sumendus.

  Form. 650.  Pulvis Scammonis cum Calomel.   (1.)
 R Scammon. Gum. Resins pulv., 3ij. ;  Hydrarg. Chloridi,
     (Calomel), Sacchari Purificati, 55, 3j.  M. Fiat Pulvis.
     Dosis, gr.  x. ad gr. xx. mane.

  Form. 651.  Pulvis Scammonis cum Calomel.   (2.)
 ft Scammon. Gummi Resins pulv., Hydrarg. Chloridi, Po-
     tasss Bitart., M, 51 j.   Misce bene simul, et sit Pulvis.

       Form. 652.  Pulvis Scammonis et Jalaps.
 ft G. R. Scammoniae, gr. xij. ; Pulv. Rad. Jalaps, gr. xviij. ;
     Potasss Bitart., gr. xxv.  Tere prolj^ in pulverem te-
     nuissimum; dein adde  Pulv. Zingiberis, gr. viij.I; di-
     vide  in partes tres squales, quarum sumat j., secunda
     vel tertii q. q. hora, donee plen£ dejecerit alvus.

             Form. 653.  Pulvis Sedativus.
 R Hydrarg. cum Cret5, jj.; Pulv. Ipecac. Comp., 3ij.;
     Magnes. Carbon., 3ss.  Tere bene simul.  Dosis, gr.
     iv.-xij., pro Infantibus.

     Form. 654.  Pulvis Senegs et  Camphors.
 ft Pulv.  Rad. Senegs, Sacch. Alb., 55, gr. xij. ; Camph.
     rass,  gr. ij.;  Olei Anisi,  fllj.  M.   Fiat Pulvis.   Dis-
     pensentur tales  doses tres.  Capiat sger, interjectia
     duabus horis, pulverem unum.  (In Chronic Affections
     of the Chest.)
         Form. 655.   Pulvis Sods Compositus.
 R Sods Carbon, exsiccat , Jvj.; Hydrargyri Chloridi, 3J.;
     Pulv. Crets Comp., Jj.   Misce.  Dosis, i gr. v. ad 3j.

      Form. 656.  Pulvis Sods cum Hydrabgyro.
 ft Sods  Carbon, exsic,  3iv. ; Hydrarg.  cum  Crela.  31].
     Misce ben^.  Dosis, gr. vj. ad  gr. xij.,  pro Infantibus
     bis quotidi^.

  Form. 657.  Pulvis Specificus Stomachicus.  (Po-
                        terii.)
 ft Ferri  Sesquioxidi, Antimonii Crudi, 55, partes squales
     vel unam; Potasss  Nitr., part. vj.   Detona seu defla-
J     gra, et lava. 
XXVI
APPENDIX OF FORMULAE.—Pulvis—SiRUVua
    Form. 658.  Pulvis Sulphatis Potasss et Ferri.
  R  Ferri Sulphatis, 3vj. ;  Potasss Sulphatis, Jxij.  Tere
      ben* simul, et adde Acidi Sulphurici,  ufxxxvj.  M.
      Dosis 3j.-3jss., bis, ter, quaterve in die.

  Form. 659.   Pulvis Sulphatis Quins Antimoniatus.
  ft  Quins Sulphatis, gr. xij.;  Antimonii Potassio-Tartrat.,
      gr. ij.  Misce bene', et divide in partes vj. squales. Ca-
      piat unam 2dis vel 3tiis horas inter paroxysmos.

  Form. 660.  Pulvis Sulphatis  Quins et Morphis.
 R  Quins Sulphatis, gr. iv.-xij.;  Morphia  Sulphatis, gr.
     j.—ij.  Misce, et divide in dos. iv. vel vj.

  Form. 661.  Pulvis Sulphureti Aureati Antimonii,
      vel Deuto-Suphuret. Antim.  (Berzelius.)
 ft  Liquoris restantis post  prscipitat.  Mineralis Kernies
     diet, quantum  veils;  infunde  Acid. Acetici quantum
     sufficiat, vel donee nil amplius prscipitationis appareat.
     Lava bend  materiam prscip. et exsicca.  (N.B. The
     Oxysulphuret of Antimony of  the Lund. Ph. is an ad-
     mixture of Kermes Mil), and the Golden Sulph.)

              Form. 662.  Pulvis Tonicus.
 ft Fern Sulphatis exsiccats, 3iij.; Potasss Sulphatis, Jij.;
     Pulveris Cascarills, Jiijss.  Misce.  Dosis, a gr. iij. ad
     gr. xv., bis terve in die.

             Form. 663.  Pulveres Tonici.
 ft  Pulv. Cinchons,  Extr. Glycyrrh., 5a, 3iij.; Pulv. Rad.
     Valerian., 3ij. ;  Sacchari Albi, 3ss.  Tere bend simul,
     et divide in Chartulas ix.   Capiat unam ter quotidie\
     (Heller and Niemann.)

      Form. 664.  Pulveres Tonico-Aperientes.
 ft  Pulv.  Cinchons,  Jj. ; Pulv. Rhei, jijss.;  Ammon. Hy-
     drochloratis, 3jss.  Misce bene, et divide in Chartulas
     xij.   (Bang et Jadelot.)

       Form. 665. Pulvis Valerians et Zinci.
 R Valerians Pulv., Jj.; Oxid. Zinci, 3j. ; Moschi, Sacchari
     Purif., 55, gr. x.; Olei Cajeputi, Ttlxij.   Tere simul, et
     divide in Chartulas vj., quarum  capiat unam ter die.

     Form. 666.   Pulvis Zinci Oxydi Compositus.
 ft Oxydi Zinci, gr.  xij. ; Magnes.  Calcinats, 3ss.; Pulv.
     Calumbs, 3j.  Tere bene simul, et divide in Chartu-
     las xij., quarum capiat unam ter quaterve in die.  (De
     Haen.)

      Form. 667. Pulv. Zinci Sulphatis Comp.
 ft Myrrhs G. R., 3j. ; Pulv. Ipecac, gr. vj. ; Zinci Sulpha-
     tis, gr. vj.;  Pulv.  Glycyrrh., Sacchar. Albi, 5a,  3jss.
     Tere optime' simul ut fiat Pulvis.  Divide in Chartulas
    ix., quarum  capiat unam ter quaterve in die ex the-
    riaca.


       Form. 668.  Sapo Olei Crotonis Tiglii.
 R Olei Crotonis Tiglii, partes ij.; Lixivii Saponani, part. j.
    Contere, et fiat Sapo.  Dosis, gr. ij. vel iij.

          Form. 669.  Sapo Terebinthins.
R Potasss Hydratis,  Jj.; Liquefac lento igne, et  adjice
    Olei Terebinthins, Jiij.  Misce bene donee refrixerat.
    (Used both externally and internally.)

          Form. 670.  Sapo  Terebinthinata.
ft Saponis Castil., Jj.; Olei Terebinth., Jijss.; adde Solu-
    tionis Potasss Carbon., 3ij.; Camph. rass, 3ij.  Misce
    bene. (Used externally and internally.)
        Form. 671.  Solutio Iodinii.  (Lugol.)
                           No. 1.    No. 2.    No. 3.
ft Iodinii    .    .    .    . gr. ij.     gr. iij.    gr. iv.
   Potassii Iodidi .    .    . gr. iv.    gr. vj.    gr. viij.
   Aqus Destil.  .    .    . rbj.      ftij.       ibj.
      Solve.   (Chiefly for external use ; for injections in
    Scrofulous Fistuls, &c.)

   Form. 672.  Solutio Iodinii Caustica.  (Lugol.)
ft Iodinii, Jj.; Potassii Iodidi, Jj.;  Aqus Destillats,  Jij.
    Solve.

Form. 673.  Solutio Iodinii Rubefacient.   (Lugol.)
R Iodinii, 3iv.; Potassii Iodidi, Jj. ; Aqus Destillatas, Jvj.
    Solve.

   Form. 674.  Solutio Morphis Hydrochloratis.
ft Morphis Hydrochlorat., gr. x. ;  Aqus Destillat.  Calid.,
    1111000.  Solve.  (Dose twenty-five  minims—equal  to
    J gr. of the Hydruchlorate.)
        Form. 675.  Solutio Morphis Sulphatis. _
  R Sulphat.s Morphis Ver., gr. iv.; Aq. Destil., 5J-  Solve.
      (Of the same strength as Laudanum.)


     Form. 676.  Spiritus .Etheris Hydrochlorici.
            (Olim, Spiritus Febrifugi Clutloni.)
  ft Acidi  Sulphurici,  ftj., Jxij. (per pond.) ;  Acidi Hydro-
      chlorici, Ibj. (per  pond.) ; Spiritus Rectificati cong., j.
      Distilletur liquor, secundum artem.

        Form. 677.  Spiritus Ammonis Anisatus.
  ft Olei Anisi, 3iij.; Spirit Ammon., Jvj.   Solve.

      Form. 678.  Spiritus Castorei Ammoniatus.
  ft Castorei contr., Jiij. ; Croci  Stigm., Jj.; Herbs Arte
      misi«e, Jvj. ; Potassas Carbon., 3ij-;  Spirit. Tenuiorii,
      Jxxx.  Macera per dies vj., et cola.  Dein adde Spirit.
      Ammon., Liquoris Ammon., 55, Jvj.  M.  Dosis, 3j.~3ij.

         Form. 679.   Spiritus Castorei Comp.
  ft Castorei contr., Jiij. ;  Croci  Stigin., Jj.; Herbs Art*.
      misis, Jvj.; Spirit. Tenuioris, ibijss.  Macera per diei
      sex, et  cola.  Deinde adde  Olei Anisi, Olei Juniperi,
      Olei Ruts, 55, 3j.  M.  Dosis, 3ss.~3jss., 3tiis vel 4tis
      horis.

         Form. 680.  Spiritus Terebinthinatus.
  R Olei Terebinth., Jjss. ; Spirit. Vini Rect., Jvj.  Distills
      leni cum calore.   Dosis, Ttlvj.-xx.  (In Jaundice.)

     Form. 681.  Spiritus Terebinthinatus Comp.
  R Saponis Albi, Jij. ;  Opii, Jss. ; Spirit.  Vini Junip. (vulgb
     Hollandii) Jxijss.; Spirit. Terebinth. Rect., Jiv.; Cam-
     phors, Jvj.  Macera  bene, et cola.  (Externally as a
     Liniment; and internally in Colics and Nephritic Com-
      plaints, in doses of from 10 to 20 drops, and in Dropsies.)


         Form. 682.   Suppositorium Opiatum.
  R Opii Puri, gr. ij. ; Saponis Duri  Hisp., gT. iv.  Simul
      contunde, et fiat massa pro Suppositorio.

    Form. 683.   Suppositorium Plumbi Compositum.
 R Emplastrum Plumbi, part. viij.; Abietis Resins cont.,
     part. ij. ; Opii  Puri  pulveriz., part, ss.-j.   Solve Em-
     plastrum et Resinam ; deinde adde Opium, et forma io
     Supposit.


           Form. 684.  Sirupus Belladonns.
  ft Fol. Belladonnas, 3>j.;  Rad. Bellad., 3j.; Sacchar. Albi,
      Ibj.  Aqus, q. s.,  ut sit Decocti, tbj.

        Form. 685.  Sirupus Morphis Acetatis.
  ft Morphis Acetatis, gr. iv. ; Sirupi Clanficati, Jxvj. Miscs
     ut fiat Sirupus.  (In doses of from two tea-spoonfuls to
     a table-spoonful every three hours, or only at bedtime.)

       Form. 686.  Sirupus Morphis Sulphatis.
 ft Morphis  Sulphatis, gr. iv. ; Sirupi  Clarificati,  Jxvj.
     Misce.  (In the same doses  as the Acetate.   May be
     given  alternately with the Acetate.)

            Form. 687. Sirupus Papaveris.
 R Extracti Papaveris  Veri (in vacuo prep.), Jj.  Solve in
    Aq. Destillats Ferventis, Oj.; cola,  et adde Sacchari
    Purificati, Ibijss.

      Form. 688.  Sirupus Potassii Sulphureti.
 R Potassii Sulphureti, Jj.;  Aq. Hyssopi vel Fosuiculi, Jij.
    Solve,  et adde Sacchar. Albi, Jiv.; et macera in baluw
    arenario.

             Form. 689.   Sirupus Quins.
 ft  Sirupi  Simplicis, Jviij.; Quins Sulphatis, gr. xxxij
    capiat Cochlear, ij. minima, bis terve de die.

        Form. 690.  Sirupus Rhei Compositus.
 R Rad. Rhei concis. et  contus., Jiij. ; Fol. Senns, Jij.; Ca
    nells Corticis  cont., Jss. ; Semin. Fosniculi cont., Jj.;
    Potasss Carbon.  3,j.;  Rad.  Zing, concis., 3j. ; Aqus
    Ferventis, Ibij   Macera per horas viginti quatuor loco

    P„r?f  ft*  COla,,xL.,qcC0lat° adde Mantt*. 5"J- i Sacch
    rurif.,  Ibnjss.  Fiat Sirupus.

       Form. 691.   Sirupus Senn* et  Manns.
ft Fol.  Senns, Jiv.; Semin. Fosniculi cont., Jjss.; Sem.
    Anisi cont  3»J. I Radicis Zingiberis, jjUf; Aq. Fer-
    ventis,  O..J.  Digere  per horas  quatuor;  exprime it
    C^*' J>™S°^at* *We Manns Optimi  ?T  Sac
    cban Albi, Jxx.j. ;  et fiat Sirupus.        ' 3 J" '

       Form. 692.  Sirupus Sulphureti Sodii
ft  Sods Purs (cum Alcoh. pr*p.),  3j., Aq. Destillat., 3v.j 
APPENDIX OF FORMULAE.—Sirupus—Tinctura.                  xxvii
    Liquefac. leni  igne, et adde Sulphuris  Puri  quantum
    solv. potest.
ft Liquoris, Jj.  ; Sirupi Communis, Jxxxj.   Misce bene in
    vase bene obturate. (Doses of 3j.-3ij. for infants, Jj.-Jiij.
    for adults.)


    Form. 693.  Tinctura Acetatis Ferri Comp.
ft Acetatis Plumbi, Jss. ;  Ferri Sulph., 31 ij.; Aceti, Alco-
    holis, aa, Jij.; Aq. Ross, 3vj.  Solve Acet. Plumbi in
    Aceto cum  lento igne ; dein adde Sulph.  Ferri in Pulv.,
    cui post  solutionem, infunde  Alcohol, cum Aq. Ross
    permistum.

Form. 694*  Tinctura Acetatis Morphis Composita.
R  Morphis Acetatis, gr. xvj.;  solve in  Aq. Destil., 3iij. ;
    Acidi Acetici, lllv.; Tinct. Lavandul. Co., 3vj. ; Spirit.
    Myristics, vel Tinct. Cinnamom. Comp., 3vij. M.  Do-
    sis, 11lx-3J-

    Form. 695.  Tinctura JEtherea  Valerians.
ft Radicis Valerian, pulver., Jj.; iEtheris Sulphurici non-
    rectificat., Jvj.; Alcohol. Rect if., Jj.  Macera per tri-
    duum et cola.

Form. 696.  Tinct. Aloetica Alkalina.  (Saxon Ph.)
R Croci Stigmat.  in pulv., part. j.; Aloes Socot. in  pulv.,
    part. jss. ;  Myrrhs pulv., part. ij.; Carb. Potasss, part.
    iv. Misce, et pone  in locum humidum ut deliquescat;
    dein infunde Aq.  Ferventis, part. xij.  Macera per ho-
    ras duodecim, et adde Alcoholis Concent., part,  duode-
    cim.  Digere leni cum calore per dies tres, et cola.  In
    dos. 3ss.-3jss.

      Form. 697.  Tinctura Alkalina Potasss.
R Potasss Hydratis, Jss.; Alcoholis Concent., Jiv.  Ma-
    cera per dies septem in balneo urenario.

      Form. 698.   Tinctura Alkalina Stibiats.
R Antimonii Crudi, Jj.; Potasss Carbon., Jij.  Melt in a
    crucible, and  reduce them to yellowish scoris; then
    powder them  immediately in a hot iron mortar, and
    pour  upon  them  rectified Alcohol, Jvj.  Macerate for
    three days, and filter.

            Form. 699.  Tinctura Amara.
R Alogs  Socot., Jiv. vel. v.;  Gum. Myrrhs, Mastiches,
    Benzoes, Rad. Calumbs concis., 55, Jij.; Rad. Gen-
    tians, Jjss.:  Croci Stigm., Jj.;  Spirit.  Vini  Gallici
    (Brandy), tbix. ; Spirit. Vini Hollandii (Hollands), Ibiij.
    Macera per mensem, et cola.  (The celebrated " Drogue
    Amere" of the Jesuits, and an excellent tonic and ape-
    rient.)

     Form. 700.   Tinctura Ammoniaci Alkalina.
 R Gummi Ammoniaci, Jiij.; Liq. Potasss Carbon., Jijss. ;
    Myrrhs, Jj. ;  Alcoholis, Oj.  Macera per dies septem,
    et cola.  Dosis, 3SS.-3JSS.

        Form.  701.  Tinctura Balsamica.  (1.)
R Olei Terebinth., Jj.;  Tinct. Myrrhs, Jij.; Tinct. Ben-
    zoini Comp., Jiv.  Macera in loco calido.  (Internally,
    and to Indolent Sores, &c.)

        Form.  702.  Tinctura Balsamica.  (2.)
ft Balsami Tolutani, Jss.; Balsami Peruviani, Styracis Bal-
    sami, Acid. Benzoic, Myrrhs, 55, 3iij.;  Croci Stigmat.,
    3ij. ;  Spirit. Vini  Rect., Jxx.  Macera per dies  tres, et
    cola.   (Wirtemburg Ph. nearly.)

       Form. 703.  Tinctura Balsami Tolutani.
ft Balsami Tolutani, Jj. ; Semin.  Anisi cont.,  Jj.; Acidi
    Benzoici, Jss.; Spirit. Rectificat., Oj.  Digere, donee
    solvatur Balsamum ; dein cola.

          Form. 704.  Tinctura Belladonns.
ft Belladonns Foliorum  exsiccatorum, Jij. ;  SpiritOs Te-
    nuioris, Oj.   Macera per dies quatuordecim,  et cola.

       Form. 705.  Tinctura Benzoica Anodyna.
ft Camph. rasas, 3jss. ; Ipecac, Balsami  Tolutani, 55, Jss.;
    Acidi Benzoici, 3ij. ; Opii Puri, Croci Stig., 55, 31JSS. ;
    Olei Anisi, 3J ; Spirit. Vini Ten., tbij.  Macera  bene,
    et cola.  Dosis, fllvj.-xxx.   (The Tinct. Opii Benzoica
    Compos, of the Aust.  Phar., and Tinct. Anodyno-Su-
    dorific. of various foreign Pharmacopoeias.)

            Form. 706.  Tinctura Bruci.e.
ft Brucis Purs, gr. xij. ; Alcoholis (s. g. 837), Jj.   Solve.
    (3j. contains gr. jss. of Brucine.  Dose  JSS.-31J.)

             Form. 707.  Tinctura Calami.
ft Calami Radicis contusi, Jiv. ; Spiritus Tenuioris, Oij.
    Macera per dies quatuordecim, et per chartam cola.
    Form. 708.  Tinctura Camphors Thebaics.
R Opii Pulveriz., 3iij.; Camphors, 3vj. ; Corticis Canellas
    contus., Croci Stigmat., 55, 3ij.; Caryophyllorum, Pulv.
    Capsici, 55,  3jss. ; Potasss  Carbon., 3ij- ;  Olei Anisi,
    3jss. ; Spirit. Vini Tenuior.  (vel Sp. Vini Gallics, vel
    Sp. Vini Hollandii), Oij.  Macera leni cum calore per
    dies viij. ad xij. ;  dein exprime et cola.

      Form. 709. Tinctura Caryophyllorum.
R  Caryophyllorum contus., Jiij.;  Spirit. Vini Tenuior.,
    Oij.  Macera bene, et cola.

    Form. 710.   Tinctura Cascarills Alkalina.
ft  Corticis  Cascarills cont., Jiv.; Potasss Carbon., Jss.;
    Spirit.  Tenuior.,  Ibij.  Macera bene, et cola.  Dosis,


     Form. 711.  Tinctura Castorei Alkalina.
ft  Castorei contus.,  Jiij.; Potasss  Carbon., 3iij. ;  Croci
    Stigm., 3ij. ; Spirit. Rorismarini, Ibij.  Macera per tri-
    duum, et cola. M.  Dosis, Jss.—jij.

    Form. 712.  Tinctura Centaurii Cacuminum.
R Centaurii Cacumin. (flowering tops of Centaury), Jiij. ;
    Spiritds Tenuioris, Oij.  Digere per dies quatuorde-
    cim, et cola.

    Form. 713.   Tinctura Cinchonis Sulphatis.
ft  Cinchonis Sulphatis, gr. xxxvj.; Alcoholis Rect., Jiij.
    Solve.  Dosis, 3j. —3iij.

            Form. 714.  Tinctura Conii.
R Conii Foliorum exsiccatorum, Jij.; Cardamomi Seminum
    contusorum, 3iij.; Spiritfls Tenuioris, Oj.  Digere per
    dies septem, et per chartam cola.

     Form. 715.  Tinctura Digitalis jEtherea.
ft Fol. Digitalis exsic. et pulv., part. j.;  iEther. Sulphur.,
    part. iv.   Macera  per  triduum,   et  cola.  (Dosis,
    fll.xx.-xxx.  ter die.  Several  Continental Pharmaco-
    poeias.)

      Form. 716.  Tinctura Diosms Crenats.
ft  Fol. Diosms Crenats, Jij. ; Spirit. Tenuioris, Oj.   Ma-
    cera per dies septem, et cola.  (Dose 3j.-3iij.)

          Form. 717. Tinctura Diuretica.
ft  Olei Juniperi, 3ss.; Spirit. JEtheris Nitrici,  Tinct. Digi-
    talis  JEtheres, 55, 31 ij.  M.   (Dosis, 3ss.—Jj., ter qua-
    terve in die.  Hufeland.)

       Form. 718. Tinctura Ferri JEthersa.
ft  Acidi  Hydrochlorici, Jij.; Acidi Nitrici Dilut., Jjss.;
    Ferri Liinaturua,  q. s.  Dissolve the iron in the  acids ;
    evaporate to dryness; afterward deliquesce the residue
    by exposure to the air, and  mix the deliquesced liquor
    with double its weight of Sulphuric ./Ether, agitating
    the mixture frequently until it assumes a golden yel-
    low colour;  then decant, and add  double the quantity
    of rectified Alcohol.  This Tincture may be used pre-
    viously to the addition of the Alcohol, or subsequently.
    In the  state of iEther the dose is from 16  to 20 drops ;
    in that of ^Ethereal Tincture, from 20 to 30 drops. It
    is useful in Diseases of Debility, and in Spasmodic Af-
    fections.

      Form. 719.  Tinctura Fructus Vanills.
R  Fructus Vanills concis. et contus., part. j. ;  Alcoholis,
    part. vj.  Macera leni cum calore per dies octo, et cola.
    (Nervine,  Analeptic, Excitant, <fcc.   1jfaff.)

      Form. 720. Tinctura Galbani Composita.
ft Galbani  Gummi Resins, Jjss. ; Piments Baccarum con-
    tus., Jj.;  Cardamomi  Semin.  contus., Jss.;  Spirit.
    Rectif., Oj.   Aq. Destil., Oss.  Macera per dies qua-
    tuordecim, et cola.

            Form. 721.   Tinctura Galls.
R Gallarum contus., Jij.; Spirit. Tenuioris, Oij. Macera
    per dies octo, et per chartam cola.

       Form. 722.  Tinctura Iodinii Fortior.
R Iodinii,  3ij. ; Spirit.  Rectificat., Jj.   Solve, terendo in
    vase vitreo.   (3j. contains five grains of Iodine.)  Dose
    Tfl,vj.-xxiv.

        Form. 723.   Tinctura Iodinii Mitior.
R Iodinii, gr. xxiv.;  Spirit. Rectif., Jj.   Solve, terendo in
    vase vitreo.   M.   (3j. contains gr. iij. of Iodine.)

       Form. 724. Tinctura Lobelis Inflat.*.
R Herb.  Lobelis Inflats exsic., Jij. ; Spirit. Vini Ten., Oj
    Digere  per dies decern, et  cola.  (Emetic in doses of
    3j. to 3ij.; Antispasmodic in doses of Ttlxx. to 3ss. ; and
    Diuretic in smaller quantities,) 
APPENDIX OF FORMULAE.—Tinctura—Unguentum

                                            Form. 741.
     Form. 725.  Tinctura Myrrhs Alkalina.
ft  Myrrhs, Jj.; Potassas Carb., 3vj. ;  Aq. Ferventis, Jiij.
    Tere ;  dein macera in balneo aren. ad mellis crassitud.,
    et adde Spirit. Tenuioris, Jx.  Macera  bene, et cola.
    Capiat 3j.-3ij. ex Infuso Anthemidis. (In Scrofula, &c.)

     Form. 726.  Tinctura Nervosa.  (Riemerii.)
R  Spirit. Cornu Cervi Rect., part. iv.; adde gradatim Al-
    cohol.  Rect., part. xvj.;  Camphors, part. ij. ;  Olei Ju-
    mp., partem j.  Solve.

        Form. 727.  Tinctura Nucis Vomics.
R  Extracti Nucis Vomics  exsic, gr. iv.; Alcoholis (36°),
    Jj.  Solve.  (3J. Tinct. ad gr. ss. Extracti.)

      Form. 728.   Tinctura Opii Camphorata.
        (Sive Elixir Paregoricum Pharm.  Pristin.)
R  Camphors, 3ij.; Opii Crud. in pulv., Acidi Benzoici,
    aa, 3j.; Olei Anisi, 3ss.; Potass. Carbon., 3j.  Omnia
    in mortario simul optime' terentur;  paulatim aflfunde
    SpiritQs  Tenuioris, Oij.; stent in  digestione  per  dies
    decern ; turn adde Radicis  Glycyrrh. inciss,  Jiv.; di-
    gere iterum per dies septem, et cola.

        Form. 729.  Tinctura Opii Composita.
     (Vel Laudanum Liquidum Verum Sydenhamii.)
R  Opii Puri contrit., Jij.; Croci, Jj.; Cort. Canells, Cary-
    ophyllorum, aa,  3jss. ; Spirit.  Vini Rect., Jiv.; Vini
    Hispan., Ibj.  Macera cum leni calore  per dies xvj.;
    dein exprime  et  cola.   (1llxv. equal to 1 grain of pure
    opium.)
   Form. 730.   Tinctura Phellandrii.  (Marcus.)
ft  Semin. Phellandrii Aq., Jss.; Alcoholis, Jvj.   Macera
    per horas xxiv., et adde Vini Burgundne, Jvj.   Macera
    per dies tres, et cola.  Capiat ttlx.-lx.  (In  Chronic
    Bronchial and Pulmonary Affections.)

      Form. 731.  Tinctura  Quins Sulphatis.
R  Quins  Sulphatis, gr. viij.; Spiritus Vini, Jj.  M.  Fiat
    Tinctura.
    Form. 732.  Tinctura Quins Sulphatis Acid.
R  Quinas  Sulphatis, gr. xlviij.; Tinct.  Aurantii Comp.,
    Jvss.; Acidi Sulphurici Dilut.,3ij. M.  Fiat Tinctura.
    (Dosis, 3ss. ad 3ij.)
    Form. 733.  Tinctura Riiatanis.  (Sprague.)
R  Krameris Radicis contus., Jiij.; Spiritus Tenuioris, Oij.
    Digere per dies octo, et per chartam cola.
     (This Tincture is strongly impregnated with  the medi-
    cinal  virtues  of  the root.  It is a very grateful tonic,
    when given according to the following formula:
R Infusi  Ross, 3x.; Acid.  Sulph. Aromat., T\[xv- ; Tinct.
    Rhataniau, Sirupi Rhoeados, 55, 3j.  M.   Fiat Haustus,
    ter in die hauriendus.)

     Form. 734.  Tinctura Rhatanis Aromatica.
R  Krameris Radicis contus., Jiij. ; Canells Corticis contus.,
    Jij.;  Spiritfts  Tenuioris, Oij.  Digere per dies decern,
    et per chartam cola.
   The following is an agreeable method  of exhibiting this
     tincture:
ft Infusi Aurantii Compositi, Jvj. ; Tinct. Rhatanis Aromat.,
     Sirupi Zingiberis, 5a, Jj.  Misce.  Fiat Mistura: cujus
     sumat coch. ampla iij. ter m die, urgente Languore vel
     Flatu.  (Sprague.)
        Form. 735.  Tinctura Rhei Anisata.
ft Radicis Rhei concis., Radicis Glycyrrh. concis., 53. Jij. ;
     Seminum Anisi contus., Sacchari Purif., 55, Jj. ; Spiri-
     tfls Tenuioris octanos, ij.   Macera per dies quatuorde-
     cim, et cola.
            Form. 736. Tinctura Rhodii.
ft Rhodii  Ligui ras., Jiv.; SpiritHs  Rectificati, Oj.  Macera
     per dies quatuordecim, et per chartam cola.

      Form. 737.   Tinctura  Sabins Alkalina.
ft Olei Essent. Sabinas, 31'j.; Tinct. Alkalius, Jvij. et 31'j.
     (F. 696).  Solve.  Dosis, fllxx.-xxx.

        Form. 738.  Tinctura Senns Amara.
ft Fol. Senns, part. vj. ; Radicis Gentianas concis., part. iv.;
     Corticis Aurantii exsic, part.  ij.; Cardamom. Semin.
     contus., part. j. ;  Spirit. Vini Ten., partes xlv.  Macera
     per dies quatuordecim, et cola.

          Form. 739.  Tinctura Stramonii.
ft Daturs Stramonii Seminum contus., Jij.; Spiritfts Te-
    nuioris,  Oj.  Macera per dies quatuordecim, et cola.

          Form. 740.  Tinctura Strychnis.
ft  Strychnis  Purss,  gr. ij.; Alcoholis  (sp, gr.  838), Jj.
    Solve, Dosis, Ulviij. ad xxx.
Macera
                       Tinctura Tabaci.

R  Fol. Nicot. Tabaci, Jij.;  Alcohol. Rect., Oj.
    per dies septem ;  exprime et cola.

      Form  742.  Tinctura Tabaci Composita.
R Tabaci Foliorum concis., Jss. ;  Camph. rass, 31* ;Spirit.
    Rectif., Aq. Destil., 55. Jiv.   Macera per dies octo, et
    cola.

     Form. 743.  Trochiscus Catechu Extracti.
R  Catechu Extracti  Pulv., Jiij. ;  Cinnamomi  Corticis  in
    pulv., 3jss. ; Olei Cinnamomi, fllv. ; Sacchari Purificati,
    Jxiv. ; Mucil. Tragacanth.. q. s.  Fiat massa in Tro-
    chiscos formanda.   (Sprague.)
       Form. 744.  Trochiscus Ipecacuanhs.
R  Ipecac Radicis Pulv., 3iv. ;  Sacchari Purificati, Ibij.;
    Mucil. Tragacanth., q. s.  Misce  secundum artem  ut
    fiat Troch. 480.  (Each lozenge contains half a grain of
    Ipecacuanha.  In recent  Coughs and in Diarrhoea.)

          Form. 745.  Trochiscus Lactucs.
R  Extract. Lactucs Concentrat. (Probart's), Extracti Gly-
    cyrrh., Pulv. Acacias Ver., 55, 3iv. Hsc optime terantur
    simul, et cum Aqua fiat massa, in Trochiscos formanda.

      Form. 746.  Trochisci Nitro-Camphorati.
ft  Extr.  Opii, gr. vij. ;  Camph. rass, gr.  xxvj.;  Potasss
    Nitratis, 3ijss.;  Sacchar. Purif., Jiij.; Mucilag., q. s,
    Misce bene, et divide in Tabulas 1., quarum capiat
    vj.-x. per diem.  (Chaussier.)

      Form. 747.  Trochiscus  Potasss  Nitratis.
ft  Potasss Nitratis Pulv.,  Jiv. ; Sacchari Purificati, ftj,
    Hsc optime Wrantur simul, et cum Mucil. Tragacanth.
    fiat massa in Trochiscos formanda.
      Form. 748.  Trochiscus Zinci Sulphatis.
ft Zinci  Sulphatis Purif., Jiv.; Sacchari  Purificati, fojj,
    Hsc optime terantur simul, et cum Mucil. Tragacanth.
    fiat massa in Trochiscos formanda.  (This mass should
    be equally divided, so that  each lozenge may contain
    gr. J of the Zinc.)


Form. 749.  Unguentum Antimonii Potassio-Tartra-
              tis, vel Febrifugum.  (1.)
ft Antimonii Pot.-Tart., gr. xxv.   Solve in Aq. Destil., q.
     s.; dein adde Antimonii Pot.-Tart. in pulv. subtiliss.
     redacti,  3jss.; Adipis Prsparat., 31.   Misce  bene, et
     fiat  Unguentum.  (Produces  Phlogosis, and  its anti-
     mony is partially absorbed.)

   Form. 750.   Unguentum Antimonii Potassio-Tar-
                     tratis.  (2.)
 ft Antimonii Pot.-Tart. in pulv.,3j. ; Adipis Prsparat.,Jj.;
     Camph. rass et subact., 3j.; Olei  Cajeputi,  Ttlxv.;
     Moschi, gr. iij.  Misce bend.

   Form.  751.  Unguentum Antimonii Potassio-Tar-
                     tratis.  (3.)
 ft Antimonii Pot.-Tart., 3jss  ; Adipis Prsparati, Jj.; Bal-
     sami Peruviani,  1fl,xv.  M.

      Form. 752.  Unguentum Argenti Nitratis.
 ft Argenti Nitratis Pulv., gr. xl.; Adipis Prspar.,  Jj.; Liq.
     Plumbi Di-acet., 3ij.  M.  Fiat Unguentum.

     Form. 753.  Unguentum Balsami Peruviani
ft Balsami  Peruviani, 3j.; Unguenti Elemi Comp., 3vij.
     Unguento balneo in aquoso liquefacto, adjice Balsamum
     Peruvianum, et fiat Unguentum.

      Form. 754.  Unguentum Belladonns.  (1.)
ft Belladonns Fol. recent., Adipis Prsparats, 55, Jiv. The
    leaves are to be bruised in a marble mortar ; after which
    the lard is to be added, and the two incorporated  by
    beating.  They are then to be gently melted over tlra
    fire ; and after being strained through a cloth, and the
    Belladonna well  pressed, the ointment is to be stirred
    till quite cold.  (Sprague.)

Form. 755. Unguentum Belladonns. (Chaussier.) (2.)
ft Ext. Belladonnas, 31J. ; Aq. Destil., Jjss.  Tere cum Un-
    guenti Simp., vel cum Axungia, Jijss.   M.

Form. 756.  Unguentum Calomelanos  et Camphors.
R  Calomelanos, Camphors, 55, 3j. ; Olei  Caryoph., miv-:
    Unguent. Simp., 3ij. M.

Form.757.  Unguentum Calomelanos cum Camphora.
R  Calomelanos 3ij.;  Camphors, 3J.; Unguenti Simp, (vel
    Ung. Sambuci Flor.), 3vj.  M.  Fiat Unguentum.

  Form. 758.  Unguentum  Camphors Compositum.
ft  Saponis Albi rasi, Jjss.; Camph. rass, 3iij.;  olei Tere. 
ADDENDA TO APPENDIX.—Balsamum—Bolus.
XXIX
    binthin., Jss.  Misce paulatim, et adde Liq. Ammonis,
    3j.  M.

         Form. 759.  Unguentum Comitisss.
R  Olei  Piments, Olei  Olivs, 55, Jijss.;  Cers Flavas, Jj.
    Solve, et  adde Pulv. Piments, Jiij.:  Pulv. Gallarum,
    Pulv.  Nucis Cupressi, Pulv. Sem. Plantagiuis, Pulv.
    Fol. Toxicodend., 55, 3jss.; Sulphatis Aluminis,  3j.;
    Camphors rass, 3ij.  Misce bene, et sit Unguentum.

      Form. 760.  Unguentum Cupri Acetatis.
R  Cupri Acetatis, Hydrargyri Chlorid., 55, 3j.; Cerati Re-
    sins, Jj.; Terebinth. Vulgaris, Jss.  Liquefac. Resins
    Ceratum  in  balneo aquoso, et Terebinthinam adjice ;
    tunc Cupri Acetatem  et Hydrargyri Chloridum (prius
    cummistos) insperge, et omnia misce.

     Form. 761.  Unguentum Deobstruens.   (1.)
ft  Ammon. Hydrochlorat. pulveriz., 3j. ; Unguenti Hydrarg.
    Fort., Jj.; Extr. Cicutas,  3jss.   Misce  bene, et fiat
    Unguentum.   (Dr. Hunefeld.   Tumours,  Indura-
    tions,  &c)

     Form. 762.  Unguentum Deobstruens.   (2.)
R  Unguenti Hydrarg.  Fort., part. xciv. ; Ammon. Hydro-
    chlorat. pulveriz., part. vj.  Misce bend.  (M. Dupuy-
    tren.)

      Form. 763.  Unguentum Galls  Opiatum.
R Gallarum in pulv. subtil., 3iij.; Opii Crudi Pulver., 3j.
    Unguenti Plumbi Acetatis, Jiij. M.  Fiat Unguentum.

 Form. 764.  Unguentum Galls Opio-Camphoratum.
ft Pulv. Nucis Gallarum, 3j.; Camph. rass et subacts in
    pauxillo Alcoholis, 3j.; Pulv. Opii Puri, Potasss Ni-
    tratis  pulveriz., 55,  3ss.; Adipis Prsparats, 3iij. ;  Olei
    Piments, fllxii.-xvj.  Misce bene, et sit Unguentum
    ter quaterve in die applicandum.

 Form. 765.  Unguentum Hypochloridis Sulphuris.
ft  Sulphuris Hypochloridis, 3J.; Unguenti  Simplicis, Jj.
    Misce bene.   (For Lepra, Psoriasis, and other Chronic
    Eruptions.)

       Form. 766.  Unguentum Potassii Iodidi.
ft Potassii Iodidi, 3ss.; Adipis Prsparats, Jjss.

           Form. 767.  Unguentum Iodinii.
ft Iodinii, gr. xij. ; Potassii Iodidi, 3iv.;  Adipis Suifls re-
    cent,  prspar., Jij.  M.

       Form. 768.  Unguentum Iodinii Opiatum.
 ft Iodinii, gr. xv. ; Potassii Iodidi, 3J. ; Adipis recent, prsp.,
    Jij.   Misce  ben£, et adde  Extr. Opii, gr. xxx.; Tinct.
    Opii,  3j.  Sit Unguentum

     Form. 769.   Unguentum Iodidi Hydrargyri.
                             No. 1.     No. 2.    No. 3.
 ft Iodidi Hydrarg.  .         . 3ij.      3iij.      3iv.
    Adipis Suifls recent.     . Jij.       Jij.       Jij.
       Misce.

        Form. 770.  Unguentum Iodidi Plumbi.
 ft  Iodidi  Plumbi, jij.~3iij.; Adipis Suil. recentis prspar., .
    Jij.   Misce.

          Form. 771.  Unguentum Nervinum.
 ft Unguenti Althss (vel Ung. Sambuci), Jiv. ; Liq. Ammon.,
    Jj. ; Camphors, Petrolei, Spirit.  Terebinth., 55, Jss. ;
    Olei, Rorismarini, 3ij.; Olei Bergamii, 3j. M. (Hufe-
    I.AND.)

          Form. 772.  Unguentum Populeum.
 ft  Gemms vel Oculor. Populi  Balsamifers vel Nigra con-
       Form. 785.  Balsamum Odontalgicum.
ft  Omi Puri, Camph. rasie, 55, 3j. ; solve  in Spirit. Rect.
    Terebinth.,  3jss.;  Olei Caryoph. et Ol.  Cajeputi, 55,
    3ss. ; Balsam. Peruvian., 3tj.  Misce bene.


      Form. 786.  Bolus Camphors Compositus.
R  Camphors,  gr.  v.-xv. ; Hydrarg,  Chlorid.,  gr. v.-xx. ;
    Opii  Puri, gr. j.-iij.; Conserv. Rosaruin, q. s., ut fiat
    Bolus.
    Form. 787.   Bolus Camphor.e et Hyoscyami.
ft  Camph. subacts, gr.  v.-xij.; Extract.  Hyoscyami, gr.
    tus., Ibss. ; Butrei recentis, Ibj.  Liquefac simul lento
    igne, vel in balneo arenario, et exprime.

  Form. 773.  Unguentum Populeum Compositum.
R Gemms Populi Bals. vel Nig. recentis, fojss.  Contunde
    cum Adipis Prsparat., ftiij., et adde Fol. recentis Hy-
    oscyami  Nigri, Fol. recentis Belladonns, 55, Jiv. Con-
    tunde simul, et macera leni cum calore donee dispareat
    humiditas; dein exprime.  (All the German Pharma-
    copoeias.)

    Form. 774.  Unguentum ad Porriginem.  (1.)
ft Sulphuris Sublimati, Unguenti Picis Liquids, 55, Jjss. ;
    Saponis Mollis, Ammon. Hydrochloratis, 55, Jss.  Misce.
    Fiat Unguentum.

    Form. 775.  Unguentum ad Porriginem.  (2.)
ft  Hydrargyri  Chloridi, 3>'j.; Aluminis Exsiccati, Plumbi
    CaTbonatis, 55, Jss.; Terebinth.  Venet.,  3vj.; Cerati
    Cetacei, Jjss.  Misce.   Fiat Unguentum.

    Form. 776.  Unguentum Sulphureti Iodinii.
ft Sulphureti Ioclinii, gr. xv.-xxv.; Axungias, Jj.  M.

       Form. 777.   Unguentum Zinci Iodatis.
ft Zinci Iodatis, 3J.; Adipis Prsparats, Jj. M.
        Form. 778.  Vinum Aloes Alkalinum.
ft  Alogs Socot.,  Croci Stigm.,  Myrrhs, 55, Jj.; Potasss
    Carbon., Jij.; Vini Alb. Hispan., Ibij.  Macera per dies
    xij., et cola.  In dos. 3ij.-Jj.  (In Pyrosis, Dyspepsia,
    &c.)

   Form. 779.  Vinum Aloes et Sods Compositum.
ft Sods Carbonatis, Jiij.; Ammon. Sesquicarbonatis, 3ivss.;
    Myrrhs, 3yj. ; Aloes Extracti, 3vj. ; Vini Albi (Sherry,
    Anglice), Jxxiv.   Macera per dies septem, et cola.
    (The dose is from one fluid drachm to half a fluid
    ounce.)

        Form. 780.   Vinum Anthelminticum.
ft  Extr. Aloes, Asafcetids, Radicis Gentians, Camphors,
    Corticis  Aurantii sic, Castorei, 55, 3j.; Croci Stig.,
    3j. ; Spirit. Vini  Ten., tbiij.; Vini Oporto, Ibiij.  Ma-
    cera leni calore, et post horas xij. cola. Capiat 3ij.~3ij.
    in Decocto Anthemid., &c.

 Form. 781.   Vinum  Diureticum Anti-arthriticum.
ft  Potasss Carbon., Jijss.; Pulv. Rhei, Juniperi Baccar.
    cont., 55, Jjss. ; Rad. Zedoarii concis. et contus., jij. ;
    Canells in pulv., 3iij- ; Scills Rad. exsic, 3j. ;  Vini
    Xers, Jxxxij. Macera bene, et cola.  Capiat Jj.-Jij.,
    bis terve quotidie.

Form. 782.   Vinum Ferri Citratum.   (Phar. Wirtem.)
ft  Ferri Limaturs, Jiv.; Aurantiorum Amar., No. iv.  Ex-
    corticatis Aurantiis, cortices et succulenta caro fruc-
    tuum cum Limaturis Ferri  in pastam redigantur mor-
    tario in lapideo.  Dies post tres infunde Vini Madei-
    rensis,  Jxij. ; Tinct.  Aurantii, Jij.   Macera per diem
    integrum, et cola. Dosis, 3SS.-3JSS.

            Form. 783.   Vini Ferri Comp.
ft  Ferri Sesquioxidi, Jj., vel Ferri Fragmentor., Jiij.; Ra-
    dicis Calami Arom., Jij.  Infunde Vini Albi Hispanici,
    Ibij., et stent in digestione  per dies 6-8.  Exinde su-
    mantur  quotidie'  uncia una  vel dus,  et suppleatur
    vinum.

              Form. 784.  Vin um Quins.
R Vini Madeirensis, Jviij.; Quins Sulphatis, gr. xvj.  M.
    v.-x.;  Potasss  Nitratis, gr. v.-viij.;  Conserv. Rosar.,
    q. s.  M.   Fiat  Bolus, hora somni sumendus.   (In
    Puerperal Mania, and in Mania after Evacuations, to
    be accompanied with cold sponging the head.)

            Form. 788.  Bolus Catechu.
R Catechu Extr., gr. viij.—xij. ; Confect. Aromat., gr. viij.,
    Sirup., q. s.  M.  Fiat Bolus.

      Form. 789.  Bolus Moschi et Camphors.
ft  Moschi, gr.  v,-x. ; Camph, rass, gr.  iij.-viij. ;  Spirit.
    Rect.,  fllj. ; Confect. Ros. Gall., q. s,  Camphoram cum
    Spiritu tere, et  deinde, secundum artem, flat Bolus.
ADDENDA  TO  APPENDIX  OF  FORMULAE. 
xxx
   ADDENDA  TO  APPENDIX.—Electuarium—Haustus.

Electuarium Deobstruens.
       Form. 790.
R Potasss Bitart., .Jj.;  Biboratis Sodas, 3iij. ; Sulphur.
    Pruscipit., 3yj.; Confectionis Senns, Jjss. ; Sirup. Zin-
    giberis, 3vj. ;  Sirup. Papaveris, 3iij.  M.  Fiat Elec-
    tuarium, cujus capiat cochlearia duo minima omni nocte.

    Form. 791.  Electuarium Ferri Sesquioxidi.
R Ferri Sesquioxidi, Sirupi Zingiberis, 55, Jss.; Confectio-
    nis Aurantiorum, Jij.   M.  Fiat  Electuarium, de quo
    capiatur moles nucis moschats bis vel ter quotidie


  Form. 792.  Emplastrum Antimonii Potassio-tar-
                      tratis.
R Emplast. Picis Comp. quantum  velis ; super Alutam ex-
    tende, et Antimon. Pot.-Tart.  pulvere leviter insperge.
    Fiat Emplastrum.

     Form. 793.  Emplastrum Picis et Petrolei.
ft Picis Liquids, Jij.;  Galbani, Jj.; Sulphuris, Succini, 55,
    3ij. ;  Semin. cumini cont., Pulv. Flor. Anthemidis, 55,
    3jss. ; Petrolei, Jss.  Liquefac Galbanum cum Aceti,
    q. s., idque  misce cum Pice liquida;  dein adde alia, et
    misce bene.
            Form. 794.  Enema Commune.
R Sodii Chloridi, Jvj.-Jj. ; Decocti Avens, Jx.;  Olei Lini,
    Jjss.-Jijss.  M.   Fiat Enema.

          Form. 795.  Enema Ipecacuanhs.
R  Rad. Ipecac, contrit., 3j. ; Aq. Ferventis, Jx.  Macera
    per horam et fiat Enema.


              Form. 796.  Fotus Conii.
R Conii Folior. exsic, Jj.  Coque ex Aquas, Oijss. ad Oij.,
    et cola.


          Form. 797. Gargarisma Capsici.
ft  Capsici Baccarum contus., gr. xv.; Aq. Ferventis, Jix.
    Infunde per horas tres, et cola.
ft  Liquoris Colati, Jvijss.; Acidi Hydrochlorici, fllxxv. ad
    fllxxxv. ; Tinct. Myrrhs, jiijss. ; Mellis Ross, Jss.  M.
    Fiat Gargarisma.  (The Biboras Sods, Extractum Cat-
    echu, or any other astringent, may be substituted, ac-
    cording to circumstances, in the place of the Hydro-
    chloric Acid.)

   Form. 798.  Gargarisma cum Soda Chlorinata.
R  Liquoris Sods Chlorinats, Jxij.; Aq.  Destillat., Jvj. ;
    Mellis, Jss.  M.  Fiat Gargarisma, sspe utendum.
Form. 75
Gargarisma Stimulans.
R Infusi Petal. Ross Gallics, Jvjss.; Acidi  Hydrochlor.
    Diluti, 3ij. ; Tinct. Capsici, 3jss. ;  Mellis, 3iij.  Fiat
    Gargarisma sspe utendum.

      Form. 800.  Gargarisma Zinci Sulphatis.
R Zinci Sulphatis, 3j.; Aq. Ross, Jvij.;  Oxymellis Simpl.,
    f. Jj.  M.  Fiat Gargarisma, frequenter utendum.


            Form. 801.  Gutts ^theres.
R Camph. rass, 3j.; Spiritils jEther.  Nit.,  Jss.; Tinct.
    Valerians, Jij.; Aq. Fontans, Jjss.   M.  Capiat 3ss.
    ad 3ij. pro dosi.

      Form. 802.  Gutts jEtheres Absinthii.
ft Olei Absinthii, 3ss.;  Spirit. Etheris Sulphurici Comp.,
    et Spirit. Vini  Rect., 55,  3ij.  M.   Sumat sger  gut.
    xx.-xxx. omni hora, aut omni bi aut  trihorio.

        Form. 803.   Gutts Antispasmodics.
ft Tinct. Ammon. Comp., 3yj. ; either. Sulphur., Jj.:  Olei
    Anthemidis, 3j. ; Tinct. Opii Comp , 3ij.;  Extr. Papa-
    veris Albi, 3j.   M.  Capiat fllxx.-xlv. in cyatho Infus.
    Anthemidis, vel Infus. Flor. Sambuci, vel Decoct. Hor-
    dei Comp., <fec  (Grimaud.)

          Form. 804.  Gutts Odontalgics.
ft Opii Puri  et Camphors, 55, gr. x.  Solve in pauxillo Al-
    coholis, et adde Olei Caryophyl., 3j.; Olei Cajeputi, 3j.
    Misce bene.—Vel,
ft Camph. rass, 3ss. ; Tinct. Opii, 3j.; Creasoti, 3j.  Misce
    bene.
          Form. 805.  Haustus Chlorins.
ft Solutionis  Chlorins, 359. ; Aq. Destillat, 3xij. ;  Sirup.
    Papaveris Albi, 36s.  M.  Fiat Haustus, 5ti« vel 6tis
    horis sumendus.
          Form. 806.  Haustus Arsenicalis.
R Confectionis Aromatic* 3j- ;  Aq.  Menth. ^ativs, Jj
    Tinct. Opii, Liquoris Potasss Arsenitis, aa, mvj.  M
    Fiat Haustus, ter quotidie sumendus.
      Form. 807.  Haustus Balsami Peruviani.
ft Balsami Peruviani, 7U.V. ad 3j. ; Mucilag. ^acis 3j.s
    Tere simul; et adde,  Mist. Camphors, J ].  Spiritus
    Anisi, 3jss. ; Aq. Anethi (vel Aq, Cinnam.), Jss.  Fiat
    Haustus, ter quaterve  de die capiendus.

   Form 808.   Haustus Belladonns et Cinchona.
ft Decocti Cinchons, 3xiv.;  Extract! Cinchons, gr. x.j
    Tinct. Belladonns, 1U«- (See F. ,04) ; Tinct. Auran-
    tiorum, 3jss.  M.  Ft. Haustus, ter in die capiendus,

        Form. 809.  Haustus Diaphoreticus.
ft Vini Ipecac, Vini Antimonii Pot.-Tart., 55, Itlx.; Liq.
    Ammon. Acet., 3ijss.; Mist. Camphors, Jj. ; Tinct. Hy.
    oscyami, Tllxxv.; Spirit. ./Ether. Nit., 3ss. ; Sirupi Au
    rantii, 3j.   M.   Fiat Haustus, quartis horis capiendus,

         Form. 810. Haustus Emmenagogus.
ft Decocti Aloe's Comp.,  Jj. ; Biboratis Sods, 3ss.-3j.;
    Tinct. Aloe's Comp., 3j.; Tinct.  Castorei, 3j.; Tinct.
    Croci, 3ss. ; Aqus Cinnam., 3ij.  Fiat  Haustus, omni
    nocte sumendus.

      Form. 811.  Haustus Hyoscyami et Anisi.
ft Extracti Hyoscyami, gr. iij.-v.; Tinct. Scills, TUx.-xij.;
    Spirit. Anisi, 3jss. ;  Aq.  Anisi,  Jjss.;  Acidi  Nitrici,
    Tllviij.   Fiat Haustus, horis tertiis vel quartis durante
    paroxysmo Dyspnoeas, &c, capiendus.

           Form. 812.  Haustus Nervinus.
ft Spirit. Ammon.  Foetid., Tinct.  Colchici  Comp., Spirit.
    .dSther.  Nit., 55, 3ss. ;  Liquor Ammon.  Acet.,  31J.;
    Mist. Camphoras, Jj. ;  Sirupi Croci, 3j.  M. Fiat Haus-
    tus, bis terve in die sumendus.

          Form. 813.  Haustus Pectoralis.
R Balsami Peruviani (vel Bals. Tolutani). 3ss.-3ss.; Olei
    Anisi, TIlv.-x.; Extr. Conii, gr. iij.—vj.; Mucilag. Gum-
    mi  Acacis, 3ij.; Aq. Piments  et Aq. Fceniculi, 59,
    Jss.  M.

        Form.  814.   Haustus Quassis et Ferri.
ft Tinct. Ferri Sesquichlor., 111vj.-xij. ; Infusi Quassis, Aq.
    Cinnam., 55, 3vj.; Tinct. Calumbas, 3j.  M. Fiat Haus-
    tus, mane et meridie sumendus.

            Form. 815.  Haustus Salinus.
ft Potasss Carbonatis, 3j.; Succi Limonum recentis,  Jss.;
    Mist. Camphors, Jj.;  Potasss Nitratis, gr. x. ; Sirupi
    Rhceados, 3j.  M.  Fiat Haustus, quarta quaque hoift
    sumendus.

      Form. 816.  Haustus Salinus Aromaticus.
ft Potasss Carbonatis, 3j. ;  Succi Limonum recentis, Jss.
    vel q. s. ; Aqus, Jj.; Spirit. Myristics, Sirupi Aurantii,
    55, 3j.  M.

      Form. 817.  Haustus Salinus Demulcens.
ft Mist. Amygdal. Dulc, Mist. Camph., aa, Jss.; Vini Ipe-
    cac, Tllx. ; Potasss Bicarbonatis, gr. xv. ; Sirupi Sails,
    3j.   M.   Sumatur cum Succi Limonis coch.  uno am-
    plo, in effervescentis impetu ipso.

      Form. 818.  Haustus Salinus Sedativus.
ft Potasss Nitratis, gr. vj.-xv.  ; Sods Carbon., gr. x.-3jss.;
    Tinct. Hyoscyami,  jss. (vel  Tinct. Camphors Comp.
    pnstin.,  jj.) ; Mist.  Camphors, Aq. Menth. Virid., 58,
    3vj. ; Sirup. Croci, 3ss.  M.   Fiat Haustus, tertiis vel
    quartis horis sumendus.

           Form. 819.  Haustus Sedativus,
ft Ammon.  Sesquicarbonatis, gr. xv.  ; Aq. Destillat., Jj.;
    Spirit. Myristics, 3j.; Sirupi Aurantii,  Jss.; Extr.
    Conn, gr.  nj.-vj. Fiat Haustus, ter quaterve quotidie
    sumendus, cum  Succi  Limonis recentis cochleari  uno
    magno, in  effervescentis impetu.

   Form. 820.   Haustus Sedativus cum Magnesia.
ft Magnes. Carb.,  3ss.; Aq. Menth.  Virid., 3xj.  • Spirit.
    Anisi  jjss.; Olei Caryoph., mj. ; Sirupi Zingib., 3ss.
    M   Fiat Haustus.                   r     e  > J

  Form. 621.   Haustus Sedativus et Refrigerans.
ft Potasss Nitratis, gr. x.  ; Tinct. Opii, filvj.; Sirupi Pa-
    pav. Adi., 3«J-:  Mist  Camphors, 3x.  Misce.  Fiat
    Haustus, omni 6tjl hora sumendus.

     Form.  822.  Haustus Tonicus Alkalinus.
ft Potasss Bicarbonatis 3j. ;  infusi  Gentians  Compos.,
    Aq. Pimentos, 55, 3vj.;  Tinct. Rhei, 31.  M  Fhtt HW
    tus, meridie et hora somni sumendus 
ADDENDA  TO  APPENDIX.—Infusum—Mistura.
     Form. 823.  Infusum Angelics Sylvestris.
ft  Radicis  Angelic. Sylvest., Calam. Aromatici, 55, 3iij. ;
    infunde cum  Aq.  Font. Ferventis, Jvj.  Stent per ho-
    ram  in  vase  clauso; cola, et adde Liquoris  Ammon.
    Acetat., Jss.  ; ^Etheris  Sulphur., 3jss.; Sirupi Cort.
    Aurantii, 3iij.  M.  Fiat Mist.  Capiat sger qualibet
    hora cochleare unum.

       Form. 824.  Infusum Anisi Compositum.
ft  Seminum Anisi, 3jss.; Foliorum  Melisss  Officinalis,
    3j.;  Aq. Communis Calidas, Ibij.   Infunde per quad-
    rantem hors ; cola,  et  adde Sacchari Albi  quantum
    libet.

             Form. 825.   Infusum Galls.^
ft Gallarum contus., Jij.;  Aq. Ferventis,  foj.  Macera per
    horas viginti  quatuor, et cola.

          Form. 826.  Infusum Serpentaris.
ft Radicis Serpentaris, 3iij.;  infunde cum Aq. Ferventis,
    Jviij.,  ebuil.  paul.  Cola, et adde JEiher. Sulphur.,
    3ij.; Tinct. Camphors  Comp., 3j.  M.  Capiat  sger
    qualibet hora cochleare unum.

    Form. 827.  Infusum Turionum Pini Abietis.
R Turionis Pini Abietis, 3iij.; infunde Aq. Fervid., Jx. per
    semi-horam ; dein exprime, cola, et adde vel Potasss
     Carb., vel  Potasss Sulphatem, vel Spir. JEther. Nit.,
    vel Sp. Junip. Comp., ut sit occasio.


           Form. 828. Injectio Astringens.
 ft  Quercus Cort. cont., 3vj.;  Aq. Destil., Jx.  Coque per
     partem hors sextam, et cola.
 ft  Liquoris Colati, Jiv.; Infusi  Lini, Jiv.; Extr. Conii,
     jjss.; Biboratis Sods, 3j.  M.
       Form. 829.  Linctus cum Ipecacuanha.
ft Olei Amygdalarum, Sirupi Limonum, sing., Jj.; Pulveris
    Ipecac, gr. vj.; Confectionis Ross Canins, Jj. ; Pulv.
    Tragacanth. Comp., 3iij.  Misce.  Cochleare minimum
    subinde deglutiatur.

          Form. 830.  Linctus Refrigerans.
R  Pulps Tamarindorum, Sirup. Althss, 55, Jij.; Potasss
    Bitart., jijss.; Potasss Nitratis, Jjss.  M.  Sumat omni
    trihorio duo cochlearia parva.

         Form. 831. Linctus Terebinthins.
R Olei Terebinth., 3ij.-Jj.; Mellis Despumati, Jj.-Jijss. ;
    Pulv. Radicis  Glycyrrh., q. s., ut fiat Linctus, de quo
    sumatur cochleare  paTvum vel  medium, nocte, mane
    meridieque.


           Form. 832.  Linimentum Opiatum.
R Tinct. Opii Comp., Jss.; Camphoras, 3ij.; Olei Amygdal.
    Dpilc, Jij.  M.  Sit Linimentum.


        Form. 833. Lotio Acidi Hydrocyanici.
ft Acidi Hydrocyanici, Jij.; Plumbi Acetatis, gr. xvj. ; Aq.
    Destill., Jvijss.; Spirit. Vin. Rect.,  31J.  Fiat Lotio,
    parti  affects applicanda.  (Thompson, in Cutaneous
    Eruptions.)

    Form. 834. Lotio Acidi Nitro-Hydrochlorici.
ft Acidi Nitro-Hydrochlor.  Diluti (F. 5), 3ij.-Jss. ; Aq. Ca-
    lids, Jxvj.  M.  Fiat Lotio, quamprimum prsparata,
    Bit, ope spongis, utenda.


       Form. 835.  Mistura Alkalina Anodyna.
ft  Sods  Sesquicarbonatis,  3j. (vel  Potasss Bicarb., gr.
    xvj.);  Misturs Amygdalarum, Jjss. ; Tinct.  Hyoscya-
    mi,  Tllxx.-3ss. ; Tinct. Cardam.  Comp., 3ss.   Fiat
    Haustus, bis vel ter die sumendus.

       Form. 836.   Mistura Ammoniaci et Conii.
ft  Acidi Nitrici, 3j.; Aq.  Pulegii, 3iv.   Misce;  dein tere
    cum Ammoniaci, 3j-, et adde Extr. Conn, Jss.; Sirupi
    Tolutani. Jss.  M.   Capiat coch. unum in Decocto Al-
    thss, <fec.

            Form. 837.  Mistura Anodyna.
ft Aq. Menth. Virid., Jvjss. ; Potasss Nitratis, 3ij.; Spirit.
    ^Etheris  Nit., 31J.  ; Tinct. Hyoscyami,  3Jss. ; Succi
    Inspissati  Samb. Nig., 3i*s. ; Extracti Taraxaci, Sirupi
    Aurantii, 55, 3ij. M.  Fiat Mist., cujus capiat cochle-
    aria duo larga, ter quotidie.

       Form.  838.  Mistura Ante Cardialgiam.
ft  Magnesias,  3J-  ! Aq. Anethi, Jivss.;  Potassas Nitratis,
    jjss.;  Liquor.  Potasss, 3j.;  Tinct. Calumbs, 31J.;
    Spirit. Carui et Spirit. Anisi, 5a, 3ijss. ; Tinnt. Lavand.
    Comp., 3j.;  Sirupi  Zingiberis,  31J.   Misce.  Capiat
    cochleare unum amplum  subinde  in  cyatho Decoct.
    Hordei Comp., prius  agitata phiala.

    Form. 839.  Mistura Anti-Dysenterica.  (1.)
R  either. Sulphurici,  31J.; Tinct. Opii Comp., 3iij.; Sac-
    chari Alb., Jss. ; Gum. Acacis, Jijss.; Olei Anthemi-
    dis, 11lxv. ; Extr. Humuli,  3jss.; Extr. Catechu, 3j.;
    Pulv.  Canells Cort., 3j. ;  Aq.  Menth.  Virid., Jvjss.
    Misce bene.   Capiat cochlearia duo, tertiis vel quartis
    horis.
    Form. 840.  Mistura Anti-Dysenterica.   (2.)
ft  Mist. Camphors, Jv.; Liq. Ammon. Acet., Jij. ; Spirit.
    .(Ether.  Nit., jijss.; Vini  Ipecac, 3ijss.; Tinct. Hu-
    muli,  Jijss. ; Extr. Humuli, 3j. ;  Sirupi Papaveris, 3iij
    M.  Fiat Mist., cujus capiat cochlearia duo larga, ter-
    tia quaque hora.

         Form. 841.  Mistura Anti-Icterica.
ft  Potasss Acetat., Extracti Taraxaci, 55, Jss.; Extr. Conii,
    gr. x.-xx.;  Aq. Fosniculi, Jvjss.; Sirupi Sarzs et Si-
    rupi Senns, 55, Jss. M.  Capiat  cochlear,  ij. vel iij.
    ampla, 4tis horis.

      Form. 842.  Mistura Asafcetids et Conii.
R  Asafcetids, 31J.; solve in  Liquoris Ammon. Acet., Jjss.;
    Aq. Fosniculi, Jiijss.; Extr.  Conii,  3j.-3ss.; Sirupi
    Senegs, Jss. Misce.

    Form. 843.  Mistura Balsami Peruviani  Comp.
ft Balsami  Peruviani Ver., 3ij.; Mellis  Despumati,  3vj.
    Misce, et adde gradatim, Mist. Myrrhs (F. 422), Jvj.;
    Tinct. Aurantii, Jj.  M.   Fiat  Mistura, cujus capiat
    coch. j. ad iij., ter quaterve in die.

          Form. 844.  Mistura Beeladonns.
ft Extracti Fol. Belladonns, gr. ij. ad iv.; Moschi  Optimi,
    gr. vj. ad xij. ; Sacchari Albi, satis  quantum ut terendo
    obtineatur  pulvis congener ; deinde adde, paulatim
    miscendo, Infusi Frigidi Rad. Valerians, Jiv.; Spirit.
    .Sther. Sulphur. Comp.,  3j.; Sirupi Papaveris,  31 ij.
    M.  Capiat sger cochlear, ij. vel  iij. larga,  3tiis, 5tis,
    vel 6tis horis.

     Form. 845.  Mistura Camphors Ammoniata.
 ft Camphoras, 3j.; Alcoholis,  Ttlvj. ; tere, et adde Moschi,
    33s.; tere  cum Sacchari Albi, 3J. ; Mist.  Amygdal.
    Dulc, Jiv.; Spirit. Ammon. Arom., 3ij.; Sirupi Au-
    rantii, Jss.   M.   Capiat Jss.-Jj., 4tis horis.

            Form. 846.  Mistura Cardiaca.
 ft Potasss  Bicarbonatis, 3jss. ;   Mist. Camphors, Jvss.;
     Confectionis Aromatics, 31J.; SpiritOs  Myristics, Jss.
     M.  Fiat Mistura, cujus sumantur cochlearia tria am-
     pla cum cochleari uno Succi Limonum recentis, in actu
     effervescentis.

   Form. 847.  Mistura Chloratis Potasss et Sods.
 ft Liq. Sods Chlorinat., Jss.; Aq. Destil., Jiv.; Potasss
     Chloratis, 3j.; Aq.  Piments, Jiijss.  M.  Capiat coch.
    j.-iij., 2dis, 3tiis,  vel 4tis horis.

      Form. 848.  Mistura Cinchons cum Acido.
 ft Infusi  Cinchons, Jvij. ; Acidi Hydrochlorici Diluti, 3j. ;
     Tinct.  Capsici, 3ss.;  Tinct. Croci  vel Serpentaris,
     3iij. ; Sirupi Papaveris, 3ijss.  M.  Fiat Mist., cujus
     capiat coch.  ij. vel iij. ampla, 4ta q. q. hora.

    Form. 849.  Misturs Cinchons  et Acidi  Sulph.
 ft Decocti  Cinchons, Jvss.; Acidi  Sulphur. Aromat., 3j.;
     Tinct.  Opii, Itlxxx.  M.  Capiat tertiam partem ter
     quotidie.

             Form. 850.  Mistura Copaibs.
 ft Copaibs Ver.,  3iij. ;  Mucilaginis Acacis Ver.,  Jjss.
     Misce.  Adde gradatim, Aq. Cinnamomi, Jiijss. ; Sods
     Carbonatis,  3J. ;  Tinct.  Lavanduls  Composits,  3ij.;
     Tinct.  Opii, 3j. ad  3jss.   Misce.  Fiat Mistura, cujus
     capiat uno. j., ter quaterve in die, agitata phiala.

      Form. 851.  Mistura Cydonis Infusi Comp.
 ft Seminum Cydonis contus., 3ij.; Radicis Glycyrrh. con-
     tus., Jj. ;  Fici Caries FructQs, Jj.; Aq., Oj. Coque
     leni  igne per partem hors sextain ; dein cola.
 ft Hujus Decocti, Jvjss. ; Potasss Bitart., 3ij.;  Biboratis
     Sods, 3j. ;  Spirit. ^Ether. Nit., 31J. ; Sirupi  Mori vel
     Sir. Limonis, Jss.  M.  Fiat Mist.

        Form. 852.  Mistura Decocti Cinchons.
 R Decocti Cinchons, Jvss. ; Tinct. Cinchons,  311 j. ; Con-
     fect. Arom., 3jss. ; Spirit. Ammon. Arom.,  3jss.  M.

         Form,  853.  Mistura Decocti Genists.
 R Scoparii Cacumin.,  Jj.; Aqus,  Oj.; coque ad Jviij., et 
xxxii                  ADDENDA TO APPEN:

    adde Acetatis Potasss, jijss.; Spirit. Juniperi Comp.,
    3vj.  M.  Capiat coch. ij. vel iij. larga, ter quotidie.

         Form. 854.   Mistura Diaphoretica.
R Vini Ipecac,  3jss.: Spirit. JEther. Nit., Jijss. ; Liq. Am-
    mon. Acet., Jij. ; Liq. Antimon. Pot.-Tart., 3jss.; Mist.
    Camphors,  Jivss. ; Sirupi Papaveris, jiij.   M.  Capiat
    cochlear, j.  vel ij. terti5 quaque hora.

    Form. 855.   Mistura Diaphoretica Anodyna.
ft Mist.  Superscript. (F. 854), Jvijss.; Tinct.  Hyoscyami,
    Jjss. (vel Tinct. Camph. Coinp., Jvj., vel Extr. Conii,
    Jss.)  Fiat  Mist.

Form. 856.   Mistura cum Digitale et Kerm. Miner.
ft Kermis Mineral., gr. vj. ; Mucilag. Acacis, Jiij.; Infusi
    Digitalis, Jiv.; Sirupi Althsas, Jj.  M.  Capiat coch-
    leare unum amp. omni bihorio.  (In Pneumonia, Pleu-
    risy, <fcc, by Brera.)

         Form. 857.   Mistura Expectorans.
ft Asafcetids, 3ijss.; trituratione solve in Aq. Menth. Virid.,
    Jivss. ; et adde Vini  Ipecac, jj.; Spirit. jEther.  Nit.,
    3ij.  ; Tinct. Castorei, 3ij. ; Sirupi Tolutani, Jj.  Fiat
    Mist., cujus capiat cochleare  unum  amplum, 2dis vel
    3tiis horis.

  Form.  858.  Mistura cum Potassii Iodido et Acido
                   Hydrocyanico.
ft Aq. Destil.,  Jivss.;  Solutionis  Potassii Iodidi, nIxv.;
    Acidi Hydrocyanici  Medicin., TUx.-xij.; Extracti  Lac-
    tucs, gr. xij.; Sirupi Althss, Jj.  M. Capiat 31J.—3iij-
    omni hora,  vel Jss. omni bihorio.

       Form. 859.  Mistura contra Hydropem.
R Fol.  Digitalis, 3J.;  Corticis  Cinchons Pulv., 3yj.; Aq.
    Ferventis, Jxij.   Macera per horam, et cola.  Liquori
    Colato adde Potassas Bitart., 3iij.; Biboratis Sods, 3J.;
    Tinct. Cinnam. Co., Spirit. Junip. Co.,55, 3iij.; Tinct.
    Opii Co., 1Uxxv.   M. Capiat cochlearia duo larga, ter
    quaterve quotidie.  (Nearly as Augustin.)

    Form. 860.  Mistura Infusi  Anthemidis Comp.
R Flor.  Anthemidis, 3ij. ; Pulv. Rad. Valerian., Jiij.; in-
    funde Aq. Fontan. Calids, Jviij.  Macera paulisper,  et
    cola.
R Hujus Infusi, Jvij.  ; Tinct. Camph. Comp., Tinct. Cas-
    torei, 55, jij.; Sirupi Aurantii, Jss.  M.   Capiat sger
    qualibet hora cochleare plenum.

Form. 861.  Mistura Infusi Calumbs et Hyoscyami.
R Infusi Calumbs, Jvijss. ; Tinct. Hyoscyami, Jij. ;  Sods
    Carbon., Jjss. ; Tinct. Aurant. Comp., Jijss.   M.   Jss.
    ter  quaterve in die.   (In Diseases of Irritability.)

     Form. 862.  Mistura Infusi Calumbs Comp.
R Infusi Calumbs, Jiv.; Aq. Menth. Piper, vel Aq. Anethi,
    Jiij.; Spirit. Anisi,  3ij- ; Liquoris Ammon. vel Liquor.
    Potasss, 3ij.; Sirupi Cort. Aurantii, Jss.  M.

       Form. 863.  Mistura Infusi Valerians.
R Infusi Valerian., Jvss.; Liq. Ammon.  Acet., Jjss. ; Liq.
    Antimonii Pot.-Tart., 3jss.; Tinct. Hyoscyami,  3jss. ;
    Aq. Piments, Jss.  M.   Fiat Mist., cujus  capiat  asger
    altera quaque hortt cochlearia duo.

     Form. 864.  Mistura Hydrochlor. Ammonis.
R Ammon.  Hydrochlor., 3jss.; Acidi Hydrochlor., 3SS.;
    Decocti  Hordei Comp.,  foj.  M.  Capiat  cochlear, iij.
    ampla, 2dis vel 3tiis horis.

        Form. 865.  Mistura Salina Sedativa,
R Potasss Nitratis,  3ss.—Jij.;  Sods Carbon., Jj—jijss.;
    Mist. Camph., Aq. Menth. Virid., 55, Jiijss. ; Extr. Hu-
    muli, 3ij. ; Sirupi  Zingiberis, 31 ij.  M.  Fiat Mist.
    (Interdum  adde Tinct. Hyoscyami,  vel  Tinct.  Cam-
    phors Co.)

           Form. 866.  Mistura Sedativa.
R Mucilaginis Acacis, Jj. ; Olei Amygdalarum, Sirupi Pa-
    paveris Albi,  55,  Jss.; Tinct.  Hyoscyami, 3jss. ;  Vini
    Ipecac, 3ij. ; Aq. Destil., Jvss.; Acidi Citrici, q. s., ad
    gratam acidulationem. Misce.  Fiat Mist., cujus sumat
    coch. unum medium subinde.

      Form. 867.  Mistura cum Sods  Biborate.
ft Mist. Camphors, Aq. Anethi, 55, Jijss. ; Biboratis Sods,
    3ij. ; Vini  Ipecac, 3jss.; Sirupi  Papaveris,  3jss.  M.
    Fiat Mist., cujus  capiat cochlearia  ii. vel iij. quartis
    horis.

 Form. 868.  Mistura cum Sods Potassio-Tartrate.
ft Sods Potassio-Tartrat. pulver.,  3yj. ;  Mist. Amygdals,
    Jss  ; Spirilds Myristics,  Jss.   M.   Sumat tertiam
    partem,  secunda quaque hora.
>IX.—Mistura—Pilule.

        Form. 869.  Mistura Stomachica.  (1)
ft Calumbs Radicis contus., 3ss. ; Calami Aromatici cont.,
    3j.; Capsici Annui Bac. cont., gr. x.; Aq.  Ferventis,
    Jviij.   Macera per horas duas ; deinde cola.
R Liquoris Colati, Jvss. ; Liquoris Potasss Carbon., J'jss- j
    Tinct.  Myrrhs,  3j.;  Extracti Conn, gr. xv.; Sirupi
    Cort. Aurantii, 31J.  M.

        Form. 870.   Mistura Stomachica.  (2.)
R Infusi Cascarills,  Jvij. ; Sods  Carbon., jijss.; Tinct.
    Calumbs, ?ss. ; jEther. Sulphur., 31J. ; Tinct. Aurantii
    Co., 3iij.  ~M.  Fiat  Mist., cujus capiat  cochlear,  ij.
    larga, bis quotidie^
       Form. 871.  Mistura contra Tenesmum.
ft Mist. Camph., Jv.; Liq. Amnion. Acet., Jij. ; V|ni Ipe-
    cac, 3ij.; Tinct. Humuli, jijss.; Tinct. Camph. Com.,
    Jss.;  Extr. Humuli, 3ss. ; Sirupi  Papaveris, 3iij.  M.
    Fiat Mist.,  cujus capiat  cochlearia dun  lurga,  tertia
    quaque hora.

        Form. 872.  Mistura Tonico-Ateriens.
ft Decocti  Cinchons, Infus.  Senns, 55, Jiijss. ;  Potasss
    Sulphatis, 3iijss. ; Tinct. Senns, Jss.  M.  Fiat Mist.,
    cujus capiat cochlear, iij.  larga, bis quotidie.

      Form. 873.  Mistura Tonico-Deobstruens.
ft Extr. Taraxaci, 311 j. ;  Extr. Gentians, 3j.; Sods Car-
    bon., Jj. ; Aq. Aurantii, Jvij.; Spirit. ^Ether.  Sulph.
    Co., Sirupi Ross, 55, Jss.  M.  Capiat Jj.-Jjss., ter die

        Form. 874.  Mistura Zinci Composita.
R Zinci Sulphatis, gr. iv. ad vj.; Infus. Ross Comp., Jvij.,
    Vini Ipecac, 3jss.;  Extr. Lactucs, 3jss.; Sirupi To-
    lutani,  3ij.   M.  Fiat Mist.,  cujus  capiat cochleare
    unum vel duo larga, tertiis vel quartis horis.

          Form. 875.  Mistura Zinci Opiata.
ft Aq. Rosas, Aq. Cinnamom.,  55, Jiijss. ; Zinci  Sulphatis,
    gr. vij. : Tinct. Opii, fllxxxvj.! Tinct. Cinnamom. Co.,
    Jij.; Sirupi Aurantii, Jjss.  M.  Fiat Mist., cujus ca-
    piat cochlearia ij. ampla, bis die.


       Form. 876.  Piluls Alkalins Anodyns.
ft Sods Carbon, exsic, jj.; Saponis Duri, Jj.; Extracti
    Hyoscyami, Jss.; Olei Junip., q. s.   M.  Fiant Pilul.
    xl., quarum capiat  binas vel tres omni  nocte.  (For
    Nephritic and Calculous Affections.)

   Form. 877.  Piluls Aloes cum Ferro Composits.
 ft Aloe's, jij. ; Asafcetids et  Myrrhs, 55, 3ss.;  Ferri Sul-
    phatis, 3J. ; Caryophyllorum in pulv., 3j. ; Pulv. Cap-
    sici, gr. xxvj. ; Bals. Canad., q. s.  M.   Fiant Pilul.
    Ixvj., quarum capiat binas vel tres pro dose.   (In Chlo-
    rosis, &c )

             Form. 878.   Piluls Anodyns.
 ft Pulv. Jacobi Veri, gr. iij.; Extr. Stramonii, gr. ss.; Extr.
    Hyoscyami  (vel  Conii), gr. iij.  Fiant Pilul. ij., hoia
    somni sumends.  (In  painful  Cutaneous Eruptions.)

      Form. 879.  Piluls Anodyno-Alterativs.
ft Camph. rass, gr. vj.; Hydrarg. cum Creta, gr. xij.; Sods
    Carbon,  exsic, gr.  x. ; Pulv. Acacis,  gr.  iv. ; Extr.
    Hyoscyami, gr. xv. ; Sir. Simp., q s.  M.  Fiant Pilul.
    xij., quarum capiat tres statim, et hora somni.

           Form. 880. Piluls Aperientes.
ft Pulv. Radicis Rhei, 3ss.; Extracti Alogs Aquosi, gr.
    xviij.; Saponis Medicati,  3ss.; Sirupi Simp., q. s.  M.
    Fiant Pilul.  xx., quarum  sumantur bins vel tres, bis
    in die.

   Form. 881.  Piluls Aperientes cum Hyoscyamo.
R Extracti Gentianas, 3ss.;  Extracti  Colocynth. Comp.,
    3ijss. ; Pulv. Ipecac, gr.  viij. ; Pilul. Hydrarg., 3j.;
    Extr. Hyoscyami, 3ij. ;  Saponis  Castil.. gr. xij.  M.
    Fiat massa squalis, et divide in Pilulas xxxvj., quarum
    capiat binas vel tres hora somni.

          Form. 862.  Piluls Astringentes.
R Aluminis contnti, gr. v. ; Myristics Nucl. contr., gr. iv.;
    Extr. Gentians, q. s. (vel adde etiam Opii Puri, gr. j.)
    Fiant Pilul. dus pro dose.

  Form. 883.  Piluls Belladonns Extracti et Cin-
                       chons.
R Extracti Belladonns, gr. j. ad ij. ; Extracti Cinchona, 3j.
    M. Fiant Pilul. viij.   Capiat ij. Otis horis.

Form. 884.  Piluls Cambogis, Aloes, et Ammoniacl
R Cambogis, Aloes, et Ammoniaci, in pulvere,  partes
    squales: solve  in Aceto;  dein liquorem cola,'et con-
    sume  donee crassitudinem idoneam habeat.  Divide in 
ADDENDA TO APPENDIX.—Pilule—Pulvis.
xxxm
    Pilulas gr. iv.  Capiat binas ad quatuor pro dose.  (Diu-
    retic, Purgative.)
    Form. 885.  Piluls Camphors kt Ammoniaci.
R Massas Pilul.  AloiSs cum Myrrha, 3j. ; Gummi Ammoni-
    aci. 3j. ; Camphors, gr. x.; Sirupi Simplicis, q. s.
    Misce. Fiant Pilul. xx.  Omni mane capiat tree vel
    quatuor.  (StolL.)
       Form. 886.  Piluls Camphors et.Opii.
ft Camphors, Potasss  Nitratis, 55, 3ij. ; Saponis Hispan.,
    Jss. ;  Extr.  Opii Aquos., 3ss.; Sirupi Tolutani, q. s.
    M.  Fiant Pilul. cxx., quarum binas vel tres ter quo-
    tidie capiat.  (Cadet de Gassicourt.)

     Form. 887.  Piluls Camphors et Quinins.
ft Camph. rass, 3j. ; Quins Sulphatis, 3ij.; Masss Pilul.
    Aloe's cum Myrrha, 3jss. ; Sirupi Zingiberis, q. s.  M.
    Fiat massa  squalis, et divide m Pilulas xxxviij., qua-
    rum capiat unam bis quotidie.

          Form. 868.  Piluls Chalybeats.
ft  Ferri Sesquioxidi,  Jss.;  Pulv.  Canells Albs, 3iij.;
    Aloiis Socot., 3jss.  ; Sirupi Croci, q. s.  M.   Fiat massa
    squalis.

 Form. 889. Piluls  Colocynthidis cum Sulphurs.
ft Entr. Colocynth. Comp., 3J.; Sulphur. Sublimati,  3J. ;
    Potasss Sulphatis, 3iv.; Sirupi, q. s.  Divide  in Pi-
    lulas L.

  Form. 890. Piluls Colocynthidis Extr. et Hy-
                      oscyami.
ft Extracti Colocynth.  Compos., 3ij.; Extract. Hyoscyami,
    3j.  Misce, et divide in Pilulas xij.  Sumat unam vel
    duas pro re  nata.

      Form. 891.  Piluls Deobstruentes.  (1.)
ft Saponis Venet., 3j.; Pilul. Hydrarg., gr. viij.—xij.; Gum-
    mi  Ammon., 3»s.; Masss Pilul. Alogs cum Myrrha,
    3j.; Terebinth., q. s.  M.   Fiant Pilul. xxx.   Capiat
    tres vel quatuor de die.

      Form. 892.  Piluls Deobstruentes.  (2.)
ft Pulv. Gummi Guaiaci, 3j.; Pulv. Gummi  Ammoniaci,
    3j. ; Amnion.  Sesquicarbonatis, gr. xv.; Masss Pilul.
    Aloe's  cum  Myrrha, 3ijss.;  Tinct. Aloe's  Comp., q. s.
    M.  Divide in Pilulas xl.; e quibus sumantur tres ter
    in die cum vasculo Infusi Anthemidis.  (Altered from
     Stoll.)
    Form. 893.  Piluls Diuretics et Antispasm.
 ft  Pulv. Fol. Digitalis, Pulv. Rati. Scillas, 55, gr. xij.; Extr.
     Hyoscyami, 3j.   Divide in  Pilulas xij.  Capiat binas
     tertiis horis.  (Brera.)

  Form. 894. Piluls Diuretics cum Hydrargyro.
 R  Gummi Ammoniaci, Extracti  Taraxaci, Saponis Venet.,
     55, 3j.; Pulveris Scills, gr. vj. ; Pilul.  Hydrargyri,
     gr. xv.; Olei Junip., q. s.  M.  Fiant Pilul. xviij.

         Form. 695.   Piluls Expectorantes.
 ft Pulveris Scills, 3j.; Ammoniaci Gum. Res., 3jss. ; Ex-
     tract. Conii, 3ij.   Contunde simul, et divide massam
     in Pilulas squales triginta;  quarum sumat duas sextis
    horis. (In  Asthma and Chronic Catarrh.)

       Form. 896.  Piluls Gentians et Aloes.
 ft  Aloes Ext. Purif., Gentians Extr., 5a,  3j. ; Saponis Cas-
     til., 3jss.  M.  Divide in Pilulas xxxvj.  Capiat unam
     ad tres pro re nata.

        Form. 897.  Piluls Guaiaci et Aconiti.
 ft  Ext. Aconiti, gr. j.; Pulv. Guaiaci, gr. viij. ; Olei Caje-
     puti, q. s., ut fiant Pil. ij. Capiat unam mane nocteque.

           Form. 698.   Pilul* Humuli Comp.
 R Ammon. Sesquicarb., gr. vj.; Extr. Rhei, gr. viij.; Extr.
     Humuli, gr. xij.  M.  Fiant Pilul. vj., quarum capiat
     tres hora somni.

     Form. 899.  Piluls Hydrargyri  Composits.
 R Pilul. Hyd. Chlorid. Comp., 3ss.;  Pulv. Jacobi Veri, gr.
    xij. ;  Extracti Conii, gr. xxij.;  Saponis Castil., gr. vj.
     Contunde simul,  et divide  massam in   Pilulas  xij.
    squales, quarum bins omni  nocte sumantur.

        Form 900.  Piluls Ipecacuanhs Comp,
 ft  Pulv. Ipecac, gr. vj.;  Pulv. Ipecac Comp., Extr. Papa-
    veris,  aa, 3j ; Extr. Humuli, 3ss. ; Olei Anisi, q. s.
     M.  Fiant Pilul. xxiv.,quarum capiat unam quartis ho-
    ris, vel binas aut tres hora somni.

  Form. 901.  Piluls Morphis et Ferri Sulphatis.
 ft  Sulphatis Morphis, gr. ij. ;  Olei  Amygdal., q. s.;  ad
    solut. dein adde Fern Sulphatis, gr. vj.; I'ulv. Glycyr.,
    gr. viij.; Mellis, q. s., ut fiant Pilul. viij.  Capiat unam
    tertia quaque hora.

   Form. 902.  Piluls Morphis Hydrochloratis.
ft  Hydrochloratis Morphis, gr. j.; Pulv. Ipecac, gr.  iij. ;
    Extr. Aconiti, gr. vj. ; Olei Amygdal. Dul., TRvj.; Pulv.
    Glycyrrh. et  Mellis, 55, q. s.,  ut fiant P.lul. viij.   Ca-
    piat unam 3tiis vel 4tis horis.

       Form. 903.  Piluls Moschi Composits.
ft  Moschi, Potasss Nitratis, 5a, gr. vj.; Camph. rass, gr.
    vj.; Conserv. Ros., q. s.  Fiant Pilul. vj.

    Form. 904.  Piluls Calcii Chloridi et Conii.
ft Calcii Chloridi, gr. ij.; Extr.  Conii, gr. iij.-v.  Fiant Pi-
    lul. dus, bis in die sumends.   (In Scrofulous Obstruc-
    tions.)

         Form. 905.  Piluls Nervins.  (1.)
ft  Asafcetids, 3ss.; Castorei,  gr. vj.; Extract. Hyoscyami,
    gr. x. ; Extract. Anthemidis, 3j.; Sirupi Papaveris, q. s.
    M. Fiant Pilul. xij.  Capiat sgra duas mane nocteque.

         Form. 906.  Piluls Nervins.  (2.)
ft  Asafcetids, 3ij.; Camph. Subacts, gr. xvj.:  Moschi, gr.
    vj. ; Mucilag. Acacis,  q.  s.  M.   Fiant Pilul. xvj., e
    quibus sumatur una omni bihorio.

     Form.  907.  Piluls Nucis  Vomics et Aloes.
R  Pilul. Alogs cum Myrrha, 3iv.; Extracti Nucis Vomicas,
    gr. x.  M.  Fiant Pilul. xxxvj., quarum capiat unain ad
    duas, mane nocteque.

       Form. 908.  Piluls  Sarzs Composits.
R  Masss Pilul. Hydrarg.,  gr. viij.; Extr. Taraxaci, Extr.
    Sarzs,  55, 3v.  M.  Fiant Pilul.  xlviij., quarum ca-
    piat tres quater in die.

    Form. 909.  Piluls Scills  et Galbani Comp.
R  Pilul.  Galbani  Comp., 3j.  ; Pilul. Scills Comp., 3ij.;
    Ol. Juniperi, Ttlv.  M.  Divide in Pilul. xxiv., quarum
    sumat binas ter quotidie^

 Form. 910.  Piluls Sods  cum Rheo et Hyoscyamo.
R  Sods Carbon, exsic, 3ijss.;  Pulv. Rhei, 3j.; Extr. Hy-
    oscyami, 3ij.   M.  Divide in Pilulas  xxxvj., quarum,
    ter quotidie, bins sumantur.

          Form. 911.  Piluls Stomachics.
R Pulveris  Rhei,  Pulveris Zingiberis, 55, 3ss. ; Extracti
    Anthemidis, 3j. ;  Olei  Anisi, q. s.  Fiat massa, in Pi-
    lulas squales  triginta dividenda, quarum  capiat  tres
    ante prandium quotidie\   (In Dyspepsia  and  Chloro-
     sis, &c)
  Form. 912.  Piluls Sesquisulphureti Antimonii.
ft Antimonii Sesquisulphuret. Crud., Extract. Dulcamars,
     partes  squales.  Suit  Pilul. gr. iij.  Capiat iij. vel  iv.
     ter die.
      Form. 913.   Piluls Thebaiacs Composits.
ft Gummi Ammoniaci, 3j.;  Camphors, 3ss. ; Moschi Muse,
    gr. xx.; Pulv.  Opii, gr. x. ; Bals. Peruviani, q. s.   M.
    Fiant Pil. gr. iij.  Sumat sger unam hora undecim5,
    iterum vespere hora quinta ;  et cubitum petens sumat
    tres.

             Form. 914.  Piluls Tonics.
ft Extracti Gentianas, Pulv. Rhei, 55, 3ss.; Saponis Castil.,
     3j.  M.  Fiant Pilul. xviij., quarum sumantur bins ter
     quotidie.

             Form. 915.   Potus Aperiens.
R  Manns, Jjss. ;  Potasss Bitart., Jss.; Seri  Lactis, Oij.
     M.   Capiat cyathum pro re nata.

       Form. 916.   Potus Tamarindorum Comp.
ft Potasss Tartratis, Pulp. Tamarind., Gum. Arab., 55,  Jj.
     Solve in Aq. Font. Fervid., foij., et adde Oxymel. Simp.,
     Jij.  M.

     Form. 917.   Pulvis Ammoniaco-Camphoratus.
 ft Amnion. Sesquicarbon.,  gr. iv. ; Camphors pulveriz.,  gr.
     ij.;  Sacch. Albi, gr. xxiv.  M. pro dose ;  vel fiant Pil.
     ij., cum Mucilag. Acacis, omisso Saccharo.

        Form. 918.  Pulvis Anti-catarrhalis.
 R Kermis Mineral., gr. iij. ;  Florum Sulphuris, Pulv. Rad.
     Glycyrrh., 5a, j>r. xij.  Fiat Pulvis, ter die sumendus.
     (Quarin and  Barthez.)

             Form. 919.  Pulvis Aperiens.
 ft Magnes. Carbon., 3ij. ;  Potasss Bitart., 3j.; Pulv. Rhei,
     Pulv. Rad. Glycyrrh.,  55, gr. vj.-xij.  Fiat  Pulvis, omni
     nocte sumendus in theriaoa cumniuni. 
XXXIV
ADDENDA TO APPENDIX.—Pulvis—Vinum.
       Form. 920.  Pulvis Calumbs et Ferri.
R  Ferri Potassio-Tartrat., gr. x.-xv.;  Pulv. Calumbs, gr.
    xij.-3j.  Fiat Pulvis, ter quotidics capiendus.

    Form. 921.  Pulvis Camphors et Antimonii.
ft  Camph. rass, gr. xvj.;  Potasss Tartratis, 3j.; Antimon.
    Pot.-Tartrat.,  gr. j.  M. Probe, et in chartulas viij. di-
    vide ; quarum sumatur una, tertia qu5que hora.

         Form. 922.  Pulvis Diaphoreticus.
ft  Kermis Mineralis, Camphors, 55, gr. iij. ; Gum. Acacis,
    Sacchar. Albi, 5a, gr. viij.; Olei Fosniculi, 1tlj.  M.

          Form. 923.   Pulvis Lientericus.
ft  Hydrarg.  cum Creta, gr. iij.;  Pulv.  Ipecac. Comp., gr.
    vj. ; Pulv. Rhei, gr. v.;  Pulv. Cinnamom., gr. vij. M.
    Fiat Pulvis, bis vel ter die sumendus.

       Form. 924.  Pulvis Moschi Compositus.
ft  Moschi, gr. vj.-xij. ; Pulv. Rad. Valerian.,  3j.;  Cam-
    phors, gr. vj.  M.   Fiat Pulvis.

    Form. 925.  Pulvis Myrrhs et Ipecacuanhs.

R  Pulv. Myrrhs,  gr. xvj.; Pulv. Ipecac, gr. iv.; Potasss
    Nitratis  in pulv., 3ij.; Pulv. Opii, gr. j.   Misce  bene,
    et divide in doses squales quatuor.  Capiat unam quar-
    ta quaque hora.

         Form. 926.  Pulvis pro Torminibus.
R  Magnes., Sacchari Albi, 5a, gr. viij.; Pulv. Canells Cor-
    ticis, gr. ij. M.  Fiant Pulvis.

      Form. 927.  Pulvis  Resolvens.  (Stahlii.)
R  Pulv. Antimonii Comp., Potassas Nitrat., Ocul. Cancror.
    Prasp., 55, 3j.; tere bene simul.  Dosis 3j.

            Form. 928.  Pulvis Salinus.
R  Potasss Chloratis, gr. v.-xij.; Sodii Chloridi, gr. viij.-xx.
    Sodas Sesquicarbonatis, gr. x.-xv.; Olei Piments, vel
    Cajeputi, vel  Sine,  Ttlij.-v.   M   Fiat  Pulvis pro  re
    nata sumendus in decocto Hordei vel jusculo Bovino.

   Form. 929. Pulvis Sods Nitratis Compositus.

R  Sods Nitratis, gr. v.-3j. ; Pulv. Cinnam., gr. vj. ; Pulv.
    Ipecac,  gr. ss.-j. ; Olei Piments, TTlj. M. Fiat Pulvis,
    ter quaterve  in die sumendus.  (For Diarrhoea, Dys-
    entery.)

     Form. 930.   Pulvis Valerians Compositus.

ft  Pulv.  Rad. Valerian., 3j.-3ij.;  Magnes., Ammon. Hy-
    drochlor., 55,  gr. v.; Olei Cajeputi, HJij.  M
    Form. 931.  Solutio Belladonns *«"£%=,.
R  Extracti Belladonns, Jj.iAq. Destillat., Jj.   M.  F.at

    Solutio.
     Form. 932.  Solutio Cambogis Alkalina.

R  Gum. Res.  Cambogi*, 3... v^^i^'^^Hnd^
    tasss, Jss. Hujus f"^.. ^.m^j q««^
    quovis in vehiculo idoneo.  idui« v
    tic.   Hamburgh Dispensatory.)

   Form. 933.  Solutio Hydro-Sulphatis Calcis.
      A Hydrosulphate of the Protoxide of Calcium.
ft  Sulphur. Pulveriz., foj.; Calcis Vivi, foij. ; Aq  Fontans,
    foxv.  Coque per partem hors quartam, et cola.  (Pibb-
    quin's Antipsoric  Milk.  Hahnemann  and Passing
    recommend it as a gargle in salivation; and a dessert
    or table-spoonful of it is to be taken internally in some
    soup (mutton or veal broth), in cases of poisoning by
    mercurials.)
          Form. 934.  Solutio Refrigerans.
ft  Nitrat. Potasss, Jss.; Ammon. Hydrochlor., 3iij.; Aq.
    Pur., Jviij.  Solve leni cum calore, et adde Camphora
    pulverizat.,  3jss. ;  Alcoholis, q.  s.  Macera.  Capiat
    jj.-3iij., in Decocti Hordei cyatho.
         Form. 935.  Sirupus Antimoniatus.
ft  Kermis Miner., 3j.; Sirupi Scills, Sirupi Althaea, ai,
    Jjss.   M.   Capiat coch. j.-iij. minima, ter  quaterve
    in die.
         Form. 936.  Tinctura Astringens.
ft  Catechu, Myrrhs, 55, Jss. ;  Pulv. Cinchons, 31'j.; Bal-
    sami Peruvian., 3jss. ; Spirit. Armoracis Comp., Spirit.
    Vini Rectificati, 55,  Jjss.   Misce, et digere.  (For
    Sponginess of the Gums.)
        Form. 937.  Trochiscus Astringens.
R Catechu, Jij.; Moschi, 3ij.; Sacchar. Albi, Jiijss.; Mu-
    cilag. G. Tragacanth., q. s. Misce. Fiant Trochisci par-
    vuli.  (For Relaxation of the Uvula, Hoarseness, &c.)
     Form. 938.  Unguenti Chlorureti Calcis.
R Chlorureti Calcis in pulv. subtil, redac, 3ijss. ; Turbith.
    Mineral, in pulv., 3ij.   Misce  bene ; dein tere com
    Axung., Jijss. ; Olei Amygdal.  Dulc, Jj.  M.  Fiat
    Unguentum.


              Form. 939.  Vinum Ferri.
ft Tincturs Ferri  Sesquichloridi, 3j.;  Vini Albi Hispan,
    3xv.  M. 
INSANITY,
CONNATE.
625
recovery of the patients.  It is  difficult, and
even not very requisite, were it easy, to state
the classifications and arrangements which may
be adopted in various circumstances.  In these
matters, as well as in the organization and man-
agement of these institutions, medical knowledge,
and an acquaintance  with  mental disorders,
under  the guidance of common sense, will
generally  enable the  physician  to  arrive  at
judicious conclusions.  But in all arrangements
and modes of organization, a due separation of
the different classes of cases, and of convales-
cents,  should be secured ; and no asylum, pub-
lic  or  private,  should  be allowed or licensed
that is not placed under the  constant superin-
tendence of a regularly educated and qualified
medical practitioner, who should reside in it,
and be in constant communication with its in-
mates.  On this particular  topic, much infor-
mation will be  obtained in many of the recent
publications referred to in the Bibliography at-
tached to  this article.  I can furnish only a
brief abstract of what has been stated regard-
ing it by Pinel, Esquirol, and Georget.
  519. a.  The classification of lunatics is requi-
site, not merely for the  purpose  of separating
such as are liable to injure themselves or oth-
ers, but also with the view of permitting those
to associate  together  who  may  contribute  to
each other's cure.   A  lunatic asylum should be
composed of several parts,  more or less insu-
lated.  There ought to  be a quarter for each
sex; a division for  the violent;  a  second for
those who are tranquil; a third  for those la-
bouring under  accidental disorders or compli-
cations ; and a fourth for convalescents.   It
is, above all, necessary to separate the sexes,
the convalescents,  and those who have depra-
ved habits and indecent manners.  Divisions
should also be  allotted for those of melancholy
feelings;  for those  in a state of imbecility or
dementia ; for the  noisy and furious ; and for
those who are untameable, or are confined  by
way of punishment.  It would be preferable for
each division to have a court planted with trees,
and a garden for the patients to walk in.
  520. b.  It is farther  requisite, for  the con-
venience and safety of the patients, and to fa-
cilitate vigilant superintendence and protection,
that an asylum should be   built  on level  or
slightly elevated ground ;  that the cells for vio-
lent patients should be  spacious, with  a door
and window opposite each other, and opening
from without;  that they should be boarded, and
not paved; furnished with a  bed firmly fixed in
the wall; that all  the  cells  should communi-
cate with  covered  galleries  or  corridors,  in
which  the  patients may walk in  bad  weather,
and by means of which the inspectors and ser-
vants may easily pass  to different parts of the
building; that all the rooms should be warmed
by pipes containing hot water in  preference to
hot air ; that water should be abundantly sup-
plied ;  that the privies should be arranged  so
as to occasion no inconvenience to the patients ;
and that there should be places appointed for a
general work-room, for a common dining-room,
for baths, shower baths,  and douches.  There
should  be  suitable dormitories for convales-
cents,  melancholic  patients,  idiots, and those
who are debilitated.  For others,  little cells
with one bed are preferable; the patients go-
ing  out of them in the daytime, and associa-
       II           79
ting with one  another, no companions  being
allowed in the night.
  521. B. The  selection of the inspectors and at-
tendants in lunatic institutions is of great impor-
tance.  Insane persons look upon the attend-
ants as accomplices in the power  which has
deprived them of liberty, and as inhuman jailers,
view them with suspicion and hatred, and even
abuse and strike them.   It is often difficult to
make servants  understand the states of those
committed to their care, so as  to enable them
to preserve their temper, and to act with kind-
ness and firmness in all circumstances ; and it
is not easy to  convince them that  the insane
have the use of some of their faculties, and are
often quick, observant, and cunning.   Those
attendants who have been themselves insane
are generally the most careful, forbearing, and
kind to those over whom they are placed.  M.
Esquirol has  a favourable opinion  of conva-
lescents  as keepers : they are compassionate
to the infirmities which they have themselves
so  recently  suffered; they aid the physician
more efficiently;  and  their examples are en-
couraging to others.  The attendants ought al-
ways to be sufficiently numerous-—one attend-
ant to from eight to twelve male patients, and
one to from ten to fifteen females, according to
circumstances.   Old military men are among
the best keepers ;  for, as Dr. Conolly remarks,
they keep up their own authority, and are obe-
dient to superior orders.  The physician of a
lunatic asylum  ought to  be careful to  instruct
those who are to have the management of the
patients.  It is  absolutely requisite that a judi-
cious arrangement of authority and subordina-
tion be established in all asylums, and  that the
power of  the physician should be superior  to
all, in respect of everything that concerns the
patients.
IX. Insanity,  Connate ; and Puerile  Imbe-
  cility. -—Syn.  Idiolcy, Natural Idiotism, Con-
  genital Privation of Intellect, Puerile Imbecility,
   Weakness of  Mind, Silliness, Stupidity, Con-
  nate Fatuity,  Primary Fatuity, Idiotism, Men-
  tal Deficiency, Original Deficiency of Under-
  standing ;  Stupiditas, Vecordia, Amentia, Imbe-
  cillitas Ingenii; Fatuitas ; Amentia Congenita,
  Sauvages, Sagar, Vogel; Ddmence innee, Fo-
  dere; Idiotisme, Pinel; Die Spracheigenheit,
  Blndsinn, Germ. ; Idiotismo, Ital.
  522. Defin.—Deficiency or  entire privation of
intellect, appearing during infancy and childhood,
depending either upon an original defect, or upon
an arrest of the  development of the mental facul-
ties.
  523. Puerile imbecility and idiotcy may be con-
sidered as representing two grades  of  primary
mental deficiency.  The former is that state or
degree in which there is an original impairment,
but not an entire want of intellect.  The latter
is a more complete grade of  deficiency, some-
times amounting to an absence not only of the
moral and intellectual manifestations,  but also
of the instincts necessary to  self-preservation.
Between, however, this, the highest degree  of
idiotcy, and the slightest state  of intellectual
deficiency, there is every intermediate grade.
Original defect  of intellect  should not be con-
founded with the imbecility, or incoherency,  or
fatuity consequent upon other forms of insani-
ty, or upon cerebral diseases—the Amentia  ac-
quisita of authors;  nor with senile fatuity, im- 
626                         INSANITY, IDIO

becility, or dotage—the Amentia senilis.   The
distinction has been very properly made by Es-
quirol and Prichard ;  and most succinctly and
correctly stated by Dr. Klein Grant, under the
article Amentia, in his edition of Hooper's Med-
ical Dictionary.  Original deficiency and entire
want of intellect may appear unconnected with
any bodily disease ; may be simple and uncom-
plicated ; or they may be associated with  other
maladies, or complicated.  Complete idiotcy, es-
pecially, may  be farther associated with con-
genital  deficiency  of some organ  or part,  or
connected with malformation, or arrest of de-
velopment of some portion of the brain,  or or-
gan of sense.
  524. i. Deficiency of Intellect appears in
every grade and form until it amounts to com-
plete idiotcy. The slighter degrees of deficiency
are manifested chiefly by weakness of charac-
ter and  capacity, or by stupidity or deficiency of
the powers of perception, or of the understand-
ing.   These grades of  defect are generally not
sufficient to render an individual incompetent to
the management of his affairs, or to conduct
himself with propriety, and are hence not con-
sidered  sufficient to constitute unsoundness of
mind, in its legal acceptation.   But as the origi-
nal defect may present every grade,  from the
slightest of those just mentioned to complete  id-
iotcy, it is difficult to draw any line of demarca-
tion between what may be considered soundness
or unsoundness of mind.   This line must still
remain unfixed, or at best be only conventional*,
for no standard or criterion can possibly be  es-
tablished.   As in consecutive impairment  or
disorder of mind, so  in original  deficiency of
intellect, there are every shade and degree of
mental manifestation, descending from the high-
est state of perfection of the human understand-
ing  down to the lowest state of  privation of
intellect and of instinct;  there being no break
in the scale, or in the continuity of declension.
   525.  Deficiency of intellect begins  to appear
from the first to the eighth or ninth year of age.
When it  is congenital, it  may manifest itself
even somewhat earlier  than the former period.
When it arises from an arrest of the develop-
ment of the  mental  faculties, owing  to  injury
or physical disease, it may not be evinced until
a later period than that assigned.   In this lat-
ter case, the  deficiency is seldom  so great as
when it occurs at earlier stages,  or depends
upon changes that have taken place in the en-
cephalon either previous to or soon after birth.
   526.  From  what has been already stated, it
is obvious that all the grades and forms of ori-
ginal imbecility cannot be described within mod-
erate limits.   Nor is minute description at  all
requisite : the works of Georget and Esquirol
will furnish it, and numerous  illustrations of it.
I may,  however, briefly observe, that imbecile
persons have a limited capacity for certain ac-
tions or employments, and  acquire some de-
gree of facility in performing them.  These
they generally execute in a  tolerable manner,
while they are quite  incapable of any  other
modes of exertion or occupation.  Habit has a
great influence  on all  their  proceedings, and
gives to many of them  an  appearance of regu-
larity which may be mistaken for the result of
steadiness and of higher powers.  All are, how-
ever, deficient in the powers of attention and
thought.  They are generally timorous, often
TIC—Grades or.

docile, weak and  inconstant in  purpose, and
frequently irascible.   The senses of some give
rise to feeble and  dull impressions ; of others,
to more lively perceptions.   Memory is strong
in some; while in others it  is weak,  confined
in its range to the most ordinary  objects and
frequently repeated  ideas, or it hardly exists.
They display some indications of mind, of in-
tellectual faculties, and  of feelings and affec-
tions ; and they have the use of speech and of
language generally in a degree proportionate to
the grade of perfection of their several senses
and mental powers.   They show the same va-
rieties of character,  inclination, and moral pro-
pensity,  as persons of stronger understanding.
Left to themselves, they are careless,  lazy, and
filthy.  At the age of puberty, they evince the
animal instincts by the most  offensive gestures,
habits, and solitary vices.   Some become sub-
ject to paroxysms  of capricious  violence, to
hysteria, to nymphomania, or satyriasis.  Many
are prone to lying, pilfering, and stealing.  Sev-
eral lapse into melancholia,  or sink in a  grad-
ual decay of physical health—frequently owing
to  an uncontrollable addiction to masturbation.
In other circumstances, they  eat and digest well,
and  females  have  the catamenia regularly.
Some imbecile  persons  evince signs  of talent
in  particular pursuits,  particularly in  music
and the  ruder  of the imitative arts.  Others
have retentive memories, learn languages, and
are capable of other acquirements, while, in all
other respects, they are deficient in any talent,
and generally in mental  power.  They  com-
monly present much of the  character, in  man-
ner and  in the development  of mind, of infants
or  children.   They are deficient in affection, in
application to any  pursuit, in the powers of
comprehension, of pursuing a train  of ideas,
 and  of  entering  into a rational  or sustained
conversation.   They are  without energy and
steadiness, and are fearful and eowardly.   They
are incapable of  reflecting,  of contriving any-
thing, or of accomplishing anything.
   527. ii. Idiotcy.—More or less complete priva-
tion of the mental faculties.—This is the highest
grade of original deficiency of intellect.  In
this state, the moral, the reflecting, and the in-
tellectual manifestations are altogether want-
ing ;  and sometimes the instinctive  emotions
of  mind are also partially or totally undevelop-
ed.  Indeed, the different  states of idiotcy de-
pend chiefly upon the extent of deficiency of
this class of the mental  powers.  Those  in-
stinctive feelings and desires which are the
most generally bestowed on the animal creation,
and which especially subserve the preservation
of the individual and of the species (see Classif.
in note to $ 66), are chiefly present—frequently
in  an inordinate degree—and are deficient only
in  the most  extreme cases. Infants that  be-
come idiots have  large or ill-formed heads, im-
perfect features, take the breast with difficulty,
are long before their eyes follow the light, and
often squint.  They are puny, lean, of bad com-
plexion,  have a  feeble  physical  development
and vital endowment, are incapable of instruc-
tion,  cannot learn to walk until they are six or
eight years of age, or sometimes till they attain
the age of puberty.  They articulate imperfect-
ly,  or learn but a  few words, or are altogether
incapable of articulate sounds, although they
may possess the sense of hearing.  When the 
INSANITY,  IDIO
head is very small or very large, or flattened in
any direction, or much deformed, death gener-
ally takes place early—generally long before pu-
berty,  or at any age between this epoch and the
first months of existence.
   528.  Idiots, both children and adults, present
not only these deformities, but all those descri-
bed in the article Cranium. Their features are
irregular  and repulsive;  their eyes are blink-
ing, and deeply set; their lips  are large, thick,
flaccid, and relaxed;  their mouths are gaping,
and admit of a  drivelling of the  saliva;  their
organs of sense are  imperfect—they see and
hear imperfectly, or are entirely deaf and dumb.
Their  taste and smell are also deficient, and
they eat without selection of food.   If speech
exist at all, it is extremely limited, and drawl-
ing or lisping, and capable of expressing only
the most  urgent physical wants.  Their chests
are narrow or contracted; their limbs ill-form-
ed ; and  their gait, as well as  all their move-
ments  and attempts  at muscular exertion, un-
steady and  awkward.  They are  sometimes
club-footed, and the muscles of the arms or legs
contracted.  They are commonly rachitic, or
scrofulous—often partially or generally  para-
lytic, or subject to epileptic fits.   Not only are
they without the reflecting and intellectual fac-
ulties,  but even their  sensibility is deficient;
and sensation, when excited, is scarcely follow-
ed by  perception of objects or ideas.  They are
incapable of directing their attention  to  any-
thing.  Owing to the defective state  of their
instinctive  feelings, they appear far below the
brutes in the scale of animal  existence;  and,
as M. Esquirol remarks, are monsters or im-
perfect beings, who  are  destined to a speedy
extinction, if the tenderness of parents, or the
compassion of others, did not prolong their ex-
istence.  Yet idiots  have the bodily appetites
and sexual desires—sometimes in an inordinate
degree and repulsive manner.   They often ex-
hibit signs of premature  puberty, and are gen-
erally  addicted to masturbation.  They are
often, also, subject to  anger and rage.  Some
display faint glimmerings of intelligence, when
their notice is excited by strong impressions
on their senses.  They then appear to look  at
certain things with a vague expression of pleas-
ure, or of curiosity -, they seem to desire  some
objects, particularly articles of food; they occa-
sionally indicate, by  gestures or cries, objects
of desire or aversion, or the pleasure or pain
which they feel; they come to know the per-
sons who habitually  take care of them ; but
they are  incapable of  dressing or undressing
themselves, or of the common  acts of cleanli-
ness.   Others are debased to the lowest  state
of being—are sometimes  even  unconscious  of
their evacuations, and incapable of command-
ing or restraining them ; and enjoy only a vege-
tative  existence, devoid of sensation and sen-
sibility.   Idiots  of  a  higher grade of develop-
ment are capable of moving from place to place;
but are, like machines, made to repeat the  same
movements ; they move their arms, as if to fa-
cilitate progression ;  laugh mechanically; ut-
ter inarticulate  sounds, as if to amuse them-
selves  ; occasionally  catch a  few notes  of a
simple tune, which they constantly repeat; and
become attached to particular places and po-
sitions.
  529.  iii.  TheCoMFLicATioNs of imbecility and
>TIC—Causes of.                         627

 idiotcy are chiefly those already noticed (<J 523,
 528), more particularly rickets,  scrofula, gener-
 al or  partial  palsy, epilepsy, contractions  and
 malformations of the extremities, deficiencies
 of the organs of sense, goitre, and, still more
 particularly, Cretinism, which, in its fully de-
 veloped states, is always associated with more
 or less absolute want of the mental powers.
 (See art. Cretinism.)
   530. iv. The Causes of imbecility and idiotcy
 are  of importance, both in a medical and in a
 social point of view.—A. The remote causes are,
 1st. Those which are referable to the parents,
 and which operate previously  to birth; 2dly.
 Those which more especially belong to the pa-
 tient,  and which affect  him subsequently to
 birth.—a.  The causes which  operate previously to
 birth are, whatever exhausts or debilitates  the
 parents, or renders the reproductive acts  im-
 perfect ;* as habitual debauchery, solitary vices,
 and drunkenness;  sexual debility, or states ap-
 proaching to impotency ;  the insalubrity of cer-
 tain localities, particularly those observed to
 produce cretinism  (§  6);  the scrofulous and
 rickety diathesis; and the advanced age or de-
 bility of one or both parents. Esquirol states
 that idiotcy is more common in the country—
 especially in  mountainous  districts—than  in
 towns.  He, as well as numerous other writers,
 insists upon  the influence  of  violent mental
 emotions,  and moral shocks during the early or
 middle months  of utero-gestation.   Several
 modern writers  have affected to  doubt this
 cause ; and, as they cannot dispute the frequent
 occurrence of arrest of development of the ner-
 vous system,  and congenital deficiency of men-
 tal manifestations in the children whose moth-
 ers had been  thus affected during the period of
 their foetal existence, yet consider the phenom-
 ena in  no way connected, as  coincidences
 merely, and as  holding no relation of cause
 and effect.  The vulgar  opinion, however, of
 this matter is nearer the truth; and the evi-
 dence of the arrest of development having been
 produced  by  the mental, and the consequent
 physical shock of the mother during gestation,
 is much more conclusive than most of the evi-
 dence usually furnished us in physiological and
 practical researches, or than that upon which
 we are constantly acting in the discharge of our
 professional duties.   It  by no  means  follows
 that the phenomena which we cannot satisfac-
 torily  explain should therefore not exist, or
 that relations of which we cannot trace the con-
 nexion conclusively are on this account alto-
 gether wanting.  Yet, even here, however diffi-
 cult may be the explanation, or apparently loose
 the connexion, both the one and the other may
 be furnished conformably with views stated in
 this and  other articles.   It is not improbable,
 even, that the means sometimes used to con-
 ceal pregnancy, or to procure abortion, may so
 affect  the  development of the fetus as to pro-
 duce idiotcy.  The same causes which occasion

  * A physician was consulted by a gentleman  who  was
 anxious to marry, to secure a fortune in  his family, but had
 been some time deterred from marriage by a consciousness
 of weakened sexual powers, consequent upon masturbation
 in early life.  As he was young, and his constitution  had
 apparently not suffered seriously, he was advised to marry,
 under the conviction that a moderate exercise of the sexual
 functions would  assist in restoring their  energies.  The
 advice was adopted ;  but the first child  that was born  was
 an idiot.  The rater children were sound: he had gradually
 recovered his powers. 
628
INSANITY, PUERPERAL—Description of.
 congenital and chronic Dropsy of the Brain (cj
 283, et seq.) will sometimes cause more or less
 complete deficiency  of the mental  fuculties.
 Inflammation, or tubercular disease of the brain
 or of its membranes during fetal existence,
 will  disturb or arrest the subsequent develop-
 ment of these parts, and  of their respective
 manifestations.   Injuries of the  head of the
 fetus, sustained during parturition, have also
 produced this effect.
   531.  b.  The causes which operate  after birth
 are,  chiefly, injuries of the head; diseases  of
 the brain—particularly acute and chronic hy-
 drocephalus ; inflammations of the brain  or  of
 its membranes ;  convulsions ; dentition  ; ex-
 anthematous fevers—especially when attended
 by cerebral affections ; tubercular disease, with
 or without inflammation of the  encephalon;
 remarkable precocity in connexion with a sus-
 ceptible  and irritable state of the constitution ;
 and very early addiction to the vice of mastur-
 bation.   This last cause is frequently produc-
 tive  of  those states of imbecility, or slighter
 forms of mental deficiency, observed  at ad-
 vanced  stages  of childhood, or  near the ap-
 proach  of puberty.   To  these causes may be
 added the  use  of improper coverings  on the
 heads of infants and children, as ably illustrated
 by M. Foville {Deformat. du Crane result, de  la
 Meth. de couvrier la  Tete des Enfans.  Paris,
 1834.).
   532. B. The  pathological  causes are  chiefly
 imperfect, deficient, or interrupted development
 of the encephalon, and affecting it either par-
 tially or generally ; sometimes associated with
 changes of the  consistence and form  of the
 brain, and  not infrequently with some  of the
 usual consequences of old  or previous inflam-
 mation   of  the membranes—particularly the
 arachnoid, and of the cerebral structure.   Mor-
 gagni and others found the brain  harder  than
 natural.   Meckel says that  it is often  drier,
 lighter,  and more  friable than usual.  Mala-
 carne states, that the convolutions of the  brain
 are numerous in proportion to the intelligence,
 and that in idiots they are always few.   They
 are very generally smaller, less prominent, and
 less numerous in these persons than in others.
 M. Esquirol has observed the lateral ventricles
 uniformly very small  in idiots.   In some, one
 hemisphere is much less developed than the
 other; and, occasionally, one lobe is more de-
 ficient than the rest.   In these  cases, one or
 more  limbs have been paralyzed.   These  defi-
 ciencies  have been  more frequently observed
in the anterior than  in the  other lobes.   The
cerebral substance is sometimes softened in one
 part, and hardened in another.  For farther de-
tails,  see the articles  Brain,  Cranium,  and
Epilepsy.*
  * [The phenomena of idiotcy, at least, would seem to prove
that the mind is not independent of the brain, as maintained
above, as a very small brain is invariably a cause of idiotcy ;
and there is no instance on record where the mind has been
manifested vigorously by a very small brain.  But idiotcy
arises not only from deficiency of size, but also from disease
of the brain, or injuries, as already stated.  Partial idiotcy
is also not unfrequently met with where an individual man-
ifests one or several  powers of the mind with an ordinary
degree oT energy, but is deprived, to a greater or less ex-
tent, of the power of manifesting all the others. Our coun-
tryman, Dr. Rush, has particularly called attention to this
partial development of certain mental powers in idiots, and
the partial possession  of the moral faculties, a phenomenon
which, it would seem, can scarcely be reconciled with the
doctrine of a single organ of mind.]
   533 v  The Treatment of imbecility and id-
 iotcy is rather preventive than curative.  Preven-
 Hon depends entirely upon the avoidance of the
 remote causes,  and upon the employment of
 those  means which  tend to strengthen the
 physical powers of the parents, and ol the off-
 spring after birth.   That much  is owing to
 the  constitutional  powers of the parents, is
 shown by numerous facts, and by the circum-
 stance of several idiots or imbecile persons be-
 ing often met with  in one family.  Attention
 to the general health  of the  infant, good nur-
 sing, daily cold  ablutions, frictions of the sur-
 face, a dry and temperate atmosphere, frequent
 changes of air, and due promotion of the sev-
 eral secretions  and excretions,  are the  chief
 means by which a healthy development of the
 offspring of debilitated persons can be secured,
 In every case, a strong, healthy, and young wet-
 nurse should be procured immediately for the
 infants of such parents.  As dentition and  child-
 hood approach and advance, the means and the
 cares advised in the articles Age and Denti-
 tion  are especially  required.   The  curative
 means are limited to physical and moral educa-
 tion, which may be of use in the slightest forms
 of imbecility, but which are of no avail in the
 more manifest states,  and in idiotcy.
 X. Insanity, Puerperal.—Syn.   Insania  Puer-
   perarum, Mania Pwerperalis; Puerperal Ma-
   nia.
 ,  534. Defin.—Disorder or aberration of  mind,
 of either a partial or general form, occurring in
 any period of the puerperal states.
   635. i. Description.—Puerperal insanity may
 appear in a slighf or partial, or in a severe and
 general form. It most frequently, however, as-
 sumes the form of mania and melancholia.  In
 a  few cases  it presents a mixed  character, or
 that of melancholia alternating with mania. In-
 sanity may occur, 1st. At any time from con-
 ception to parturition—the insanity of pregnan-
 cy—Insania gravidarum; 2dly\ From parturition
 to about three weeks or a month subsequently
 —the insanity of parturition—Insania post par-
 turn; 3dly. At any  period during lactation, or
 soon after weaning—the insanity of lactation—
 Insania lactantium.  In the first of these peri-
 ods, it is usually slight  or partial, chiefly affect-
 ing  either the moral manifestations or the un-
 derstanding.  In the second, it most frequently
 assumes  the form of acute mania, sometimes
 passing  into  a chronic state, but rarely  assu-
 ming the character of dementia or fatuity.  In
 the third, melancholia,  slighter forms of mania,
 and partial insanity are the most common.  Any
 of these states of disorder, occurring in any of
 the periods now specified, may be simple or com-
plicated,in respect of  succession, or co-exist-
 ence with  some other malady, particularly hys-
 teric affections, epilepsy, convulsions, catalepsy and
 cataleptic ecstasy, uterine hamorrhage, disease of
 the uterus or ovaria.
   536. A. Insanity  during Pregnancy—Insania
 Gravidarum.— Pregnancy  generally occasions
more or less excitement of the  nervous and
vascular systems ;  and sometimes gives rise to
various morbid impulses or aberrations of mind,
especially in females hereditarily predisposed to
insanity.   The mental disorder may appear im-
mediately upon conception, and disappear on
quickening ;  or it may  occur at any period of
utero-gestation,  continue through, and cease 
INSANITY, PUERPERAL—Description of.
629
upon delivery, or it may persist through all the
circumstances consequent upon parturition.  In
this latter case, however, it seldom retains the
same  form or character, but passes into one
more  general or  severe ;  melancholia, or any
other  partial disorder, being aggravated  into
mania.   In  some cases,  the mental affection
commences as hysteria, or in some one or oth-
er of it's  numerous states ; and in two cases in
which I was consulted, it was preceded by cat-
alepsy and cataleptic ecstasy—affections  inti-
mately allied to hysteria.
   537. The most  frequent states of mental dis-
order observed in  this period are melancholia,
and the moral disorders described above (§ 69, et
seq.).   The  singular feelings and  desires,  the
whims and  caprices  frequently attending this
state, cannot be considered as amounting to in-
sanity, inasmuch as they seldom engross the
mind, or withdraw it from all  other thoughts
and pursuits, or overwhelm the natural feelings,
or influence the conduct.  As  soon, however,
as any singular desire exercises such  a sway
as this—when it engages the mind and influ-
ences the conduct, uncontrolled by natural sen-
timents  and  requisite occupations — it  then
amounts to moral  insanity,  and requires  both
moral and. physical treatment.   In some fe-
males, pregnancy occasions not only irrepress-
ible fears and melancholia, but also various dis-
ordered impulses, productive of crime  or vari-
ous unlawful acts, either before the control of
reason can be exercised, or in opposition to the
feeble efforts of the understanding (§ 92).   In
unmarried females, the  melancholic  feelings,
the irrepressible fears, and the morbid impulses
of the mind are often heightened by shame, re-
morse, the  abandonment of the seducer, the
consciousness of poverty, or the fears of ill
treatment.  Under such affliction, the mind may
be so disordered as to perpetrate various crimes,
or even  suicide.   In this state, consciousness
may be lost for a time, and acts be committed,
before it be restored, of the most flagrant na-
ture,  and the most repulsive  to the natural dis-
position and feelings.  This is the more likely to
occur if  the mental distress be  attended by fits
of leipothymia, or of fainting, or by convulsions.
In some cases, recovery from these attacks, or
the restoration  of consciousness, is  attended
by a short period of maniacal excitement, or a
state of  momentary delirium, during which su-
icide, murder, or incendiarism has  been per-
petrated.  In most cases of mental disorder oc-
curring during pregnancy, and in all that I have
seen, there was either an hereditary predispo-
sition to it,  or the patient had been previously
subject to obstinate hysterical  affections, and
had experienced overwhelming or intense emo-
tions of the mind.
   538. B. Insanity  after Delivery—Insania post
Purtum—Paraphrosyne Puerperarum, Sauvages.
—a. Insanity consequent upon parturition is
often preceded, during pregnancy, by harassing
fears and unfavourable presentiments.  In some
cases, various hysterical affections, preternat-
ural susceptibility, great exuberance or depres-
sion of spirits, suspicions, irritability, a state of
stupor or sopor, and slight or short attacks of
mental aberration, have occurred during gesta-
tion.  Generally  the disease appears  from the
second or third day to the sixteenth or seven-
teenth ;  but it may occur almost  immediately
after parturition, or be delayed to the third or
fourth  week.  Some writers  assign  the  third
and fourth, and the thirteenth, fourteenth, and
fifteenth days, as the most frequent periods of
its appearance.   The chance of an attack, how-
ever, progressively diminishes after the  third
or fourth  day.   The disorder may commence
with want of sleep, inquietude, sadness, anxie-
ty, or ill-grounded fears respecting some mat-
ter ; the phenomena of mania, or profound mel-
ancholia, supervening  upon  these symptoms.
Sometimes an explosion of mania takes  place
more or less suddenly; but more frequently the
patient's manner becomes quick, the temper ir-
ritable, and the nights restless, for two or  three
days before the attack.  The  form of the men-
tal disorder varies remarkably ;  but the mani-
acal states  are  the most common.   Next to
these are melancholia, and diversified forms of
monomania.  During either of these disorders,
and in melancholia especially, suicide  may be
attempted or committed.   Mania may alternate
with melancholia,  and  this last with other va-
rieties of partial insanity.  At first, and partic-
ularly  in cases occurring soon after delivery,
the disorder  is maniacal.  Sometimes the pa-
tient evinces a childish disposition for harmless
mischief; is gay and joyous ;  laughs, sings, and
talks loud and long, occasionally obscenely, and
is careless of the infant and of everything about
her.   She is  often, also,  suspicious ; imagines
everything poisoned; and is  busy with  some
idea, illusion, or some  fancied object.  In oth-
er cases, the maniacal excitement is much more
intense; and the  conversation and conduct
more violent.   These states may pass into mel-
ancholia, but very rarely into dementia or fa-
tuity.
   539. b. The physical  symptoms are referrible
chiefly to the digestive organs, and to the ner-
vous system.  The bowels are torpid, the secre-
tions and excretions impaired and morbid ; the
stools  are  unhealthy, and generally very dark
and  offensive; and, from inattention or  obsti-
nacy, sometimes passed without regard to the
natural calls.   The  tongue  is  moist, white,
furred, or loaded ;  and as the  disease proceeds,
it sometimes becomes brownish, mucous sordes
accumulating on the teeth and lips.   There is
little  or no  appetite, and rarely much thirst.
The pulse is frequent,  small,  weak, compressi-
ble ; and sometimes it is but little, or not at
all, accelerated, or it becomes less frequent as
the disease proceeds.  The skin is relaxed and
moist, particularly about the  neck,  and gener-
ally cool, especially on the extremities.   The
head is often hot,  or is warmer than usual, but
the heat is not always permanent; it frequent-
ly occurs at intervals,  and is  sometimes great-
est when the rest of the body is cool.   Occa-
sionally the scalp is cool throughout.   The gen-
eral heat of the body is rarely increased, unless
when  the  disease is coincident with the first
secretion of milk, or with inflammation of the
breasts, or unless when  caused by the violent
exertions of the patient.   Pain, sense of press-
ure, or tightness of the head,  is often felt, with
uneasiness of the scalp, noises in the ears, and
sometimes throbbingsof the  temporal arteries.
There is little or no sleep.  The face is gener-
ally pale, unless when the maniacal excitement
is great, and then  it is often  flushed or turgid.
The eyes  are  vivid or slightly red; but both 
630
INSANITY, PUERPERAL—Diagnosis.
 they and the face are occasionally pale, although
 the patient is most violent.  The abdomen is
 usually soft, cool,  and free from pain on press-
 ure, unless sometimes in the hypogastric and
 iliac regions.  The breasts are generally flaccid,
 and the secretion of milk either impaired or ar-
 rested ; but the milk, in  some instances, is not
 materially diminished, although  it is generally
 deficient in its healthy and nutritive properties.
 The lochia are  often deficient, but they are
 sometimes abundant or offensive.
  540. c. The  insanity of females recently de-
 livered commonly assumes the  form now de-
 scribed ; but  its character  varies remarkably :
 in some cases,  it nearly resembles sub-acute
phrenitis, delirium  supervening, as in the form
 of the disorder  described by  Dr. J. Burns,  in
 which the  symptoms of morbid vascular action
 in the  encephalon precede the mental disorder.
 In other instances, the insanity verges in its
 character towards low nervous fever; it is then
 generally preceded by watchfulness, fever, the
 supine posture, heat of scalp, and injection of
 the conjunctiva.  Images  or illusions super-
 vene, the ideas become rapid, and the delirium,
 passing into a muttering delirium, is soon con-
 firmed.  The  pulse is quick, and the milk and
 lochia are usually suspended.  Enough has been
 stated to show  that, as  regards puerperal in-
 sanity, as  well  as many other  maladies, the
 marked lines  of demarcation  attempted to be
 drawn by authors and  nosologists do not exist
 in nature ; but that there is a gradual approxi-
 mation of  character observed in this, to other
 diseases of the nervous system—that the tran-
 sition from puerperal  insanity to phrenitis on
 the one hand, and  nervous fever on the other,
 is often manifest; cases occurring in practice
 of an intermediate nature, and referrible to one
 malady as  much as to  another.
  541. C.  Insanity during  or  after Lactation—
 Insania Lactantium—Mania Lactea, Sauvages—
 is generally gradual in its approach ;  or  it is
 preceded by symptoms premonitory of its oc-
 currence.  When, however, violent impressions
 are made  upon  the  mind, or  the secretion of
 the milk is  suddenly disturbed, the disorder may
 burst forth unexpectedly.  Generally, howev-
 er, a change of temper or disposition is remark-
 ed for  some time previously.  The manner be-
 comes hurried, sleep disturbed, the temper irri-
 table, the countenance suspicious or distrust-
 ful, and the patient voluble and negligent of her
 infant.  At length, sleeplessness, incoherence,
 or violence of language and conduct, and delu-
 sions,  supervene.   Occasionally, various  hys-
 terical and cataleptic symptoms  are associated
 with these ;  and sometimes acts of violence,
 or attempts at  suicide,  are perpetrated, even
 before the  nature of the malady is suspected by
 her friends.  The disease may occur at any pe-
 riod of lactation ; but it is more frequent on
 weaning, or very soon afterward, than at any
 other time. The  melancholic and monomani-
 acal forms of insanity  are oftener observed du-
 ring this period,  than violent mania :  and when
 the latter occurs, it is apt to pass into melan-
 cholia, or to alternate with  it.  Insanity during
 this and the  preceding  periods  may  present
 some one or other of the complications noticed
 above (§ 166,  et  seq.).
  542. ii. Diagnosis.—The diagnosis of puer-
 peral insanity is sometimes difficult, especially
after delivery.  Some modem writers have err
deavoured to point out differences.rather than
to describe  the relations really subsisting be-
tween it and other diseases, especially phrenitis
and low nervous fever.   But, as I have already
stated, the transition of the one into the other
is not infrequent, or the pathological condition
of these maladies are very nearly the same m
many cases.  The absence of fever has been
considered as  particularly characteristic of pu-
erperal insanity ;  but fever accompanies a con-
siderable proportion of  cases, especially those
commencing about the fourth or fifth day, when
the secretion  of milk excites some degree of
febrile commotion in the system, and, at a later
period, when the lochia disappear.  Still, it  is
a rapidity  of pulse, and an irregular determina-
tion of blood,  with increase of heat about the
head, rather than fever, that are more com-
monly observed.
  543. a. In phrenitis, the patient has headache,
vertigo, throbbing in the temples, a beating
noise in the ears, flushing of the face, injection
of the conjunctiva, intolerance of light and of
noise, heat of the scalp, rapid pulse, dry skin,
suppression  or sudden diminution of the milk
and  of the  lochia,  constipated   bowels, and
scanty and  high-coloured urine, before deli-
rium appears ; and very frequently these symp-
toms are ushered in with chills or rigours.  In
proportion as these phenomena are manifested
before the mental disorder appears, the disease
may be viewed as possessing an  inflammatory
character. Puerperal phrenitis, moreover, soon
passes into stupor, coma, subsultus of the ten-
dons, catchings in the limbs, and unconscious
evacuations, and often terminates unfavourably
as early as  the third, fourth,  or fifth day, and
rarely passes  the eighth ;  whereas puerperal
mania, even in the most febrile and unfavour-
able cases, generally is prolonged beyond this
period, unless very injudiciously treated.  In
the former, the physical disease is manifest and
developed before the delirium appears, and  is
evidently the cause of it; in the latter, the men-
tal disorder is coetaneous with, or even pre-
vious to the physical disturbance.
  544. b.  When low nervous fever occurs after
delivery, or  during lactation,  it will hardly be
confounded  with this disorder, as the febrile
commotion  precedes  mental disturbance for
several  days; muscular power is prostrated,
the patient  preserving the supine posture, or
being incapable of continuing any other; the
pupils are  but little sensible to light; the tongue
is tremulous ;  the patient is sleepless, and com-
plains of confusion and giddiness, rather than
of pain of  head ; and when delirium supervenes
it is of an incoherent and muttering kind, and
very rarely violent or attended by muscular ex-
ertion.  The  pulse is very quick and small;
the bowels are readily moved ; and the lochia
or milk is  suppressed.   As the  malady pro-
ceeds, coma, startings of the tendons, pickings
of the bedclothes, unconscious evacuations, and
the usual phenomena of nervous exhaustion,
terminate  life.
  545. These maladies the discriminating phy-
sician will never confound with true puerperal
mania, and he will carefully  distinguish  such
cases as present an intermediate form between
either of them and the latter disorder. He will,
moreover, keep in recollection the circumstance 
INSANITY, PUERPERAL—Cause*.
631
 of these  diseases  frequently leaving,  as the
 physical disorder subsides, more or less of men-
 tal disturbance behind them, which may as-
 sume the form of chronic mania, or melancho-
 lia ; and the risk of this result will be great in
 proportion to the evidence of a hereditary pre-
 disposition  to insanity, and to the nervous or
 melancholic temperament of the patient.
   546. c.  The relation of puerperal insanity to de-
 lirium tremens has not  been adverted to by wri-
 ters, although the connexion is obvious in many
 instances, and of practical importance.  I have
 been called  to several  cases which, in their re-
 mote causes and essential features, were in-
 stances rather of delirium tremens occurring in
 the puerperal state than true puerperal insani-
 ty.  In some cases, the tremor is hardly to be
 observed, or is present only for a short  time ;
 and yet the affection presents the  other char-
 acters of that disorder, and  has  arisen chiefly
 from the  abuse of intoxicating liquors.   Puer-
 peral insanity, attended by tremor, usually ap-
 pears soon  after delivery, and is to be imputed
 chiefly to the effect produced on the system,
 already injured by excesses, by the shock of
 parturition, by the consequent evacuations, and
 by the abstraction of accustomed stimuli.
   547. iii. Prognosis.-^Opinions of the  result
 of puerperal insanity were either stated in too
 favourable  terms, or  imperfectly ascertained
 previously to the appearance of  the works of
 Esquirol, Haslam, Burrows, and Gooch. M.
 Esquirol states, that of 92 cases, 53 recovered
 and 6 died,  leaving 31, or  1 in 3, as incurable.
 Of 85 cases, admitted  at Bethlem, Dr. Haslam
 observed  50 recover,  and 35  incurable. Dr.
 Burrows mentions 57 cases, of which 37 re-
 covered, 28 within the first six months ; 10 died,
 1 committed suicide, and 11 remained uncured.
 Dr. Gooch observes, that these statements pre-
 sent a prospect unnecessarily gloomy and dis-
 couraging;  for,  of the many patients  about
 whom he had  been consulted, he knows only
 two who  are now, after many years, disorder-
 ed in mind, and of them, one had already been
 so before her marriage.   It should, however,
 be recollected that only the more  obstinate and
 severe cases are  sent  to asylums, and not un-
 til medical treatment had been already employ-
 ed ; hence the more unfavourable results fur-
 nished by Esquirol, Haslam,  and Burrows
 Of those not sent to such institutions, a much
 greater proportion than that assigned by these
 writers recover under judicious management,
 particularly of the non-febrile form  of the mal-
 ady, which  is, fortunately, the most common.
 Cases attended by much febrile action, more
 especially those approaching either to the char-
 acter of phrenitis on the one hand, or to that
 of nervous fever on the other, are attended by
 more danger, and frequently either terminate
 fatally, or in permanent insanity, particularly
 if a hereditary predisposition to insanity exists.
 Of the 10 cases which ended in death, out of 57,
 recorded  by Dr. Burrows, 7 occurred within
 twelve days, 2 within seven weeks,  and 1 after
 four months.  Two had active uterine disease,
 and 2 others died in consequence of relapses.
   548.  The causes have a considerable influence
 oo the result.   Of the cases which I have seen
 in the Queen's Lying-in Hospital, and to which
 I have been called in private practice, a  much
larger proportion  of incurable and  fatal  cases
has  existed among the unmarried than in the
married.  Previous distress  of mind is suffi-
cient to account for these results. Of the cases
of married females that have occurred in the
above institution  since I  became  consulting
physician to it (1822), two were represented to
me by the matrons as having been caused by
remorse  consequent  upon  incestuous  inter-
course, and both these  terminated fatally.   It
may be inferred, from the results observed by
several practitioners, that about four patients
in five recover their intellects ; and that about
one in eight die, generally within the first month
of the disease, the greater number within a fort-
night.  The proportion, however, of  unfavour-
able cases is manifestly greater than this  in
unmarried females.  The chief danger  in this
disease, especially in the more pure, or non-feb-
rile  form of it, arises  from debility and ex-
haustion of nervous power.  And this  is the
more to be dreaded when the disorder follows
haemorrhage, or improper bleeding,  when the
pulse is very rapid, weak, or small, or flutter-
ing ; and when there are great restlessness and
long-continued  want  of sleep.  Recovery  is
generally  more likely to take place,  the more
remote the attack from the period of parturi-
tion, or when the disorder occurs during lacta-
tion.  The appearance  of the  disease during
pregnancy should lead  the physician to antici-
pate a severe form of it after delivery.   Moral
causes, also, give rise to more severe and dan-
gerous attacks than physical causes; and the
maniacal form terminates favourably more fre-
quently, and in a shorter time, than the melan-
cholic, in  as  far as the recovery of  reason  is
concerned ;  but  deaths are more likely  to oc-
cur in it, at least after  a short period from the
attack.  Of 55  recoveries, M. Esquirol  states
that 38 took place within the first six months.
Of 35 recoveries, recorded  by  Dr. Burrows,
28 occurred within the same period.  When the
delirium is of a  gay character, and the patient
sings, laughs, talks wildly, and  is a little mis-
chievous,  it rarely lasts long ; but when it  is
attended by great suspicion, apprehension of
poison, and sullenness, or when suicide »s med-
itated or  attempted, it then  assumes a more
serious character, and is not soon cured.  Upon
the whole, this disorder requires a very cau-
tious and  guarded prognosis.
  549. iv.  Causes.—A.  "The predisposing  causes
of puerperal insanity are nearly the same as fa-
vour the occurrence of other forms of mental
disorder, the puerperal states  being superadded
causes of predisposition to these, and the pe-
riod  immediately following delivery  being the
most influential of these states.  Hereditary in-
fluence, constitutional debility, and susceptibil-
ity of the  nervous system, most powerfully co-
operate with the puerperal states.   Of the 92
cases noticed by Esquirol,  16  were attacked
from  the first to the fourth day; 21  from the
fourth to  the fifteenth  day;  17 from the six-
teenth to  the sixtieth day; 19 from  the sixti-
eth to the twelfth month of lactation ; and 19
after  forced or  voluntary weaning.   Dr. Bur-
rows remarks, that of  the 57 cases which he
has observed, the disease commenced  on or
before the fourteenth day in 33 ; and after the
fourteenth day, and before the  twenty-eighth,
in 11 instances.  As to the age at which the
disorder most frequently occurs, he  observes, 
632
INSANITY, PUERPERAL—Causes.
 that from the age of twenty to thirty it is more
 frequent than at any other age, in the propor-
 tion of nearly two to one.   M. Esquirol states,
 that of 92  females, 22 were from twenty to
 twenty-five years of age; 41 from twenty-five
 to thirty;  16 from thirty to  thirty-five;  11
 from thirty-five to forty;  and 2 from forty to
 forty-three.  The comparative frequency of this
 disease in married and unmarried females has
 not  been duly attended to.   Nearly one third
 of the  cases adduced by  M. Esquirol were
 those of unmarried women : while a fourteenth
 only of those observed by Dr.  Burrows were
 unmarried.   There can be no  doubt that the
 disease is, relatively to the number of pregnant
 single  women, much  more common  in  them
 than in the  married.  This is to be imputed to
 the more general and  intense operation of the
moral exciting causes on  the former than  on
the latter.   M. Esquirol imputes the.frequency
of this malady in the unmarried, in great meas-
ure,  to the influence of suppression of the lac-
teal  secretion, and  premature  weaning, com-
paratively few unmarried females suckling their
children.  In this country, however, the ma-
jority of them find situations as  wet nurses.
 Females who have been subject to hysteria, par-
ticularly its more severe and obstinate forms,
 previously to pregnancy, are  very liable  to pu-
 erperal mania; and those who have been once
 attacked are highly  predisposed to the disease
 on each successive return  of the puerperal
 states.   Of the predisposition  arising out of
 hysteria, I have met with  several remarkable
 instances.   Some writers  have remarked, that
 nearly one half of the cases  which they have
 treated have, more or less, depended upon he-
 reditary predisposition.  Of the instances  which
 I have seen in the  lower  classes, a large pro-
 portion has occurred in those  who  had been ad-
 dicted to the inordinate use of  spirituous or
 malt liquors.
  550. B. The exciting causes are  also very fre-
 quently the same as produce mental disorders
 in other  circumstances;   although there  are
 others which especially belong to the puerperal
 states, or which produce their effect chiefly in
 these states.  There are some, also, of a phys-
 ical or pathological kind, consisting of changes
 in the sexual organs and nervous system, con-
 nected with impregnation, parturition, and lac-
 tation.  The most common exciting causes are.
 moral emotions and errors of diet and regimen.
 Of  the latter, improper food,  stimulating or
 heating articles, exposure  to cold air or cur-
 rents of air, damp clothes, the evaporation of
 liquid perfumes, the suppression of the lochia,
 or of the milk, premature exertion, the use of
 cold fluids, and neglect of the abdominal  secre-
 tions and excretions.
  [Insanity also results from lactation unduly pro-
 tracted, especially where previous predisposition
 to mental disease exists, and  which bears close
 resemblance to puerperal mania.  The latter, as
 is well known, occurs most commonly in women
 of weakly, hysterical,  and  irritable habits ;  and
 in the same class, mania from over-lactation is
 most frequently witnessed.  Where  it  arises
 from protracted lactation, it commences  by pe-
 culiarity of sentiment or temper,  and is plainly
 evinced by pertinacious adherence to an opin-
 ion  once formed, however erroneous.   If the
 child is not taken  from the  breast, the pulse,
notwithstanding a more generous d.et, becomes
quick  and  sharp,  the skin parched  and  the
whole  system  deranged.  Drs  Lavcock.and
Ashwell think that  insanity from  this  cause
is rarely  of a  serious nature, except in  cases
where generous diet and wine are injudicious-
ly administered.  We are to  seek for the  pa-
thology of this functional result of undue suck-
ling in an  impaired and attenuated condition
of  the blood,  and  a consequently depressed
state of the nervous  system,  especially of  the
organic system of nerves.  Dr. Ashwell sup-
poses that any prolonged, undue lactation may
induce organic changes in the brain, lungs, and
uterus.*  ('• A Practical Treatise on the Diseases
peculiar to Women,  &c , Am. ed.,  p. 514.)]
  551.  Moral emotions have a remarkable effect
upon both the nervous system and the secre-
tions during the puerperal states—great in pro-
portion to the  nearness of their occurrence to
the period of delivery.  The comparative influ-
ence of the moral causes  has been attempted
to be estimated by  M. Esquirol  and Dr. Bur-
rows ;  but  the application of numbers to  the
estimation of the separate value of individual
influences in the  production  of disease,  espe-
cially as diversified combinations of both exci-
ting and predisposing causes generally occasion
it, leads rather to erroneous than  to correct
conclusions, and is, at best, a parade  of  accu-
racy in respect of  matters which admit only
of approximations to the truth.   Besides,  the
relative influence of particular causes vary with
the age, constitution,  modes of living, previous
health, and occupations of  the  patient; and
with seasons, weather, epidemic states of  the
air; and  with climate, situation,  and peculiar
circumstances of the country.  M.  Esquirol
states that  46 of 92 cases of puerperal insanity
were caused by moral emotions, while Dr. Bur-
rows estimates the physical as being ten times
more  influential than the moral  causes.  My
observations lead me  to infer  that M. Esquirol
is very much nearer  the truth, even allowing
  * [Case of insanity resulting from undue suckling.—Mrs.
P., aged 28, of fair complexion, blue eyes, and light hair, at
the age of 17, suffered from chlorosis ; but, under a course
of tonics and sea air, she recovered. In 12 months she again
relapsed, and again recovered under the same treatment. At
the age of 19 she married, and before her 20th year she had
a living male child.  She nursed this child for 12 months, and
was again confined soon after she had reached her 21st year.
Since this period she has borne four living children, and
has miscarried twice: she has  nursed every child.  Her
last infant was born eight-weeks before I saw her. My at-
tendance was requested on account of her having been
weak, very desponding,  and sharp in her manner.  On vis-
iting her, I was struck with her pale, anxious countenance ;
the pupils were dilated ;  the pulse was small, quick, and
irritable. She complained of great thirst, of a pain at the
top and back of her head ; and there was also excessive leu-
corrhcea. I obtained answers to my questions with some
difficulty, although, in general, she was exceedingly com-
municative.  Tonics, change of air, &c, were  ordered, and
the child was partially weaned  and fed.  The symptoms,
however, became worse, and her conduct was exceedingly
violent.  She attempted, more than  once, to destroy both
husband and child.  The latter was immediately removed,
her head was shaved, nutritious, but unstimulating diet was
ordered, together with tonics and sedatives.  These meas-
ures were diligently prosecuted ; but at length it was thought
right to remove her to an asylum. Here she continued four
months, and returned home entirely recovered.  Ten months
subsequently she was again confined of a living child, and
within five months her insanity returned.  After a fruitless
employment of remedies,  she was again placed under re-
straint ; and having remained there  five months, she was
sent home quite well. Twelve months from this period she
gave birth to another living infant, and, at the suggestion
of her medical attendant, she did not attempt to nurse it
and her intellect has continued unimpaired.—(Loc. cit )1 ' 
INSANITY, PUERPERAL-
hereditary predisposition, which exists in a very
large proportion of cases, to be a physical cause.
The most frequent moral emotions are  those
which have been already noticed (cj 549) as op-
erating  chiefly on the minds of the unmarried ;
also fright, fear, anxiety,  chagrin, anger,  do-
mestic dissensions, grief at the desertion of the
father, or at the death of the infant;  dread of
the malady after having experienced an attack,
&c.   The  influence  of terror and fear was
shown by the cases which came under the care
of M. Esquirol in 1814 and 1815.   Of 13 which
he admitted in the former year, 11 were caused
by fear.  A sudden shock, or whatever startles
or alarms the patient, as a sudden clap of thun-
der, will often occasion the  disease, especially
soon after parturition.  The abuse of intoxica-
ting liquors exerts both an exciting and a pre-
disposing influence, and it has not only a direct,
but  also an indirect  effect.  These liquors ei-
ther excite the malady by immediately stimu-
lating the nervous and vascular systems, at pe-
riods when  susceptibility is  augmented and vi-
tal power impaired, or,  in other cases, they in-
directly cause it, by the sudden abstraction of
the accustomed excitement they have afforded,
at a time when the frame  is depressed by the
suffering and by the evacuations attending par-
turition. When puerperal  insanity  proceeds
from this source, it may either assume more or
less of  the  characters of delirium  tremens (<$
546), or vary but little from its usual forms.  In
order that  the treatment should be  successful,
care ought to  be taken  to ascertain the exist-
ence or non-existence of this cause from  the
attendants  most competent to furnish the infor-
mation.
   552.  v. Pathological States.—A.  The ap-
pearances observed after death, caused by pure or
true puerperal insanity, particularly when it oc-
curs soon after delivery, or during suckling, con-
sist chiefly of deficiency of blood in the' brain
and its  membranes, and, in  some instances, of
slight effusions of serum  between the  mem-
branes  and in the ventricles.   There are no
signs of inflammation, or even of congestion,
excepting in such cases as have approached in
their characters to phrenitis on the one hand,
or to nervous fever on the other ;  and in these,
appearances of an inflammatory or of a congest-
ive nature, with or without effusions of serum,
are  often observed.  The  pure cases of  the
malady present little besides anaemia of the brain
and  its membranes, and of the system general-
ly.   Morbid changes in  other parts of the body,
or even in the sexual organs, are coincidences
or accidents only.
  553. B. The morbid condition more immediately
occasioning  the malady seems to consist  of in-
creased nervous susceptibility and greatly  im-
paired power, frequently associated with defi-
ciency of blood.  The balance of the circula-
tion  is also often disturbed, and irregular de-
terminations of it take place, especially to the
brain and to the uterus.  While the circulation
is more  active in one  quarter, it is deficient in
others, and  the functions of the brain  are thus
directly or  sympathetically  disordered.  After
impregnation, the organic nervous influence of
the uterus and ovaria is more or less develop-
ed and exalted, and the excitement of these or-
gans often extends to, or reacts upon, the cer-
ebrospinal nervous system and its manifesta-
                     80
—Pathology—Treatment.                633

tions, exciting and disordering it and its func-
tions.   After delivery, the susceptibility of the
brain, and of the nervous system generally, is
increased, and the disposition of these  to be
sympathetically affected by the states  of the
mammae, uterus,  and  ovaria  proportionately
augmented, the  susceptibility being  great in
proportion to the shock which the system has
sustained from the. parturient process, and to
the loss of blood and exhaustion.  The occur-
rence of the disease during lactation is to be
imputed chiefly to exhaustion, debility, and vas-
cular inanition, and its appearance after wean-
ing, to a disturbance of the balance of the cir-
culation, a greater determination of blood ta-
king place to the brain than to other parts, upon
the cessation  of the secretion of milk, as well
as upon  the premature cessation of the lochia.
  554. vi.  Treatment.—A. Insanity occurring
during pregnancy is generally either partial, or
of short duration when it assumes a maniacal
form.  In  either  case, the  treatment should
chiefly depend  upon the state of the vascular
system  as to fulness, action, and tone.  When
the circulation is deficient in none of these con-
ditions, and particularly when plethora exists,
a small blood-letting will then be useful; but in
doubtful, or other circumstances, cold applied
to the head, warm and stimulating pediluvia,
refrigerants,  and  refrigerating  diaphoretics,
cooling  aperients,  and  antispasmodics,  con-
joined with narcotics, as  hereafter prescri-
bed, must constitute our principal means of
cure, aided, however, by judicious moral man-
agement, and  by appropriate diet and  regimen.
  555. B.  Insanity occurring soon after parturi-
tion requires the utmost  discrimination in as-
certaining, 1st, the presence of the disease in
its  pure or unmixed  character ; 2dly,  those
mixed states which partake either of the char-
acter of phrenitis, or of that of low nervous fe-
ver, and the greatest care in the  selection of
remedial agents.  In this disease  it is always
most important to consider the state of the vas-
cular system, in connexion with nervous ex-
citement, and to inquire as to the dependance
of whatever degree of vascular action  that may
be  present upon  the  condition of the nervous
system, and upon the mental disorder and mus-
cular efforts.   In all cases, moreover, it should
never be overlooked that the frame has receiv-
ed a shock during the parturient process, that
the nervous system has endured great excite-
ment and suffering, and that the vascular sys-
tem has sustained a loss,  sufficient, in many
cases, seriously to  disturb the healthy relation
subsisting between the state of the vessels and
their contents, and to disorder the balance of
the circulation in different parts of the body.
These considerations will generally guide the
practitioner in the treatment of the more diffi-
cult, doubtful, or mixed cases : the more sim-
ple and pure instances of the disease will pre-
sent neither difficulty nor doubt.
  556. a. Blood-letting in any mode is most in-
jurious in puerperal mania and melancholia, and
in such cases as are attended by fever, or where
the symptoms approach those of delirium tre-
mens.  Indeed, puerperal insanity, occurring in
the lower classes of society, not unfrequently
is very closely allied to that disorder,  owing to
the circumstances already noticed ($ 546,551).
In those cases which assume the form of ner- 
634
% INSANITY, PUERPERAL—Treatment.
vous fever vascular depletion is also pernicious.
Where, however,  the  malady approaches,  in
some of  its  features,  a  phrenitic form—when
the head is hot, the face flushed, the pulse hard
or strong, and the secretions  suppressed—the
propriety of blood-letting might seem to be ob-
vious ; yet even in these cases the practice, al-
though cautiously resorted to, might be injuri-
ous, or fail of proving beneficial.   Those symp-
toms  are sometimes  fallacious, for they are oc-
casionally produced by the violence of the ner-
vous and  mental excitement, or of the physical
exertion, relatively to the power of the system,
and are of short  duration, dangerous exhaus-
tion soon supervening.  In such instances, even
a small blood-letting  would only hasten and in-
crease the consequent depression.   In cases
which commence with headache, fever, flushing
of the face and eyes, diminished secretion and
excretion, and  occasionally preceded by chills
or rigours, and  in which the mental disorder is
clearly consequent upon the inflammatory and
febrile symptoms,  a  recourse  to blood-letting,
and to other  antiphlogistic means, is obviously
requisite, for the disease is more or less in-
flammatory, or consists of a state of active con-
gestion approaching  inflammation.  Yet, even
in these cases,  the practitioner will be guided,
in some  measure, by the rapidity with which
the mental disorder  followed the physical dis-
turbance, by the previous condition  as well  as
the existing  circumstances of the patient,  by
the  evacuations   attending  and  consequent
upon  parturition, and by the several phenom-
ena characterizing the case.   Whenever the
mental affection follows quickly upon the cere-
bral and constitutional symptoms,  vascular de-
pletions of any  kind are seldom of service, un-
less very prudently prescribed.
  557. When there are much heat of the scalp,
flushing of the  face,  beating of the carotid ar-
teries, and no indication  of urgent debility  or
exhaustion, the previous  condition and evacu-
ations of the patient furnishing no sufficient
reason for the existence  of these states, then
may leeches be  applied  behind  the ears,  or
around the occipit, and cold to the head, with
great advantage.   While ice, cold lotions, &c,
are placed around the shaved head, the feet and
legs should be frequently bathed in warm water,
to which  mustard or scraped  horse-radish has
been added.  In the majority of cases, where
inflammation is dreaded after  delivery, there is
only active determination of blood to the head,
the circulation in  the extremities  and in other
parts  being impaired  ; and in these the contin-
ued application of cold to the head, and the fre-
quent or persevering use  of derivatives to re-
mote  parts, or to such as  experience an insuf-
ficient supply of  blood, will generally remove
the disorder.   The application of blisters to the
nape of the neck has  been advised  by many, but
they are  seldom of much service in the mania-
cal states of disorder. In the melancholic form,
or when there  is a tendency to stupor, rather
than to high  excitement,  blisters on the nape,
or behind the ears, are generally of use.
  558. b. In  a great  proportion of cases of pu-
erperal insanity, faecal accumulations have form-
ed in the alimentary canal, and morbid secre-
tions have collected  in the gall-bladder, hepatic
ducts, in the  caecum, and in the cells of the co-
lon.  The existence of these  collections is in-
dicated by a  loaded, foul, or furred tongife, by
a fetid breath, by a  land or discoloured state
of the skin and of the complexion, by more or
less fulness in the regions  of the cecum and
sigmoid flexure, and by dark  and offensive evac-
uations.   The propriety of purgatives in all such
cases, and of emetics in  many of them, is nn-
doubted.   The latter, however,  should not be
used when debility or exhaustion is extreme—
when the face is pale,  the  skin cold, and the
pulse  very quick and weak.  Ipecacuanha is
the best emetic in ordinary  circumstances, but
when vital depression is considerable, amy of
the warmer emetics  prescribed in the Appendix
(F. 402, 403) may be used.  After its operation,
calomel may  be given with  camphor and some
cathartic extract, and a few hours subsequent-
ly, a draught, with  rhubarb and magnesia, or
any other purgative, may be taken.  The full
operation of  these upon  the bowels should be
secured either by their repetition or by the ad-
ministration of enemata, and especially of those
containing castor oil and spirits  of turpentine.
In most cases, the stomachic aperient, consist-
ing chiefly of the compound infusions of gentian
and senna (F. 266), or the compound aloetic
pill or decoction, will be the most appropriate
medicines.
   559. c.  Having evacuated morbid secretions
and  faecal collections,  it is next requisite to
support the constitutional powers and allay ner-
vous  excitement by antispasmodics or diffusive
stimulants, conjoined with narcotics or sedatives.
Where debility, exhaustion, or  vascular inani-
tion is urgent, it will generally be necessary ei-
ther to combine restoratives or stimulants with
alvine evacuants, where the latter are requi-
site, or to give the former in the intervals be-
tween their exhibition.  Narcotics are more ben-
eficial in puerperal than in  any other form of
insanity, particularly when conjoined with cam-
phor, ammonia, or  aromatics.   Since 1815,1
have  usually prescribed five grains  of the ex-
tract of hyoscyamus,  with an equal quantity of
camphor,  in the morning and  afternoon,  and
double this quantity of each  at bedtime. Where
there are much heat of the head, flushing of
the face, and thirst,  these symptoms should be
removed  by  cold applications,  purgatives,  re-
frigerants, and external derivatives, before cam-
phor or ammonia is exhibited ; but, notwith-
standing their presence in a moderate degree,
the camphor and hyoscyamus may be exhibited,
provided that these means are persisted in, and
the enemata  already advised are occasionally
administered.  In still more urgent cases, the
camphor  may be given  more frequently, con-
joined either with hyoscyamus, or with opium
or morphia, a larger dose being given shortly
before bedtime.  I  have rarely found the fol-
lowing draught to fail in  giving repose, and in
contributing to the clearing up of the mind sub-
sequently, when prescribed after the requisite
alvine evacuations, and when the head is kept
cool, and  the lower extremities  warm : the en-
ema has also proved very generally of service.

  No. 277. R Morphia Acetatis gr. J; Liquoris Ammonia
Acetatis 3jss. ; Mist. Camphorae fj. ; Acidi Acetici fllvj. i
Spiritus Lavand. Comp.,  Spir. Myristicae, Spir. Rosmarini,
5a 3ss.; Sirupi Papaveris 3j.  M.  Fiat Haustus, horft som-
ni sumendus.
  No. 278. R Camphors rasa gr. x. ; Asafcetidas Tss.—Ti.:
Extr. Rule 3ss.; tere cum  Olei  Terebinthinae ?j •  Olei
Ricini %y  (vel Olei Olivs fiij.); Decocti Avenue Jx  ad 
INSANITY, PUERPERAL—Treatment.
635
Jxiv.; Sirupi Papaveris 3ij. ad Jss. Fiat Enema, pro re
nata. injiciendum.
  560. d. It is important to administer due sup-
port to the system during the treatment of the dis-
ease, more especially when there is neither a
febrile state of the pulse, nor heat of the head
or surface; and this  support, whether medici-
nal or dietetical, should have due reference  to
the previous modes of living and habits of the
patient.   When  puerperal insanity  becomes
chronic, or when  it appears in  the course  of
suckling, and particularly when there  is a total
absence of inflammatory or febrile symptoms,
tonics, especially  the  infusion or decoction  of
cinchona, or any of the bitter infusions, may then
be given with ammonia and aromatics, the se-
cretions and excretions being promoted by the
usual means; change of air and of scene, and
appropriate moral treatment, being brought in
aid of the physical remedies.   When the pa-
tient has been addicted to  the use of intoxica-
ting liquors, and  especially if the disease as-
sume a form approaching to delirium tremens,
then  opium, with  camphor or  with  ammonia,
should  be freely administered.  Brandy or wine
may be given  in  arrow-root;  or  even warm,
spiced, or mulled wine, or ale may be occasional-
ly allowed.
   561. e. The dietrequires much attention. Drs.
Prichard  and Gooch remark, that patients  in-
cur some risk of being starved in this disease,
through the mistaken notions of their attend-
ants, who are apt to consider the excitement of
the  malady a reason  for withholding  food;
when this very state, owing to  the exhaustion
often  produced by it, renders due  support  es-
 pecially necessary.  Farinaceous  fluids of a
 nutritive quality, as rice, arrow-root, sago, &c,
 should be  given at short intervals, when febrile
 symptoms  preclude the  use  of animal food.
 Warm milk, or broth, may also be allowed, but
 should be taken  in small quantity at one time.
 In protracted  cases, solid meat, malt  liquor,
 wine and water,  bottled  porter, or the bitter
 ale usually sent  to India,  will often be of ser-
 vice.   Patients who have been accustomed to
 live fully, and to the use of stimulating liquors,
 must  be  allowed such food and beverages as
 their physical symptoms  will  permit, without
 reference to the state  of  the mental disorder.
 When suckling   is concerned in  producing,
 heightening, or perpetuating the mental affec-
 tion* by draining  an  already weakened consti-
 tution, a  nurse must be  procured, and a  nu-
 tritious and tonic diet and regimen prescribed,
 with change of air, and the use of chalybeate
 waters.
   562. C. When  insanity  appears during suck-
 ling, the treatment is  nearly the same as that
 just described ;  a nutritious  and cordial  diet
 should be  immediately allowed, and meat ta-
 ken  daily, with  about four  ounces of wine.
 Purging in such cases is injurious, but the bow-
 els  should be kept in a  regular state  by  the
 compound decoction of aloes,  or by the infu-
 sions of gentian and  senna.   If the mental dis-
 ease occur after  sudden weaning, and particu-
 larly if it assume a maniacal form, and if there
 be any reason to  infer that an inflammatory af-
 fection of the brain  has  supervened upon  the
 sudden suppression of the milk—if the symp-
 toms  already mentioned, as  indicating this
 state, appear, then appropriate means should be
prescribed; but this is not to be determined,
nor is the  treatment to be regulated by the
disorder of the mind, but by the bodily symp-
toms.
  563. When  the milk  becomes  scanty, or
ceases to be secreted, and the  mental disorder
seems to be aggravated by this circumstance,
or has supervened upon it, the secretion should
be  encouraged by  keeping the child to the
breast.  If the lochia  disappear prematurely,
means should be taken to procure its return.
For this purpose, the warm bath, the semicu-
pium, or the hip bath, may be used; and, if
these fail, leeches may be applied  on the in-
sides of the thighs, near to the groins, and the
hip bath be  subsequently employed.  Warm
fomentations may also be  applied  to  the pu-
denda, or  over the pubes.  At the same time,
cold applications around the shaved scalp ought
to be assiduously employed.
  564. The constant attendants on the patient
should control her mildly, but  effectually ; no*
irritate her, but protect  her from self-injury :
servants,  or  monthly nurses, can  seldom do
this ; they ought, therefore, to be removed, and
a nurse accustpmed to the care of deranged fe-
males placed in their stead. The patient should
never be left alone, and everything with which
self-injury  can be effected should be carefully
removed; the windows  ought also to be se-
cured.  The  husband or near relations ought
never to be  left alone with  the patient, but
should be excluded until the state of the disor-
der permits  their admission.  It  is generally
necessary to remove all persons who are sour-
ces of excitement of any kind.   Seclusion, in
some mode or other—partial or complete—i3
generally necessary ; at least, for some time.
There is often, however, great difficulty in car-
rying this into effect in such a way  as will tend
to  the comfort and speedy recovery of the pa-
tient.  Removal to an asylum is not so fre-
quently requisite  for the  mental disorders of
puerperal patients as for insanity occurring in
other circumstances.  It is principally required
 in  the more obstinate and prolonged cases, and
 after other measures of partial or complete se-
 clusion have been tried.  Dr. Gooch remarks,
that, where seclusion has been adopted,  there
 may come a time at which some interruption
 to this solitary life  may be advisable.  When
 the disease has lasted long, when  the patient
 expresses a strong wish to see some near friend,
 when she entertains illusions which the sight
 of some one may efface, the admission of such
 person should be tried.  It is well observed by
 Dr. Haslam  {Moral Management of the Insane,
 p.  14), that confinement  is too indiscriminately
 recommended and persisted in.  An intercourse
 with the  world has dispelled, in many instan-
 ces,  those hallucinations  which a protracted
 seclusion, in  all probability, would have added
 to and confirmed.   In its passive state, insani-
 ty has been often known to  wear off by per-
 mitting the patient to enjoy her liberty, and to
 return to her usual occupations  and habits.
 There is obviously a period of the malady ap-
 proaching convalescence, in which the bodily
 disease is loosening its hold over the mental
 faculties, and in which the latter are capable of
 being drawn out of the former by judicious ap-
 peals to  the mind, and by a  salutary moral
 management. 
DAL—Occasions  of.

 when it is not an incentive, it cannot, at least,
 impose any restraint upon  an impulse to^com-
 mit this act when a weak-minded person is sub-
 jected to chagrin, passion,  and miser>'
   568. That suicide is frequently, or even gen-
 erally, caused by some one or other of the nu-
 merous  forms of insanity, may be adnutted
 but that  it is  thus occasioned  in  all cases, is
 not so manifest.   It may be said that it is an
636                      INSANITY, SUICII

  [Out of 511 cases of insanity admitted at the
Bloomingdale Asylum from physical causes, 43
cases followed parturition, and assumed the
different forms of mania, monomania, melan-
cholia, and dementia; two cases occurred du-
ring pregnancy; four during lactation ; 20 ca-
ses originated in functional and organic disease
of the uterus ; eight were attributed to the final
cessation of the menses : making a total  of 77
instances of mental derangement dependant on
the peculiarities of the female system.— (Mac-
don ald.) M. Esquirol states that there were 92
cases of puerperal madness out of 1119 insane
females admitted during four years at Salpe-
triere; he found  the  proportion, however, far
greater in the higher  classes of society,  being
as high as 21  out of 144.  Dr. Haslam enu-
merates 84  cases of  puerperal mania in 1644
cases admitted at Bethlem ; and Dr. Rush reck-
ons five such cases in 70 received into the hos-
pital for lunatics in Philadelphia.]
XI. Suicidal Insanity.  Svn.—Suicide—Self-
  homicide ; Suicidium, Autochiria; Melancholia
  Suicidium ;  Selbstmord,  Germ.; Le Suicide,
  Fr. ; Suicidio, Suicida, Ital.
  565. Under suicidal insanity, I proceed to con-
sider self-destruction or self-homicide, whether it
be seriously  entertained, or  attempted,  or perpe-
trated.
  566. The  religion,  the  laws, and the  man-
ners of a people contribute in a remarkable de-
gree to the opinions entertained respecting sui-
cide, and to the frequency of it among  them.
Of  the influence of the laws on self-destruc-
tion, sufficient proofs have  been furnished  in
recent times ;  and the restraints formerly im-
posed  by them upon  minds insufficiently in-
fluenced by rational views  of  religion,  being
now, in a great measure, removed, this  crime
has become much more common, and has as-
sumed an importance equally great, in a  moral
and social, as in a strictly medical point of view.
  567.  The ancients, in  general, condemned
suicide, unless on occasions calculated to ben-
efit the common weal. Several stoical writers,
however, attempted  to justify it  by reasoning
and by their  examples, while the opinions  of
others respecting it were either contradictory
or insufficiently expressed. Legislation regard-
ing it was formerly, and still remains, very dif-
ferent  in different countries, it being in  some
places allowed by the laws, in others tolerated
only in certain circumstances, and in some con-
demned as a crime,   The Christian religion, of
whatever sect, and the doctrines of the Koran,
regard it among the greatest of sins ; while it
is permitted, or even encouraged,  by numerous
pagan rites.   At the present day,  the opinion,*
by no means generally received, although very
commonly acted upon in this country, that sui-
cide is always an insane act, leaves every  mem-
ber of the  community at  liberty, without any
degrading penalty attached to the act, to dis-
pose of his own life as  he pleases, without
reference to the claims  of those  depending
upon him, or of society in general.  The knowl-
edge that no indignity will result to his  body,
and no discredit to his memory, thus becomes
an  incentive  to  self-destruction;  and,  even
  * In respect of suicide, opinion is as strong as a legislative
enactment, inasmuch as it determines the coroner's jury as
to their verdict—this act being always found by them as
that of insanity.
act of moral insanity ; and, as far as immorality
and passion  may be viewed as temporary in-
sanity, so  far may it  be considered as such.
But that it alone constitutes insanity, or that,
in a considerable proportion of the cases of it,
especially  those wherein mental sanity  has
been disputed, the  mind is  disordered even to
the extent contended  for,  in  respect to the
forms of moral and partial insanity described
above, is not so evident.  That the mind is im-
paired, and the judgment so far weakened as to
be swayed by morbid feelings and impulses, or
to be unable  to withstand  the  suggestions of
passion and chagrin, may be allowed;  and, as
far as a weakness  of mind, permitting the im-
pulsions of passion their full  career, may be
-considered-as-insanity, so far may suicide be'
viewed in  this light.   We observe the mind of
the petted and spoiled child to have the weak-
ness and susceptibility natural to the early sta-
ges of its  development increased by the indul-
gence, and remark the effects  produced upon
it when a  desired  object is withheld.   In like
manner, the adult  mind, unexercised  and im-
perfectly strengthened by opposition  and dis-
appointments, and pampered by enjoyment and
success, experiences a  sudden revulsion upon
unexpected reverses or indignities, is thereby
irritated as well as depressed, and accuses it-
self  or  Providence, the impulses  excited by
these feelings being sometimes carried into ef-
fect  before the sober dictates of reason can
withstand them, or these impulses more or less
quickly overthrow the efforts which reason may
make.  In most cases, these  efforts are too
feeble to counteract the impulses  arising out of
outraged feelings,  or to subdue the sufferings
of wounded self-love, or the stings of injured
honour. The mind, already weakened  by indul-
gence,  is  the  easier   overwhelmed by these
emotions,  the more intensely feels the shock,
more quickly sinks before  it, and is  the less
capable of making an  effort to recover itself,
the less it is swayed by the dictates of religion
and principle, and the  less it  is deterred by
fears of any indignity, or of the reprobation of
opinion.  All these sentiments come in aid of
the mind in adversity,  or during contrarieties,
when duly regulated, although  weakened, and
conduce to a healthy moral reaction ;  but  they
can have no influence where they have never
been habitually  entertained.
   569. i. Occasions op  Suicide.—A. The  exci-
ting causes, or the circumstances determining self-
destruction, are very diversified.  Whatever may
be the motives  or incentives to this act, they
promise to the imagination  something prefera-
ble to life, or a lesser evil than existence : 1st.
Suicide may  be committed in circumstances,
or with motives calculated to excite  admira-
tion,  or, at least, to preclude the imputation of
blame; but such occasions are rare ;  and al-
though  not infrequently recorded in  ancient
history, they rarely or never occur  in modern 
INSANITY, SUICIDAL—Occasions op.
637
times, or in the present state of society.  2dly.
Suicide is often caused, in some countries, by
religious rites or institutions, by received no-
tions  respecting injured honour, and by hopes
of thereby passing into a  happier state of ex-
istence.  3dly. It is very frequently occasioned,
in barbarous communities, by a species of nos-
talgia, by forcible removal from home, or by
slavery, and by ill usage, in connexion with a
belief of thereby returning to  former abodes in
another state of  existence.  4thly. It occurs
very frequently during delirium and mania, in
consequence generally of some illusion, false
perception, or error  of judgment.   5tldy. Du-
ring melancholia it is very commonly attempt-
ed, and the  idea of committing it is generally
entertained long before it is perpetrated. 6thly.
It is  sometimes, also, attempted in almost all
the other forms of partial insanity, and particu-
larly those attended by depression and anxiety
respecting a state of future existence, or by
unsettled  views of religion.  7thly. Suicide oft-
en is suggested by the emotions  consequent
upon  reverses, wounded self-love, chagrin, and
contrarieties of all kinds, and by the violence
or intensity of passion and anger: the enraged
feelings, being incapable  or unable  to exhaust
themselves  upon  the object which   excited
them, recoil upon themselves, and  often thus
originate  a  suicidal  impulse, which is not al-
ways successfully resisted.  8thly.  A suicidal
suggestion may arise from various circumstan-
ces of a negative or passive kind, from  satiety,
from  ennui, from the want of excitement, from
the excess of gratification, and the  exhaustion
of all its sources, &c.  In such circumstances,
the idea  may  long  be  entertained, and, ulti-
mately, either carried into effect or laid aside
from a  change in the mental or physical state
of the individual.  9thiy.  It may proceed from
a mental infection or sympathy—from the de-
tails  contained in the public caterers  to the
gratification of the more  debased of our moral
sentiments, of various modes or instances  of
self-destruction — and  from  a desire,  during
states of chagrin  or disappointment, of obtain-
ing notoriety by the manner of carrying it into
effect.  lOthly. It is often committed in order
to avoid public exposure and.ignominy, or pun-
ishment of a severe or lasting kind,   llthly.
It is more rarely had recourse to in order to es-
cape  from violent pain, or the various miseries
attending want and destitution, and from feel-
ings of despair.  12thly. From remorse or self-
reproach.   13thly. From  a morbid or  insane
impulse, without any other obvious  mental dis-
order.  14thly. From a species of fascination,
as when looking down  from great  heights.
15thly.  By  weak minds in a state of irritation
and chagrin, in order to injure the  feelings,
to  occasion regrets, and thereby  to revenge
slights  or contrarieties on those  who  caused
them.  16thly. Suicide may  be mutual and re-
ciprocal, caused by the same feelings,  and  by
the same or different  means.  17thly.  It may
follow murder.  18thly.  It may be simulated.
Certain of these require farther remark.
   570. a. The  instances of self-destruction or
of self-devotion caused by patriotism, or by a
wish  to benefit the community, or to escape
dishonour, have been generally viewed as pre-
cluding blame, and  as hardly deserving to  be
ranked  as suicidal.  The cases of Codrus, of
Decius Mus, of Curtius, of Otho, of the  citi-
zens of Calais and of Rouen, may be referred
to as being of this kind.  Zeno and his follow-
ers inculcated that a wise man should be ever
ready to die for his country or his friends ; and
the Stoics, in general, taught that suicide  was
preferable, not only to dishonour of  any kind,
but even to the enduring of severe pain or lin-
gering disease.  Among the Greeks  and Ro-
mans, self-destruction was preferred by many
to subjection to  a victor, or to a state of sla-
very.   Isocrates, Demosthenes,  Brutus, and
Cato  terminated  their own lives, rather than
fall into-the hands of conquerors.
  571. Theoxena and the virgins of Macedon
committed suicide to escape dishonour;  and
numerous instances of a similar kind have oc-
curred in ancient and modern times.   Lucretia
would not survive the dishonour she  could not
prevent.   Lycurgus and Charondas  sacrificed
their lives in order to  maintain the inviolability
of their own laws and institutions.  Most of the
above instances  of suicide may be viewed as
precluding blame, and some of them may claim
our admiration.  But other instances, commit-
ted on less laudable occasions, have been con-
sidered as excusable by Montaigne, Dr. Donne,
Rousseau, Hume, and others.  When Josephus,
who commanded the  Jewish army, wished to
surrender to Vespasian, from a conviction of
the hopelessness of resistance, his soldiers in-
sisted upon their having recourse to suicide,
rather than to yield to a  conqueror.   But he
resisted their importunities, and  concluded his
arguments by observing that " self-murder is a
crime most remote from the nature of all ani-
mals, and an instance of impiety against God,
our Creator."
   572. b.  The victims of religious rites, as in
India, and in the Canaries  in former  ages—of
national  customs and manners, as in the Isle
of Ceos, Japan, &c.;  and of ignorance ;  and
of those persuasions  which constitute  a  part
of religious belief, also—are not to be viewed
as instances  of suicidal insanity, but as proofs
of the influence of high moral and religious con-
siderations and expectations, of the tyranny of
custom, and of  false notions of honour;  and
they result legitimately from  the training or
education of the mind from an early  period of
its development.  They are altogether different
from the suicides which were so frequent du-
ring the decline of Roman greatness, and which
proceeded chiefly from vice and licentiousness,
or, rather, from the sentiments and impulses
which are generated from these sources—sour-
ces so productive of suicide in some countries
at the present time.
   573. c.  Suicide in states  of mania, or of delir-
ium,  occur either from some  involuntary or
blind impulse, or from  some delusion, halluci-
nation, or false perception—as when a person,
in either of these states, throws up the window
of his room, and walks out of it, in the persua-
sion of his going out at the door.   Maniacs, also,
attempt  to destroy themselves at  the com-
mencement of the malady, under the influence
of the moral despair which caused it; and oth-
ers commit the act from the distress  caused by
a knowledge that the disease is approaching or
is returning.  A patient for whom I was  con-
sulted during an attack of mania, from which
he recovered, experienced, after a time, similar 
630
INSANITY, SUICIDAL—Occasions op.
symptoms  to those which ushered in the for-
mer attack.  His friends were directed to take
the necessary precautions regarding him ; but
these he eluded, and committed suicide.  This
act is occasionally, also, attempted during con-
valescence from mania, in consequence of re-
flecting upon the excesses  committed during
the attack.  It may even be accidental, owing
to attempts at escaping from restraint or se-
clusion.
  574. d. In melancholia and monomania, suicide
is occasioned by illusions, or by the violence or
intensity of some passion or sentiment, or by a
sudden  impulse which reason is incapable of
restraining, or which induces the  act before
reason can be exerted, as more fully explained
above (c) 91, 92). In some  cases, the  morbid
impulse is partially or fully carried into effect;
and, either in consequence of the nature of the
means of self-destruction employed, or of rea-
son having at last come to the rescue, attempts
are made by the individual himself to counter-
act them, these attempts either succeeding or
not, according to circumstances.   The suicidal
impulse is  occasionally developed in an early
stage of congestion of, or of inflammatory de-
termination of blood to, the brain ;  and either
previously to, or contemporaneously with, such
impulse, insane delusions or acts may be man-
ifested.   If, in  such cases,  the means of de-
struction shall have the effect of removing the
morbid physical condition before extinguishing
life, the patient will make efforts at self-pres-
ervation.   This is  not infrequently the case
when suicide is attempted by dividing the ves-
sels in the  neck.  When self-murder is resort-
ed to during melancholia, from a fear of be-
coming  insane, and with the feeling that it is
the patient's fate or destiny to commit it, the
conviction  is sooner  or later completely verifi-
ed.   Indeed, when  it is contemplated or at-
tempted in any form of partial insanity, the in-
tention  is generally persevered in, although it
may be  variously concealed, until it is  accom-
plished in one way or another.
  575. In melancholia, and other states of par-
tial insanity, or even previously to any symp-
tom of insanity being sufficiently prominent to
attract notice, or in consequence of some men-
tal shock or perturbation, the patient may con-
ceive that an internal voice calls upon him to
commit suicide, and may act in conformity with
it; or he may entertain the idea long afterward,
either without being able to divest his mind of
it, or resisting the impulse to perpetrate it with
the greatest difficulty, and with the  utmost ex-
ercise of his reason.  A lady consulted me on
account of headache, during which she could
not look upon  a knife without experiencing a
strong desire to use  it against her own life;
but her reason had always resisted the impulse,
which  disappeared  after treatment. In  such
cases, if medical and moral means  be not ap-
propriately employed, and often notwithstand-
ing the aid of both, the morbid impulse is ulti-
mately  carried  into effect.  Among persons
who have  been but  little accustomed to self-
control, or  to listen to the dictates of moral and
religious principles,  such impulses  are often
soon acted upon.  M. Esquirol furnishes sev-
eral instances.  A monomaniac, he states, heard
a voice within him say, " Kill thyself! kill thy-
self!" and he  immediately obeyed the  injunc-
tion.  This writer remarks, that he has never
known an instance of suicide from an irresist-
ible impulse without some secret grievances,
real or imaginary, serving as motives to the su-
icidal propensity.  There are few states of par-
tial insanity that may not be attended or follow-
ed by this propensity.  Of the  delusions which
characterize melancholia,  there are none more
productive of self-destruction, as  Dr. Darwin
has remarked, than the fear of  future damna-
tion and of present poverty.
  576.  e. Suicide may be committed under the
influence of passion, of violent anger, or of self
accusation or remorse.  When intensely excited
by anger,  the mind, for the  time, is in a state
truly maniacal ; and acts of violence to others,
or to the person himself, may  be committed in
the height of the paroxysm, according to  the
nature of the circumstance or occurrence caus-
ing the  excitement.  Suicide  from this cause
is most likely to be the fate of those who have
not been sufficiently taught  to curb  their feel-
ings, and who have been improperly indulged in
early life, as Childe Harold describes himself:
              " My brain became,.
   In its own eddy boiling, and o'erwrought,
   A whirling gulf of phantasy and flame :
   And thus, untaught in youth my heart to tame,
   My springs of life were poisoned."

Remorse  and self-reproach  frequently lead to
self-destruction, as the only mode of escaping
from the enduring agonies they occasion.   The
passions which " madden to crime" are  often
followed by  the most  anguishing feelings of
self-accusation, which not infrequently arm the
hand of the sufferer against his own existence.
Shakspeare has powerfully and  naturally illus-
trated this state of mind  in his  delineation of
the character  of Othello.  The victim of re-
morse is often haunted by dreams, from which
he awakens in a state of phrensy, or of delirium,
in  which  attempts  at  suicide are  sometimes
fully carried  into effect; and  in his waking
hours,  his mind  is  haunted  by recollections
which become his  domestic  furies, and  lash
him  on  to madness.   " Sua quemque fraus,"
says Cicero, " et suus  terror maxime vexat;
suum quemque scelus agitat, amentiaque afficit;
sua;  mala? cogitationes conscientiaeque animi
terrent.   Hae sunt impiis assiduae domesticaeque
Furia;."   But, while remorse thus leads to su-
icide, by at first more  or  less obviously disor-
dering the mind, this act as frequently is  the
proximate result of the moral sentiment;  the
attempt, or the commission  of it, being prece-
ded by no other morbid manifestation of mind
than the moral torture proceeding from the con-
sciousness of having committed  a crime,  great
either m itself or in relation to the various cir-
cumstances connected with it.
  577. /.  Reverses,  mortified pride,  impatience
under misfortune, and disappointments, are  fre-
quent causes of suicide, especially in commer-
cial  countries, and under free  governments,
where there is a constant  straining, among the
more  educated classes, after  wealth,  honour,
and other direct or  indirect means of power.
Many of the ancient, as well as modern instan-
ces of self-murder, are to be attributed as much
nnnJti,    9  a   ^' and mortified pride
upon the mind as to the higher motives to which
this act has  been referred.  The suicides of
Brutus, Antony, and  Cleopatra, and of Pe- 
INSANITY, SUICIDAL—Occasions op.
639
tronius and Sardanapalus, may be viewed in
this light.  Instances of self-destruction from
mortified pride, consequent upon the failure of
attempts at becoming conspicuous  at public
meetings, in the senate, or at the bar, or even
upon  the boards of a theatre, are not rare in
modern times.  The passion for notoriety too
frequently entertained by silly or weak persons,
when suddenly or rudely humbled, is often fol-
lowed by a state of extreme mental collapse or
depression, which sometimes terminates itself
in suicide.   The shock produced by the failure
of long or warmly cherished hopes, of whatev-
er kind, either suddenly overwhelms all efforts
of reason and judgment—the suggestions and
impulses of passion and feeling being followed
without control—and thus  induces at once a
state  of moral insanity as harbingers of the su-
icidal act, or more slowly and surely develops
some one or other of the forms of mental dis-
ease above described.   In either case, the en-
tertaining  of the idea of  self-destruction is an
indication  of insanity, inasmuch  as  it is  con-
nected with, or dependant upon an overthrow
of reason and judgment in the one, and a man-
ifest  disorder of mind in the other.   But, in
many instances, the act is perpetrated after the
first shock of a reverse or disappointment has
subsided—after Reason has resumed her swajr,
and has been  more or less exerted in calmly
combating the  feelings and suggestions which
such  reverse may have  called into activity.
In these cases, the suicidal act is the result of
a weighing of the present and consequent mis-
ery—of the wretchedness attending  upon ex-
isting and prospective emotions, against the
contingencies following the commission of this
crime ; and whatever of insanity may be pres-
ent consists only of the excessive  emotions
which  reverses  occasion, relatively to  the
strength of moral and religious  principles by
which they are, or should  be, controlled. Hence
it follows  that a number of suicides  are com-
mitted after disappointments, losses, &c, in  a
state of mind  not absolutely amounting to in-
sanity—during an impatience under misfortune,
unrestrained by these  principles, owing either
to their weakness or absence.   Various kinds
and grades of disappointment  or misfortune
will lead to the commission of this crime, ac-
cording to the susceptibility of the mind, the
early education, the previous trials and tutor-
ing of the  understanding, the preceding career
of success or  amount of distinction, and vari-
ous accessory circumstances  connected with
existing states of society and  manners.  The
most common, however, are losses of fortune
or of reputation, losses from gambling or from
transactions  of  this  description, moral  and
worldly humiliations, disappointed  affection,
and the losses  of friends, several of these being
combined in their operations upon the mind.
   578. g.  One cause  of  suicide,  of no infre-
quent occurrence in the present state of socie-
ty, has been insufficiently considered by medi-
cal as well as psychological writers: this is,
the satiety and ennui consequent upon excessive
sensual gratifications, felt by minds imperfectly
or viciously educated, and unaccustomed to
those pains, privations, and contrarieties of life
that  impart happiness to the enjoyments by
which they generally are sooner or later fol-
lowed.   Continued and excessive gratifications
destroy the susceptibility and excitability of the
nervous system, and exhaust its manifestations.
The languor consequent upon enjoyment is not
allowed to subside, or to be succeeded by re-
newed vigour, before the indulgence is repeat-
ed ; and as languor and exhaustion  increase
with the repetition of the  gratification which
occasioned them, so the desire of escaping from
these  unpleasant sensations becomes also in-
creased, and the want of varied and augmented
excitement is experienced.   Thus gratification
begets desire,  and desire calls for gratification,
until all its sources are exhausted, all its vari-
eties and  grades are  enjoyed; and the sated
mind, no longer  finding objects capable of ex-
citing it, or of enabling it to  emerge from the
languor or depression consequent upon inordi-
nate enjoyment,  and deriving pleasure no more
from the numerous sources which afford it to
better regulated minds, feels most bitterly that
" all is vanity and  vexation of spirit."  In the
career of gratification, moral and religious prin-
ciples are gradually, at first, departed from, and
ultimately  altogether  despised ; and once the
mind  is no longer able to receive enjoyment
from the usual means,  and has exhausted all the
sources of it within its reach, it  has also ap-
proached the lowest grade of moral degradation,
which either takes refuge in suicide, or is ready
to have recourse to it, in moments of deep de-
pression, or on occasions of severe contrariety
or disappointment.  The restraining influences
of principle, and of regard  to reputation, have
ceased to  influence the conduct;  and as  soon
as the  continued and varied indulgence has ex-
hausted vital and mental power, and  dried up
every spring of enjoyment, circumstances which
depress or vex the mind will often give occa-
sion to suicide, or suggest  it; or the mind, no
longer being capable of gratification, entertains,
at first, the idea of suicide, and ultimately has
recourse to it, in order to escape from the  mis-
ery of the extreme languor which it is incapa-
ble of  dissipating.  While  most of the causes
of suicide, and especially those already noticed,
are of an active kind, this may be viewed as al-
together passive.  While  the former acts by
violently exciting and disturbing the mind, the
latter results from a defect of such excitements
as will rouse it,  and afford those gratifications
without which it either cannot exist, or prefers
not to exist at all.
   579. It has  been said that a society for the
mutual encouragement of suicide  exists  in
Paris, the members of which undertake to ter-
minate their own existences when life becomes
insupportable ; and the circumstance  is almost
verified by the character of the prevailing lit-
erature, and of the drama, in that capital.  Nu-
merous are the  instances, not only throughout
France, but  also  in  this  country,  of persons
who, having run an unbroken and rapid career
of sensual gratification, and either exhausted
its sources or their own means of enjoyment,
have therefore put a  period to their existence
without any farther  reason, and without any
previous  proofs of their  insanity beyond the
inordinate indulgence of their desires and pas-
sions, and the predominant sway these had ob-
tained over all their sentiments and actions.
   580. h. Closely allied to  the preceding is the
occurrence of a morbid or irresistible impulse to
commit suicide, without obvious mental disorder, 
640
INSANITY, SUICIDAL—Occasions of.
 act %Sh Ca?tSufficient t0 acc°""t ^r the
 IV n n!r n  el°,f this kind occur n,ost frequent-
 PronePt„S •"! **■ °nging t0 families hereditarily
 Lme inV  amty  0r  suicide=  and he"ce, in
 SpSances; ,may be viewed as the  ^st
 man,festatI0n of the menta, disorder   But th
 ncewise are committed by persons who are not
 ™us, P^disposed,  and  under  circumstances
 which require a brief examination.   1st. From
 a species of mental sympathy or infection, caused
  • Per.uslnS  the details of cases of suicide fur-
 nished so circumstantially and injuriously as
 respects the minds of the community, by the
 weekly and  daily press.  Instances are  often
 occurring, of not one only, but of several sui-
 cides being committed during the first few days
 following the publication of some notorious case
 of self-murder—notorious as respects either the
 rank of the  individual, or the mode of perpe-
 trating it,  or other circumstances  connected
 with it.  Such instances have  been long re-
 marked, and  are of increasing frequency, owing
 to the existing state of society, of which  some
 notice has already been taken ($ 272, 320), and
 to which a  brief reference  will hereafter be
 made ; 2dly.  Suicide is, in rare instances, per-
 petrated from  a species  of fascination.  The
 very knowledge of  having in  hand the means,
 or by a single step the power of self-destruc-
tion, may give occasion to the impulse of com-
 mitting it, which may even be instantly carried
 into effect by the weak, susceptible, or the mor-
 bidly disposed  mind.   I have had, on several
occasions,  to prescribe for highly nervous per-
sons—those labouring under a morbid sensibili-
ty of the nervous system, and anxious, suscep-
tible states of the  moral feelings—who could
not handle a razor or sharp knife without being
distressed by the desire or the idea of attempt-
ing suicide.  Such  persons, also, are unable to
look down from great eminences,  or  over a
precipice,  without  experiencing  a  desire of
throwing themselves  headlong.   Bvron has
noticed this feeling, and ascribed it to
 ',' The lurking bias, be it truth or error,
   To the unknown ; a secret prepossession,
   To plunge with all our fears—but where ? you know
     not,
   And that's the reason why you do—or do not."
 The bias to the unknown, here noticed by the
 poet,  has little or  no  influence in originating
 this singular feeling, which is sometimes expe-
 rienced by persons both physically and morally
 sane, as well as by the  weak in mind and body.
 This desire or impulse to precipitate one's self,
 when looking downward from a very high pre-
 cipice, obviously arises from no process of rea-
 soning.  Probably the suggestion of contrast
 may be concerned in  producing it; and some-
 thing may be owing to the unusual impression
 made upon the mind through the sense of sight
 __to the nature  of the sensation itself.   That
 this sensation is even pleasurable—that it is
 attended by a  sort of fascination—is admitted
 by those who  have experienced  it; and, with
 many persons, the desire is so strong as to re-
 quire the active exertion of reason to overcome
 it.  That it causes a physical as well as a mor-
  al effect—that it affects  the  circulation in, as
  well  as  the  manifestations  of  the brain, is
  shown by  the vertigo which accompanies it,
  and which  often occurs  without the desire of
  self-precipitation  or  destruction.   Indeed,  I
doubt much whether or not the feeling produced
in the mind by this impression on the sense of
sight is primarily attended by such a desire.  It
would seem that the  sensation is pleasurable,
and that it excites a desire to throw one's self
headlong in the gratification of it.   But reason
immediately dictates that this act would be at-
tended  by self-destruction ;  and from  this the
sane mind  recoils with a shudder—recoils from
the consequences of enjoying the feeling which
the nature  of the sensation had thus suggested.
This subject, although noticed by Falret, An-
dral, and others, has not been hitherto  inves-
tigated  with  reference to suicide.   But it is
not improbable that persons who have  enter-
tained the idea  of self-murder,  and yet have
not been able  to summon resolution to commit
it, knowing the  influence of the sensation of
looking down  from a precipice upon the  mind,
have  had recourse to it, in order to aid their
weak resolves.  Others, probably, in states of
high susceptibility  and extreme  weakness of
the nervous power, have followed the impulse
or fascination  thus  produced, before reason had
time, or recovered power to counteract it.
  581. i. Suicide may, under certain circum-
stances, become almost epidemic.   Indeed, an
epidemic prevalence of the act has been noticed,
without any other causes beside those juststa-
ted to account for it.   Sydenham has mention-
ed such an occurrence, and others  have  taken
place in more  recent times.  During the atro-
cities of the French Revolution—atrocities the
most humiliating in the history of the human
mind—the  " damned  spot" in the  annals of
France,  which neither her  science  can  oblit-
erate, nor her military glory can conceal—sui-
cides were most prevalent, owing to a variety
of causes,  and often  to a combination of cir-
cumstances and feelings: the loss  of honour,
fortune, and friends ;  the impulses of passions,
and  of  remorse, despair, &c.  The  frequency
of suicides at  certain periods and in particular
places is caused chiefly  by  political changes
and by commercial  crises, affecting the position
of numerous  individuals in  society, mortify-
ing their pride and changing their prospects.
Something, also,  may be imputed, on certain
occasions, to mental sympathy  or imitation, and
somewhat even to a passion  for notoriety; but
impatience under misfortunes and  disappoint-
ments is the most common cause.  M. Andral
states, as proving the influence of imitation in
causing suicide, that one of the inmates of the
"Invalids" was found hanged in a particular cor-
ridor. Two days afterward, a second was found
in the same place; then a third, and even a
fourth.*  This corridor was shut;  after which no
more hanged themselves.  He farther remarks
that, not long ago, it was the fashion for people
to throw themselves from the top of the column
in the Place  Vendome.   This was, however,
only a fashionable mode of committing an act
which Is always common in  Paris, and  which
was not the more  frequent because this mode
was preferred  to the other means more usually
adopted.  It has often been noticed,  in most
civilized as well as uncivilized countries, and
particularly in communities closely associated
byjeelings and interests, as in regiments, &c  ,
v-ai: ^'n93t,haat„d3lrrnplo1desiroyed therasei- *
ished by their own hands in Rouen.]
■ • .....i lii I.*"* "c=»"yeu memsejves in
i'h^'V" °"?year'1506> ^y p«- 
INSANITY, SUICIDAL—Occasions of.
641
 that a single instance  of self-murder is  soon
 followed by many.
   582. k. Self-murder has been often perpetra-
 ted in order to  escape exposure and punishment
 consequent upon detected crimes.  Indeed, this
 is one of the most common  moral causes of
 suicide in  this  and other civilized  countries,
 and instances of it  are  of daily occurrence.
 Many of the actors and prime movers in the
 unprecedented atrocities  of the  French Revo-
 lution  committed or attempted suicide  when
 they came, in their turn, to experience a direful
 retribution.  Criminals of all  grades, from the
 petty depredator to the state  delinquent,  have
 sought refuge in self-murder from the accusa-
 tions of conscience, the shame of exposure, and
 the extreme wretchedness attending conviction
 and the last penalties of the laws.   Detection
 of, as well as remorse caused by conjugal infi-
 delity, has  been followed  by suicide.  In the
 one case, this act  is resorted to in order  to
 avoid the exposure and shame consequent  upon
 detection,  although  remorse  influences the
 mind, in part, to form  the resolution; in the
 other, self-reproach is often the sole cause.
   583. The desire  of escaping from moral  or
 physical pain, or from anticipated or impending
 want, is not infrequently productive of self-de-
 struction. Under this head may be comprised se-
 duction and despair, however produced. How nu-
 merous are instances of suicide  caused by the
 despair consequent upon seduction, the deser-
 tion of the seducer, and all the contingent mis-
 eries, heightened by the.fears and anticipations
 of the seduced, by the desertion of friends, and
 the scorn of society.  Physical  pain is much
 less frequently a cause  of suicide than moral
 suffering.  Many, however, of the ancient Sto-
 ics put an end  to  pain by terminating   their
 lives : thereby following the example of Zeno,
 the founder of their sect; and several Romans
 have been  mentioned by  Pliny  and others  as
 having adopted this course.  Dr.  Haslam states
 that a gentleman destroyed himself to escape
 from the tortures of gout.  I have  been  told
 by several persons that, while  suffering the
 pangs of neuralgia, it required the utmost ef-
 forts of their moral principles to  restrain them
 from perpetrating self-murder.  Numerous in-
 stances are on record of persons who, having
 believed  themselves suffering incurable mala-
 dies, have had recourse to suicide  as  a more
 pleasant mode of dying;  this crime being com-
 mitted by them under the impression that a
 natural death is  more painful than that inflicted
 by themselves.   It has,  however, been  long
 known, and shown by Hufeland and W. Phil-
 ip,  that death from  disease,  even when the
 mental faculties  are retained to nearly the  last,
 is attended  by a gradual  abolition of the  gen-
 eral sensibility that is by no means painful  or
 distressing;  the patient  ceasing to exist  as
 happily and calmly as when falling asleep, un-
 less under peculiar circumstances.
  584.  I. Suicide is often committed in states
of irritation and chagrin, particularly by persons
of a morose,  splenetic, or irritable temper.  It
is sometimes  suggested to such persons  by a
desire to excite  regrets  or self-reproach in the
minds of those who have offended them,  by a
feeling of revenge.   Most  of the suicides com-
mitted  by children are caused by a  desire of
this kind, particularly when they  follow punish-
     II               81
 ment of any description.   Self-murder arising
 from jealousy,  also, depends chiefly upon  the
 promptings of this feeling in connexion with
 anger, and is most apt to occur in hysterical,
 nervous, or weak-minded females.  Some years
 ago I was present at an evening party, where
 a young lady, engaged to a gentleman present,
 was seized with hysterical convulsions in con-
 sequence of his attention to another.   Upon
 recovering from them, she suddenly left  the
 house, without the direction she took being  ob-
 served.  The following day she was taken  out
 of  the  canal  near the Regent's Park, in  her
 ball-dress, she having gone upward of a mile in
 order to carry her design into execution.   A
 lady, on a similar occasion, took a large quan-
 tity of laudanum.   The usual means of resto-
 ration producing no effect, I was sent for :  she
 was ultimately recovered  by the affusion of
 cold water on the head.
  [We  were recently called to resuscitate a
 young lady, aged sixteen, who had thrown her-
 self into the Hudson River because her mother
 wished  to send her on an errand in Broadway
 in her ordinary dress, thus exposing her to  the
 public in an attire very decent, but not as fash-
 ionable  as she thought necessary.   Our  at-
 tempt, however, was  unsuccessful.   No other
 cause for the rash act could be assigned.  Bur-
 rows speaks of a girl but little over ten years
 of age, who, on being reproved for some trifling
 indiscretion, cried and sobbed bitterly, went up
 stairs, and hung herself in a pair of cotton bra-
 ces ;  and of another, eleven years old, who
 drowned herself for fear of simple correction.
 A French  journal has  recently  reported  the
 case of a boy, twelve years old, who hung him-
 self by fastening his handkerchief to a nail in
 the wall, and passing a loop of it around  his
 neck, for no other reason than because he had
 been shut up in his room, and allowed only dry
 bread, as a punishment for breaking his father's
 watch.j
  585. Domestic contrarieties  and  misery —  the
 frequent recurrence of petty vexations —  the
 tyranny of intimate connexions, and the  posi-
 tive ill-usage of others—suits in courts mis-
 called those of equity, on the lucus a non lucendo
 principle—may, from their continuance, severi-
 ty, and repetition, especially under aggravating
circumstances,  and in states of high suscepti-
 bility in the unhappy sufferer, drive even the
strong-minded  and  the well-principled into a
state of temporary despair or desperation—may
fire  the  brain to madness, during which self-
destruction may be attempted.  A most talent-
ed and accomplished young lady, suffering from
a combination of the above circumstances, took,
upon retiring to rest, and with a suicidal inten-
tion, a very large quantity of laudanum, more
than is usually productive of a fatal effect. She
wakened late the  following day with a most
distracting headache and general disorder, rec-
ollected the act of the previous night, regretted
the  attempt, and sent for medical aid, deter-
mined, however, to conceal  the  cause.  Her
health, from this and the other circumstances
alluded to, continued greatly impaired for many
years, and several physicians were consulted.
She  came  under my care, and  at  last men-
tioned the  suicidal attempt, which was never
farther divulged.  She now continues, in good
health, to ornament the society in which she 
642
INSANITY, SUICIDAL—Occasions or.
 moves.   M. Falret mentions,  among  other
 causes of chagrin producing suicide, that  of
 having been calumniated ; and he states, that
 a considerable number of persons commit this
 act chiefly with  a desire of vindicating their
 reputation, no other means of vindication being
 in  their power.
   586. The state of desperation into  which  a
 person influenced by the passion of love may be
 thrown by disappointment is  actually that of
 insanity, at least, of moral insanity.  A gentle-
 man endeavoured to obtain the favourable no-
 tice of a lady, of whom he had become enam-
 oured, but had not succeeded.  He committed
 suicide by opening a  vein in his arm,  and,
 while the  blood was flowing, he  wrote a note
 with it, acquainting her with his act.   She was
 soon after attacked by nervous  fever, which
 was  followed by insanity, during which she
 fancied that she heard a voice commanding her
 to commit suicide.  Other instances of a simi-
 lar kind may be adduced!
  587. Some persons, during intoxication, have
 a remarkable disposition to commit self-murder.
 This disposition maybe the consequence of ei-
 ther habitual  or  occasional  intoxication; and
 it is sometimes connected with delirium tremens,
 or,  rather, depending upon the illusions attend-
 ing that disease.   Some persons,  who have re-
 ceived at a former period of their lives severe
 injuries of the head, experience this disposition
 when even but slightly affected  in  other  re-
 spects, by intoxicating liquors, especially if they
 suffer any contrariety or opposition at this time."
 Cases of this kind have been noticed by M. Fal-
 ret and others, and by the author.
  584. m. Instances of mutual- or associated sui-
 cide are not rare, particularly in recent times.
 The  self-homicides of Lucius VeRus, Sextta,
 and Pollutia, during the reign of Nero, and
 of Sardanapalus, may  be noticed among the
 many instances recorded in  ancient history.
 During the French Revolution, and  the  wars
 consequent upon it, associated suicides  were
 frequent.   Nine conscripts who had concealed
 themselves, having been  discovered,  deter-
 mined to destroy themselves rather than serve:
 they drowned  themselves together.  The most
 common  causes of this mutual crime are, op-
 position on the parts of parents  to the fulfil-
 ment of marriage engagements  entered into by
 young persons, want or  disappointments in the
 married  state, and family  dishonour.   The
 bodies of two young persons were found in the
 Seine with a piece of paper attached  to them,
 testifying to their  ardent affection,  and that
 they perished together that they might be eter-
 nally united.  Occurrences of this kind are,
 however, not unfrequent in this and other civ-
ilized countries ; and instances are not rare of
lovers committing mutual suicide, even where
there was no opposition to the  consummation
of their wishes. In this latter case, some cause
of chagrin or disappointment has occurred, and
maddened the  mind already disordered by one
dominant passion, the suicidal intention enter-
tained by either being  adopted by the other.
From the accounts of several cases of mutual
suicide attempted in recent times, there is every
reason to suppose that the attempt was merely
simulated by one of the persons who had agreed
to  commit this crime;  and that  it had been
 contrived entirely with the intention of getting
 rid of an object no longer one of endearment.
 This is more likely to be the case when a young
 woman has become pregnant by one of those
 drunken,  debased workmen, who prey upon fe-
 males in large or manufacturing towns.  This
 and similar instances have appeared in the pub-
 lic prints.  A man out of work, and his para-
 mour, having agreed to commit mutual suicide,
 procured  some laudanum  (about four ounces),
 and divided it into two equal quantities.  The
 man  proposed that they should turn back to
 back while  taking it, in order that they might
 not falter in the  act.  The female died soon
 after, but the man did not appear to be affect-
 ed. From  the evidence at  the inquest, it did
 not appear that he had actually entertained an
 intention  to destroy himself, or  had taken any
 of the laudanum.  Analogous cases have oc-
 curred where drowning has been the mode of
 carrying the suicidal act into effect, one of the
 parties having escaped.
   589. Want and other causes of distress, and
 even more  petty grievances, may, in states of
 mind but little influenced by moral and religious
 principles, induce husband and wife to commit
 mutual suicide.  In the present state of society,
 especially in Paris,  where  the passions are
 roused and  excessively gratified before reason
 and judgment are informed—where sensibility
 is exhausted at an early age by the excitement
 of sensations in great variety, in rapid succes-
 sion, and increasing intensity—where the thirst
 for pleasure is promoted by a loose and stimu-
 lating literature—and where the end of enjoy
 ment is generally shown, in the pages of the
 novelist and in the scenes of the dramatist, to
 be murder and suicide—instances of associated
 self-destruction, even among persons in noway
 dependant upon each other, have not been rare.
 Young  men,  who have  exhausted either the
 means or the power of enjoyment, or both, in
 the career  of vicious  indulgence, and  unre-
 strained by  principle and by fear, have followed
 the example held out to them by the popular
 writers of the day, and " shuffled off this mor-
 tal coil" in the most dramatic forms they could
 devise.   Two young men entered a restaurant,
 ordered an expensive dinner, with costly wines,
 without the intention or the means of paying
 for it,  and soon afterward  committed suicide
 together.  On a table in their room were found
 written papers expressing  aspirations  after
 greatness without  either labour or  care, and
 contempt for those who could live by their own
 exertions, with sundry quotations from Victor
 Hugo and other exciting writers  of the day.
 The whole was terminated by a request that
 their names and the manner of their deaths
 might be sent to the newspapers !  Sensation
 is  the object and end of living with many hi the
 present day; and when it can no longer be ex-
 cited—at least, to the pitch, or in the tone, ca-
 pable of yielding enjoyment—life is relinquished
 in  such a  way as  is most likely to excite the
 sensations of others.
  590.  n.  Murder is often committed first, and
suicide afterward, prompted by the same or dif-
ferent motives.   Jealousy is one of the  most
frequent causes of this combination of crimes,
which, however, may be prompted by a variety
of circumstances, indeed, by all which occasion
suicide or insanity.   The following instances
are fully detailed by Mr. Win slow •  M  De Pon- 
INSANITY,  SUICIDAL—Occasions of.
643
 talba, Whose son Was a most distinguished of-
 ficer, and married to a most extravagant wom-
 an, saw with distress  the ruin  she was  bring-
 ing upon him.   In order to save the son, the
 father shot the daughter-in-law, and afterward
 himself.  A gentleman of London was married
 in the country to the  object of his affections.
 He had drawn the charge from his pistols the
 previous night, but his servant had loaded them
 again the following morning without acquaint-
 ing him.   After  the  ceremony he took up one
 of the pistols, which he knew he had unloaded
 the night before, and playfully rallied the lady
 on her cruelty, saying, " You shall die, you ty-
 rant !  you shall die with all those instruments
 of death about you—with that enchanting smile,
 those killing ringlets  of your hair?"   " Fire 1"
 said she, laughing.   He pulled the trigger, and
 she was shot dead.   He called  up the servant,
 and, upon his entering, locked the door, and in-
 quired if he had loaded the pistols.  " Yes,"
 was answered; on which  his master shot him
 with  the  undischarged pistol.  He wrote* to
 his wife's father, explaining the calamity, and
 then threw himself upon his sword.
  591. Instances are  not rare of a parent or pa-
 rents, influenced either by want or by homici-
 dal monomania, killing their children, and then
 committing suicide.  Although extreme wretch-
 edness is sometimes the chief occasion of these
 occurrences, yet it is  seldom the only occasion.
 More frequently some form of partial insanity
 is either the principal or concurring cause; some
 circumstance having occurred to excite the
 homicidal propensity.  Dr.  Gall mentions the
 case of a soldier, of whose wife an officer had
 become enamoured without succeeding in his
 wishes..  The  soldier  appeared dejected and
 morose, but the  following day  appeared  quite
 tranquil.   A few days  afterward  he and his
 wife  attended  the  confessional  and took the
 sacrament; they dined in good spirits, and went
 out to walk ; he expressed his strong affection
 for her, and inquired if she had made a full con-
 fession to the priest.   He then  plunged a pon-
 iard in her breast.   He repaired to his house,
 and seizing  his children,  killed them with a
 hatchet.   He afterward went to the main guard
 and deliberately detailed the whole particulars,
 concluding  with  the  words, "Let the officer
 now make love to my wife, if he pleases !"  He
 then stabbed himself  to the heart.
  529. o.  Suicide is often  simulated, with' a
 view  of  obtaining  a  desired end ; the  lover
threatens or seems to attempt it, to induce a re-
turn of his affection ;  the spoiled child, to obtain
a compliance with his wishes;  and the indul-
  * The  letter will show the state of mind produced by
causing the death of a much-loved object, particularly as
leading to suicide. This gentleman had written immediate-
ly upon the performance of the ceremony, and had conclu-
ded the note as follows : " The bride gives her duty, and is
as handsome as an angel.  I am the happiest man breath-
ing."  This soon afterward was written : " Two hours ago,
I  told you truly that I was the happiest man alive.  Your
daughter lies dead at my feet, killed by my own hand, through
a mistake of my man's charging my pistols unknown to me !
I  have murdered him for it.  Such is  my wedding-day.  I
will follow my wife to her grave ; but, before I throw my-
self upon my sword, I command my distraction,  so far as to
explain my story to  you.  I fear that my heart will not
keep together till I have stabbed it. Poor good old man, re-
member that he who killed your daughter died for it!   In
death, I give you thanks,  and pray for you, though I dare
not  pray for myself.  If it be possible, do not curse me.
Farewell for ever!"
 ged wife, submission to her caprices.   In such
 cases, either a small portion of laudanum is
 usually procured, and this is diluted with some
 fluid, to increase the apparent quantity; or a
 large quantity is taken, when seen by some per-
 son, or when instant aid maybe obtained. Fe-
 males have resorted to this plan to try the af-
 fection, or to compel the fulfilment of the en-
 gagements  of their  lovers ;  but,  in cases of
 this kind, little more is necessary to be known
 than that such acts are sometimes resorted to ;
 and that a poisonous dose  may be actually ta-
 ken, in order to appear  the  more in earnest,
 knowing that assistance is near, and that it will
 besuccessfullyemployed.  Drowning,even,may
 be  feigned in similar circumstances.   I  have,
 however, seen two cases  in which fatal results
 very nearly followed this  experiment upon the
 endurance of affection.
  593. B. Predisponent Circumstances.—Besides
 the above exciting occasions of suicide, others,
 which powerfully predispose the mind  to  their
 influence, and to which attention has been im-
 perfectly directed, require to be briefly noticed,
 namely,  hereditary  predisposition;  systems of
philosophy and of morals;  states of education, of
manners, and of society ; distracting  subjects and
studies ; irritation caused by  difficult  and perplex-
ing circumstances ; injuries of the head, and phys-
ical disease ;  the influence  of climate, of seasons,
weather, and states of the air on the nervous sys-
tem, and of age, sex, and temperament, &c.
  594. a. The influence of hereditary predisposi-
tion in occasioning suicide  is  well established.
 In a very large proportion of instances, either
self-murder has been perpetrated by one of the
Older members of the family,  or some form or
 other of insanity has appeared in one  or  more
 of them.  Very frequently one or both  parents
 of the suicide have been noted for eccentricity,
 or the waywardness, instability, or violence of
 their dispositions and tempers.  Instances have
 occurred  of  the children  of a parent who has
 committed  self-destruction  perpetrating the
same act when they have grown up, or at later
periods of their  existence.  Even more than
one—several—of the offspring have experien-
ced this fatal disposition upon arriving at near-
ly the same epoch of life as that  at which  it
was committed by their parent. Dr. Gall has
observed the suicidal predisposition in  several
successive generations.   I  have known  it in
three generations.   M. Falret considers sui-
cide to be more intimately dependant upon he-
reditary predisposition than any other form of
insanity; but this is chiefly  the case in  respect
of suicide connected with  melancholia and oth-
er forms of partial insanity.
  [We could relate several  instances of a he-
reditary predisposition to suicide that have oc-
curred under our own observation.  Dr. Gall
relates  the  following very remarkable case :
" The  Sieur Gauthier, the owner of various
houses built without the barriers of Paris,  to be
used as entrepots of goods, left seven children,
and a fortune of about two millions of francs
to be divided among them.  All remained at
Paris, or in the neighbourhood, and preserved
their patrimony; some even  increased it by
commercial speculations.   None of them met
with any real misfortunes, but all enjoyed  good
health, a competency, and general esteem.  All,
however, were possessed with a rage  for sui- 
644
INSANITY, SUICIDAL—Occasions of.
cide ; and all seven succumbed to it within the
space of thirty or forty years.  Some hanged,
some drowned themselves, and others blew out
their brains.  One of the first two had invited
sixteen persons to dine with him one Sunday :
the company collected, the dinner was served,
and  the guests were at the table: the  master
of the house was called, but did not answer.
He was found hanging in the garret.  Scarcely
an hour before, he was quietly giving orders to
the servants, and chatting with his friends. The
last, the owner of a house in the Rue de Rich-.
elieu, having raised his house two stories, be-
came frightened at the expense, imagined him-
self  ruined, and was  anxious to  kill himself.
Thrice they prevented him ; but soon after he
was  found dead, shot by a  pistol.  The estate,
after all the debts were   paid, amounted  to
300,000 francs, and he might have been  45
years old at the time of his death."]
  595. b. The influence of systems of philosophy
and of morals in increasing the frequency of
suicide is undoubted.   The doctrines of Zeno
and  Epicurus encouraged  it among the  an-
cients.   Since  the revival of learning, Mon-
taigne was one of the  earliest and  ablest  of
those who favoured the perpetration of this act,
but all his arguments are derived from the an-
cient Stoics.  The early writings of Dr. Donne
seemed to favour  suicide ;  but they actually go
no farther  than to show that contempt for, or
even the sacrifice of life is praiseworthy in the
discharge of our duties, and in the execution of
beneficent  and  noble undertakings.   The rea-
sonings of Hume, and the indirect support which
the doctrine they favour received from the wri-
tings of Montesquieu, of Rousseau, of Gothe,
De Stael, and others, probably contributed less
than is, supposed to the increase of this crime.
It is, however, not to be disputed that the loose
principles disseminated, and the violent feelings
displayed and exerted, by  the warm and pas-
sionate writings of Rousseau and Gothe, pro-
moted this  end much more than the metaphys-
ical and moral arguments urged in favour of it.
Madame De Stael has stated that the Sorrows
of Wer.ter caused more suicides, at one time, in
Germany, than  all  other circumstances com-
bined.   Whatever of mischief has arisen in this
direction from modern writings has been indi-
rect—has proceeded chiefly from the injurious
influence exerted upon the mind by an exciting,
profligate, and debauching literature, for  which
the state of society and manners has procured
a very extensive circulation ;  and not so much
from the arguments adduced by a  few meta-
physical  writers  of more  confined, although
more lasting reputations.  The poison instilled
continually, and in wide  profusion, into  the
minds of all classes of the community, through
the media  of the numerous works  of passion
and imagination with which the presses  of the
civilized world at present labour;  the taste for
their perusal, which numerous circumstances
of the times conspire to diffuse ; and the moral
contamination  which they spread., or render
still  more  deep and malignant, most sensibly
dispose the mind to  suicidal impulses, when
subjected to the exciting  causes already no-
ticed.  That the doctrine of Materialism, how-
ever, and the general skepticism to which  it
leads, disposes  the mind to suicide, inasmuch
as it weakens the belief of a future  state of re-
wards and punishments,  canno  be deputed.
The infidelity so  widely d.ffused towards  the
close of the last century, by means of the skep-
tical writings of that, and of a somewhat earlier
period, doubtless  contributed to the frequency
of  suicide, especially  in  France, during that
eventful  epoch  ; and there is every reason to
believe  that  its influence  is still exerted, al-
though to a somewhat  less extent than then.
  596. c. Education and states of manners and of
society may be such as  to favour, or to counter-
act a tendency  to self-murder.   If education be
conducted without regard to religious and mor-
al principles—if the knowledge of words, of
things, of facts, and of phenomena  be made to
supersede sound principles of conduct and of
belief—if the amount of knowledge communi-
cated rise above, or  reach beyond  the sphere
of utility and of enjoyment—if, in short, educa-
tion be conducted in  the manner in which I
have already shown it (§ 271, 272) to be gener-
ally conducted  in the present day, it will tend
much more to increase the number of our wants,
to develop our desires and passions, to aug-
ment their intensity and violence, at the same
time that it removes from them those salutary
restraints which prevent them from becoming
dangerous to others or destructive to ourselves.
The influence of education thus loosely con-
ducted, upon the pseudo-liberal principle of ren-
dering it acceptable to all creeds—to the Church-
man, the Romanist, the Presbyter, the Baptist,
the Socinian, and all other persuasions—"to
Christian, Turk, and Jew"—proves injurious,
not only in the  way just stated, but also in giv-
ing rise to forced', unnatural, over-reaching, am-
bitious, and unprincipled states of society ; and
these states, in proportion as they are devel-
oped, are the parents  of crime, insanity, and
suicide.  Throughout the community, and par-
ticularly  in the  middle  classes, there is a con-
stant effort to rise above the ranks which Prov-
idence has  assigned, and  to partake  of the
pleasures and luxuries which are far  beyond
the means of some, and are  conducive to lib-
ertinism  and profligacy in  many of those who
enjoy them the most.   The  end of excessive
indulgences, and of debauchery in every form,
particularly when early pursued, is suicide oi
insanity, or the  unequivocal combination  of
both,  in many instances.
  597. There can be  no  doubt of the perni-
cious principles recently inculcated, particularly
among the lower orders of society, and to which
the name of  Socialism has been given, having
already conduced, in several cases, to suicide.
This doctrine, inasmuch as it unlooses the ties
of society and of consanguinity, as it admits of
no moral responsibility, and as it allows no ex-
pectations of future rewards and punishments,
is' opposed to all moral and religious obliga-
tions—it favours vice and profligacy, overthrows
all  virtuous and  salutary restraints upon the
feelings,  and, by allowing without control  the
indulgence of the  desires and passions, favours
what has just  been shown to be the ultimate
consequences of this course.   In this state of
society, the endearments of friends, of connex-
ions, and even of relations, cease to exist.  The
ties which bind society together in harmony
are broken asunder; and  as soon  as the race
of selfish indulgence is run—as the power of
enjoyment is exhausted—the mind, having no 
INSANITY, SUICII
 affections, no friendships, no self-consoling and
 truly gratifying recollections to repose upon,
 at once sinks into a state of abject wretched-
 ness, which it seeks to terminate by .self-mur-
 der.
  598. In illustration of what I have stated, I
 may  adduce  what has  been  advanced  by a
 French writer, in accounting for the frequency
 of suicide.  This writer remarks, that the high
 civilization and  refinement,  the  luxury, the
 clash of interests, the repeated political chan-
 ges, combine to keep the moral feelings of the
 Parisians in a state of tension., Life does not
 roll on in a peaceful  and steady current, but
 rushes onward with the force and precipitation
 of a torrent.  In the terrible struggle, it often
 happens that  the small minority,  which  has
 been elevated high above the multitude for a
 time, falls down as suddenly  as it has risen.
 The drama of life is full of miscalculations, dis-
 appointments, disgust, and despair ; hence the
 numerous suicides.  But there are  other caus-
 es in operation—and not the least, the remark-
 able character which romances, plays, and spec-
 tacles have assumed.   The public taste has un-
 dergone a complete revolution in this respect.
 Nothing is more patronised now at  the theatre
 than the display of crime unpunished, human
 misery  unconsoled,  and a low literature, im-
 pregnated by a spurious philosophy, declaiming
 against society, againt domestic life, against
 virtue itself; applauding the  vengeance of the
 assassin, and  recognising  genius only as it is
 seen in company with spleen,'poison, and pis-
 tols.  This writer concludes with appealing to
 those who read the novels of the present day,
 and who visit the theatres, whether he has ex-
 aggerated his statement;  and I may appeal to
 all  in this  country, who are acquainted, not
 only with  the  state of our popular literature,
 and of the stage, but also with the character of
 the daily,  weekly, and even monthly publica-
 tions, which are hourly devoured by all classes
 —with  their  natures and contents—whether
 this writer has not under-estimated the influ-
 ence of these causes.
  [These remarks will apply,It is believed, with
 still greater force to the theatrical representa-
 tions and the light literature of our own country.
 The poison disseminated by these two sources
 can scarcely be imagined ; and, what is worse,
 the evil not only goes on unheeded, but no at-
 tempts are made to bring about a reformation.
 The more licentious and profligate the charac-
 ter of the daily press, the more is it patronised ;
 and papers that do not cater for the very low-
 est passions of our nature, and are not well
 spiced with scandal, obscenity, and records of
 crimes, are but little in demand, and soon give
 place to others of an opposite character.  The
 trashy,  miserable novels of  the Bulwer and
 Paul de Kock style, for want of an internation-
 al copyright law, flood our whole country ;  and
 what  else can  be expected than a gradual de-
 generation of morals, crime, insanity, and sui-
 cide *  It  is time that parents, guardians, and
 teachers,  if not  legislators,  should take this
 matter in  hand, and display as much solicitude
 against  causes that poison the soul as those
 that contaminate the body.]
  599. d. Harassing subjects  and abstract stud-
ies, especially when undertaken by minds which
have undergone an imperfect preliminary course
DAL—Occasions of.                      645

 of information and discipline, sometimes occa-
 sion so much distraction as to give rise to sui-
 cide or some form of insanity.   Several instan-
 ces of suicide have occurred from the pursuit
 of subjects  too abstract either in themselves,
 or in relation  to the power of the individual's
 mind.  In such cases, an extreme state of irri-
 tability of temper is often.evinced before the
 suicidal act is attempted.   Indeed, the irrita-
 tion produced by any difficult and perplexing
 circumstance,  as  well as by great losses and
 disappointments, is very apt to terminate itself
 in self-murder, when experienced by the weak,
 the indulged, the fortunate,  or the undecided
 and  wavering mind.  In the present general
 scramble for wealth, often merely for existence,
 and  as often only to obtain  the means of re-
 taining a position falsely usurped, or too san-
 guinely entered upon, the irritation and distrac-
 tion which often necessarily result, not infre-
 quently  lead on  to suicide.   The rich  man
 gambles in the funds, foreign  or domestic, or
 in  joint-stock  shares, [railroad projects,] or in
 the prices of foreign and domestic  produce, in
 order to double by a single  speculation what
 he had slowly  acquired by prudence or applica-
 tion.  The  poor man  places his  last or only
 stake, and his  own and his family's happiness,
 upon a contingency not more secure than the
 hazard of a  die.   In either case, adverse  for-
 tune brings distraction, which reason is not al-
 ways able to calm.  A gentleman, who had ac-
 quired a large fortune by a long life of prudent
 application to business, ventured the greatest
 part of it in the foreign funds : he might, at one
 time, have sold with great advantage ; but they
 fell rapidly ;  and, under the contemplated loss
 of £70,000, he terminated his existence.   An-
 other, similarly circumstanced, went repeated-
 ly with the intention of selling at a time when
 he might have gained many thousands.   His
 want of decision prevented him on each occa-
 sion from carrying his design into execution :
 the period  of extricating himself had passed ;
 and, in a state of irritation at  his loss, and at
 his wavering state of mind, he committed sui-
 cide.  But such occurrences almost daily take
 place ; for trading and commercial transactions
 very generally  possess, in the present day, very
 much of the same gambling  character.   Even
 the small capitalist is desirous  of investing, or
 of speculating with the savings of years, in
 some one or other of the numerous schemes,
 promising  large  returns, concocted  by those
 who are well aware of the existing passion for
 gain, and who know well how to turn it to their
 own advantage,  but to the  loss,  misery,  and
 destruction of their dupes, many of whom, in
 a state of distraction occasioned by their ruin,
 commit suicide.
   600. e. Injuries of the  head, and physical dis-
 ease, sometimes  either predispose, or directly
 give occasion to suicide.   Injuries  received at
 a remote period may  give rise to it, without
 having previously excited any marked state of
 disease, or even mental disorder; and yet, upon
 examination after  death, lesions of structure
 have been, in  some instances, detected either
 in the brain or its membranes, or even in both.
 More frequently, however,  physical disease,
 often slight,  but still manifest, shows itself; or
 some degree of mental disorder, or some  illu-
 sion, is evinced, of which the suicidal impulse 
DAL—Occasions of.

 the proportion which suicides bore to the pop,
 ulation, in several places in Europe,  for the
 year 1817.  I abstract only a few cities :
 twu„      <>7 suicides   166,584popul., or 0,34 in 1000.
 Rrl »„ '  '  58  -       63,020-  br 0,92 in 1000.
 Breslau .  .  58                _  or 1,79 in 1000.
 Magdeburgh  50  -       ^°   _  or n fi„.
 Copenhagen  51  -       ™,    _   or0f4ain IO00L
 .?   •  -XXX      mnnnnnnn —  or 0.20 in MOB
 646                      INSANITY, SUICI

 is only a symptom or a concomitant.   In most
 cases, the  injury which originated the mischief
 has been so slight as to be considered unim-
 portant by both the patient and his friends.
   601.  Visceral disease has  a similar influence
 in causing suicide, as I have shown it above
 ($ 309, et seq.)  to exert in producing insanity.
 When the abdominal viscera, particularly the
 digestive organs,  are chiefly in fault, hypochon-
 driasis and melancholia are first developed;  the
 disorder of these organs acting upon, or disor-
 dering the  circulation in the brain.  When the
 intention or the impulse to commit self-murder
 originates in primary disease of the brain itself,
 some form of monomania, or of mania gener-
 ally either precedes or  attends it.  In  most
 cases of suicide arising from visceral disease,
 either organic nervous energy has been remark-
 ably depressed by exhausting causes, as by
 masturbation, drunkenness, and libertinism ; or
 this disease has been only an accidental or con-
 curring cause, one or more of the  circumstan-
 ces  or occasions  already  noticed having been
 more or less concerned in producing the suici-
 dal determination.
  602. /. Seasons, weather, and climate have been
 generally supposed to exert some influence in
 disposing to suicide.  M. Villeneuve considers
 that a warm, cloudy, and humid state of the air
 increased the number of suicides in Paris, Mar-
 seilles, and Rouen ; and that stormy weather
 seemed to exert a similar influence.  The effect
 of warm and humid states of the air upon  the
 nervous  system is often very manifest in  de-
 pressing its energies, in weakening the mental
 powers, and in lowering the spirits.  The great-
 est number of suicides has been said to occur
 when the thermometer ranges above 75°.   Dr.
 Burrows observes, that, on examining  the
 tables kept at Westminster  from 1812  to 1821
 inclusive, and at Hamburgh  from 1816  to 1822
 inclusive, the number of suicides in both cities
 was greatest in July, and least in October.   A
 similar result has been remarked in respect of
 Rouen and Copenhagen.  From  1817 to 1826,
the number of suicides  committed in Paris
 amounted to 3205 ; of which 997 were perpe-
trated in spring, 933 in summer, 627 in autumn,
 and 648 in winter; the following being the num-
 bers with reference to  the  months: January,
213 ; February, 218 ; March, 275 ; April, 374 ;
May, 328 ;  June, 336 ; July, 301 j August, 296;
 September,  248 ;  October,  198;  November,
 131 ; December, 217.  November has been said
to occasion greater despondency and despair,
 and more suicides, than any other month;  yet
 this  month, both in London  and  in Paris, pre-
sents the smallest number of self-murders, with
 the  exception  of October.   Notwithstanding
the influence of warmth  and humidity of  at-
mosphere in increasing the number of suicides,
this  act is  much  more  common in the colder
than  in  the  warmer  countries  of Europe;
France, Germany, England,  and Denmark  be-
 ing the kingdoms  in which it is most frequently
committed.  In the summer of 1806, 60 cases
took place in Rouen, and nearly 300 in  Copen-
 hagen ;  the weather being  warm and moist.
 In Berlin, 500 instances occurred in six years
 and a half;  while at Naples there were, in 1826,
 only 7, in a population of 349,000; and in all
 Spain, in the same year, there  were only 16
 cases.  Dr. Kamptz, of Berlin,  has assigned |
  London.  .200  —   luu.vuu,""" —   --,-«... «u».
  No just inference, however, can be drawn from
  returns of the suicides committed during one
  year only in different climates or countries;  as
  several circumstances, either uncommon or for-
  tuitous, may have occurred, in one or more of
  these climates, at that period,  to  increase  or
  diminish the usual numbers, as great prosperity
  or adversity, plenty or scarcity, political com-
  motions or revolutions, &c.   Nor is it to climate
  or season that much influence is to be imputed
  in occasioning suicide;  but chiefly to the va-
  rious circumstances already noticed in connex-
  ion with religion,  commercial speculation, and
  states of society.  It is sufficiently established,
  however, that, throughout the most of Europe,
  and  in the United States of America, suicides
  have become much more frequent  than at the
  above, or at almost any preceding period, un-
  less during the French Revolution. The num-
  ber has increased  in Paris from  300 in 1817, to
  511 in 1826 ; and  in Copenhagen from 209 du-
  ring 1790 and the  four successive years, to 319
  during the first five of the nineteenth century.
   603. The admitted increase of suicides, more
  especially in this country, is not to be altogeth-
  er referred to the more general influence of the
  several occasions  already mentioned;  but in a
  great measure, also, to  the  increased numbers
  and  circulation of those  prints  which abound
  with the disgustirig details of profligacy, crime,
  and  suicide.   Dr. Burrows justly  remarks,
  " that the  public taste  has become more and
  more vitiated and debased  by this species oi
  gratification ; and  nothing is found so attractive
  as tales of horror  and of wonder, every inquest
  that is held upon  a person who has destroyed
  himself being read with  great avidity."   The
  ludicrous  police reports of  criminal  acts fur-
  nished by the daily panderers to our  more de-
  based desires, scenic representationsof success-
  ful vice and crime, and the constant circulation
  of suicidal acts in all the periodical prints, serve
  most essentially to familiarize the minds of the
  lower classes especially with these  acts, and
  to diminish  the detestation with which they
  are generally viewed at first, until the moral
  sensibility becomes altogether blunted by theit
  perusal.  The repeated presentations of these
  crimes to the minds of the ignorant and vicious,
  often not only divested  of their  attendant hor-
  rors, but even clothed in attractive garbs, read-
  ily suggest a recourse to them in circumstances
  which cause distress, irritation,  or distraction.
  Literature, if, indeed, the trash vomited hourly
  from the steam-press should be dignified with
  the name, has become the  most  debased  of
  modern ways of traffic ; and its chief end,  in
  the present day, is to encourage those feelings
  and desires by  means of which its  diffusion
  and profitable returns may he augmented.   In
  order that this may be the more surely effected,
  and with the greatest amount of moral contam-
  ination  to  the community,  and  of pecuniary
.  profit to the,writers and proprietors—that the
I  criminal appetite may be pampered and inpreas- 
INSANITY, SUICIDA
ed ;  that each successive meal of criminal in-
dulgence may be  followed by a greater relish
and a more craving desire for its repetition—
foreign countries are ransacked to furnish what
our own cannot supply in sufficient frequency
and piquancy.
  604. g. Age and Sex.—The frequency of su-
icide varies at different ages.  During the early
epochs of existence, the sanguine expectations,
which are  generally indulged,  and which soon
take the place  of  temporary despondency and
distraction occasioned by disappointments and
losses, tend to diminish the number of suicides.
In the middle and more advanced periods of life,
sensibility becomes exhausted or blunted, while
cares and anxieties increase in number and in-
tensity ; and the attachment to life is much im-
paired.  The desire of life afterward increases,
and frequently in proportion as old age advan-
ces.   M. Falret has shown that it is from 35 to
45 that the greatest number of suicides occur.
Of 6782 cases, 678 were under 20 years of age;
and  of this number 487 were  between 15 and
20, and 181 below the age of 15.  A child of
nine years old* wished to destroy itself; but
this  is the  only case of so early an age.  After
45, suicide becomes more and more  rare ; and
above 70, there are scarcely any instances of
it.  The father, however, of  the celebrated
Barthez killed himself at the age of 90; and
his son, when he was old, wished to follow his
example.
  605. Both sexes display the suicidal tendency,
but the male sex most frequently.  M. Esquirol
considers the proportion of males to females to
be three to one ; but there are differences ac-
cording to countries, arising from the greater
or less influence of many of the circumstances
shown  to  favour  this act.  Thus, in France,
there are more suicides among women than in
Germany.   It,has been observed, both in Eng-
land  and  on the  Continent,  that  nearly two
thirds of suicides were unmarried.  This state,
therefore,  is much  more  favourable to  self-
destruction than the married condition.
  606. h.  Suicides are most  frequent  among
persons of the melancholic temperament and bil-
ious  constitution, with a pale or sallow, or yel-
lowish complexion, and hard or sharp features.
Such persons are more liable than others to dis-
orders of the biliary and digestive organs.  But
this  crime  is not infrequently committed by the
nervous and irritable, and even by the sanguine
and plethoric.  Females of this latter constitu-
tion  occasionally  attempt  or  perpetrate  self-
murder just before or during the catamenia, or
from some irregularity of this evacuation.  M.
Esquirol states, that the scrofulous diathesis is
remarkable in a number of suicides.
  607 i. Several tables, showing the frequency
of the several causes of suicide, have been  pub-
lished, but  are obviously deficient in precision,
as well  as  in the truth of the data upon which
they are based.   Moreover, this act is not gen-
erally prompted by  a  single circumstance or
cause only, but by the combination, concur-
rence, or  succession of several.  With great
allowances and reservation, the following may
be adduced, in  the absence of more accurate
information, as  to  the comparative influence of

  * I am now attending, for a physical ailment, a boy of 12
years of age, who attempted suicftle by" hanging, from a feel-
ing of revenge for being punished.
JL—Occasions of.                        647

the circumstances occasioning this crime.  The
suicides committed in  London,  between the
years 1770 and 1830, have been stated (London
Med. and Surg. Journ., vol. v., p. 51) to be 4337
men, and 2853 women ; and the causes have
been thus assigned :
               Causes.             Men    Women,
  Poverty...........905     511
  Domestic grief.........728     524
  Reverses of fortune.......322     283
  Drunkenness and misconduct  .  .  .  . 287     208
  Gambling...........155     141
  Dishonour and calumny......125      95
  Disappointed ambition......122     410
  Grief from love.........97     157
  Envy and jealousy........94      53
  Wounded self-love........53      53
  Remorse...........49      37
  Fanaticism..........16       1
  Misanthropy...........   3       3
  Cases unknown .....  ...   1381     377

According to M. Falret, of 6782 suicides com-
mitted between 1797 and 1823, 254 were from
disappointed  love,  157  being in women;  92
from jealousy;  125 from the chagrin caused
by ^calumny; 49  from  a  desire, without the
power, of vindicating character ;  122 from dis-
appointed ambition ; 322 from  reverse of for-
tune ;  16 from wounded vanity ; 155 from gam-
bling ; 287 from crime and remorse ; 728 from
domestic distress ;  905  from poverty ;  16 from
fanaticism.   Upon  comparing this  table with
the preceding, very great inaccuracy will be ap-
parent, proving the very little dependance to be
placed upon  numbers  in medical details.  Of
500  suicides  committed in Berlin  during six
years  and  a half,  Dr.  Caspar states that  14
were caused  by offended honour ; 61 by insan-
ity-; 54 by drunkenness and dissipation ;  32 by
dread of punishment;  18 by debt and  domestic
trouble ; 12 by love ;  11 by matrimonial strife;
3 by disgust of life ; 12  by disease and pain ;  1
by  religious  excitement; and  282 by causes
which were not specified.
   608.  C.  The modes selected  of quitting life
may  be briefly noticed.  These, in many in-
stances, have some reference to the occupation
or profession of the suicide.  Thus, military
and naval men shoot themselves; chemists and
medical  men poison  themselves, chiefly' with
prussic acid ;  barbers  and hair-dressers cut
their throats; shoemakers stab themselves,
&c.   Fire-arms and sharp  instruments, partic-
ularly pistols, razors, knives, and daggers, are
most frequently employed by men.  Drowning,
hanging, poison, and  precipitation from win-
dows or great heights,  are the means of self-
murder most commonly resorted to by women.
In France, asphyxy, by the vapour  of burning
charcoal, is often selected by females,  and even
by males, particularly in cases of associated
suicide.  Hanging, drowning, and poison are,
however, the means most frequently resorted
to by both sexes.   The choice thus made does
not always depend upon what may be supposed
to cause the easiest or the most rapid death ;
but, probably, upon that mode which offers the
greatest facility, or is the most readily carried
into effect in moments of irritation, distraction,
or depression.  It  is remarked that a very large
proportion of suicides by drowning in London
are committed by persons residing in the vicin-
ity of the river and of the Regent's  Canal.
  609. Dr. Caspar  states that of the 525 cases
of suicide already noticed, 234 were committed
by hanging ;  163 by shooting ; 60 by drowning i 
648
INSANITY—SUICIDAL—Arrangement of the Causes or.
17 by cutting their throats; 20 by stabbing ; 19
by throwing themselves from windows; 10 by
poison ;  2 by opening an artery.   M. Esquirol
gives the following details of 205 cases of sui-
cide in females: 49 by hanging and strangula-
tion ; 45 by precipitation from windows, &c.;
2 by fire-arms; 18 by sharp instruments ;  7 by
poison;* 5 by asphyxy;  48 by starvation; 31
by drowning.
  [In 1840, 10,881 cases  of violent deaths and
suicides were reported in England and Wales
{Registar GeneraVs Report), of which 900 were
cases of suicide, and 65 were murders.t, If we
take the instrument or means of death employ-
ed by suicides,  the following will be the order
of their frequency:  hanging, strangling, and
suffocation, 381; poisons,  161;  wounds,  129;
drowning,  107;  gun-shot  wounds, 45;  leaps
from heights, 18 ; unascertained, 60.   Of the
cases of suicide by poison, 26 were by arsenic;
19  by opium;  3 by oxalic acid; and  113 by
other, poisons.  During the year 1844, 184 cases
of suicide were published in the Journal of Com-
merce of this city, as having occurred in differ-
ent parts of the  United, States ;  of which 154
were men, and 30 women—the ages ranging
from 16 to 81.  The largest number occurred in
the month of July—26.   The quarter cornmen-
cing with July  numbered 56; that commencing
with April, 48; October, 36; January, 32. They
were distributed  through the different states of
the  Union in very unequal proportions; New-
York having furnished 44 ; Pennsylvania, 25 ;
Massachusetts, 20;  Louisiana,  13; Maine, 9,
&c.  In 29 cases, mental derangement was as-
signed as the  cause ;  in 9, habitual intemper-
ance ; in  12, depression of mind; in 4, domes-
tic trouble ;  in 3, Millerism ; in' 3, dissipation ;
weariness of life, jealousy, and remorse, each
2; while dyspepsia, ill-health, seduction, infi-
delity of wife,  murder of  neighbour,  delirium
tremens, apprehended insanity, fever, dread of
death, want of  employment, poverty, violent
passion, love, disappointed love,  unlawful love,
gambling, orphanage, each, is assigned as the
cause of one case of suicide. In 101  cases no
cause was assigned.   In 64 cases, suicide was
committed by hanging (54 men,  10 women); in
26, by drowning  (17 men, 9 women);  in 26. by
shooting with gun or pistol (all men);  in 25, by
cutting the throat (24 men, 1 woman); in 8, by
taking laudanum  ; in 5, by opium ; 1, morphine ;
2, narcotic poisons ;  stabbing with poisoned sti-
letto, 1  ; by arsenic, 4; prussic  acid, 1 ; corro-
sive  sublimate,  1;  opening an  artery, 2; by
cutting  the arm nearly off, 1 ; by jumping from
height,  1 ; by wounds and exposure,  1: total,
142 men, 29 women:  15 were foreigners, the
rest Americans :  89  were married ; 32 single ;
1 widow; 1 widower ; the remainder not stated.
   No accurate estimate, however, can be made
from these data  as to the number of suicides

  * The  small  number of suicides by poison, in the tables
furnished by Caspar and Esquirol, deserves remark.  On
the Continent, it is very difficult to procure poisonous sub-
stances unless by means of a physician's prescription. In
this country, a  child or any wretch may procure them for
purposes  of murder or suicide, without any difficulty and
at the lowest prices, at all the shops, with very vew excep-
tions, where drugs and medicines are vended.
  t [There were registered in England  and Wales, in the
year 1842, 118,825 marriages, 517,739 births, and 349,519
deaths being an excess 6f births over deaths of 168,220, the
average mortality being 1 in 45 ; in France it is 1 in 42; in
Prussia, 1 in 38; in Austria, 1 in 33 ; and in Russia, 1 in 28 J
In 1805 .	. . 26	In 1818
1806 .	. . 15	1819
1807 .	. . 16	1820
1808 .	. . 8	1821
1809 .	. . 16	1822
1810 .	. . 8	1823
1811 .	. . 9	1824
1812 .	. . 5	1825
1813 .	. . 11	1826
1814 .	. . 6	1827
1815 .	. . 5	1828
1816 .	. . 15	1829
1817 .	. . 18	1830
lODZ 1632 .	. . 39
1833 .	. . 30
1834 .	. . 33
1835 .	. . 29
1836 .	. . 33
1837 .	. . 42
1838 .	. . 43
1839 .	. . 45
1840 .	. . 28
1841 .	. . 39
184* .	. . 33
1843r .	. . 19
committed throughout our cc untry    J any
particular portion of it, as a  argc major, y  ,t
 s  presumed,  are  never  published.   Besides
 hose found dead and drowned are no-included
among suicides, and yet we know that^ drown-
ing is one of the most common  modes of ter-
mfnating life in the suicidal  The annual num-
her of suicides in the city of New-York for he
last 38 years,  according to the Reports  of the
City Inspectors, is as follows  :
                           . 24
                           . 27
                           . 15
                           . 16
                           . 13
                           . 18
                           . 19
                           . 14
                           . 29
                           . 23
                           . 22
                           . 33
                           . 29

   These, however, constitute, it is believed, but
 a  part of the actual number of suicides com-
 mitted, as  many reported under other  heads,
 as "sudden," "accidental," "apoplexy," "un-
 known," &c, doubtless belonged to this  class.
 The population of the city was, in 1805, 75,770;
 in 1810, 96,373 ; in 1815, 100,619 ; in 1820, 123,-
 706; in 1825, 166,086;  in  1830, 197,112; in
 1835, 270,089 ;  in 1840, 312,852.]
   610.  ii.  Arrangement of the  Causes of Su-
 icide.—A. Circumstances predisposing to this Act.
 —Hereditary predisposition ; the melancholic,
 bilious, and irritable temperaments ;  the mid-
 dle period of life ;  the male sex ; the unmarried
 state ;  indulgent  and  injudicious education,
 without reference to  moral and religious prin-
 ciples ;  masturbation  and  sexual excesses;
 drunkenness ; immoral amusements and exhi-
 bitions ;  the perusal of loose productions, and
 of criminal and suicidal details ; idleness and
 indolence ; habitual recourse to powerful men-
 tal  excitement; infidelity, or a disbelief of a
 future state of rewards and punishments; states
 of the air,  or of the season,  or  weather, occa-
 sioning depression of the nervous energy.
   611.  B.  Circumstances exciting' this Act,  or
 occasional exciting Causes.—a. Direct  occasional
 Causes.—The passions and feelings, particular-
 ly lo.ve, conjugal  affection, jealousy,  ambition,
 humiliated pride, sentiments  of dishonour, loss
 of female virtue, feelings of shame, violent an-
 ger, fear, terror,  and  remorse; gambling, ei-
 ther from want, or a desire of strong emotion
 and excitement, or covetousness; imitation, or
 mental infection ; fascination on looking down
 from precipices ;  chagrin,  desperation, or dis-
 traction ; reverses of fortune; disappointments,
 domesticunhappiness,  and family dissensions;
 the several forms of moral and partial insanity,
 especially melancholia and religious insanity;
 the  different  states of general  insanity, par-
 ticularly  mania and puerperal  insanity ; and
 the delirium consequent upon numerous physi-
 cal maladies.
   612.  b.  Indirect  occasional  Causes. — Bodily
 diseases  of various kinds ;  violent  pain, and
 incurable maladies ; the abuse of intoxicating
 liquors, of opium, of mercury ; distaste of life
 connected with the  change of life in  females,
 and  the  loss  of  attractions  from smallpox,
 &c.  ; ennui, or taedium vitae,  consequent upon
 an effeminate  and indolent state of existence, 
INSANITY, SUICi:
 or a state of mind in which the passions are
 without an object to excite interest, or are in-
 capable of being roused to feel an  interest ;
 want, and its attendant miseries;  anticipated
 exposure or  punishment ;  motives of revenge.
   613. c. General Causes.—Governments which
 furnish  numerous  examples of violent deaths
 in the execution of their laws, or, which pos-
 sess a  sanguinary penal  code ; the  military
 spirit, and .military governments; republican
 and democratic  constitutions ;  political com-
 motions, revolutions, and catastrophes, espe-
 cially  at their breaking out, or after the state
 of excitation and turbulence has passed away ;
 religious fanaticism, and, still more, the want
 of religipn ;  superstitious  doctrines ; unsound
 religious and philosophical opinions ;  depraved
 states of society, of manners, and customs.
   614. C. Causes  most  influential in this  and
 other  Free and  Commercial Countries:—The
 range given to the social  passions; the haz-
 ards and losses  in mercantile  speculations in
 the funds, and in joint-stock speculations  and
 companies, and the consequent ruin  and  de-
 basement of families;  habits of dissipation ;
 the indolence and ennui consequent upon wealth
 and sated enjoyment; the importance  attach-
 ed to public opinion, and the instability of that
 opinion ; the violent shocks and collisions of
 opposing parties ; the inactivity to which mili-
 tary and naval  persons  are reduced  during
 times  of peace ; the enthusiasm of religious
 and philosophical sects ;  the immorality of the
 literature and  scenic  representations  of the
 age; and the details of crime and of suicide,
 which constitute  a principal part of the daily
 reading of all classes of the community.
   615. iii. Pathology.—The Lesions observed in
 Suicides upon Dissection.—These, in many ca-
 ses, will necessarily be the same as have been
 already described in cases of manifest or fully-
 developed insanity.  In many instances the le-
 sions will have  no reference to  the production
 of this act, and  in some they will be  merely
 the consequences  of previous disease, which
 had nothing  to do with the subsequent occur-
 rence  of a suicidal impulse.  The physical dis-
 ease may have, in some cases, predisposed to
 the indulgence of a suicidal intention, by weak-
 ening  the vital manifestations, and particular-
 ly the  powers of mind; but, even in  such ca-
 ses, the mental emotion is to be looked upon as
 the efficient  cause of the act.  Without, how-
 ever, attaching much importance to the influ-
 ence of the structural alterations in producing
 it, as  far as  they have  been yet investigated,
 unless when  it is unequivocally dependant upon
 insanity, I shall briefly state those which have
 been most  frequently noticed.   Heister  ob-
 served lesions of  the liver, gall-bladder,  and
 pancreas.  Falket considers alterations of the
 liver to  be rare; M. Esquirol  remarked  dis-
 placement of the colon ;  Osiander, congestion
 of the  vessels of the brain, and chronic inflam-
 mation of the intestines ;  Corvisart, Alberti,
 and Osiander, diseases of the heart;  Greding
 and Gall, thickening and condensation of the
 cranial bones ;  Home, dilatation of the sinuses
of the dura mater, and effusion.of serum in the
ventricles, and  between  the membranes;  Re-
camier and others, thickening of the arachnoid
and dura mater, with ossific depositions in  the
latter; Falret and Foville, traces of vascu-
                    82
3AL—Pathologv of.                      649

 lar irritation and excitement in the membranes
 and substance of the brain ;  and Frank  and
 Esquirol  have failed, in  many instances, to
 detect  any appreciable  lesion  of any  organ.
 From 1333 inspections of suicides, the follow-
 ing results have been given, but with little ap-
 pearance of precision or accuracy: Thicken-
 ing of the cranial bones in 150; bony excres-
 cences  from their inner surface in 50 ; disease
 of the membranes of the brain in 170 ; inflam-
 matory appearances of the brain in 90 ; simple
 congestion of the brain in 300 ; tumors in  the
 brain in 10 ;  softening of the brain in 100 ;
 disease of the lungs in 100 ; lesions of the heart
 in 10;  disease of the stomach in 100 ; altera-
 tions of the  liver in  80 ;  lesions of the intes-
 tines in 50 ;  suppression of the natural secre-
 tions in 15 ; syphilitic  disease  in 8 ;  and no
 apparent structural change in 100.   (See § 223,
 et seq.)
   616. B. Physiological Pathology.—Suicide may
 be viewed, in many cases, even when proceed-
 ing from  passion and feeling,  as the result of
 deranged action of the vessels of the encepha-
 lon and  of its membranes, consequent upon al-
 tered sensation or excited emotion ; but it can-
 not be considered as essentially and exclusive-
 ly depending upon this pathological cause. The
 intellectual  and moral phenomena, which  ei-
 ther directly or indirectly give  rise to the sui-
 cidal determination, cannot be shown to be al-
 ways the consequence of vascular  lesion, or
 even of excited vascular action, although they
 often lead to such lesion, from  the  intimate
 connexion existing between the mental mani-
 festations and the  organic actions.   The  nu-
 merous  instances in which suicide is attempted,
 from ebullitions  of temper, or  gusts of passion
 or feeling, and in which the means of self-de-
 struction fail of accomplishing the intended
 end, leaving those who made the attempt calm,
 resigned, and happy at having failed in  their
 intentions, fully prove the absence  of estab-
 lished vascular  lesion, and show the remark-
 able difference  between these and  cases  de-
 pending upon real and confirmed insanity, which
 we never find so immediately and permanently
 cured as those instances of attempted suicide
 fortunately are, and cured  by the same means
 as so generally fail in  every  form of suicide
 proceeding from manifest  insanity, wherein it
 may be presumed that lesion  of vascular  ac-
 tion in  the  encephalon, as well as of organic
 nervous power, actually exists.  We are there-
 fore obliged to  conclude  that mental power
 may be, hereditarily or originally, or from  the
 influence of the predisposing causes  of suicide,
 so weak, or so morbidly impressible or suscep-
 tible, as to  give way to the impulses to this
 act, arising  out  of  any of  its  exciting causes,
 either before the contrplling  powers of mind
 have had time to react and to resist the suici-
 dal impulse, or from the circumstance of those
 powers  having been so weakened as to be in-
 capable  of sufficiently resisting  this impulse
 when excited by powerful or by combined caus-
 es.  In  these cases, this act is to be imputed
 to the state of mental energy—to a constitu-
 tion of the mind arising out of hereditary con-
 formation, and the  prolonged operation of pre-
 disposing circumstances,  rather than to any
 appreciable disorder of the  cerebral circulation.
  617. On the other  hand, it  ought  to be  ad- 
650
INSANITY, SUICIDAL—Pathology of.
 raitted, that incessant  application to study, to
 business, to political events, to the views and
 interests of parties and sects, to the discharge
 of public  duties,  or  to the support of public
 measures, as well as many of the  numerous
 causes above  specified, will  so far overturn
 the equilibrium of the circulation as to occasion
 an erethism of the vessels of the brain and its
 membranes, verging  upon inflammation, if not
 actually amounting to it.  Such a condition of
 this organ may betray itself by a slight  deliri-
 um, or partial or slight form of mental aliena-
 tion, by general irritation or nervousness, or by
 slight  fever, or by burning headache, with lit-
 tle other disturbance  of the system ;  or it may
 evince itself by a peculiarity of manner, by the
 unusual  direction  of  ideas, or  by the  state of
 temper and feelings.  If, during this condition
 of disorder, the ideas should be led to self-de-
 struction, or if any circumstance, whether do-
 mestic or public, should occur, which,  by exci-
 ting the temper or affections, may suddenly in-
 crease the cerebral  disorder, as well as  the
 consequent morbid ideas or resolution, suicide
 may be attempted ; or if, either after or before
 the ideas prompting to this act have  suggested
 themselves, thenndividual should be placed in
 a state of comparative inactivity, and his ideas
 be allowed to flow in  a  direction most likely to
 suggest or to confirm  the resolution to resort to
 self-murder, the event,  although more  mature-
 ly contemplated, may not be the less certainly
 accomplished.
   618. Suicide, viewed in  this  direction—the
 only one  in which it can be  considered with
 propriety as a physical disease—may be at-
 tempted by the strongest and most accomplish-
 ed minds, although much less  frequently than
 by others educated without just principles, and
 undisciplined in the school of difficulty, disap-
 pointment, and misfortune.  It is, under these
 circumstances, like other mental alienations,
 the result of vascular disorder  in an organ in-
 timately connected with the  intellectual and
 moral  manifestations.  We cannot,  therefore,
 be surprised that persons subjected to the most
 important  and  harassing duties, and underta-
 kings,  and anxieties,  should suffer in  that or-
 gan which is the medium  or  instrument of
 these distracting operations ; and that  the con-
 sequences resulting from them, both  to the or-
 gan itself, and to the  faculties related to it,
 should be exactly those which these causes are
 most likely, both from theory and experience,
 to produce.
   [This subject derives great importance from
 the fact that policies of life insurance are held
 to be valid  in  cases  where suicide  has been
 committed in a state  of insanity, but forfeited
 if  the  act is done in  an opposite mental con-
 dition.   The doctrine that suicide  is  always
 the result of insanity must be  abandoned as
 altogether  untenable; and the  same evidence
 of mental unsoundness,  in doubtful suicidal ca-
 ses, should be required as would be necessary,
 in a court of justice, to establish the validity of
a will.  Suicides must be divided into two class-
es,  founded upon the different causes or cir-
cumstances by  which they are actuated: the
first, including those who have  committed the
 act from  the force of  moral motives  alone ;
the second, those who have been affected with
some pathological condition of the brain, exci-
 ted or not by moral motives.  The act itself,
 apart from the circumstances under which it is
 done, should never be quoted as positive  proof
 of insanity;  although we believe that the ca-
 ses are few in regard to which it would be safe
 to affirm that the excitement  of the organic
 action of the brain and nervous system, which
 accompanies the perturbation of mind leading
 to the act, had not transcended  the  limits  of
 health, and passed into real pathological irrita-
 tion.  What  renders the question  a difficult
 and very complicated one, is the admitted fact,
 that suicide is often committed under the im-
 pulse  of mental derangement, even when men-
 tal  derangement would not otherwise have
 been  suspected.   But this subject will be dis-
 cussed in the ensuing section.  (See " A Trea-
 tise on the Medical Jurisprudence  of Insanity," by
 J. Ray, M.D., 2d ed., 1844.)]
   619. G. Is there a Suicidal  Monomania ?—M.
 Andral remarks, " that man is sometimes pos-
 sessed by a sentiment which tends  to self-de-
 struction    This feeling is designated ' Suicidal
 Monomania.'  It  is not always the result of
 mental alienation : some persons put an end to
 their existence who are not monomaniacs," &c.
 Now this is a contradiction, both in  terms and
 meaning, not very consistent with the reputa-
 tion which this  writer  has  obtained in  this
 country.  After what has already been stated,
 it will be  evident that suicide is either the re-
 sult of some form or other of general or partial
 insanity, or of some state of excessive passion
 or feeling which  does not, in the usual accepta-
 tion of the term, amount to insanity ;  although
 such passion or feeling  may, at the moment, as
 completely  overpower reason and self-control
 as any form of monomania.  If moral  insanity,
 which I have described above as constituting a
 form  of partial insanity, be  farther extended
 than I have ventured upon, and, instead of be-
 ing confined to those moral states of aberration
 which either are slowly developed, or are  per-
 tinaciously  entertained, or both, be  made to
 comprise  those momentary states of excessive
 passion or  feeling which are suddenly excited
 by intense  moral causes,  and which, in  well-
 regulated minds, soon subside, without any very
 appreciable impairment  of  reason and self-
 control, but which, in impressible minds unac-
 customed  to  control,  to  disappointments, to
 losses, and  distraction, often  give occasion to
 insanity or suicide—then those cases of this
 act that thus originate, and that seem the least
 of all dependant upon insanity, may be consid-
 ered as actually the result of the insane state;
 and to these the term suicidal monomania, or
 any other equally expressive of the insane con-
 dition, may be applied.   But if we thus extend
 the meaning of moral insanity, we must stretch
 it still  farther, and make it comprise, also, every
 act of passion or anger, even the act of just
 indignation  roused by insult; especially when
 insult  is repelled  by a retributive blow which
 may endanger the life  of the  aggressor.  It
 may be granted that, in  a few cases, suicide is
 the first symptom of insanity, the patient hav-
 ing been previously undisordered in mind.   But
 this is  an assumption rarely admitting of proof,
 unless where the act has been attempted only,
 and  not carried into effect, other insane acts
 being  afterward  committed.  M.  Andral, aa
just  noticed, admits that persons destroy them- 
                           INSANITY, SUIC

Belves as the  result of other circumstances
than the want of reason ;  and yet he terms
suicide  thus occasioned a form of partial  in-
sanity, and designates it" suicidal monomania."
Self-murder may depend On many grades of in-
sanity, and may, as I have shown, be the con-
sequence of the several forms of  moral insan-
ity ;  but when no degree of this malady is man-
ifest beyond this act, it would be more correct
to view it as the consequence of intense pas-
sion or feeling—the impulse  to self-destruction
arising  out  of  these  emotions overpowering,
for the moment, the dictates of reason and the
control  of the judgment.   According to this
view, the term here  used may still be said to
be appropriate ; .and  it may be allowed to be so,
if the word insanity be extended to the utmost,
so as to comprise  the momentary impulses of
passion, feeling, and mental depression.  Sui-
cide committed, or even attempted, in such cir-
cumstances, may then be viewed as a proof of
insanity, or  be considered as a fprm of moral
insanity, or, as M. Andral has done, with va-
rious contradictions of himself, as a monoma-
nia—the aberration of mind  consisting only of
the impulse  to self-destruction.   If, on the oth-
er hand, insanity is to be viewed in a less com-
prehensive sense—if it is not to be extended to
those momentary  impulses  of excited or de-
pressed passion and feeling which lead to acts
of violence  against others or  ourselves, and
which only for a time overpower reason and
judgment—then suicide, committed or attempt-
ed in the circumstances referred to, cannot  be
justly viewed in the above light, but should  be
looked upon as an  act of  passion, that, like
other violent  acts, cannot,  consistently with
good morals, or even with the safety of soci-
ety, be treated as an insane  act.  In the forms
of moral insanity noticed above (§ 69, et seq.),
it has been shown that, in addition to its more
or less gradual development, the moral aberra-
tion is generally pertinaciously adhered to ; and
that, when  suicide follows,  the connexion of
this  act with such  aberration, and with impair-
ment of the mental powers, is very obvious :
but where disorder of the moral manifestations,
or of the judgment, is not apparent, suicide be-
ing attempted, from a desire  to escape the pun-
ishment of crime, or from humiliations of any
kind, or from intense passion, distraction,  or
depression suddenly excited—from some mor-
al shock, the  dependance of this  act  upon a
state of mind actually insane  is not so mani-
fest ; and it will be to the benefit of the com-
munity not to consider it, in such circumstan-
ces,  as  the  result  of insanity.  Numerous  in-
stances have  been recorded  of persons who
have had recourse to suicide from  imitation or
fascination—from the mental infection caused
by the self-murder of some one, however little
noted for station or character.  In such cases,
a predisposition to this crime may have already
existed, or circumstances may have  occurred
to favour the suggestion of ideas of self-de-
struction ; the  suicidal disposition being con-
firmed or determined by perusing  the details of
this  act, generally so lavishly furnished by the
daily and weekly prints.  In some of those  oc-
casions  of imitative or epidemic  suicide, the
moral infection has been arrested by inflicting
unusual indignities on the bodies of those who
perpetrated  the  crime; thereby showing that
IDAL—Prognosis.                        651

 this act was not, as respected many of the ca-
 ses which occurred in these circumstances, al-
 together the result of the absence of reason, or
 that the persons who had committed it could
 not be accounted irresponsible agents.
   [Dr. Ray remarks, that when a person in good
 health, and surrounded with everything that can
 make  life  dear to  him, deliberately  destroys
 himself without any visible cause, no balancing
 of motives  or scrutiny  of private  circumstan-
 ces  can  satisfactorily explain it, and we are
 obliged to consider it as a form of  partial mor-
 al mania. Where a person labours under a sui-
 cidal monomania, we  believe it may be gener-
 ally recognised by other signs ; as  deep melan-
 choly,  eccentricity of conduct, &c.   Most of
 these individuals labour under a constant de-
 jection of spirits, presaging nothing but evil;
 imagining that they have committed some hei-
 nous offence ;  that their friends have forsaken
 them, and are watching  their movements ;  that
 they are hated and despised by the world ; they
 complain of neglect; become morose and taci-
 turn ; utter  bitter complaints ; weep ;  say they
 have committed the  unpardonable sin;  that
 their damnation  is inevitable, &c.  More or less
 bodily derangement is usually present in these
 cases, as a weak and irritable nervous system,
 quickened circulation, imperfect digestion, and
 especially derangement of the hepatic function.
 After this state has continued for some time,
 the mental derangement becomes more promi-
 nent, and the wretched victim begins to see
 visions, and  to hear strange voices, and believes
 that he has  communications from superior be-
 ings. All this time the idea of self-destruction
 is frequently, if not constantly, before the mind,
 and unless the patient be narrowly watched, he
 will  finally  succeed, after various attempts,  in
 accomplishing his purpose.—Ray.]
   620. iv. Prognosis.—The suicidal determi-
 nation is generally removed with difficulty ; and
 more especially when it is consequent upon any
 of the forms of moral and partial  insanity,  or
 is connected with chronic mania.   In the Ad-
 vanced stages  of melancholia particularly, as
 well as in several other states of  both partial
 and general  alienation of mind, the determina-
 tion  to commit suicide may be concealed, fre-
 quently in so artful a manner as to  lull the sus-
 picions of the most careful  attendants; but it
 is never removed, unless the mental disorder,
 of which it is the associate, be altogether cured;
 and  even in this latter  case, the incipient re-
 turn of insanity, or even  the occurrence of
 some of the symptoms usually preceding its re-
 turn, may be attended by the suicidal attempt.
 When suicide, however, is the consequence of
 violent passion and  feeling—of some shock
 which the   mind is incapable  of  enduring  at
 the  time—when it proceeds  from temporary
 causes, and  more especially  where the attempt
 has  been made  when the mind has been  sub-
 jected to the first impression of the direct occa-
 sional causes (§611), and when the  predisposing
 causes are not powerful, nor  retain their influ-
 ence in  the mind—then well-grounded hopes
 of the removal of an inclination to suicide may
 be entertained.   When this act has  been at-
 tempted from  causes favouring an  unusual de-
 termination of blood to the  head, or erethysm
 of the capillary circulation of the brain, as vio-
 lent mental excitement, controversy,  distrac* 
DAL—Treatment of.
 652                      INSANITY, SUICII

 tion, or intense mental exertion,  the violent
 shocks of revolution, or the collision  of oppo-
 sing parties, &c—then an appropriate  physi-
 cal treatment, especially that  directed to the
 removal of increased  action in the brain, and
 of interrupted secretion,and excretion, will gen-
 erally, also, remove every disposition to a repe-
 tition  of the attempt;  unless, indeed, similar
 exciting causes again come in operation.  In
 all  cases  of attempted suicide from powerful
 passion or feelings, the possibility of some form
 of insanity, particularly melancholia and mania,
 being soon afterward developed, should be anti-
 cipated, and the more especially if mental disor-
 der or a suicidal propensity has appeared in any
 of the members of the patient's  family.  In fami-
 lies thus circumstanced, the suicidal attempt is
 sometimes the first manifestation of insanity.
  621. v.  Treatment.—The  treatment of a
 suicidal disposition  in  most cases, and espe-
 cially in those which  are  connected with the
 more obvious manifestations of partial or gen-
 eral insanity, is to be conducted on nearly the
 same principles as have been  explained with
 reference  to these states of disease.  In such
 cases,  the suicidal determination is only a part
 of the disorder, requiring the increased care
 of the attendants, and  greater caution on the
 part of the,medical advisers, particularly during
 apparent convalescence and recovery, and the
 strictest precautions against  a return of the
 malady, and upon the appearance of symptoms
 usually preceding this occurrence ; but in other
 respects demanding little or no modification of
 the physical and moral means  of cure already
 advised for  the several forms  of  mental dis-
 ease.  The few observations, therefore, which
 it will be  necessary to offer on the treatment
 of the suicidal impulse or  disposition, may be
 divided into those  which  refer,   1st, to the
 careful removal of the circumstances  which
 suggested or occasioned it; 2dly, to the phys-
 ical means which should be resorted to ; and,
 3dly, to the preservative measures or means of
 repression, moral and legislative, which may be
 instituted.
  622. A. The avoidance or removal of the cir-
 cumstances or  causes which suggested  or occa-
 sioned the suicidal attempt is the basis  on
 which  both physical and moral means of cure
 must necessarily be placed.  This end, however,
 cannot always, or even generally, be attained ;
 particularly  where  certain events  have pro-
 duced a powerful or morbid impression on the
 patient's mind, or where the attempt  has pro-
ceeded  from an insane delusion.   Under the
former circumstances, we  can  only endeavour
to  counteract or to weaken the emotion pro-
duced :  in the latter case the delusion  will dis-
appear only upon the  removal of  the mental
disease. A knowledge  of the several occasions
of the suicidal determination will  sometimes
enable the physician to recommend means to
 neutralize their injurious influence, even when
 he finds that the patient is incapable of escaping
 from their baneful influence on his mind.
  623. B. The physical means of cure should be
 directed chiefly with reference to the svmptoms
 indicating the  condition of the circulation in
 the brain, and the  state  of organic  nervous
 power.  These symptoms  should  be carefully
 investigated and considered in  connexion with
 the phenomena more intimately connected with
the suicidal impulse, and with mental disorder.
If the impulse has followed any of the states of
moral insanity, or melancholia,  or other forms
of alienation, the treatment, physical and mor-
al, is altogether the same as already described ;
stricter precautions during the  treatment, and
upon the restoration of the patient to society,
being requisite.   In many of these cases, par-
ticularly those depending upon melancholia, and
where  the suicidal determination  has appeared
in consequence  of the circumstances which
have  been  shown generally to  occasion  in-
creased action of the cerebral vessels, and of
violent, passion, chagrin,>or distraction, general
or local vascular depletion, purgatives, refriger-
ants, and  derivatives are requisite.  The pain,
tension, or constriction, and uneasiness so fre-
quently experienced in the head ;  the disorder-
ed action of the carotids  and cerebral vessels,
and the appearance of the eyes ;  the tempera-
ture of the  scalp,, and the changes frequently
observed after death—all evince  the propriety
of repeated blood-lettings, especially in the im-
mediate vicinity of the brain, or of the haemor-
rhoidal  vessels.*  Cold affusions on the head,
cold applications, the shower bath, purgatives
conjoined with sedatives and repressants,  re-
frigerants with diaphoretics, occasionally pow-
erful or deobstruent cathartics,  and sometimes
emetics, anodynes with  antispasmodics,  dry
cupping, setons, blisters, or other derivative
applications on the nape of  the  neck, or on the
hypochondria, and, after depletions and deob-
struent evacuaqts,  restoratives  and  tonics—
constitute,  in such cases,  the  chief physical
means of cure ; but they require to be varied
appropriately to the peculiarities of individual
cases,  and  to be aided by hygienic and moral
measures,  according to the circumstances or
motives occasioning the suicidal attempt, and
the form of insanity of which it  may have been
a manifestation.  In most instances, however,
exercise in the open air, manual and mental oc-
cupations, travelling, active amusements, hiint-
ing and horseback exercise, visiting watering
places, &c., living in a dry and equable atmo-
sphere, change of air and of scene, and'the mor-
al influences (§ 500, et sea.) already fully de-
scribed, should be  brought  in aid of the more
strictly medical agents. '
  624.  After vascular depletions, where they
are indicated,  emetics,  even a repetition  of
them, are  often  of  great  service,  where the
suicidal propensity has recently appeared ; and
if much biliary disorder is present, a dose of
calomel, followed by stomachic purgatives,  and
subsequently by restoratives and  antispasmodics,
as the preparations of valerian, will often be
useful.  Warm bathing, and cold  sponging the
head during the bath, or the cold affusion on the
head, and the shower bath every  morning, the
feet being  immersed in warm water,  are also
important, and generally appropriate remedies.
The  suicidal determination  is very /requently
associated  with,  and  sometimes  the  conse-
quence of prolonged sleeplessness, arising from
the remote causes of the mental affection.  In
 * LThat attempts  at suicide are often  occasioned by a
fulness of the cerebral vessels, is evident from the fact that
the loss of blood occasioned by an ineffectual attempt to sev-
er the large vessels of the neck has effectually removed the
propensity to destroy life ; the same effect, also, has fre-
quently followed a plunge into cold water for the purpose
of drowning.! 
INSANITY, SUICIDAL—Treatment of.
653
 these cases, a recourse to narcotics becomes
 requisite; the  selection and combination  of
 them, as well as the particular indications con-
 nected with  the use of them, being guided by
 the principles already explained (§475, et seq.).
   625. C» Surveillance and  Restraint.—When-
 ever  a suicidal propensity appears, the disease
 should be treated, as  respects seclusion and
 control, in every respect as above recommended
 (§ 388, et seq.), and the paiient be placed in the
 charge of an experienced and vigilant attend-
 ant.  Care should be taken  to remove from his
 person and apartment every article by means
 of which he  may carry his  design into execu-
 tion,  and the windows, doors, &c, should  be
 secured.  Even the bed-clof,hes should be care-
 fully examined, lest portions of them should be
 torn off for the  purpose of self-strangulation.
 Although melancholic and other insane persons
 are not so likely to attempt  suicide when others
 are present as  when  alone,  yet the former cir-
 cumstance is no,t always  sufficient to  deter
 them  from  it.   Dr. Burrows adduces aii  in-
 stance in which a medical man, while another
 person was present, attempted to open the fem-
 oral artery with a penknife.  His father and
 grandfather  had  both  destroyed themselves.
 He had  never  met with any circumstance  to
 occasion him particular disquietude ;  but at the
 age of forty-five he became  dyspeptic, low-spir-
 ited, and listless.  He expressed extreme sor-
 row for the attempt  on his life; yet, in three
 or four days, he seized a razor from the dress-
 ing-table, while his keeper's back was turned,
 and at one  stroke divided  one of the  carotid
 arteries.                    ^
  626.  A person  who has  once  entertained a
 suicidal propensity should  not be confided  in,
 however strongly he may express his  regrets
 at having made an attempt to carry it into ef-
 fect,  as long as the feelings continue either
 more than usually blunted  or morbidly sensi-
 tive—while the bearing of  the patient contin-
 ues embarrassed or perturbed, or his ideas con-
 fused, unsettled,  or disturbed.  If he complain
 of heats and flushings  in various parts of his
 body, qr partial sweats ;„ and especially if his
 nights are sleepless ;  if he cannot look the per-
 son whom he addresses fully in the face, with
 a firm expression ; and if his eyes betray timid-
 ity, fearfulness, distrust, and restlessness, oth-
 er attempts will be made.   Although the pa-
 tient may have recovered his serenity of mind,
 a return of these indications ought to call for
 the most watchful solicitude from the medical
 and other attendants  ; for, although the patient
 may not seem to entertain any ideas of suicide,
 or may actually not feel any inclination to com-
 mit the act, yet the occurrence of an opportu-
 nity, or the accidental sight of an instrument
 of self-destruction, may give rise to the im-
pulse, which may instantly be. carried into fatal
effect.
  627. Whenever a great calamity has overta-
ken a person of weak resolution, of the melan-
cholic, nervous, or irritable temperament, and
especially if insanity or suicide have occurred
in any branch of his family—particularly if the
affliction is  sudden or recent, and  productive
of great mental  distress, or  of singularity of
conduct or conversation—the probability of his
attempting suicide bught not to be overlooked.
The design, however, in these circumstances
 may be concealed from superficial observers;
 but the physician will detect, in the expression
 of the eyes and looks, in the suppressed strug-
 gle to conceal his emotions, in the constrained
 respiration, and the accelerated, excited, or ir-
 regular pulse, sufficient causes to require the
 utmost vigilance on the parts of both friends and
 attendants.   In such cases, the previous char-
 acter and fortitude of the patient may lull every
 fear ; but the greatest talents and the strongest
 minds have'yielded to intense emotion.  The
 moral character and disposition of the  patient
 may have been changed before the suicidal pro-
 pensity was developed; many of the circumstan-
 ces to which  this propensity had been directly
 imputed actually occasioning a state of moral
 or partial insanity, of which the suicidal inten-
 tion  was only an attendant or consequence.
 Moreover, character and disposition only should
 not afford any grounds of confidence in persons
 subjected to the more intense emotions, or to
 the more energetic occasions of this act; more
 especially if they have not formerly experien-
 ced events requiring the exertion of mental en-
 ergy and fortitude.  Many men, eminent for tal-
 ent and excellence of disposition, have commit-
 ted suicide when overtaken by adversity. Sev-
 eral instances of this kind occurred, during an
 early part of the present century, in this coun-
 try, and have been adduced by  some writers
 as proofs of the strongest minds being liable to
 give  way to  the suicidal impulse.   But emi-
 nence and talent are distinct from fortitude in
 adversity; and even from that constitution of
 mind to which the terms  strength of mind or
 force  of character have been applied.   It is
 doubtful how  far  these  persons* were really
 possessed of  these latter characteristics, inas-
 much  as they are usually acquired in combat-
 ing difficulties, in  patiently bearing  adversity
 and disappointments,  and  in  controlling  the
 more  poignant emotions which  difficulty and
 adversity call forth.  In this school, where true
 force of character and fortitude are chiefly, if
 not only to be acquired, these persons may not
 have  been sufficiently disciplined; for, when
 the course of prosperity has been uninterrupted
 and rapid, however eminent the abilities which
,have contributed to it may have been, sudden
 adversity may endanger the perfect  sanity or
 fortitude  of a mind unaccustomed to sustain
 and unprepared to meet its shock.
   628.  There is no part of a physician's duty
 which is so difficult, as Dr. Burrows has re-
 marked, as to decide upon the exact time when
 he may place confidence in a convalescent sui-
 cide.  If this  confidence be yielded premature-
 ly, the act, which time and great care had been
 employed to avert,  may be  immediately  perpe-
 trated ; while, if it be withheld when the  pa-
 tient feels that he has been labouring under a
 delusion, the effect  may be such as to endanger
  * [The distinguished accoucheur who attended the Prin-
cess Charlotte in her fatal confinement destroyed him-
self under the sudden impulse of grief and mortification.
The sight of a pair of pistols in the room to which he
retired for repose was sufficient, to  a mind harassed by
long and anxious attendance, and overwhelmed by the re-
sponsibilities of his situation, to provoke a desire, which he
may never have felt before,'to die by his own hands.  Sir
Samuel Eomilly, the eminent English barrister, commit-
ted suicide immediately after sustaining a severe domestic
bereavement—the loss of a beloved wife.  In both these ca-
ses we should, perhaps, be warranted in believing that rea-
son was temporarily overthrown.—(Bay.)] 
654
INSANITY,  SUICIDAL—Prevention  of.
 a return of his delusion, or of the suicidal pro-
 pensity.
   629. When the suicidal determination cannot
 be carried into effect by any other means, ow-
 ing to the care of the attendants, the patient
 sometimes determines to starve himself.  Man-
 agement may do  much in overcoming this in-
 tention.  Kind entreaties and  stratagems may
 be resorted to ; and tempting  articles may be
 set before him, or left within his reach, without
 any farther notice.  If he. partake of it, no re-
 mark  should be made, but the same course pur-
 sued.   If these means fail, the stomach-pump
 ought to be resorted to.
   630. M. Falret observes, that noisy or im-
 moderate gayety irritates melancholic suicides,
 or, at best, affords only a transient pleasure,
 followed by increased misery.  He states, that
 he has accompanied these persons to the  thea-
 tre and to the hospitals, in  order to  compare
 the effects produced upon them by these oppo-
 site spectacles ; and he has found that visits to
 the really afflicted were  most useful, by sug-
 gesting the idea that  others had still greater
 cause than they of being unhappy.
   631. D. Prevention and Repression.—The
 increasing frequency of suicide, as well as of
 manifest insanity, requires some notice of the
 means by which it may be, in  some measure,
 repressed, although no sanguine hopes of suc-
 cess from  them can rationally be entertained
 in the present states of society.  As long as
 education, manners, morals, and social inter-
 course continue as they now are;  as  long as
 crimes, murders, and  suicides  are seductively
 detailed  and  daily furnished  to the public,
 through a thousand channels, for the purposes
 of private gain ; as long as the  perpetrators of
 crimes and of homicides are held out, both on
 the stage and  from the  press, as heroes of their
 day ;  as long as  the overthrow of moral and
 religious principles and the  infection  or con-
 tamination of the public mind are made objects
 of gainful speculation, into  which  persons in
 place or authority are not considered dishon-
 oured by entering; as  long as  the streams of
 moral  pollution are allowed to flow without ei-
 ther strenuous, or well-directed, or combined
 efforts to confine  or to counteract them;  as
 long as the most  instant and  efficient agents
 of self-destruction are openly sold in every
 street, at little or no price, and to any purcha-
 ser, without either " let or hinderance ;" as long
 as the struggles of great parties in politics and
religion absorb, in connexion with  the details
 of every vice and every crime, the public mind,
each party endeavouring  to  depress and ruin
the others, without regard to the general weal;
 as long as provision for the pecuniary wants
 of the state,  and the power and patronage of
 office, constitute the chief objects of govern-
 ments ; as long as justice is within the reach
 only of the wealthy, as laws protect chiefly the
 bad, as the weak  are unshielded, and  the de-
 serving unrewarded ; as long as

             " The whips and scorns of time,
   The oppressor's wrong, the proud man's contumely,
   The pangs of despised love, the law's delay,
   Tho insolence of office, and the spurns
   That patient merit of the unworthy takes,"
 shall continue to  " puzzle the  will;"  as  long
 as the lives of all  classes are endangered, and
 their  minds distracted by unprincipled and ig-
 norant  pretenders  to medical  and  religious
 knowledge, who are allowed, and even encour-
 aged, to take advantage of  the  credulity and
 fears of the weak-minded ;  as long, in short, aa
 moral degradation and physical destitution ex-
 ist, and as long as  the safety of  the people is
 not the  supreme law  of the  state ; as long as
 these several conditions of a  country continue,
 and in  proportion to their separate and combi-
 ned influence, so long will suicides be frequent,
 or even increase.
   [It is a generally  admitted fact  that suicides
 are increasing to a most alarming extent in our
 country.   But few find their way into the pub-
 lic prints, and yet our newspapers contain very
 frequent instances of the kind.  The causes are
 to be sought for chiefly, we believe, in our de-
 fective systems of education, separating moral
 and religious culture from intellectual studies,
 and making the latter the great, if not sole ob-
 ject of public and private teaching.  The dis-
 proportionate attention  thus  paid to the culti-
 vation of the intellect destroys the healthy bal-
 ance  of the mind ; takes from it the support and
 influence of those high and holier motives, feel-
 ings,  and  aspirations, which  support it under
 trials and losses, soothe it in  affliction ;  which
 moderate  the whisperings  of selfishness and
 ambition, and enable us to await the events of
 futurity with composure and resignation.
  If the young were properly educated, " man-
 ners,  morals, and  social intercourse"  would
 take care of  themselves ; they would necessa-
 rily improve, and  the other causes of suicide
 maintained by bur author, as theatrical shows
 and a licentious press, would  be comparatively
 harmless.  Indeed,  in  a healthy  state of the
 public mind  and public  morals, such  streams
 of moral corruption would be checked at their
 very source.   Hence  we deem it the duty of
 every patriot and every philanthropist to use
 all  possible  exertions to reform  our present
 vicious system of public school education—the
 fons  et origo  mali.]
  632.  The history  of all nations has demon-
 strated the prevalence of this act,  both as a dis-
 ease  and as  a psychological  phenomenon, du-
 ring periods  of surpassing luxury, of criminal
 debasement,  of public commotion,* and of the
 decline of public and private spirit and virtue.
 In such circumstances, laws directed simply to
 this act, and without reference to the sources
 of the evil—to the various contaminating mor-
 al agents poisoning the minds of the communi-
 ty—will be of but little avail.  It is obvious,
 that laws which, as  at present, affect only the
 property of the suicide, are unjust, as they can-
 not punish the  guilty, but fall exclusively on
 the innocent—on those already punished by the
 act of the suicide.    The only  means of preven-
 tion which  have been found  to succeed, on oc-
 casions of epidemic or imitative suicides, have
 been  such as tended to impress  the ignorant
with the moral  and  religious  turpitude of the
act, to influence public opinion in its reproba-
tion,  and to  convince the perpetrator of the
crime that, although he escapes  from  feeling

  * In  the summer of 1793, upward of 1300 suicides were
committed in Versailles  and its vicinity! During  "the
reign of terror,"  or, rather, of crime, suicides were commit-
ted by the guilty, by the terrified, by infidels, and contem-
ners of moral and religious principles, by public and private
criminals, and by those distracted by  losses of fortune and
friends, in unheard of numbers throughout  France, 
INSANITY AND  SUICIDE—Bibliography  and References.
655
 the punishment it merits, every indignity which
 is compatible with the good of society will, as
 a consequence, be offered  to  his body, and to
 his memory.   Each member of the community
 lives not for himself alone, but for the common
 weal, and in order to contribute to the general,
 the mutual, the public, and the private support
 requisite to the healthful constitution  of socie-
 ty.   As it is the chief purpose of good govern-
 ment to preserve inviolate this principle of ex-
 istence in all  associated  communities, so ought
 every effort to contravene it, or to escape  from
 the responsibilities it involves, to be repressed
 and punished in ways the most effectual, con-
 formably with the spirit in which only should
 punishment be inflicted;  and even  those who
 either directly or indirectly aid in the commis-
 sion of this act should be subjected to punish-
 ment.   The difficulty, however, is to determine
 upon  measures which may have any influence
 in diminishing the number of suicides, who are
 either irresponsible agents, or are in that state
 of mind which is uninfluenced by worldly con-
 siderations.  There is every reason to believe,
 nevertheless, that many of those who commit
 this act without being manifestly insane—who
 entertain a suicidal propensity from depression
 of spirits ;  from mortified pride ; from domes-
 tic  chagrin  or irritation  ;  from excessive  pas-
 sion or  feeling ; from imitation, fascination, or
 mental infection ; from extreme profligacy, de-
 bauchery, and satiety, &c—would be  deferred
 from it  by the conviction that, if they perpetra-
 ted this crime, some indignity to their bodies,
 and disgrace  to their memories, would be the
 result.   If  it were enacted that the body  of a
 suicide, who had  not evinced sufficient proof
 of  previous insanity to require restraint,  or
 whose  relations had not seen sufficient proof
 of mental disorder to obtain medical aid, or oth-
 er assistance  requisite to the protection'of oth-
 ers as well as  of  himself,  should be made sub-
 servient to medical instruction, and consequent-
 ly to the general weal, I am confident that the
 number of  suicides  would diminish,  notwith-
 standing the increased and increasing sources
 of mental  contamination, and of mental dis-
 ease.  Means of repression directed to the prop-
 erty of  a suicide  would have little  avail, and
 would, moreover, punish the innocent without
 affecting the guilty ;  but  such  means ought  to
 be strenuously directed against those who  deal
 in  poisonous substances, and ought  to be  ren-
 dered so stringent as entirely to prevent such
 substances  from  being   procured  unless  by
 means of a physician's  or surgeon's  order  or
 prescription.   It is well  known that suicide is
 often  committed  in  moments  of irritation  or
 passion, and that as soon  as  the  feeling  sub-
 sides—in the  course even of a few  minutes—
 the  suicidal impulse  or intention may  cease  to
 influence volition  so powerfully as to lead  to
 the  commission of the act.   Therefore, if diffi-
 culties were thrown  in the way of resorting  to
 it, during periods of  irritation  and suicidal im-
pulse, it might  not afterward be entertained,  or
the sober mind would recoil with so great  hor-
ror from the morbid  idea, as to view it with in-
creased  dislike, or would endeavour otherwise
to fortify or  to protect itself against a return of
the propensity.
  633. Having thrown out these hints  as to the
only means of repression  which can be  suggest-
 ed, after a consideration of those which have
 been enacted in this and in foreign countries, I
 would merely add, that the growing frequency
 of suicide requires that means, direct and indi-
 rect, should  be taken by the Legislature to re-
 strain  it.  As, however, many of the most in-
 fluential causes of suicide can only be indirect-
 ly affected by legislative measures, and as some
 of these causes  belong to the liberty enjoyed
 by all classes, although appertaining chiefly to
 the most worthless parts of that liberty, but lit-
 tle hope can  reasonably be entertained that the
 frequency of this act will be much diminished,
 as long, at least, as  the  circumstances arising
 out of the education, morals,  amusements, and
 social  relations of the community, to which it
 is  in  great  measure referrible, continue un-
 changed.
  Biblioo. and Refer.—Celsus, Lib. iii., c. 18.—Plinius,
 Lib. xxviii., c. 17. — Aretaus, Cur. Chron., lib. i., c. 5.—
 Paulus Mginetus, Lib. iii., c. 14.—Oribasius, Synopsis, lib.
 viii., c. 7, 8.— A. Constantinus, De Melancholia, lib. ii., in
 Opera, fol.  Basil, 1536. — T. Stocker, The Worlde pos-
 sessed with Devils ; from  the French, 8vo.  Lond., 1583.—
 Primerosius, De Morb.  Muliel)., lib. iii., c.  8.— Willis, De
 Anima Biutorum, c. 11, 12 —Zacutus Lusitanus. Med. Pr.
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vol., 8vo.—R. Gooch, On the most important Diseases pecu-
liar to Women.  Phil., 8vo,  1836. — /. M. Good, Study of
Medicine, Am. ed., by A. Sidney Doane, 2 vols.,  8vo.  N.
Y., 1843  ; et Book of  Nature, 1 vol., 8vo.  Hartford,  1844.
—C. J.   Guthrie, On  Injuries  of  the  Head affecting the
Brain, 4to, plates.  Lond., 1843.—/. S. Thorburn, Thoughts j

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  on the Mental Functions, <fcc, 12mo.  Ed., 1843.—R. Ver-
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  tion,  &c, 8vo.   Lond, 1839.—F. Voisin, De l'Idiotie chez
  les Infans, <fcc, 8vo.   Paris, 1843.—A. Walker, On the Ner-
  vous  System, <fcc.  Lond., 8vo, 1834.—M. Baillarger, Lec-
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  1  vol., 8vo.  Lond., 1841.—New Memoir on the Nervous
  System,  1  vol., 4to, with plates.  Lond., 1843.—Report of
  her Majesty's Commissioners on the Poor Laws of Scotland,
  presented to Parliament in 1844, with Remarks on said Re-
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  ritation,  <fcc.  Lond.,  1840,  8vo.—T. Robertson, On Spinal
  and Nervous Diseases, &c, 8vo.  Lond., 1842.—P.  M. Roget,
  Outlines of Physiology, &c, 1 vol., 8vo.  Phil., 1839. —
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  1842.—M. B.  Sampson, Criminal Jurisprudence considered
  in Relation to Mental Organization, 8vo. London, 1841.—
  M. Marc, De la Folie Consideree  dans  les Ramports avec
  les Questions Medico-Judiciares, 2  vols., 8vo.   Paris, 1840.
  —H. Mayo, The Nervous System and its Functions, 1 vol.,
  8vo.   Lond., 1842 —Outlines  of Human Pathology, 1 vol.,
  8vo.   Phil., 1841.—E. Meryon, The Physical and Intellect-
  ual Condition of Man considered, 1 vol.,  8vo. Lond., 1836.
  —G.  Lostritto, in  Journal des Progres, vol. v., 1827. — /.
  Braid, Neurypnology, or the Rationale  of Nervous Sleep,
  12mo.  Lond., 1843.—Wm. Braithwaite, The Retrospect of
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  —P. J. G. Cabanis, Rapports  du Physique et du  Moral de
  I'Homme, "1 vol.  Paris, 1843.— W. B. Carpenter, Principles
  of Human Physiology, Am. ed.  Phil., 1843, with Notes by
  Clymer, &c. — R.  Carswell, Pathological Anatomy, folio,
  with plates.  Lond., 1836.—/. Chitty, Practical Treatise on
  Medical Jurisprudence, 2d Am. ed., 8vo.  Phil.,  1836.—F.
  Churchill, On the principal Diseases of Females, et Diseases
  incident  to Pregnancy and Childbearing, 2d Am. ed.  Phil.,
  1843,.with Notes by R. M. Huston,  8vo.— A. Combe, Obser-
  vations on Mental Derangement, 1 vol., 8vo, Am.  ed. Bos-
  ton, 1834.—Principles of Physiology applied to  the Preser-
  vation of Health, &c, 18mo.  New-York, 1844. — Geo.
  Combe, Elements of Phrenology.   Bost., 1835.—The Con-
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  Glasgow, 1842.—C. Crawther,  Observations on the Manage-
 ment  of Madhouses, 2d ed., 12mo'.  Lond., 1841.—Cruveil-
 heir, Anatbmie Pathologique, <fec, folio, 125 coloured plates.
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 dy, On the  Phenomena of Dreams, &c., et  Philosophy  of
 Mystery.   N. Y., 1845.
   Am. Bibliog. and Refer.—A. Brigham, in Appendix to
 Am. ed. of Spurzheim on  Insanity.  Boston, 1836. — Am.
 Journ. of Insanity, quarterly.  Utica, Sept., 1844, 8vo,  p.
 96.—Reports of "Retreat for the Insane," Hartford, Conn.,
 from 1839 to 1842.—Notes to Am. ed. of Combe on Mental
 Derangement.   Boston, 8vo, 1834.—Observations on the In-
 fluence of Religion upon the Health and  Physical Welfare
 of Mankind, 8vo.   Boston, 1835. — An  Inquiry  concerning
 the Diseases and Functions of the Brain, the Spinal Cord,
 and Nerves, 2d  ed., 12mo.  New-York,  1840.—/. Ray,  A
 Treatise on the Medical Jurisprudence of Insanity, 2d ed.
 Boston, 1844, 12mo, p.  490 ;  et Reports of " Marine Insane
 Hospital," 1842, 3, 4 ; and in Am. Jurist.—Med. Repository,
 21 vols., passim.— Wm. Sweetser, Mental Hygiene; or, an
 Examination of the Intellect and Passions,  &c.,12mo. New-
 York,  1843.—Edward Jarvis, - Essay on  Insanity.   Louis-
 ville, Ky.—Insanity among  the Coloured  Population of the
 Free States, Am. Jour.  Med.  Sci., vol. vii., N. S., p. 71.—C.
 B.  Coventry, Med. Jurisprudence of Insanity, in Am. Jour.
 of Insan., vol. i., p. 134; et vol. ii., p. 1. — An Essay  on
 Physiology of the Brain.—Thomas C. Upham, Outlines of
 Imperfect and Disordered Mental Action.  New-York, 12mo,
 1840.—T. Romeyn Beck, Inaugural Thesis on Insanity, May,
 1811. — Elements of Medical Jurisprudence, 7th  ed., 8vo.
 Phil., 1840.—Various Articles in Am. Jour. Med. Sciences,
 and Am. Jour, of Insanity, &c. — Pliny Earle,  Report of
 " Bloomingdale Asylum for the Insane," for 1844-5.—Es-
 says in Am. Jour, of Insanity, vol. i., p. 193, <fcc.—A Visit
 to Thirteen Asylums for the Insane in Europe, <fcc, &c,
 with an Essay on Insanity.  Phil., 1841. — Historical and
 Descriptive Account of the  Bloomingdale Asylum for the
 Insane, in Am. Jour, of Insan., vol. ii.,p.  1.—On  Pathology
of Insanity, in Am. Jour, of Insan., vol.  ii., p. 218. — Re-
searches  in  Relatioa to Insanity, in Am. Jour.  Med. Sci., 
658
INTESTINES—Inflammation of.
 vol. xxii., p. 339. — Review of Ellis on  Insanity, in Am.
 Jour. Med. Sci., vol. xxvi., p. 155.—Notices of Reports on
 Insanity, in Am. Jour. Med. Sci., vol. iii., N. S., p. 185 ; vol.
 iv., p. 136 ; vol. vi., p. 144 ; vol. vii., p. 150, 412 ; vol. viii.,
 p. 179; vol. ix., p. 414, 155, 157.—Notice  of Jacobi on the
 Construction, <fcc, of Insane Hospitals, vol. iii., N. S., p. 415.
 —Review of  Leuret, on  the Moral Treatment of Insanity,
 in Am. Jour.  Med.  Sci.,  p. 375.—Of Webster's Statistics of
 Bethlehem Hospital, vol. vii., N. S., p. 153.—On Pulse of
 the Insane, Am. Jour. Med. Sci.. vol.  vn., N. S., p. 306 ; vol.
 ix., p. 56.—Notice of White on Insanity, in Am. Jour. Med.
 Sci.. vol. vii., p. 423.—M. M. Bagg,  Transl. of Eulogy on
 Pinel, by W. Pariset, in Am. Jour. Ins., vol. ii.,  p. 207. —
 Pinkard, Letcher, Price,  An. Report of the Lunatic Asy-
 lum  of Kentucky  for 1843. — Boston Med. and  Surgical
 Journal, 33 vols, (passim).—Samuel B. Woodward, Annual
 Reports of " State Lunatic Hospital," Worcester, Mass.,
 from 1833 to 1846. —William H. Rockwell, Reports of the
 " Vermont Asylum for the Insane," from 1836  to 1846.—
 George Chandler, Reports of the " New-Hampshire Asylum
 for the Insane," from 1842 to 1846.—Luther 0. Bell, Reports
 of the M'Lean Asylum for the Insane," Somerville, Mass.,
 from 1836 to 1846.—Report to the Trustees of the " Butler
 Hospital for the Insane  ;" on the " Construction, Ventila-
 tion, and Warming of Buildings for the  Insane," in Am.
 Jour, of Insanity, vol. ii., p. 13.—Rufus Wyman, Reports of
 the Trustees of the" Butler Hospital for the Insane, 1834-5.
 —Eli Todd, Reports of the " Retreat  for the Insane," Hart-
 ford, Conn., 1824 to 1833. — Silas Fuller, Reports of the
 "Retreat for the Insane," Hartford, Conn., 1833 to 1839.—
 John S. Butler, Reports  of the  " Retreat  for the Insane,"
 Hartford, Conn., 1844 to  1846. —James Bates, Reports of
 " Maine Insane Hospital," 1844-5.—John  M. Gait, Reports
 of " Eastern Lunatic Asylum of Virginia," Williamsburgh.
 —" The Treatment of Insanity," 8vo. New-York, 1846.—
 Essay, in Am. Jour, of Insanity, vol. i., p.  122.—Charles H.
 Stedman, Reports of " Boston Lunatic Hospital," 1843, 4, 5.
 — Thomas S. Kirkbride, Reports  of the " Pennsylvania
 Hospital for the Insane," from 1841 to 1846; and an Ac-
 count of " Pennsylvania  Hospital for the  Insane," in Am.
 Jour. Med. Sci., vol. iii., N. S., p. 373.—Notice of Ray on
 Insanity, in Am. Jour. Med. Sci., vol. ix., p. 239.—Samuel
 White, "Address on Insanity," before the New-York State
 Med. Society, Feb., 1844, 8vo.—Tames Macdonald, Reports
 of the " Bloomingdale Asylum," 1832 to 1841 ; also, Statis-
 tics of the " Bloomingdale Asylum for the Insane," in the
 New-York Journal  of Med.  and Surgery, vol. i., p. 307.—
 Cases of Monomania, in  New-York  Journal of  Med. and
 Surgery, vol. iii., p. 307.— Charles Evans and /. H. Worth-
 ington. Report of  the "  Friends Asylum  for the Insane,"
 near Philadelphia, 1844-5.— Evans and Porter, Reports of
 Cases of Insan., in Am. Jour. Med. Sciences, vols, xix., xx.,
 p.  99, 61, 350; vol.  xxiii., p. 97.—F.  T. Stribling, Reports
 of " Western Lunatic Asylum," Staunton, Va., 1844, 5, 6.
—Daniel H. Trezevant,  Report, of "South  Carolina Asy-
lum for the Insane," 1835 to 1846.—David Cooper, First An-
nual Report of the Resident Physician of the  "Lunatic,
Idiot, and Epileptic Asylum  of the State of Georgia," 1845.
— Wm. M. Awl, Reports of the  " Ohio Lunatic Asylum, at
 Columbus," 1839-1846. — John R. Allen, Rep. "Kentucky
 Lunatic  Asylum,"  Lexington, 1840-5.— William Fisher,
 Rep. of "Maryland Insane  Hospital," Baltimore, 1844.—
 S. G. Morton,  Crania Americana, 78 Plates, 1 vol., fol.
Phil.—Crania JEgyptiaca, &c,  1 vol., 4to.  Phil., 1844.—
 D. Oliver, First Lines of Physiology, 2d  ed., 8vo. Phil.,
 1841.—/. A. Smith, Select Discourses on the Functions of
the Nervous  System, <fec, 12mu.  New-York, 1840. — S.
 Sally, The Human Brain, &c, 8vo.   Lond., 1836.—/. Har-
rison, Essay towards a correct Theory of the Nervous Sys-
tem, 1 vol., 8vo. Phil., 1844.—R. W. Haskins, History and
Progress of Phrenology, 12mo.   Buffalo, 1839.]

 INTESTINE—Syn. 'Evrepov (ab evrbc, intus)
   —Intestinum (from intus, within).—Intcstin,
   Boyeau, Ft. Darm, Ger.  Intestino, Ital.—Bow-
   el ; Gut; Intestinal Canal; Intestinal  Tube.
   1. Most  of the disorders  and structural dis-
 eases to which the intestines, in general, are lia-
 ble, are discussed in appropriate articles. The
 seat and nature of these  affections required a
 separate consideration for them;  and, at this
place, it remains for me chiefly to  supply what-
 ever I may have omitted in  these articles, and
to treat of  those subjects which have not been
 entered upon, under different  and more appro-
priate heads.
   2. It need hardly be stated that the intestines
 comprise, or consist of the following parts, de-
 scending from the stomach to the verge of the
 anus, namely,  the  duodenum, the jejunum, the
 ilium, the cacum, the colon, and the rectum.  Am
 each of these portions of the intestina  canal
 presents most important  connexions with, and
 relations to other viscera, that are not  possess-
 ed to an equal degree, or in a similar  manner,
 by the others ; as they are, in many respects,
 and  particularly as  regards certain  of  their
 functions, distinct organs ; and as they are oft-
 en severally the seats of disorders, more or less
 limited to either of them, so I have treated of
 the diseases to which each of these portions of
 the intestinal canal are most liable under their
 respective heads.  As there are certain mala-
 dies  which  affect in  some  degree  or  other
 more than one of these distinct portions of the
 bowels, and which often implicate, or even ori-
 ginate in some one or more of the collatitioua
 viscera,  and in which not only the intestines,
 but the various  related viscera, and even the
 frame generally, frequently are also disordered,
 although in different grades and forms, and to
 a varied extent, according to numerous circum-
 stances connected with  the cause  of the dis-
 ease, and state and constitution of the individ-
 ual attacked, so I have treated of these mala-
 dies  under the   names commonly  applied to
 them, but with strict reference to their seats,
 natures,  and  pathological  relations.    Thus,
 while I have considered  the diseases individu-
 ally seated  chiefly in either the duodenum, ca-
 cum, colon, &c, under these heads respectively,
 I have likewise discussed colic and ileus, cos-
 tiveness and constipation, diarrhoea, ckolera, dysen-
 tery,  gastro-enteric disease, flatulency,  intestinal
 hemorrhage, intestinal concretions,  and worms,
 &c,  in these  several  articles, because these
 complaints  are not  limited, in their seats, to
 one portion of the intestinal canal only, but oft-
 en extend to several portions of it, although in
 different grades, and frequently depend  upon
 disorder of the  adjoining  viscera, and some-
 times even of distant organs, and of the system
 in  general.   Moreover, as  the  organic lesions
 which  occur in the intestines are not  peculiar
 to any one portion, but extend, in different mal-
 adies and persons, and in different degrees of
 frequency and  severity, to all of them, and even
 also  to the stomach and  oesophagus—to the
 whole digestive canal from the lips to the anus
 —so  I  have considered these lesions under the
 head "Digestive Canal,"  and have  thereby
 avoided the repetitions into which I should oth-
 erwise have been betrayed.   It here chiefly re-
 mains for me to  consider those maladies seat-
 ed  principally in  the small and large intestines,
 in the  ileum, jejunum, and colon, that  are not
 discussed under  different or more appropriate
 heads.   The functional disorders and the struc-
 tural  changes to which the intestines are liable
 being fully treated of in the articles just men-
 tioned, I now proceed to  consider chiefly their
 inflammatory  diseases.   In  the article  on the
peritoneum, however, much will be found more
or less intimately connected with inflammations
 of both the small and  large intestines, to which
 sufficient reference will be also made in those
sections where inflammation extending to the
peritoneal coat of the bowels, and the  compli-
 cations of enteritis, are considered.
 I. Inflammation of  the  small Intestines.—
  Svn. Xopdatyoc, EtXeof, Aretaeus, Galen.  Fe-
  bris  intesiinorum inflammatoria,  Hoffmann.
  Intesttnorum Inflammatio, Boerhaave.   Enter- 
                    INTESTINES—Inflamma

  *h's, Sauvages, Vogel, Sagar,  Cullen, Pinel.
  Empresma Enteritis, Good.   Cauma Enteritis,
  Young.   Ged'drmentzundung, Entziindung der
  Gedarme, E.  der  Darmen,  Germ.   Entirite,
  Inflammation des Boyaux, Fr.  Inflammazione
  a"Intestini, Ital.   Inflammation of the Bowels.
     Classif.—1. Class, Febrile Diseases;  2.
      Order, Inflammations (Cullen).  1. Class,
      Diseases of the Sanguineous Function ;
      2.  Order, Inflammations  (Good).  III.
      Class, I. Order (Author  in Preface).
  3. Defin.—Tenderness or pain of the more cen-
tral parts of the abdomen, increased on pressure,
generally with symptomatic fevery disordered def-
ecation, and frequently nausea and vomiting.
  4. Inflammation generally commences in one
only of  the constituent tissues of the small in-
testines, and  frequently continues to  be thus
limited  during its  course; but  it  frequently,
also, extends to the other parts, until even all the
textures forming a portion of  intestine are im-
plicated.  Thus the glandular apparatus, or the
mucous membrane  only, may  be inflamed, and
the disease may not extend farther, although it
may exist long, or  be extremely acute ; but it
often, also, invades the other tissues, more es-
pecially the connecting cellular tissue, until the
peritoneal coat is at last inflamed, and  all the
phenomena of circumscribed or diffused  peri-
tonitis are produced.  When all the constituent
tissues  of a portion of intestine are affected,
the inflammation usually has  commenced and
proceeded in this manner; for it is but seldom
that there is reason to infer that the inflamma-
tion has either simultaneously invaded  all the
coats composing a  portion of bowel,  or has
proceeded in an opposite direction, namely,
from the peritoneal to the other coats ; unless,
indeed, in cases of external injury, or of stran-
gulated hernia, or when the inflammation has
extended from adjoining parts to the intestines.
  5. Inflammation  of the  intestines, whether
limited  to one only, or implicating two, or  all
of their constituent tissues, may assume any
grade of intensity and acuteness, from the most
acute down to the slightest degree and the most
chronic form.  It may appear, in either of these
states, as a simple or uncomplicated disease, or
associated with other maladies.   In this latter
state, it may be either primary or idiopathic,  or
consecutive or symptomatic.   In each  of the
above forms it will  be here considered.
  6. i. Inflammation of the Mucous Surface
of  the Intestines.—Muco-Enteritis of Arm-
strong.— Muci-Enterite,  Entirite Villeuse,  of
French  pathologists.  This complaint varies in
its  characters  with  its intensity, and with the
temperament and habit of body of the patient:
a slighter grade of it often causing, in irritable,
nervous,  and plethoric persons, more  acute
symptoms than a severer degree in those who
are melancholic or leucophlegmatic.  The symp-
toms, moreover, are farther varied by the ex-
tension of the inflammatory affection, in some
degree, to the duodenal or gastric villous sur-
face on the one hand, or to the internal surface
of the caecum and colon on the  other ;  for the
mucous coat of the  small intestines is inflamed
more frequently  in  conjunction with one  or
more of these than in an  unassociated form;
and not infrequently some one of the adjoining
viscera  is also more or less  disordered.  In-
deed, the enteric disease may be  altogether
ion of Small—Symptoms.                659

consecutive of, and caused by derangement  of
one or other of these viscera. Thus, a discharge
of acrid or otherwise morbid bile into the duo-
denum may occasion  or perpetuate inflamma-
tion of the mucous surface of the  intestines,
and often,  also, of the large bowels.
  7. A. Symptoms.—a.  In the acute or sub-acute
states of the complaint, the abdomen is usually
distended,  sometimes tense, and flatulent.   A
dull or heavy, deep-seated pain or soreness, oc-
casionally with a sense of heat, is felt upon firm
pressure, especially around the umbilicus,  or
towards  the right iliac  region; but this latter
symptom is often absent, and is more general-
ly found when the follicular glands are affected.
In the more acute cases, the abdominal parie-
tes are warmer than other parts of the body;
and a feeling of internal heat of the bowels  is
also often  complained of, with colicky pains,
particularly after  cold  drinks, and the more
heating or  indigestible  articles of food.  Mus-
cular power is much weakened, and the skin is
harsh and dry.  There is more or less thirst;
and the appetite is impaired or lost.   In severe
cases, or when the disease is far  advanced,
there is often nausea  or vomiting;  this latter
symptom depending much upon the extension
of the affection to the internal surface of the
duodenum  and stomach.  The  alvine evacua-
tions are generally morbid, sometimes too fre-
quent, at other times too rare and scanty ; but
usually preceded or attended by flatulence, bor-
borygmi, and the escape of much flatus. When
the internal surface of the large bowels is un-
affected, constipation is often present, but short
attacks of  diarrhoea,  occasionally alternating
with costiveness, frequently occur.   The stools
frequently vary in colour and consistence with
the state of the biliary  functions  and the kind
of the ingesta: when there is  diarrhoea, they
are generally pale, yeasty, and crude,  or insuf-
ficiently digested ; when the bowels are costive,
they are often offensive, dark,  and  scybalous.
The urine is high-coloured and scanty, and often
deposites a copious sediment.   The  mouth is
clammy, with a bitter or unpleasant taste.  The
tongue is white or yellowish in the centre, but
red at its point and edges.  The pulse is accel-
erated, and generally small and soft when there
is diarrhoea, and full,, or even  hard, when the
bowels are confined.
  8. In more intense or acute cases the fore-
going symptoms are more prominent.   The ab-
dominal distention amounts almost to tympani-
tis ;. the  pulse  is quick and constricted; the
thirst is  great; the tongue is  furred, loaded,
and dry ; the urine scanty and high-coloured,
and all the secretions  and excretions diminish-
ed.  Pain,  soreness, internal heat, and tender-
ness of the abdomen are greatly increased, and
the surface is  hot, dry, and harsh.   The affec-
tion of the intestinal  mucous surface extends
its influence to the cerebro-spinal system, caus-
ing sleeplessness, restlessness, and ultimately,
in the more unfavourable cases, delirium, start-
ings of the tendons, and in young persons and
children  especially,  convulsions  and  coma.
In many of these more severe attacks, partic-
ularly in  the  sanguineous temperament  and
plethoric habits, and in warm climates or sea-
sons, the inflammatory affection of the mucous
surface  rapidly extends to the external coats
of the part of the intestine chiefly diseased; 
vtion of Small—Symptoms.

  practitioner.  In some cases, soreness and fis-
  sures of the lips, with exfoliation of the epithe-
  i;..™_____K„„\.„^hiP  and the cuticle often 13
6G0                 INTESTINES -Ini l.vmmj

and  the  form of enteritis about to  be noticed
(y 30) supervenes.
   9. Acute muco-enteritis commences variously
—sometimes slowly and insidiously, with im-
paired appetite, slight thirst, loaded or white
tongue, a slight sense of heat in the abdomen,
or colicky pains and slight disorder of the bow-
els.  These symptoms, at first, are hardly ap-
preciable, but they become gradually mpre and
more severe, until the pulse and system become
obviously affected.  In other instances the at-
tack is more sudden, and severer from the be-
ginning,  especially when caused by the more
energetic causes—errors of diet and regimen,
by irritating  ingesta or intoxicating fluids, by
irritating purgatives,  by exposure to cold, to
currents of air, and  by damp or wet clothes.
In these latter circumstances especially, it is
sometimes ushered in by chilliness or slight
rigours.  It not infrequently follows some one
of the varieties of Diarrhoea or of Colic, espe-
cially the former, and is often attendant upon
it; in such cases, however, the  morbid action
is seldom confined to the small intestine, but is
extended, also, to the mucous  surface of the
large bowels.
   10. The progress of muco-enteric inflamma-
tion  is seldom very rapid, unless when caused
by poisonous substances and the most intense
causes, and then dangerous cerebral symptoms
often supervene,  or the morbid action extends
either to the adjoining portions of the aliment-
ary canal, or to the more external tunics.   Its
duration most commonly varies  from three or
four days to thirty, or even forty ; but thirteen
or fourteen days may be said to be its medium
continuance.  It  most commonly terminates in
resolution ;  but when neglected, or improperly
treated, and in faulty states of the constitution,
it often passes into the  chronic form (Y  11), or
extends to the other tissues of the intestines,
or to the adjoining viscera.   A fatal issue gen-
erally is  owing to this circumstance, or to con-
secutive affection of the brain, which latter is
a frequent occurrence in children, especially in
infants.
   11. b. Chronic inflammation of the mucous sur-
face of the intestines is characterized chiefly by
the presence, generally in, a slight  degree, of"
the symptoms already enumerated, for  a con-
siderable time—for six or seven weeks, or even
longer.   It may have been consequent upon a
more severe state  of the  disease, or it may
have been slight from the commencement, and
hence prolonged from this circumstance or from
neglect.  In  many  instances, little or no ab-
dominal  uneasiness, or pain, or heat, or flatu-
lence,  or distention, is  felt until three or four
hours  after a meal.   Chronic muco-enteritis
is  exasperated by indigestible articles of diet,
by a heating regimen, warm condiments, and
by stimulants.  Thirst, dryness of the lips and
mouth;  harshness  and dryness of the skin;
flatulence,  borborygmi, and costiveness, the
motions  being scybalous, dry, and dark, some-
times alternating with slight diarrhoea ; abdom-
inal distention  during digestion,  and slight
evening  fever, are generally complained  of.
The occurrence of abdominal pain, tenderness,
thirst,  heat of skin, acceleration of pulse, and
lassitude, after the principal meal,  imparts to
the complaint an intermittent or remittent char-
acter,  which may mislead  an  inexperienced
num. are ooservauie, aim »"« -----
thrown off in minute pulverulent scales.
  12  c. In children muco-enteritis is one of the
complaints most  frequently observed.  It oc-
curs in either an acute, sub-acute, or chrome form.
In slighter as well as in  severer states,  it is
common  in  the youngest infants,  more  espe-
cially in large  or  manufacturing towns, and in
the more delicate subjects ; in whom, however,
the morbid action usually extends to the stom-
ach on the one hand, and to the large bowels
on the  other, in a more or less marked form, at
some period  of its course.  Indeed, many of the
diseases of infancy and childhood are merely con-
secutive  upon  neglected  states of this  com-
plaint,  more especially cerebral maladies and
convulsions,  infantile  remittent fever, disor-
ders of the liver, mesenteric obstructions and
enlargements, peritonitis, scrofula, and diseases
of the glands and joints.
  13. a. In infants at the breast, muco-enteritis
may, even in the acute and sub-acute states, be
attended by  very little febrile disturbance.  In
them the symptoms vary with the parts of the
digestive canal principally affected.  When the
small intestines are only implicated, there  is
generally vomiting, tympanitic distention of the
abdomen, and tenderness upon firm pressure,
with heat of skin, and slight or occasional diar-
rhoea.  When the morbid action extends to the
colon, there is more severe or continued diar-
rhoea, much  less abdominal distention and ten-
derness, and less frequent or no vomiting.  In
many cases  of this class of patients an erythe-
matous redness is observable around the anus.
The tongue is dry, or loaded, and red at the
point or edges, and sometimes over the whole
surface.   The stools are various, but frequent-
ly consist of a yellowish substance.   There are
also thirst, dryness of the skin, and agitation;
but the pulse is often not much affected.
  14. During  the period of dentition infants are
often attacked in a still more  severe manner.
In many the complaint commences insidiously
with slight diarrhoea and flatulent distention of
the abdomen,  and proceeds in this manner for
some time, until it assumes a well-marked form.
The evacuations are occasionally not more fre-
quent than  usual;  sometimes  they are three,
four, or five in the twenty-four hours, but they
are loose, and more or less disordered;  and all
the local and  constitutional symptoms are se-
vere.  In the  fully developed state of the com-
plaint there  are heat of skin, fretfulness, thirst,
dry tongue,  disturbed sleep, sometimes vomit-
ing, accelerated pulse, abdominal tenderness on
firm pressure, and distention, crying and agita-
tion before passing a stool, which  is often for-
cibly ejected with much flatus.  The evacua-
tions vary remarkably in the course of the dis-
ease, from a healthy to a clay-coloured, yeasty,
pale, and slimy, or to a greenish, or brownish;
or reddish, watery and dark state.  They some-
times consist  of  a dark fluid ;  at other times,
of a dark or reddish-brown mucus.   Their ap-
pearance is, however, much influenced by the
food and medicine taken, much of the former
passing off in the stools, but little or not at  all
changed.  This acute state of disease may con-
tinue for some time ; but great exhaustion, rap-
id pulse, dry or crusted tongue, sunk eyes, pal- 
INTESTINES—Inflammat
lid or waxen countenance, coma, and partial or
general convulsions frequently supervene  and
terminate  existence.  In infants and young
children, this stateof the disease may exist for
a considerable time, and even with much se-
verity, without fever being unequivocally de-
veloped.  Vomiting,  diarrhoea,  colicky pains,
flatulent distention of the abdomen, tenderness
on firm pressure, and often increased heat, es-
pecially of the belly, are the symptoms which
chiefly indicate, in this class of patients, the
presence of acute muco-enteritis.   Frequently
the first two of these symptoms alternate.
   15. In  infants who are either prematurely
weaned, or are attempted to be brought up by
hand, or otherwise insufficiently or improperly
fed, this complaint is very prevalent.  Indeed,
it is much more common than any other ; and
in it nearly all the other diseases, to which in-
fants thus circumstanced are liable,  actually
originate; these arising consecutively in con-
sequence of sympathetic  disturbance,  and the
intimate connexion subsisting between the vi-
tal organs,  by means of  the  organic  nervous
system.   The  complaint commonly called the
*' Weaning Brash" is merely a modification of
acute muco-enteritis, in which the irritation of
inappropriate or unaccustomed food not only in-
duces a degree of inflammatory action, but  also
an increased secretion ; this latter often, how-
ever, favouring the resolution  of the morbid
vascular action.  In this complaint the essen-
tial symptoms are those just described, varying,
however, in different cases, according as the
inflammatory irritation is extended either to the
stomach,  in the form of Gastro-enteritis, or
to the large bowels, in the form of Ileo-colitis,
hereafter to be noticed.  However modified this
disease may be  in children, by peculiarity of
constitution, by combinations of" the causes, and
the extent or intensity of the  morbid action, it
has a most manifest influence, in all its forms,
to induce  sympathetic  or consecutive inflam-
mation of either the  membranes or the sub-
stance of the brain, or even both, and disease of
the mesenteric glands.  After weaning or den-
tition, acute muco-enteritis sometimes assumes
a  form which is with  difficulty distinguished
from  the  acute variety of  Infantile Remittent
Fever.  Indeed, the one complaint often  runs
into the other; and the more severe state of
the latter disease is frequently  complicated, as
will hereafter be shown, with the former, a fa-
tal issue in these being generally owing to this
complication.
   16. /?. Chronic muco-enteritis is also frequent
in infants and young children.   It is  more gen-
erally  attended by diarrhoea  in them than in
adults ; the dejections being glairy, watery, and
greenish.   The belly is tympanitic and large;
and, as the disease continues,  contrasts strong-
ly with  the  emaciation  of  the  extremities.
About one or two hours after a meal, fretful-
ness, or uneasiness with depression, may be re-
marked, occasioned by an increase of ailment
when the ingesta are passing along the ilium.
There are also thirst, dryness of skin, and often
increased heat of the abdomen, especially to-
wards evening.  The pulse is sometimes accel-
erated, and generally small and soft.   Tender-
ness and soreness are frequently evinced upon
firm pressure of the abdominal regions, or upon
examination of them by percussion.  This state
pion of Small—Symptoms.                 661

 of enteritis in children seldom continues long
 without  superinducing  enlargement  and ob-
 struction of the mesenteric glands, and the usu-
 al consequences  of these lesions.  It  is often,
 also, a complication of the  more chronic states
 of Infantile Remittent Fever, and not unfrequent-
 ly the former complaint is mistaken for the lat-
 ter, the exacerbations attending it arising from
 the effect of food upon the  character  of the
 symptoms, or from the constitutional  effects
 of irritations of a vital organ, and the periodi-
 city which the slighter forms of febrile  action
 are prone to assume, especially when  the local
 affection commences in a slight form and ad-
 vances slowly.
   17.  ii.  Inflammation of the Glands of the
 Intestines.—Glandular  Enteritis  (Author).—
 Entente Folliculeuse, of French writers. Inflam-
 mation^of the solitary and aggregated (Peyer's)
 glands and of the simple follicles (Lieberkuhn's)
 is rarely observed as a primary disease, un-
 less as  a consequence of a peculiar  class of
 causes, which operate not  merely locally in re-
 spect of the alimentary canal, but also  upon the
 system in general.  It is scarcely ever a simple
 or an  unassociated malady;  but generally a
 consequence  of  an  antecedent morbid  condi-
 tion, either of some other vital organ,  or of the
 constitution—a result of an important  lesion of
 the vital energy, and of the circulating and se-
 creted fluids.  Follicular or glandular enteritis
 is to be viewed rather as a consecutive  or symp-
 tomatic, affection,  than as a primary and  simple
 disease.  Yet it has  been considered by several
 pathologists, and particularly by MM.  Louis,
 Roche, and  others,  as a primary malady, and
 the essence of the typhoid forms of fever. That
 it forms a most important complication of con-
 tinued, and  even of remittent fevers,  is un-
 doubted, as I have already shown (see Fever,
 Y 462), especially in certain epidemics,  and  in
 those localities  where the causes which act
 more directly upon the alimentary canal co-oper-
 ate  with other predisposing and exciting caus-
 es of fever.   Thus  it was a most prominent
 feature in the epidemic Mucous Fever  (see Fe-
 ver, v 406), described by. Roederer and Wag-
 ler, and in  that denominated by M.  Breton-
 neau dothincnterite, and ileo-dyclidite by  M. Bail-
 ly.   It  is frequently  observed  in  a adynamic,
 putro-adynamic, and  true typhus fevers,  and is
 seldom absent when these fevers assume the
 enteric character or complication;  and which
 they are prone to assume when they arise from
 those  concurring or exciting causes, which ei-
 ther act injuriously on the alimentary  canal, or
 contaminate the circulating fluids; as  putrid
 food, water containing decayed animal or vege-
 table matter, &c. It exists also, but in connex-
 ion with inflammation of  the follicular  glands
 of the cacum, colon, and rectum, in the adynamic
 forms of Dysentery (y 20, et seq.), as will be
 more fully shown in the sequel.  Glandular en-
 teritis, occurring consecutively of, or as a com-
 plication  of  low  fevers (see  Fevers, y 453,
 474),  necessarily assumes, in its  course and
 consequences, an acute  character;  but  it also
 occurs consecutively of other diseases, more
 especially of tubercular consumption, of tuber-
 cles in various organs, and of scrofulous dis-
 ease of the joints, bones, and glands ; and in all
 these symptomatic relations it presents a  chron-
 ic form. 
662
INTESTINES—Inflammation of Small—Symptoms.
    18. In its primary and simple states, glandular
 enteritis cannot be advantageously viewed with-
 out reference to its special causes.  These are,
 as respects predisposition, the female sex ; the
 earlier epochs of life, particularly those antece-
 dent to puberty;  relaxed and lymphatic consti-
 tutions ;  the scrofulous diathesis ; and persons
 possessing a fine white skin, a fair complexion,
 and  light hair.   The more  efficient or exciting
 causes of follicular enteritis are also peculiar.
 These are  a cold and humid atmosphere ;  low
 and damp localities; an air contaminated with
 vegetable and animal miasmas ;  the use of wa-
 ter rendered impure by putrid animal or vege-
 table  matters or exuviae ; immature, or stale,
 or decayed fruit or vegetables; animal food
 passing into a state of putridity or decay ;  all
 septic substances taken into the stomach ;  im-
 mature or spoiled, or musty wheat or rice ; dam-
 aged  or mouldy  bread, biscuit,  &c.; the pro-
 longed use  of purgatives, and whatever impairs
 vital power, and deteriorates the chyle and the
 circulating  fluid.   MM. Bretonneau, Leuret,
 and Gendron, consider that cases  originating
 in one or more  of these causes may generate
 an effluvium which may infect healthy persons.
 There can be no doubt that these causes, when
 they operate upon a number of predisposed per-
 sons,  and in circumstances favourable to their
 injurious impression,  and to  the  accumulation
 of the emanations proceeding from the diseased,
 will produce a  disease  capable of propagating
 itself in these  circumstances ; but the disease
 will either  be dysentery, or  fever with enteric
 complication, as shown in nnmerous instances,
 particularly where  these  circumstances have
 been aided by the endemic  influences just  al-
 luded to,  and by epidemic constitutions.
   19.  A.  Symptoms.—a. In the sporadic and sim-
 ple state of glandular or follicular enteritis, the
 patient frequently complains, at first, only  of
 slight disorder of the  digestive functions, con-
 sisting chiefly of want of appetite, colieky pains,
 and relaxation of the bowels, ceasing and re-
 curring from time to  time.   There  are  also
 borborygmi, flatulence, mucous stools, a relish,
 chiefly, for the more stimulating articles of food,
 a  white  or  loaded tongue, a soft and  languid
 pulse, and a turbid state of the urine.  In  other
 cases  the symptoms are more severe at  the
 commencement.   The  appetite is  lost; the
 tongue presents  a grayish-white  or yellowish
 coating, and is somewhat red at its point and
 edges ; the  mouth is clammy, occasionally aph-
 thous, with  an insipid, sickly, nauseous, or sour
 taste ; the  breath  is disagreeable and foetid ;
 and  there  is tenderness  upon firm pressure
 around the navel.  Borborygmi, and eructations
 of an acid and nidorous flatus; colicky pains,
 often  followed by flatulent and mucous evacua-
 tions,  occasionally containing lumbrici ; great
 depression of strength ; dusky discoloration of
 the skin ; occasional outbreaks  of slight but
 acid perspiration  ;  and  a small, frequent, and
 feeble  pulse, are  generally also present at  an
early period. There is little or no heat of skin,
and but little thirst.  Shifting pains in theJimbs
are often felt.  The urine is thick or turbid, and
deposites a grayish or brick-coloured sediment.
Diarrhoea is  neither severe nor of any continu-
ance, unless the glands of the large intestines
are also affected.
  20.  b. In  its more acute or severe states, the
  affection  of the glands is  seldom confined to
  the small intestines, or to  the solitary glands,
  or to Peyer's glands, or to the simple follicles
  solely, although either may be chiefly diseased.
  In the more complicated  cases,  particularly
  those presenting the forms of adynamic fever
  and dysentery, Peyer's or the aggregate glands
  are principally implicated ; and the disease ex-
  tends from the lower third of the ileum, where
  it is most prominently marked,  to the simple
  follicles and solitary glands of the large bowels,
  on the one hand, and to those of the upper por-
  tions of the  intestine canal, on the other.  In
  these more acute states, severe pain in the ab-
  domen, often extending from the navel to  the
  right iliac or csecal  region, and increased on
  pressure ; a loaded tongue, with dryness of the
  mouth, and thirst;  symptomatic fever, which
  becomes increased towards evening, with a dry,
  harsh skin;  depression of spirits;  disinclina-
  tion to move ; a dull, and often a sunk state of
  the  eyes, and  discoloration  of the lips  and
  around the mouth, are usually present,  and are
  commonly attended  by fulness or flatulent dis-
  tention of the  abdomen in general, or more
  especially towards the caeca! region ; by nausea,
  and  occasionally vomiting; and  by frequent,
  mucous, offensive, ochrey, or otherwise morbid
  stools and scanty urine.  As the disease pro-
  ceeds, it usually assumes all the  characters  ei-
  ther of Asthenic Dysentery,  or  of Mucous or
  Adynamic Fever (see these articles), in a severe
  and more or less advanced form, according as
  the affection extends along  the digestive canal,
  or gives rise to exbaustion of the cerebrospi-
  nal functions, and to deterioration of the circu-
  lating and secreted  fluids.  When it assumes
  any of the forms of Asthenic or Adynamic Dys-
  entery (see Dysentery, y 2f>, et seq), the caecum,
  colon,  and rectum are especially  implicated;
  and when it passes into adynamic fever, the ag-
  gregated glands, particularly in the  lower third
  of the ilium, are extensively diseased,  ulcera-
  tion extending from them to the more external
  tissues.
   21.  c. Inflammation of the intestinal mucous
 follicles often  assumes, particularly in low and
 humid localities, and  when  occurring epidemi-
 cally, or even endemically, as occasionally ob-
 served, especially on the Continent, either the
 form described under the article Mucous Fever,
 or that very closely resembling it, denominated
 by M. Petit Entero-mesenteric Fever, and which
 is described by  him  nearly as follows:  There
 are at  first  debility,  general uneasiness, ano-
 rexia, irregular attacks of fever, and diarrhoea.
 The countenance is dejected, the  eye dull, and
 the skin pale or slightly livid, particularly about
 the lips and near the alae nasi;  decubitus on
 the back ; disinclination to motion ; torpor, and
 some degree  of prostration of  the intellect-
 ual powers.   The  fever is  slight or obscure
 during the  day, but gradually comes on in even-
 ing paroxysms, without  rigours or much heat,
 but with a dry, harsh skin, injection of the eyes,
 and slight delirium.  There is great thirst; the
 teeth are dry ;  and the tongue is eovered with
 a grayish paste.  The stools are bilious  or se-
 rous,.variable in frequency  and quantity, but
are not such as to account for the prostration
of the patient.  The belly is soft and not swol-
len ; and little or no pain is felt in  it, unless on
pressure  towards the  right  side, between the 
INTESTINES—Inflammation of Small-^-Symptoms.
663
 umbilicus  and  the  crest  of the  ilium.   The
 symptoms are gradually increased ; the lips and
 alae nasi are slightly retracted ; the cheeks be-
 come  livid,  the eyes sunk  and injected, and
 somnolence and delirium constant, although the
 answers are correct,  but  painful.   Continued
 fever, with nocturnal  exacerbations, petechiae,
 and subsultus tendinum, now appear ; the pulse
 is frequent, and very compressible ; the teeth
 are covered by sordes, and the tongue with a
 brownish or black  crust.   The abdomen  be-
 comes more painful; sometimes, however, the
 pain is confined to its  first  situation, and is un-
 attended by  distention ; but in other cases it
 is  more extended,  and is accompanied with
 tympanitis.  The stools become serous, foetid,
 and frequent;  the urine scanty; and excoria-
 tions of the nates, or the situations of blisters,
 are disposed to  gangrene.
   22. d. In many cases; glandular enteritis is
 consequent upon fevers, or occurs during conva-
 lescence from them.   This sequela has present-
 ed itself more frequently after some epidemics,
 and in certain localities, than in others.   It has
 been well described  by Dr. Cheyne, in his Re-
 ports;  as it appeared in Dublin in 1817.   A pa-
 tient in fever has become so much improved
 that a speedy convalescence is expected, but in
 a few days it is found that strength is not re-
 turning ; the pulse continues quick, and the ap-
 petite, although sometimes restored, is oftener
 deficient or capricious.  The patient expresses
 no desire to leave his  bed,  and he does not gain
 flesh.  His tongue becomes dry, and he com-
 plains of a dull pain and uneasiness in his belly,
 with soreness on pressure, and a degree  of ful-
 ness.  To these succeed looseness of the bow-
 els, with  great  weakness.   Probably at the
 next visit, the patient is found lying on his back,
 with a pale, sunk countenance, and a very quick
 pulse, and without  mental  energy.   Mucous
 stools pass from him in bed, and the urine also.
 His breathing becomes frequent, and often hic-
 cough occurs.   Death is now nearly at  hand ;
 opiates, astringents, and cordials being  alike
 unavailing.
  23. e. In the more severe cases, and particu-
 larly when, they assume either of  the  above
 forms, the  abdominal or local symptoms occa-
 sionally become suddenly  exasperated.   The
 patient complains of violent  pain in the abdo-
 men, which is greatly distended, tense, and ten-
 der on the slightest  pressure.  He lies  on his
 back, with his  knees  drawn up.  His counte-
 nance  is anxious and collapsed;  his pulse is
 weak,  small, remarkably accelerated, followed
 by  extreme depression and  sinking, by quick,
 laboured breathing, cold extremities, and occa-
 sional  hiccough.  Death in  these cases  com-
 monly  takes  place within 24 or  36 hours from
 the accession of the severe pain and tympanitis;
 and is  owing to ulcerative perforation  of the
 intestines and  consequent  peritonitis rapidly
 extending over the greater part of the perito-
 neal surface.
  24. /.In other instances,  intestinal haemor-
rhage occurs in the  course of the  disease, and
sinks the patient more or less rapidly, accord-
ing to its amount relatively to his powers, &c.
In these cases,  especially if the blood is poured
out slowly  in the small intestines, and in small
quantity, it is more  or less intimately mixed
with the other matters passed by stool, and the
 evacuations are generally more frequent  and
 abundant than in other circumstances.   Intes-
 tinal haemorrhage, particularly when the blood
 is more or less pure, is, however, much more
 frequent when ulceration has taken place in the
 large intestines.
   25. g. Follicular or glandular enteritis may,
 particularly when occurring  in a simple  and
 sporadic form, assume a more or less chronic or
 sub-acute slate.  But in either of these states it
 will hardly be  distinguished from  the more
 chronic forms of muco-enteritis already noticed
 (y 11), unless by a more offensive mucous or
 muco-puriform state of the stools, and a weak-
 er and more frequent pulse; but these  cannot
 be relied upon.  Very often, also, muco-enteri-
 tis  and follicular enteritis are associated, es-
 pecially in children.  Enteritis consequent upon
 tubercular consumption is commonly  seated
 chiefly in the follicles, and  is chronic in its du-
 ration ; but it  is seldom limited to  the small
 intestines,  it generally extending, also, to  the
 ccecum and colon.
  26. h. The progress of the simple and spo-
 radic states of follicular enteritis  is generally
 slower, and the duration of it, consequently, long-
 er than the progress and  duration of similar
 grades of muco-enteritjs.   It seldom proceeds
 to ulceration, or the ulcerative process rarely
 proceeds far in the situation of these  glands
 without giving rise to inflammation and enlarge-
 ment of the  mesenteric glands corresponding to the
 diseased intestinal glands and follicles.  Indeed,
 it is not improbable that consecutive inflamma-
 tion, enlargement, and obstruction of the mes-
 enteric glands often  arise  before  the follicles
 and glands become ulcerated, and yet are owing
 to the  primary  disease of these follicles and
 glands.
  27. i. In infants and children, glandular enter-
 itis  is  a  very  frequent disease*  particularly
 among infants that are brought up by hand, or
 imperfectly nourished, or injudiciously fed, and
 that live in close, low, and damp cellars and
 localities, especially in large and  manufacturing
 towns.  It is frequent, also, at the time of wean-
 ing, and in humid, cold, and miasmatous situa-
 tions.   It often assumes a slight  and chronic
 form, and then generally occasions mesenteric
 disease, which very frequently occurs consec-
 utively  upon either follicular or muco enteritis,
 particularly the former.  These  two forms of
 enteritis are with great difficulty distinguished
 from each  other in children or infants.   Nev-
 ertheless, an opinion as to  the presence  of ei-
 ther may be formed from the descriptions fur-
 nished above (y  12-19).  In the  follicular vari-
 ety, the stools are more generally mucous, and
 the diarrhoea is more  marked than in the other
 variety.  Indeed, mucous diarrhoea in children
 is very commonly caused by inflammation of
 the intestinal follicles and glands, or by a state
of irritation which is very prone to pass into
inflammation, which will assume either a slight
and chronic, or a severe and an acute form, ac-
cording to  the constitution  of the  patient, and
 numerous  concurring circumstances.  In the
more acute cases, there is more or less  fe-
 ver> which  generally assumes a remittent char-
acter ; and it is sometimes attended by nausea
or vomiting, and always by thirst.   The abdo-
men is tumid, uneasy, although not always pain-
ful or tender on pressure.  Griping pains are 
664
INTESTINES—Inflammation of  Small—Symptoms

                                     —Inflammation extending to the cell:
often felt, especially before an evacuation ; but
there is no straining, unless the large bowels
become implicated; and this often is the case
as the disease proceeds; and it then  assumes
a truly  dysenteric character, the stools often
consisting of a reddish-brown mucus.
  28. k. The  more slight and chronic  states of
follicular enteritis in children are apt to be over-
looked,  or seldom come under the eye of the
physician until  it has passed  on to  organic
change, generally to enlargement of  the folli-
cles  or  incipient ulceration, with consecutive
disease  of the mesenteric glands.  The chron-
ic state of the  affection  is often the conse-
quence of its slightness or its gradual increase,
which causes it to be neglected, or injudicious-
ly treated, in respect both of regimen and of
medicine.  It is frequently, also, produced  in
connexion with the more slight or chronic form
of muco-enteritis ; and it often proceeds from
morbid states of the chyle and blood, or, at least,
from causes which operate chiefly by deteriora-
ting  these fluids.  The chronic affection is. as-
certained with difficulty in children, and infants,
especially during its  early stages.   It closely
resembles, not only the chronic form  of muco-
enteritis, but also infantile remittent fever and
mesenteric decline:  Indeed, the remittent fever
may be  altogether symptomatic of it;  or it may
be developed in the course of the fever.  I have
seen cases, both in public and in private prac-
tice, conclusive  of this intimate connexion—of
these sequences of morbid action.   The  ad-
vanced  state of the  chronic disorder may. not
differ from mesenteric disease ; for the former
is rarely of long continuance without superin-
ducing the latter.  In many cases, the affection
of the glands and follicles is slowly produced
in consequence of general cachexia, or of a
morbid  condition of the circulating fluids;  the
constitution, especially the soft solids and sur-
face, manifesting  general disease and the  di-
gestive organs  more or less  disturbance, the
stools   being  mucous, offensive, or  otherwise
morbid. In  children, as  well as m  adults,  it
commonly supervenes, and proceeds  to exten-
sive ulceration, during the progress  of tuber-
cles of the lungs, and in the course of hectic or
slow fever proceeding from the absorption of
morbid  matter or diseased secretions, or from
local sources of irritation.
   29. I. The  chronic form of glandular enteritis
may terminate in perforation of the intestines,
and  in partial or general peritonitis, mesenteric
disease having been previously developed, and
more or less advanced ; but I believe that per-
foration is a less  frequent consequence of the
chronic than of the  more acute or  sub-acute
states of the disease.  When consequent upon
the  chronic form, it is chiefly when  this  form
arises from tubercles in the lungs, or when it
occurs in the scrofulous constitution.   (See art.
Digestive Canal, y 38, et seq.).   Hemorrhage
from the intestines is probably,  also, less fre-
quently caused by the chronic than by the acute
states of the follicular disease—at least, accord-
ing  to  my observations,  although I  have  met
with several instances of its occurrence in the
 chronic variety, consequent upon tubercles and
ulceration of the lungs.
   30.  iii- Inflammation  implicating all  the
 Coats.—The Enteritis Phlegmonodea of Cullen ;
 JS. Jliaca of Sauvages ; Sero-enterilis of mod-
ern Writers.--ihjiu,,*.-----.       ~,„//„ the ner
lar, and affecting all the tunics upc£\ZJlJr-
itoneal.-This variety °{ °nte"}K"^LTZ.
izcd chiefly by the  severity and continued du-
 ation of the  Jain of the abdomen, particularly
around the navel;  by  frequent vomiting and
great tenderness and tension of the belly,  by
the very  accelerated, constricted,  small and
even cord-like pulse ; by the marked  tendency
to constipation ; and by the severity of the ac-
companying  fever.   As the inflammation ex-
tends to  the  peritoneum, or in proportion  as
this coat  is affected from the commencement,
these symptoms are prominent, but in vari-
ous grades of severity, according  as the dis-
ease is consequent upon muco-enteritis, or upon
strangulation,  or upon  inflammation of some
adjoining viscus, and according to  the causes
which have directly produced it.  Sero-enteritis
may thus  be either primary or consecutive ; acute
or sub-acute ; but very rarely chronic, unless in
a  particular   form, in  connexion either with
chronic ulceration of the  intestines, or with
chronic peritonitis.
   31. Description.—A. Acute  sero-enteritis, or
phlegmonous enteritis, may occur primarily, par*
ticularly in warm or in tropical countries, and
in warm seasons in temperate  climates ;  but it
more commonly is consequent upon some grade
or other of muco-enteritis,  although the symp-
toms of the latter may have'been  overlooked,
or have not fallen under the observation of the
physician.  When it oecurs primarily, it is gen-
erally ushered in by chills or rigours ; but when
it  is developed more gradually, owing to the
extension of inflammatory  action from the mu-
cous to .the  cellular tissue, and thence to the
peritoneal coat, then it is  evinced by the  ap-
pearance of  the more acute and characteristic
symptoms.—a.Jn the early  stage of the disease,
more especially if it be ushered in by rigours,
there is  great vascular and febrile  excitement,
 which passes into exhaustion with  a rapidity
 proportioned to the degree of  the previous  ex-
citement, and to the progress  of the  inflamma-
tion and of  its consequences.  Pain and ten-
 derness of the abdomen are early felt, particu-
 larly under pressure, during which the  patient
winces, and  evinces increase of pain or anguish
 by the expression of his face.   The abdominal
 integuments  become  hard,  irregular, tense,
 harsh, and hot, and the whole abdomen tense
 and distended, chiefly  by flatus, which  the pa-
 tient feels to  increase  his  sufferings.   As  the
 tenderness increases, he is more constantly on
 his back, with his legs  drawn up, as if instinct-
 ively to relax the muscles  and to keep off the
 pressure of the bed-clothes from the belly.   If
 nausea,  retching, or vomiting does not appear
 at the commencement of the attack, they are
 sure to occur as it proceeds, and to increase in
 severity with its progress.   Constipation is ob-
 stinate in proportion as the more  external  tu-
 nics are affected ;  and  the  more obstinate it is,
 the more urgent is the vomiting,  which often
 occurs either without being excited  by the in-
 gesta, or a considerable time  after substances
 have been taken into the stomach.   The urine
 is scanty and high-eoloured.   The skin is  hot-
 ter than natural, and  always drier, excepting
 on the forehead and palms of the hands, where
 it is often moist.  The  pulse is very quick ; gen-
 erally from  100 to 120, or even quicker, in  the 
INTESTINES—Inflammation of Large—Symptoms.
665
more intense cases, and at a far advanced pe-
riod.   It is small, constricted, resisting,  and
firm ; but as exhaustion comes on, it becomes
small, thready, and weak.   The respiration is
quick and  anxious, and chiefly effected by the
diaphragm and intercostals, the abdominal mus-
cles acting slightly or almost imperceptibly.
The tongue is covered by a whitish fur,  and
there is excessive thirst.
   32. b. As the vascular and febrile excitement
passes into exhaustion, the  abdomen becomes
more distended and tense, and the pain and ten-
derness, which had recently been mbs); intense,
subside more or less rapidly.  The concentra-
tion of heat in the addomen  still continues,
while the temperature  of the extremities sinks.
Respiration now becomes laboured; retching
and vomiting more frequent, and the counte-
nance more anxious  and collapsed.  As  the
stage  or  period  of exhaustion is  more fully
evolved, the pulse is remarkably quick, general-
ly ranging  above 120, and weak, small, thready,
or undulating.   The heat of the surface falls
remarkably on the extremities, which are damp
and clayey cold,  and,  ultimately, even on  the
trunk.  The hands and feet often appear mot-
tled with dark-red or livid spots.   Respiration
is  irregular, embarrassed,  or  interrupted by
catchings or hiccough.  Vomitings occur with-
out retehings or effort, the contents of the stom-
ach being discharged by a retrograde action, or
by a gulping-like motion.   The tongue Is dry,
brown, and furred; the faceis sunk, the orbits
hollow, and muscular  power altogether pros-
trate.  This state continues but a  short time,
until the patient sinks, generally with a collect-
ed mind, and  sometimes with hopes of recov-
ery entertained  until almost the last  moment,
or after all hopes  have ceased to  inspire the
practitioner.
   33. B. Sub-acute sero-enteritis differs from the
acute chiefly in the severity of the symptoms
and in their duration.  The abdominal symp-
toms are less severe in this than in the acute
form ; and the  attendant fever  is also less.
The acute variety is seldom protracted beyond
the sixth or seventh day, very often not beyond
the fourth ; whereas, the sub-acute may be pro-
longed to twelve, fifteen, or even twenty days.
The rapid progress even of the latter, and still
more of the acute, should not be forgotten, nor
their almost constant tendency to terminate fa-
tally, as these circumstances most unequivo-
cally prove the necessity for adopting a most
active,'decided, and a judicious treatment at the
commencement  of the disease ; for, when  ex-
haustion begins to appear, every means will be
inefficacious.
   34. Althougha  cute  and sub-acute phlegmo-
nous  or sero enteritis most frequently arises
from  the extension of inflammation from  the
mucous coat to'the connecting cellular  tissue,
and thence to the external tunics of the intes-
tines, yet  these  tissues may be almost coeta-
neously affected, or the inflammation may com-
mence in,  or extend to, the serous coat,  and
thence to the rest.  This latter is  most likely
to be the case when sero-enteritis appears con-
secutively upon external injuries, upon inflam-
mations of adjoining parts, and upon strangula-
tion, &c.   Death, in the unfavourable cases of
acute and  sub-acute sero-enteritis, is common-
ly caused  by the extent to which inflamma-
                    84
tion and its consequences have proceeded in-a
vital organ, and by the shock  imparted  to the
organic nervous power by intense disease of a
viscus most intimately connected with this vi-
tal  part of the nervous system.
II.  Inflammation of the Large Intestines.—
  Syn.  Colitis, Colite,Fr. Eine entziindung des
  Kolons-, Germ.
    Classif.—III. Class, I.  Order (Author).
  35. Defin.—Pain and tenderness in the course
of the colon, commonly originating in the region of
the  ccecum, and extending to the left iliac  region
and sacrum; with frequent, and often ineffectual,
efforts at fcecal evacuation, generally preceded by
tormina, and attended by tenesmus, the motions be-
ing mucous, and streaked with blood; symptomat-
ic inflammatory fever.-
  36. The ccecum is sometimes primarily infla-
med, without the disease advancing to a great
extent,  either to the small  intestines on the
one hand, or to the colon on the  other.   This
limitation of the inflammation to the caecum is,
however,  comparatively rare,  especially when
its  mucous surface is  the part of it affected.
Inflammation  of  the cecum,  particularly  when
thus confined, is fully treated of in the article
Caecum  (y 15).  When inflammation commen-
ces in this viscus, it generally extends  to the
colon, and even to the rectum ; less frequently,
it extends also to the ilium.   When this latter
intestine is inflamed, especially when its villous
surface  or its  follicles are chiefly affected, the
caecum often participates in the disease,  which
frequently advances, also, to the colon and rec-
tum.  Such is the  case in the several varieties
of Dysentery, which, in most instances, either
commences with, or soon passes into, inflam-
mation of the mucous surface of the large in-
testines, extending often to  the ilium.   In the
purely inflammatory form of dysentery, the lo-
cal  morbid action  is of the sthenic kind, and
the accompanying fever,  also, of this nature.
In the low, adynamic, infectious, and epidemic
forms, the local action is asthenic, and the at-
tending fever of a low or typhoid  character.
In most of the forms  of dysentery, there are
portions of the large intestines somewhat more
severely implicated than others, and these are
the internal surface of the caecum, of the sig-
moid flexure  of the colon, and of the rectum.
The other portions of the colon and the ilium
are likewise  inflamed, but generally in  a less
degree, unless in very severe or protracted ca-
ses, where they also present very remarkable
lesions.  In the different states of  dysentery,
also, the follicular glands, as well as the mu-
cous surface itself, are affected, although prob-
ably in  different degrees, particularly at the
commencement of the complaint, at which pe-
riod, however, dysentery is not always identi-
cal  with inflammation of these parts, for dys-
entery,  particularly in its asthenic, endemic,
and epidemic appearances, usually commences
with indications of morbid secretion and of inor-
dinate action of the muscular coats of the intes-
tines—with signs of irritation  chiefly ; inflam-
matory action, either of a sthenic or asthenic
kind, being consecutive.   However, in many of
the  more acutely and sthenically inflammatory
cases, and especially in those which occur spo-
radically, and from causes which will hereafter
be noticed, this  disease is truly inflammation
of the villous surface  of the large intestines, 
666
INTESTINES—Inflammation of Large—Symptoms.
 seated, in some cases, chiefly in the colon and
 rectum ; in others, in the caecum and colon ;
 and, in many, in these three parts equally, and
 extending  also to the ilium;  but  in  all, the
 morbid action is not limited to the villous sur-
 face itself, nor to the follicular glands solely
 of these intestines, although it may  commence
 in either, or be more prominent in  one or the
 other.
   37. Inflammation of the Colon—Colitis—which
 will be chiefly considered  at this  place, as In-
 flammation of the  C/ECUM and Inflammation of
 the RtcTUM are discussed in  separate articles
 —generally commences in the villous  or mucous
 surface, or  in  the follicles, and comparatively
 seldom in the  cellular or connecting tissue of
 the coats of this bowel, or in  the  peritoneal
 coat.   It may, however, originate in either of
 these latter, as in the case of phlegmonous enter-
 itis (v 30), when it has been caused by wounds
 or external  injuries,  by strangulation, or has
 occurred consecutively upon  inflammation  of
 an adjoining viscus,  or of the peritoneum, or
 of the omentum or mesentery.
   38. A. Symptoms of Acute Colitis.—When the
 inflammation commences in the villous surface,
 as is usually the case, the bowels are, at  first,
 loose or irregular, or mucous diarrhoea is pres-
 ent, feculent  evacuations  being first passed.
 In this state  there may be neither  chills nor
 rigours, or they may be slight.  When, howev-
 er, the coats of the bowels are more deeply and
 acutely affected, the disease is usually ushered
 in with rigours and chills. Pain and tenderness
 on firm pressure are generally  felt in the course
 of the colon, extending from the caecal region
 to the right hypochondrium, across  the abdo-
 men, midway between the pit of the stomach
 and navel, to the left side and left iliac region.
 The pain occurs in paroxysms, is often griping,
 and followed by an inclination to  go to stool,
 the evacuations consisting chiefly  of  mucus
 with blood.   If there be straining or tenesmus,
 with pain in the direction  of  the  sacrum, the
 inflammation has extended to  the  rectum.   If
 inflammation of the  large.bowels assumes  a
 sub-acute form, it is attended by the same symp-
 toms, and it observes the same course, as sta-
 ted in the article Dysentery, at the place where
 the sthenic or  inflammatory states of that dis-
 ease  are described (y 11-16).  If it be very
 acute, it will differ but little, if,  indeed, at all,
 from the variety of dysentery (Y 17, et seq.) ob-
 served so frequently in Europeans in warm and
 inter-tropical countries.  Indeed, the  chief dif-
 ferences between colitis, or  inflammation of the
 colon, and inflammatory dysentery, arise from
 the extension of the  morbid action, in the lat-
 ter, to the rectum on the one hand, and to the
 caecum, and even,  also, to  the ilium, in some
 cases, on the other.  When, however, the rec-
tum is unaffected, there will neither be strain-
 ing, nor  pain at the  sacrum, the other  symp-
toms  attending acute  inflammatory dysentery
remaining; the inflammation of the rectum, in
connexion with colitis, occasioning some of the
chief characteristics of inflammatory dysentery.
(See article Rectum.)
  39. When inflammation has invaded all the
coats of the colon, either by extending from the
 internal surface to the peritoneal coat, or from
 the latter to the other tissues, or by attacking
 them all nearly coetaneously,  the  second  and
 third  modes  being,  however,  comparatively
 rare ; then pain, increased heat  and tender-
 ness in the course of this viscus become more
 severe and constant, and extend over the ah-
 domen ; flatulent distention of it increases, par-
 ticularly in parts; the stools are  preceded by
 tormina; are frequent, scanty,  mucous, or sli-
 my, ve*y dark, streaked with florid  blood ;  con-
 tain either scybala, or broken-down faeces ;  are
 passed with much flatus ; and are at last foetid,
 with shreds of lymph or muco-punform matter
 in them.  The tongue varies in its appearance,
 but  it usually becomes  covered with a dark
 sordes, which forms  into a  crust as the disease
 proceeds.  The  mouth  is  dry: there is con-
 stant  thirst, and occasionally vomiting.  The
 urine is scanty and high-coloured, and the calls
 to pass it, frequent and  painful. The pulse is
 quick, hard, and small,  and ultimately small
 and weak.   The heat,  pain, tenderness,  and
 flatulent distention of the  abdomen  go  on  in-
 creasing, and the disease, in most respects, ex-
 cepting the dysenteric' symptoms, assumes the
 features of  the  worst  cases of sero-enteritis
 (y 31), or passes  into a state of partial ox gen-
 eral  Peritonitis, or becomes identical with the
 far-advanced  stage of the most  acutely inflam-
 matory fprm of Dysentery (y 17); the local
 and  constitutional symptoms  attending the un-
 favourable terminations  of these,  particularly
 of the  last, also accompanying similar termi-
 nations of  it.  As colitis,  however, appears
 more frequently associated with other diseases,
 than as a primary malady, especially with in-
 flammations  of other parts of  the alimentary
 canal, o«r with those of the liver,  omentum, peri-
 toneum, &c. ;  and as it occurs  in a variety of
 endemic and  epidemic, circumstances, and in
 various states of the constitution,  so both the
 local and  constitutional  symptoms  vary in dif-
 ferent cases, and even  in  different  stages of
 the same case.  Still, the pain, heat, distention,
 and  tenderness in the course, or in some part
 of the colon, in connexion with the  state of the
 stools and the severity of the local and consti-
 tutional disturbance, will sufficiently  mark the
 presence of the disease.
  40. B.  Chronic inflammation  of  the colon—
 chronic  colitis—is either consequent  upon the
 acute or sub-acute states of colitis, or is itself a
 primary  disease, the  chronic  condition pro-
 ceeding from its slight grade and  slow prog-
 ress.   As it  usually  occurs in practice, it is
 identical with the sub-acute or chronic forms oj
 Diarrhoea and Dysentery (y 45, et  seq.),  the
 symptoms varying much according  to its com-
 plications, and the circumstances of the locali-
 ty in which it prevails,  and of the individual
 affected, as above stated (y 39).  Its most com-
 mon  complication, however, is with sub-acute
 or chronic disease of the liver, with abscess
 in this organ, and with disease-of the mesen-
teric glands ; but it may attend other diseases,
particularly tubercles in the lungs.   The symp-
tomatic fever, in  this  state of colitis, is very
frequently of a remittent or hectic type; and
 it often, particularly in warm  and miasmatous
climates, occurs in the course, or as a sequela,
of intermittent and remittent fevers.
  41. Chronic colitis  generally occasions, and
becomes associated with, chronic inflammation
of the ileum, the disease affecting chiefly either
the mucous surface, or the  follicles of this in- 
INTESTINES—Inflammation of—Symptoms.
667
testine; but  in  this case the ccecum also is
more or less implicated.  As this state of co-
litis proceeds, ulceration takes place; and the
inflammation  advances in parts, through  the
medium of the  connecting  cellular  tissue, to
the peritoneal coat,  coagulable  lymph  being
thrown out on its surface, and giving rise to
adhesions, &c.  Similar changes, although to
a less extent, also take place in the adjoining
portions of the alimentary canal, and the dis-
ease terminates either in partial or in general
peritonitis, or in thickening and  constriction
of the coats of the intestine, or as more fully
described  in the  article Dysentery (y 48-58).
III. Inflammation of both Sma.ll and Large
  Intestines. — Ileo - colitis — Entero-colitis, of
  various  authors.   Ileo-colite — Entero-colite,
  Fr.   Entziindung  des Ileums u. des  Colons,
  Germ.
  42. This is  a frequent form of inflammation
of the intestines, the morbid action affecting
the  ilium  and colon solely, but  in  different
grades in  either, or extending also to the oth-
er portions of the small and large intestines,
although  in various  degrees.  It is probable,
however,  that the disease  is not limited long
to the ilium and colon without the rectum being
more or less affected; and we cannot reason-
ably exclude the caecum from an  equal  share
of the malady when the ilium and colon are at-
tacked. Indeed, there is reason to believe that
the ccecum is sometimes the part first affected,
inflammation extending to the colon on the one
hand, and to the ilium on the other, especially
when the mucous surface is the tissue primari-
ly attacked.
  43.  A.  Acute Ileo-colitis.—a.  The  symp-
toms vary according to the portion of intestine
chiefly affected; but the most characteristic of
the more acute states are, pain, aching, or sore-
ness, with frequent  gripings in  the  right iliac
region, and between this part and the umbili-
cus, often extending across the hypogastrium,
and occasionally above and around the navel;
tenderness on firm pressure of these places ;
diarrhoea, the  stools being thin, mucous, or wa-
tery ; and symptomatic fever.  At  the com-
mencement of the slighter cases, there may be
neither chills nor rigours; or they may be slight,
or they may  recur and  alternate with  febrile
heat; but they  generally usher  in  the more
acute attacks.   As the  disease is developed in
its acute form, the patient complains of a sense
of heat in the above  situations, particularly in
the region of  the ileo-caecal valve ; and of flat-
ulent  distention, pressure frequently  causing
a  gurgling  sound in this region.  The  abdo-
men  is hot, dry, and more and  more painful,
distended, and tender on pressure  as the in-
flammation proceeds.  The stools become more
disordered,.darker, more offensive, mucous, or
watery, and occasionally streaked with  blood,
or  contain  imperfectly-digested substances.
The complaint,  when judiciously treated, will
generally  not proceed  farther,  all the  symp-
toms gradually subsiding ; but when it is neg-
lected, and when it  is complicated with dis-
ease of the liver or other organs, or associated
with  remittent or adynamic forms of fever, or
when it extends to the rectum,  thereby  giving
rise  to a  most severe and dangerous form of
dysentery  (v 17), the inflammatory action very
often proceeds  to disorganization, the perito-
neum ultimately becomes implicated, and the
several lesions described in the article just re-
ferred to (y 59, et seq.), and in that on the pa-
thology of the Digestive Canal (y 34. et seq.),
supervene and terminate life.
  44. b. Inflammation of both the small and large
intestines  seldom  extends, in  temperate cli-
mates, to  all the coats or tissues of all these
viscera in  the same case.  When inflammatory
action attacks  or  extends to  all the coats, or
even to the peritoneal coat, portions only of ei-
ther the small or large bowels are thus impli-
cated :  more  rarely of both.   Yet I have fre-
quently  observed, particularly in warm  cli-
mates, all the coats—the mucous and perito-
neal inclusive—inflamed both in the ileum and
in the colon, including the caecum and even the
rectum.   In these  cases, the disease  commen-
ced either as inflammatory diarrhoea, or as in-
flammatory dysentery, the morbid action ex-
isting in the mucous surface  of the ileum and
colon in the former^and in the rectum, also, in
the  latter, ultimately extending  to all the tu-
nics, in portions of these intestines, and  giv-
ing  rise to partial or general peritonitis, and
to the other consequences of enteritis already
noticed, with the symptoms attending them, in
their most severe and most prominently marked
forms, or  in  the form about to be described.
When the inflammation proceeds thus far, the
chances of recovery are very few, the  change
of structure  already produced on the internal
surface of the intestines combining with the in-
tensity of the morbid action, and with its con-
sequences in the  external coats, in destroying
the patient.  In these, the symptoms vary much
in different cases,  according to the part chiefly
affected, and the other circumstances connect-
ed with the production  and  course of the dis-
ease ; but either  a combination of  the local
symptoms  characterizing both  sero-enteritis
(y 30) and sero-colitis (y 39), or a predominance
of the symptoms  of either, with great, febrile
commotion—with heat of surface, particularly
of the abdomen, very quick, sharp, constricted,
hard, and small pulse; dry tongue, thirst, oc-
casionally  vomiting ;  scanty, high-coloured
urine ; and ultimately physical exhaustion, sin-
gultus, or flatulent eructations, cold extremi-
ties, &c.  When  the morbid action  thus in-
vades the external coats of the bowels, the
diarrhoea subsides, and constipation often takes
place, the seat of pain and of tenderness gen-
erally indicating the portion of the bowels chief-
ly affected.
  45. B. Ileo-colitis of Warm  and  Inter-
tropical Countries.—a. Inflammation  of the
small and large intestines is of frequent oc-
currence among Europeans residing in intertro-
pical countries, and, indeed, among the  inhab-
itants of  all hot  climates.  It generally com-
mences in the villous coat, but it occasionally
attacks all the intestinal tissues almost simul-
taneously, or the  peritoneal  coat chiefly, par-
ticularly when it is caused by exposure to cold
in any way,  or by sudden suppression  of the
perspiration.  When  it  originates in the  vil-
lous surface, it is often owing to, or, at least,
connected with,  a  morbid condition  of  the
bilary  and  other  secretions  poured into  the
intestinal canal, the  alvine  evacuations being
more or less  disordered.   It rarely commences
in the peritoneal coat, unless consecutively upon 
mmation  of—Symptoms.

  If the disease is now arrested, all these symp-
  ____•______:„ vmionw   The  features are
 668                   INTESTINES—Infla:

 inflammation of the liver, with which it is often
 complicated, especially in India.  At  first, the
 bowels are seldom obstinately constipated, but
 they are sometimes  costive ; they are oftener,
 however, laxer than  usual, and  diarrhoea is
 present  in many  cases.  Indeed,  the disease
 often commences  in the form of inflammatory
 diarrhoea, or of dysentery, and continues in ei-
 ther of these, particularly the former, as long
 as  the villous  coat  and follicles only are af-
 fected.  The stools are morbid, of various col-
 ours, and frequently change their  appearance.
 They  are  offensive, often dark-coloured, wa-
 tery, or serous — sometimes pale, fluid, and
 frothy, resembling fermenting yeast; at other
 times they are  slimy-green, gelatinous, or mu-
 cous.  As  the  disease advances, they are of a
 dark green, with lighter shades, or with brown
 or yellowish-brown  streaks, and at last  they
 become very dark and grumous, occasionally
 bloody, especially  when the colon is  much af-
 fected.
  46. b. As the inflammation extends  to  the
 other coats, the griping pains, which manifest-
 ly, from the morbid appearances of the motions,
 arise from, or are increased by, the irritation of
 disordered secretions,  are  attended  by more
 continued suffering,  and by a sense of internal
 heat, or burning, with  great soreness and ten-
 derness of the abdomen upon pressure.  The di-
 arrhoea subsides, and the stools become scanty ;
 and  attempts at evacuation are accompanied
 with violent exacerbations of pain.  The tongue
 is white, excited, red at its point and edges, and
 afterward very loaded at its middle and base.
 The strength, especially of the lower limbs, is
 remarkably prostrated.  The pulse is quick, soft,
 and small.   Vomiting occasionally occurs, par-
 ticularly after cold fluids taken to quench the
 urgent thirst.   The  abdomen is  generally hot,
 tense,  and tender. •  As the disease advances
 through the parietes of the bowels, the above
 symptoms  increase.   The  stools, which were
 previously, and while  the internal  surface of
 the intestines was  chiefly affected, of a watery,
 serous, mucous character, sometimes streaked
with blood, now become more scanty and mor-
bid ; the abdomen more tumid, painful, and ten-
der, and vomiting more frequent and distressing.
  47. c. When  the inflammation commences in
what has been called  the  pblegmonoid form,
seizing at once  upon the different coats of the
bowels, the symptoms are much more acute
and violent from the first.   The patient com-
plains consecutively upon, Or coetaneously with<
cold chills or rigours, of sharp pains around the
umbilicus, in the right iliac region, or between
these regions, and  extending down to the hypo-
gastrium.   The pulse is hard, quick, and con-
stricted, or small.  The tongue is loaded, clam-
my, and dry.  The bowels are irregular or con-
stipated, and inefficiently acted upon by cathar-
tics, until depletions have been freely practised.
When the disease commences in this  form, its
progress is very rapid.  The face soon  becomes
anxious ; the stomach irritable, and the vomit-
ings frequent;  the tongue  deeply coated, dry,
and brown; the abdomen  very  tense, tumid,
and  tender ;  the  skin, particularly over the
trunk,  very hot, harsh, and dry; the calls to
stool most distressing and unsatisfactory ; the
urine very  scanty  and  high-coloured ; and the
respiration suppressed, and chiefly intercostal.
 toms increase  in violent.   *»~----■--
 sharp and anxious ; the patient lies on his back,
 with his knees drawn up; the hands and feet
 are cold and clammy, while the abdomen is hot;
 the pulse is small and weak ;  the breathing la-
 boured, hurried, and irregular, sometimes diffi-
 cult, or attended by hiccough.  The pain and
 tenderness are often more diffused over the ab-
 domen, extending to the hypochondria and hy-
 pogastriuni; and the distention is augmented.
 At last, exhaustion, cold sweats, faintness, hur-
 ried respiration,  singultus, with increased ac-
 tion of the alee nasi, collapse of the features ; a
 weak,  small, thready pulse, extreme restless-
 ness, and death, supervene.
   48.  C. Sub-acute and Chronic Ileo-colitis.
 —a. The sub-acute and chronic states of ileo-co-
 litis, particularly in the slighter cases, differ in
 nothing from the serous and mucous varieties of
 Diarrhoea (y 9-12).  I have shown, in that ar-
 ticle, that these varieties  of diarrhoea, although
 generally commencing in  irritation, usually de-
 pend, especially in children, upon inflammatory
 action, seated chiefly in the mucous surface and
 follicles of the ileum, caecum, and colon;  and
 that these, as well as some other forms of di-
 arrhoea, (y 13-18), particularly When severe, of
 long duration, or attended by fever, pain, or ten?
 derness in the situations stated above (y  43)$
 always present the  usual consequences of in-
 flammation of these parts upon  examinations
 after death.  The symptoms, therefore, of sub-
 acute and chronic ileo-colitis are identical with
 those described as attendant  upon the  inflam-
 matory states of Diarrhoea.                 :
   49. b. The more chronic states of ileo-colitis
 are most frequently associated With visceral dis-
 ease of a chronic, and sometimes obscure kind.
 They most commonly attend tubercular consump-
 tion, and in this case the mucous follicles  and
 the solitary intestinal glands are chiefly affect-
 ed, and contain, in the early stage, tubercular-
 like  matter!  Chronic disease of the liver,  and
 enlargement of the mesenteric glands, are also
 frequent complications, the  former generally
 preceding, the latter supervening upon  the in-
 testinal affection.  The acute and  sub-acute
 forms  of ileo-colitis  are often associated with
 inflammation of the substance of the liver,  and
 with certain endemic and epidemic  fevers, of
 which, however, they are  usually consecutive.
 Chronic ileo-colitis is seldom a simple disease,
 but,  in  its different  complications, the  affec-
 tions which precede  or occasion it, as well as
 those to which it gives rise,  should be ascer-
 tained before the intentions of cure be resolved
 upon.  When  the disease affects the rectum
 and sigmoid flexure of the colon, the desire to
 go to stool is almost constant, and the  strain-
 ing often  urgent.  In this case, the  complaint
 becomes identified with chronic Dysentery.
  50. c. The symptoms of chronic ileo-colitis
 differ but little from those of chronic diarrhoea.
 When  the colon is  but slightly  affected,  the
stools  may not be very frequent; but if it be
the chief seat of the disease, there will be more
or less diarrhoea, the evacuations being yellow-
ish, greenish, or clayey, or even muco-puriform
 in a  more advanced  stage, or  when ulceration
has taken place.  Uneasiness and soreness are
 usually felt in the abdomen, and sometimes pain,
at one place acute, at another dull, or fixed or 
INTESTINES—Inflammation of.
669
 moveable.   These sensations are exasperated
 some time after a meal, also by moral emotions,
 by violent exercise, or by the motions of a car-
 riage.   The tongue is often not materially af-
 fected ; it  is  sometimes pale.  The appetite,
 particularly when the disease is symptomatic
 of tubercular consumption, is often not materi-
 ally impaired.  At. an advanced stage, the ab-
 domen is usually large and tympanitic, contrast-
 ing remarkably with the emaciated extremities,
 especially in children.  In this class of patients,
 mesenteric disease supervenes  on the intesti-
 nal affection,  and marasmus is  produced.  In
 some cases, however, especially in adults, the
 abdomen is either not swollen, or is even  more
 than  usually sunk.  A short, dry cough fre-
 quently attends  the latter periods  of the dis-
 ease.   The duration of chronic ileo-colitis-is in-
 determinate.  It is often  recurrent, intermit-
 tent, or remittent, presenting longer Or shorter
 periods of remission,  or of immunity from dis-
 order, especially in its slighter states and ear-
 lier stages.  But it generally recurs upon slight
 errors of diet or regimen, or after exposures to
 cold or humidity.
   51.  D. Pseudo-membranous Enteritis.—En-
 tente  pseudo-membraneuse,  Cruveilhier.—a.
 This form of  enteritis was first described  by
 Dr. Powell.   (Med) Trans, of Col.  of Physic,
 vol. vi., p. 106.)  It has  more  recently been
 observed by Cruveilhier, Andral, Gendrin,
 Guibert, Bretonneau, and myself.  It rarely
 appears in an acute, but generally in &sub~aeute
 and chronic  form—the fatter especially ; or, in
 other  words, acute inflammation of the villous
 surface of the bowels is rarely attended by the
 formation of a false membrane  on  its surface
 to any extent, although portions  of coagulated
 lymph of considerable  size are occasionally
 passed along with the other matters evacuated
 in the advanced course of the disease. Pseudo-
 membranous enteritis  is most frequently chronic
 and intermittent, or, rather, it may be said to de-
 pend upon a latent  and prolonged  state of in-
 flammation, extending along a very large por-
 tion, sometimes the greater part, of the intes-
 tinal canal, as  evinced by the quantity thrown
 off; the most  prominent symptoms subsiding
 for a  considerable time, and reappearing after-
 ward,  and continuing, with more or less severi-
 ty, until the  false membrane produced by it is
 detached and discharged.  I have met with two
 cases  of this disease in its most  severe forms,
 and  several instances in a much slighter de-
 gree.  Both the former, and most of the latter,
 occurred in females, in which sex all the cases
 observed by Dr. Powell  also occurred.
   52.  b.  The symptoms  are often very slight,
 and consist chiefly of a sense of soreness, slight
 heat,  and tenderness  on firm pressure of the
 abdomen.  The bowels are generally irregular,
 either too relaxed or too costive,  and rarely
 natural, as respects  either the times of evacua-
 tion or the state of the motions.   After con-
 siderable intervals, sometimes of several weeks
 or even  longer, colicky and violent abdominal
 pains are experienced,  and the stools after-
 ward  passed  contain  shreds  of false  mem-
 brane  of various  sizes, occasionally formed
into  complete  tubes  of  considerable length.
These formations are occasionally white and
soft, and sometimes yellowish, consistent, and
even elastic.  From their appearances, as well
 as from the  symptoms preceding  their  dis-
 charge, there  is reason to  infer that they may
 be produced in any part of  the intestinal canal,
 or in both the small and  large bowels at the
 same time.  While the symptoms are often so
 slight as hardly to occasion any inconvenience,
 they are sometimes much  more severe in re-
 spect both of  the intervals and of the painful
 attacks preceding the evacuation of these mor-
 bid productions.  In  these, the symptoms  of
 chronic  muco-enteritis, or of chronic ilio-colitis,
 are generally present.  Heat, soreness, aching,
 or dull or acute colicky pains,  are felt at inter-
 vals ; but these pains are seldom increased by
 pressure,  although soreness and aching  are
 usually aggravated by it. After slighter or se-
 verer local symptoms of this kind being occa-
 sionally felt for some weeks,  or even longer,
 and augmented by any error in diet, or depar-
 ture from an abstemious regimen, a more vio-
 lent attack occurs, and resembles either severe
 colic,  or the symptoms  attending the passage
 of biliary calculi into the duodenum. The bow-
 els then generally become more lax, and the
 stodls contain  portions  of false  membrane,
 which continue to be voided for two, three,  or
 four days, three or four evacuations often ta-
 king place daily.  Occasionally the bowels do
 not act spontaneously, the  discharge of these
 membranes being assisted  by medicine.  The
 severe symptoms afterward.subside, until the
 morbid formation is again  developed, and be-
 gins to be  detached.  The pulse is sometimes
 not affected, but it is often somewhat accelera-
 ted.   The  tongue is  usually  covered by  a
 whitish or yellowish-white  mucus or coating,
 and is seldom red at its point or edges.  The
 appetite is impaired; there are thirst, and much
 flatulence of the stomach and bowels ; but tlie
 temperature of the surface, the state of the
 skin, and the urine, are not materially affected.
 During the severity of the paroxysm, vomit-
 ing frequently  takes place; and  Dr. Powell
 observed jaundice  precede  it,  probably owing
 to an inflamed  state of the  villous coat of the
 duodenum having prevented the discharge of
 bile into the intestines,.or  to the false mem-
 brane extending over or into the common duct.
  53. Dr. Powell states, that in all the cases
 he  observed there was indigestion, with  fre-
 quent recurrence of pain ; that the more vio-
lent seizures consisted in sudden and excess-
 ive pain, frequently increasing  in paroxysms,
 and rather  relieved by pressure, but  leaving
great soreness  and tenderness during the inter-
vals ; and that  this state continued under four
days, the stomach during it being very irritable,
and the tongue clammy and coated.  This phy-
sician justly considered the false membranes*
  * A lady, who came from Yorkshire to be under my care
and remained several months in London, was the subject
of this complaint, associated with Hysteria in its most se-
vere and complicated form, and occasionally amounting to
catalepsy.  She experienced a recurrence of the more pain-
ful seizures every four, five, or six weeks, followed or at-
tended by the discharge of the false membranes in large
quantity, and sometimes in the form of perfect tubes.  The
catamenia were always most painful, somewhat irregular,
attended by vomitings and severe abdominal pains, yet abun-
dant; but they were also accompanied with the  discharge
of shreds  of false membrane from the uterus.  The dis-
charge of the membranes from the bowels and vagina was
not, however, contemporaneous, although sometimes nearly
so. The nature and the severity, the rare complication, and
the persistence of the disease, led to consultations, other phy-
sicians thus also witnessing this almost singular case. 
670
INTESTINES—Inflammation of—Complications.
 thus discharged to have been formed in a simi-
 lar manner to those observed in croup, and, in
 a few instances, in bronchitis.   (This subject
 is farther noticed in the article Digestive Ca-
 nal, $46, 48.)
   54. IV. Associations or  Complications.—
 Several of these have already been noticed.
 The follicular variety of muco-enteritis is often
 associated with adynamic or typhoid fevers, or,
 rather, it occurs as a frequent complication of
 these fevers,  especially in  certain localities,
 epidemics, and circumstances,  to which suffi-
 cient allusion has already  been made (y 17).
 Its  complication with  tubercular consumption,
 also as a consequence of that malady,  has like-
 wise been stated (v 17).  With disease of the
 mesenteric glands it is likewise very often asso-
 ciated ;  but in this complication it is generally
 the  primary affection.  Muco-enteritis  is yery
 commonly connected with disorder of the biliary
 functions and with disease of the liver, particu-
 larly in India and warm climates.  Either affec-
 tion may be consequent on the other, but most
 frequently enteritis  is  the secondary disease.
 When matter is formed in the substance of the
 liver, follicular enteritis, with diarrhoea, or a
 chronic form of dysentery, is produced ; but not
 so much by the  acrid or otherwise  disordered
 bile  discharged into the intestines as by a mor-
 bid state of the blood, caused by the absorption
 of a portion of the matter from the liver.  The
 blood thus contaminated induces disease of
 the intestinal  follicles, and particularly of Pey-
 er's glands.  It is only when the surface of the
 liver is  inflamed that the disease sometimes
 extends to the peritoneal surface of either the
 small or the large intestines, inducing sero-en-
 teritis, or sero-ileo-colitis, the omentum, and even
 the mesentery, being sometimes also implicated.
 It is,  however, not  improbable that  disease
 of the follicles, particularly if ulceration have
 taken place, will occasionally be followed by
 the passage of morbid secretions into the por-
 tal circulation, inflammation of the portal veins
 and abscesses of the liver being thereby occa-
 sioned.   Jaundice is  also  sometimes  compli-
 cated with muco-enteritis, and may arise either
 from disease of the liver or ducts, or from ex-
 tension  of the inflammation to the common
 duct, or the occlusion  of its opening  into the
 duodenum, owing to  turgescence of the sur-
 rounding tissue.
  55. Inflammation of the internal surface of
the small intestines sometimes  extends  from
the duodenum to the stomach and gastritis, as
respects the villous coat,  being  complicated
with muco-enteritis.  In some  instances the dis-
ease proceeds in an opposite direction, and in
others both the  stomach  and intestines  are
nearly coetaneously affected ; this latter occur-
rence being very frequent in fevers.   Indeed,
inflammation of the villous  coat of both  the
stomach and  intestines constitute one of the
most common  and important complications in
remittent, malignant, and exanthematous fevers;
but this part of my subject is  fully discussed in
the article Gastro-enteric Disease  (y 10, et
seq.).   The various forms of enteritis, but es-
pecially muco-enteritis,  very  frequently appear
as complications in the course  of scarlatina,
smallpox, and measles, although often in slight
or latent states, or more or less masked by the
 other phenomena of these maladies.  In scarla-
 tina, gastro-enteric inflammation is a part of
 the morbid conditions invariably  present in
 some grade or other, or, in other words, inflam-
 matory injection of the villous surface of the
 stomach and intestines is as constantly present
 as the same condition of the vascular rete of the
 skin, and most probably at a still earlier period
 of the disease, and to a much greater extent,
 when the eruption  either is imperfectly devel-
 oped on the surface, or disappears from it pre-
 maturely.   This, indeed, is demonstrated by the
 symptoms in  all cases, wherein they are care-
 fully observed.  The affection of the intestinal
 mucous surface, more  especially in those cases
 just alluded to, is evinced by pain, tenderness,
 tension, and  fulness of the  abdomen, and by
 nausea, vomiting, or diarrhoea ;  the stools be-
 ing serous, dark-coloured, and containing flakes
 of lymph of a much lighter colour.   In the com-
 plication of scarlatina with enteritis, the villous
 coat itself is the part chiefly affected ; while in
 that of smallpox with enteritis, the mucous fol-
 licles are  often  implicated.   In the advanced
 stages, however, of these maladies, sero-enter-
 itis occasionally supervenes,  either alone, or
 in connexion  with  peritonitis.
   56. Enteritis may also occur as a complica-
 tion of the advanced stages of measles, more es-
 pecially upon the premature, or the regular de-
 cline of  the eruption ;  but it is generally slight
 in degree, and rarely the cause of an unfavour-
 able  termination of that disease, unless when
 associated with general bronchitis, or with pneu-
 monia.   In some of such cases, the inflamma-
 tion,has been found affecting the villous sur-
 face of the intestines to a considerable extent,
 the mucous follicles and the mesenteric glands
 being enlarged or  inflamed.  There are other
 contingent  complications of enteritis, as those
 with splenitis, with peritonitis, &c.; but they re-
 quire no particular notice at this place, having
 been noticed under those heads.
   57. In children, the different forms of enter-
 itis  appear more  frequently  associated with
 other diseases than in uncomplicated states;
 for they seldom  continue long in  those latter
 states without superinducing other disorders.
 In  many instances  the complication  is either
 accidental or contingent; in others, it depends
 upon the nature  of the predisposing and exci-
 ting causes ; while  in some, the associated dis-
 eases arise as consequences  of the primary af-
 fection of the intestinal canal.   Sufficient allu-
 sion has already been made to these complica-
 tions ; the most important are, infantile remit-
 tent fevers, cerebral  congestions,  &c, bron-
 chial affections, tubercles, disease of the mes-
 enteric glands, &c.   It is  not unusual to ob-
 serve, particularly in some seasons, a form of
 fever very prevalent, or even epidemic among
 children, in which  both the  digestive and the
respiratory mucous surfaces are affeoted by a ca-
tarrhal form of inflammation, and in which the
state of irritation seems to predominate in these
surfaces above that of true inflammatory action.
In many of  these cases, it is difficult to deter-
mine whether  the digestive canal or the respi-
ratory organs are first affected ; either may ex-
perience a priority,  or predominance, of disor-
der ; and the one may become free from disease
as the other is more severely affected.  These
circumstances  are of great importance in the
management of this  complication, which, is ex- 
INTESTINES—Inflami
tremely frequent in infants and children in Lon-
don, particularly  in  the  poorer classes  and in
children insufficiently or improperly nourished
and clothed.
  58. V. Diagnosis.—Little need be added on
this subject, as much has already been stated
in reference to it; and as, both in pathological
and in therapeutical  points of view, it is as ne-
cessary to point out  relations, approximations,
or alliances, between diseases, as to assign dis-
tinctions between them, that exist only in the
more extremely removed cases, and that cannot
be detected in the majority of instances, or only
partially, and in their slighter or finer shades.
Writers, who had little knowledge of disease
from  close personal observation, have been in
the habit of stating certain distinctions between
allied affections of the digestive canal, as if they
were describing  different genera, or distinct
substances  in  natural history, or certain un-
varying  entities, or algebraic quantities  ; and
hence misleading, more frequently  than  in-
structing, the  inexperienced.  The disorders
which they have thus endeavoured to distin-
guish from the different varieties of enteritis,
or, rather, from enteritis simply,  as they  have
known  but little of its various forms and as-
sociations, are colic, ileus, gastritis, peritonitis,
constipation, diarrhea, cholera,  and dysentery;
and it must be obvious to the scientific and ra-
tional practitioner, that it is quite as important
for him to trace the connexions between diseas-
es, and the transitions of the one into the oth-
er, as to recognise differences, which are  often
more apparent than real, and which should be
estimated as they truly exist—as modifications
rather than differences—as indications of some-
thing in common, but as  something also  pecu-
liar  or proper to each, which ft  is necessary
thus  to establish.
  59. A. There are certain circumstances con-
nected with the  seats of enteritis to which
some reference  may be made,  as  being not
without importance in practice ; and these may
be comprised in an answer to the following
question : How far may the  symptoms enable us
to conclude as to what portion of the intestinal ca-
nal is chiefly or solely affected ?  Before any con-
clusion should be arrived at, the exact seat of
pain, the part in which it commenced, the seat
of tenderness or  distention; the  state of the
stomach and bowels, and the periods after .ta-
king food when vomiting or  purging occur ; the
sounds and sensations caused by percussion  ;
the appearance of the evacuations ; and the na-
ture of the exciting causes, should be duly con-
sidered.—a. The seat of pain at the commence-
ment of the attack  is always deserving of at-
tention, as indicating, although  not always cor-
rectly, the part affected.  If the disease  begin
in the region of the duodenum, or if this part be-
come consecutively  affected, irritability of the
stomach a very short time  after food is taken,
and  either increased or interrupted discharge
of the bile, are  more likely to occur, and the
calls to stool are not nearly so frequent as  when
the lower portions of the bowels are inflamed.
(See Duodenum, v 7, el seq.) When pain, ten-
derness, and fulness commence around  the na-
vel, or between it and the right ilium, inflam-
mation of the ilium  may be suspected ; and if
there be diarrhoea, and pain in the region of the
cacum, the pains assuming a colicky or griping
mation of—Diagnosis.                    671

character,  and extending in the course of the
colon, the extension of the disease to these vis-
cera may be inferred, especially  if tenderness
exist in these situations, if there  be little or no
vomiting, and if the symptoms be exasperated
two or three hours after a meal.  When inflam-
mation of the  villous surface of the colon is
sub-acute or chronic, even although it impli-
cate the lower part of the ilium, or when chron-
ic ilio colitis  is present, the functions of the
stomach are often but little affected, unless the
attendant  diarrhoea  is  suddenly arrested, or
constipation  occur.   It is chiefly at the com-
mencement, or during the early stages of in-
flammation, that  it is limited to one portion of
intestine, or  to a single tissue.   The  rapidity
of extension of the disease to adjoining parts
is generally great in  proportion to the depres-
sion of vital power, the state of  this power in
connexion with that of the blood giving rise to
the particular form or character of the inflam-
mation, and of its consequences or products.
  60. b. A serous  state of the stools, particular-
ly if albuminous flocculi, or pieces of lymph, be
contained in them, show that the villous mem-
brane is chiefly affected;  while  a  mucous, or
muco-puriform condition of them  indicates  dis-
ease of the follicular glands : a combination of
these two states  suggests the probable associ-
ation of these affections.  The presence of di-
gested fcecal matters in the stools, duly colour-
ed with bile,  evinces the performance of the
functions of the upper portions of the alimenta-
ry canal;  but  when the food is imperfectly
changed, impairment of these functions,  and
great irritability of the muscular coat, owing to
general  and  local debility, and disease of the
mucous  surface,  may be inferred ; the inflam-
matory irritation generally extending, in such
cases, to both the  small  and laxge intestines.
If the stools are devoid of their peculiar or
usual odour, the large bowels are probably af-
fected.   If they  contain  small but numerous
streaks  of blood,  or.if the blood be mixed in
small quantity with the  other matters, a severe
form of" muco-enteritis is generally present.  If
the blood be passed in larger quantities ; if it be
mixed with the other evacuated matters ; or if
it be grumous, or muco-puriform matter be
also observed, ulceration consequent upon fol-
licular enteritis is usually found.  If it  be void-
ed quite pure, in large quantity,  and but little
mixed with the rest of the motion, it common-
ly proceeds from the large bowels.
  61. c.  Percussion should seldom  be  omitted
in endeavouring to ascertain the  seat of enter-
itis.  It can rarely be endured when, or in  situ-
ations where, the inflammation has advanced to
the serous coat.   It  assists in  indicating the
parts most distended  by flatus, or obstructed by
faecal accumulations, by internal strangulation,
or by adhesions, or thickening, &c, of the coats
of the bowel.  As long as the disease is  con-
fined to the  inner  surface, it  seldom causes
much pain at the time, although soreness, or
aching, is usually increased by it afterward.
  62. d. Among other circumstances contribu-
ting to a correct diagnosis of the several forms
and complications of enteritis, the nature of the
causes, the constitution  and the previous health
of the patient, are not the least material, par-
ticularly as respects the character of the  at-
tendant  fever, and of the local  affection.  If 
672
INTESTINES—Inflammation of—Diagnosis.
these causes are of a septic, contaminating, or
depressing kind, such as already enumerated
(v 18), the mucous follicles  will be especially
affected, and the fever will present the adynam-
ic state.   If the powers of life have been pre-
viously  sunk, or if the circulating fluids have
become morbid or contaminated,  or if there
have  been manifest cachexia conjoined with
great debility, the local and the constitutional
affections will be such as just stated ; and both
the small and the large bowels will be similar-
ly and almost coetaneously affected.   When
inflammation in these cases advances to the
serous surface, particularly  after  perforation
of the coats, it extends rapidly over this sur-
face, and gives rise to a more or less copious
fluid effusion, the state of local as well as of con-
stitutional'action being, in such circumstances,
rarely capable of producing coagulable lymph,
as shown in the article Inflammation (y 58.)
  63. B.  If it  be necessary to ascertain the
parts of the intestines which are the seats of
inflammation, it is still more requisite to deter-
mine whether or not inflammation is really present.
This, however, is not always so easy as many
have  believed ; for inflammatory  action may
exist in the digestive  canal, so as  to give rise
to many of its most dangerous results, without
those symptoms  by which inflammation has
generally been  supposed to be indicated hav-
ing been observed.  Several of these disorders,
usually viewed  as functional merely, and which
undoubtedly are such in many, or even in the
majority of cases, often proceed from infiamr
matory action in  a portion of the villous sur-
face, that either extends itself in  a gradual or
rapid manner, or becomes resolved when the
causes have ceased to act, or when the secre-
tions from the part have had the effect of re-
moving the irritation, or of unloading the con-
gested  and inflamed  vessels.   Many  cases
which have been viewed,  from the character
of the prominent symptoms, as flatulenoe, or
constipation, or colic, or diarrhoea, have actual-
ly been some form or other of enteritis, or in-
flammatory states, in which certain portions of
the intestines, or of the tissues composing their
parietes, have been affected'in a different man-
ner, or in a modified form or degree.
   64. a. Flatulence, constipation, and colic  are
chiefly  functional disorders of the digestive ca-
nal ;  but they often depend  upon inflammatory
irritation of some portion of it, and are apt in-
sensibly  to pass into  inflammation.   They,
moreover, both severally and conjointly accom-
pany, as  prominent and important symptoms,
the most severe and dangerous forms of enteri-
tis.  Hence the necessity of determining their
sources,  and their connexions with, or inde-
pendence of inflammatory action.   If the least
tenderness or  soreness  on  percussion, or  on
firm pressure of the abdomen, be felt or indica-
 ted ; if this examination soon afterward occa-
 sion  soreness, pain,  or uneasiness internally,
 although neither may have been complained of
 at the time of making it; if the pulse be hard,
 constricted, or full, or accelerated; if  the ab-
 domen become tumid  or  tense,  dry,  hot,  or
 harsh ; if the tongue be white, the papillae erect,
 and its point or edges red ; and more especial-
 ly if nausea or vomiting occur, the connexion
 of either of these affections with, or their  de-
 pendance Ubon incipient or developed inflam-
mation, should be inferred, and a strictly anti-
phlogistic treatment prescribed.  I have  met
with instances where enteritis had been treat-
ed as simple constipation with colicky pains,
and where the slightness of  the above symp-
toms, or the presence of only  one  or two of
them, had  deceived the  inexperienced-practi-
tioner into the exhibition of acrid and heating
purgatives, which had aggravated the disease
until it had proceeded too far  to be arrested by
the most judicious means, fatal symptoms sud-
denly appearing, and the patient sinking before
the mischief-was anticipated.
  65. b. Ileus, v like the  preceding  affections,
may or may not be associated with, or be en-
tirely owing  to inflammation.  It is shown in
the article on  Colic and Ileus (y  37-45), that these
affections are often thus related, the latter par-
ticularly ; and that, even when depending upon
the pathological  states there enumerated, in-
flammation is very often either an  associated
or a superinduced lesion, generally implicating
all the  coats of a  portion of intestine, or the
serous coat more especially.   In many of these
cases,  either some internal  constriction, or
strangulated hernia, or  an intus-susception, is
the cause of suffering; but in these, as well as
in those originating differently, inflammation
soon supervenes, although it  is not  always an-
nounced by rigours or consequent reaction, or
even by the general character of the symptoms.
Indeed, the  sufferings of the patient are  fre-
quently so great, and the vital power is so ex-
hausted by the nature or extent of the lesion
—the  shock sustained by the constitution is
such—as to prevent the development  of the
phenomena of general vascular reaction,  and
to extinguish life before the local changes char-
acteristic  of inflammation had proceeded  far,
or before  symptomatic  fever had supervened.
These  attacks, and particularly those varieties
of colic usually denominated  the Lead, and the
Madrid colic (y 16, 25), have been  viewed as
forms  of enteralgia merely, or of -neuralgia of
the intestines, and described  as such  by sever-
al Continental writers.   That  the sensibility
of the  nerves of the intestines is morbidly ex-
cited  or affected,  will be admitted; but  that
these diseases consist only of altered sensibil-
ity, cannot *e conceded.  This is a  part, mere-
ly, of the pathological states constituting these
maladies; impaired and disordered  secretion
and excretion, a morbid condition of all the se-
cretions poured  into  the intestinal canal, and
diseased action  of the  muscular coats of the
 bowels, equally form a part, arid often the most
 important and efficient  part  of them, various
 other assooiated functional derangements being
 also present.
   66.  c. Diarrhoea, Cholera, and Dysentery may
 be associated with intestinal inflammation, or
 may pass into it; and, equally with the  fore-
 going disorders, require to be  carefully distin-
 guished in their simple and in their sympto-
 matic or complicated states.—a. Diarrhoea, par-
 ticularly its  serous and mucous forms, has been
 already shown to be one of the earliest indica-
 tions of enteritis, particularly when  the mucous
 coat and follicles of the small and  large intes-
 tines are the tissues affected.  But the slighter
 and more evanescent states of diarrhoea are
 generally Independent  of inflammation, and
| proceed chiefly  from Irritation and  increased 
            INTESTINES—Inflammation of-

exhalation and secretion, caused either by the
nature of the ingesta, or by checked cutaneous
and pulmonary transpiration, or by the state of
the secretions poured into the digestive canal;
the irritation and  increased secretion, howev-
er,  often  passing  into  inflammatory  action
whenever a predisposition to it is present.  As
soon as  this change takes place, the states of
the stools, of the abdomen, of the skin, of the
pulse, and of the tongue, as described above (y
7, et seq.), will generally indicate it to the care-
ful observer.
  67. j3. The same observations apply to Chol-
era, which also may pass into enteritis ;  but  it
should be recollected that when muco-enteritis
in an intense form is seated chiefly in the duo-
denum and jejunum, that the  symptoms may
nearly approach those of cholera; vomiting,
diarrhoea, and sympathetic spasms of the mus-
cles of the extremities, being often as severe in
this state and seat of enteritis as in that  dis-
ease.  It has already been shown  that.. bilious
cholera (y 25) sometimes passes into enteritis ;
the irritation of morbid or acrid bile exciting
inflammatory action in the mucous surface, that
either subsides without proceeding farther than
this surface, or extends to the external coats
when the inflammatory disposition  is consider-
able.   In either case, particularly in the latter,
the physician will be guided by the symptoms
evinced  by the parts and in the manner already
named (y 59) in forming his diagnosis.
  68. y. In Dysentery, more  or  less inflamma-
tory action of the mucous surface and follicular
glands of the large intestines is-generally pres-
ent, especially  in the sthenic forms, and in the
developed states of the disease.  Still, the in-
flammation is often a superinduced and an as-
sociated, rather than a primary morbid condition
in this  malady, the abdominal  secretions and
excretions being the  first disordered.*   These
secretions irritate the mucous  surface and its
follicular apparatus, and induce inordinate or
spasmodic action of the muscular coats  of the
bowel,  and  particularly  of the  rectum  and
sphincter ani, causing the retention of the more
hardened portions of faeces, which  farther aug-
ments the irritation, until inflammation, with its
various  consequences, is produced.   In such
cases, it is not merely the existence  and the
exact seat Of inflammation that should  be as-
certained, and  which the description already
given will generally indicate ;  but  the charac-
ters of the local action and of the constitution-
al affection ought also.to be closely observed
and correctly estimated.
  69. d.  When inflammation extends to the se-
rous coat of the intestines, it becomes identified
with peritonitis ; and whether it be limited to a
small portion of this coat, or extend more or less
generally, it is  in all respects an intestinal per-
itonitis, of the diagnosis of which sufficient no-
tice is taken under that head (see Peritoneum),
to which,  and  to  the  article Stomach,  where
enteritis is distinguished from gastritis, the
reader is referred for farther  remarks on the
diagnosis of these very intimately-related mal-
adies.
  * [We believe that the increased secretions and excre-
tions in the first, or forming stage of dysentery, are the con-
sequences of the inflammatory congestion of the vessels of
the mucous tissue, and that any other pathology must ne-
cessarily load to erroneous practice.]
      II           85
—Terminations of, and Prognosis.         673

   70. e.  As the complications of enteritis are so
 important, it becomes requisite that the diag-
 nosis of them, and even the successions of their
 appearance should not be overlooked.  This is
 still  more important in warm climates, where
 enteritis is very often a complicated malady w
 When functional and  organic diseases of the liv-
 er are attended by a  morbid secretion of bile,
 or when this fluid has become acrid, enteritis
 is very commonly induced in one or other of its
 forms, and is then rarely limited to  the  small
 intestines, the  colon  and  rectum being often
 implicated,  and  hepatic dysentery developed.
 But chronic enteritis, or ileo-colitis, may occa-
 sion, as already  shown (y  49), disease of the
 liver, particularly of its internal structure, ei-
 ther with or without purulent formations in it.
 In this case, increased frequency of vomiting,
 tenderness and fulness in  the right hypochon-
 drium  and  epigastrium,  chills,  rigours, and
 jaundice, may supervene, and indicate  the  na-
 ture of the complication, or they maybe almost
 or "entirely absent.  In warm climates, enteri-
 tis, hepatitis, and dysentery are often associa-
 ted, and without sufficient proof being furnish-
 ed of their course of succession.  In the East-
 ern hemisphere, however, the disease  of the
 liver is  most frequently the primary affection,
 although it sometimes is induced by either, or
 by both  of the other maladies.  Of the compli-
 cation with  gastritis,  it is unnecessary to add
 more than that its existence should always be
 expected when enteritis is occasioned by stim-
 ulating, acrid, or poisonous  ingesta, or by an
 excessive quantity of rich and heating food or
 drink.   In these cases, the frequency of the
 vomiting, the recurrence  of it instantly after
 substances  are  taken into the stomach,  the
 constant or frequent  eructations of flatus, the
 epigastric tenderness, soreness, pain, and ful-
 ness, in addition to the symptoms  of enteritis,
 will indicate the  morbid  association.   When
 this complication arises from the nature or the
 quantity of the  ingesta, the affection  of the
 stomach  sometimes  subsides  as  that  of the
 small or large bowels increases, and thus gas-
 troenteritis may pass into muco-enteritis,  and
 thence  into  ileo-oolitis or dysentery.   This
 succession is not infrequent in warm climates,
 or in temperate climates -in summer and au-
 tumn, and particularly in those who have par-
Uaken of unwholesome food, or who have ex-
 ceeded  in the use of spirituous or fermented
 liquors.  Enteritis in connexion with gout, or
 in the gouty diathesis, and especially upon the
 disappearance of gout from the extremities, is
 not uncommon, and  is always sudden and se-
 vere in  its occurrence ;  but farther  allusion
 will be made to it hereafter.
   71. VI. Terminations or Consequences  and
 Prognosis.—A.  A. favourable termination of en-
 teritis is indicated by a diminished severity of
 the more prominent symptoms, by the decrease
 of fever, by a more natural state of the evacua-
 tions as to their appearance and their frequen-
 cy,  by a more copious discharge of urine, by a
 more clean,  moist,  and natural state  of  the
 tongue, by a less frequent pulse, and by a dim-
 inution  of the  tenderness, soreness, fulness,
 tension,  and heat of the abdomen, the general
 surface becoming more moist and  natural.
   72. B.  The unfavourable consequences or ter-
 minations of inflammation  of the  bowels are, 
674
INTESTINES—Inflammation of—Lesions.
1st.  Ulceration, with its consequences,  intes-
tinal haemorrhage, or perforation of the  intes-
tines ;  2d.  Various organic lesions of the coats
of the intestines and of the mesenteric glands ;
3d. Peritonitis in some one  or other of its
forms;  4th. Exhaustion of, or fatal shock to
the vital powers; and, 5th. Sphacelation of a
portion of the intestinal tissues or parietes.—
a.  Ulceration of the intestines is not necessari-
ly  a fatal lesion, although it is so with few ex-
ceptions ;  for ulcers have been found cicatrized
in  this situation,, the  patient having  died of
some other disease  which had  occurred long
subsequently to the intestinal affection.  These
cicatrices very rarely present  any regeneration
of  the villous tissue, although this has been ob-
served by M. Andral.  Their bottoms consist
of  a cellulo-serous tissue, of a grayish white,
without either villi or follicular  glands, gradu-
ally assuming the appearance of the surround-
ing mucous coat, and possessing considerable
firmness and tenacity.   Ulceration of the intes-
tines—which is fully described in all its  forms
in  the  article  Digestive Canal (9 36-40)—is
not satisfactorily indicated by  symptoms; al-
though a combination of phenomena may lead
to  a just conclusion as to its presence.  A mu-
co-puriform or ochrey appearance of the stools,
an increased frequency of them, the presence
of large quantities of blood in them, and symp-
tomatic fever assuming an adynamic or chronic
remittent, or hectic form, are the surest indi-
cations of ulceration.   Trie diarrhoea appearing
in  the course of tubercular disease is generally
dependant upon,  or connected with disease of
the follicular glands, and, at an advanced stage,
with ulceration.  Whenever muco-enteritis or
follicular  enteritis occurs  in the course of a
constitutional malady or vice—of fever, of tu-
bercles, or of general cachexia, the rapid super-
vention of ulceration may be anticipated.
   73. b.  Various  organic lesions of the parietes
of the intestines, similar to those  about to be
noticed, or  more fully described in the article
Digestive Canal (y 25, et seq.), and of the mes-
enteric glands, may be occasioned by enteritis,
the patient continuing for months or years sub-
sequently to evince  disorder of the sensibility
or functions  of  the  bowels.   These lesions,
particularly dilatations, contractions,  thicken-
ing of the coats, &c, according  as they influ-
ence the caliber, or the secretions,  or the con-
tractility,  or the organic sensibility of the intes-
tines, occasion flatulence, constipation, colic,
indigestion, retchings, emaciation,  faecal accu-
mulations, hypochondriasis,  and various ner-
vous complaints, and, at last, either an attack
of inflammation of the bowels, or of one  of the
associated viscera, or some other malady, car-
ries  off the patient.
   74. c. Peritonitis, whether circumscribed or
general, takes place in two ways: from ulcera-
tion, and from the extension of the inflammation
to the serous coat without ulceration.   It may
arise from ulceration without perforation of this
coat.  In this case the peritonitis is usually lim-
ited.  If the ulcer have perforated all the coats,
general peritonitis, caused by the effusion of a
portion of the contents of the intestines, com-
monly results.   Sometimes, however, perfora-
tion takes  place  without  effusion  occurring,
owing to  adhesions of the opposing serous sur-
faces having taken place before the coats of the
intestine had  been entire y penetrated.  This
consequence of enteritis is fully illustrated i„
the articles on the Peritoneum and Digestive
Canal (6 40-43), where numerous  instances
and references are  adduced.  The extension
of the inflammation from  the internal to the
external surface of the bowel, whethor it con-
tinue  limited to a portion only of the latter, or
extend  more  generally, is a  frequent conse-
quence  of enteritis, which is indicated by the
symptoms already enumerated (y  31), and by
those more fully described  when  treating of
inflammation of the  Peritoneum.
  75.  d.  Exhaustion of', or the shock sustained by
the  vital  powers, is more frequently a termina-
tion or  consequence of  enteritis than sphace-
lation or gangrene.  Many of the instances of
death which have been attributed to this latter
change have actually depended upon the former;
but, when sphacelation of  a  portion of the in-
testine  does take place, very nearly the same
symptoms which indicate  the  one accompany
the other.   It is extremely probable, moreover,
that in some of those cases where gangrene of
a portion of intestine is detected  after death,
the gangrene  had not existed at the moment
of death, or  had  commenced either then or soon
afterward ;  and that the symptoms were those
of vital  exhaustion  or shock, leading not only
to death, but also to sphacelation of the most
inflamed part, death occurring first, and spha-
celation soon afterward, or both  nearly con-
temporaneously ; an opposite course, however,
taking place in  rarer cases.  When  the pulse
becomes very rapid, small, weak, irregular, ot
intermittent; when the breathing is hurried,
laboured, irregular,  and attended by  increased
action of the nostrils ; when hiccough or regur-
gitation of the contents  of the  stomach without
retchings occurs ; when the patient complains
of sinking,  coldness of  the general surface 01
of the extremities, or  becomes restless ; when
the abdomen is  tympanitic without increase of
pain,  or the skin is cold and clammy;  and when
the eyes are sunk, surrounded by a dark circle,
and all the  features sharp and collapsed, vital
exhaustion, in connexion with more or less of
structural lesion, has then  proceeded too far
to admit of  hopes of recovery.
   76. e. Although gangrene oftener follows im-
mediately upon than precedes dissolution, yet
we sometimes have its existence antecedently
to this issue sufficiently  demonstrated.  When
the inflammation is caused by strangulation,
and an  operation is  performed at a too late pe-
riod,  the portion of intestines thus circumstan-
ced has  been occasionally  found in a sphacela-
ted state, although more frequently it is a state
of venous congestion, or a condition about to
pass  into sphacelation,  rather than this latter
state that is observed.   Moreover, in cases of
enteritis caused by intus-susception, a consider-
able portion of intestine has been thrown off in
a gangrenous state.   Even portions of the vil-
lous coat of 4he bowel have been  detached by
effusion of fluids underneath it, whereby, its
vascular connexion  being destroyed, sphacela-
tion has taken  place.   In all  such cases, the
symptoms of vital exhaustion above enumera-
ted (y 75) present themselves, and  death en-
sues, with very few exceptions.  These excep-
tions occur only when adhesions of the oppo-
sing surfaces had formed so as to admit of the 
INTESTINES—Appe
IARANCES AFTER DEATH.
675
detachment of the sphacelated portion without
effusion of the intestinal contents into the per-
itoneal cavity taking place.  When gangrene
precedes  dissolution, then, in addition to  the
symptoms just noticed, extreme tympanitic dis-
tention of the abdomen, with  diminution of the
pain, or complete cessation of pain ;  faintness,
breathlessness,  syncope on raising  the head,
sinkings,  cold sweats, and coldness of the sur-
face ;  constant  hiccough, with flatulent eruc-
tations ;   unconscious  or unrestrained evacu-
ations, with a  putrid or cadaverous  odour ;
a  small,  weak, imperceptible or  intermitting
pulse; collapsed features, sunk  eyes,  and  dis-
coloured  surface indicate the disorganization,
and soon  terminate in death.
   77. VII. Appearances after Death.—I must
refer the reader to the articles on the Digestive
Canal (v  18-13), Diarrhoea ($ 13-23), and Dys-
entery (v 58-60), for a detailed account of the
structural changes consequent upon inflamma-
tions of the intestines, and merely state, at this
place, those more generally observed.  When
enteritis or entero-colitis supervenes upon in-
flammation of the stomach or liver—the  dis-
ease of these  organs  occasioning death,  and
thus furnishing an occasion of observing the
earlier changes connected with enteritis—the
villous coat is then more vascular  and florid
than usual, and more turgescent, particularly
the valvulae conniventes ; and in many places
the mucous glands  are more developed,  and
marked by a deeper tinge.   The  appearances
are not uniform throughout the canal, but are
most remarkable in the duodenum  and upper
portions of the ilium, when enteritis has been
caused by a morbid state of the  bile, or  has
been consequent upon gastritis.  In these slight
or incipient states, the inflammation is present
only in broad patches  or streaks, leaving the
intermediate spaces of a nearly healthy state.
The lowest portion of the ileum, the ileo-caecal
valve, and caecum are oftenest found diseased,
particularly in acute cases, and where enteritis
or entero-colitis occurs as a complication of
febrile diseases.
   78.  «. In the acute forms of enteritis, the* vil-
lous coat  is not only more vascular and turgid,
but it is  also  softer,  and sometimes thicker
than natural.   If the inflammation has pro-
ceeded far, it presents a brick-red  tinge, and  is
easily detached from the subjacent  coats, the
connecting cellular tissue being soft, turgid, and
inflamed.   When this state exists in a consid-
erable portion of the tube, the coats are appa-
rently thickened, arising from the'extension  of
the inflammation to  the more external tissues,
till the attached surface of the intestinal peri-
toneum is reached.  The substance  or parietes
of the bowels  may be  considered as  affected
in these cases, even  although the external sur-
face may present no  farther lesion than  red
vessels shooting into it.  Occasionally, in ad-
dition  to  this state,  the red  capillaries in the
inflamed peritoneal coat are connected with the
effusion of coagulable  lymph, particularly  in
those parts  where they are most  numerous,
the lymph or albuminous exudation existing  in
specks, or in considerable spots  or patches, on
the serous surface.   When, however, these lat-
ter appearances are  remarked, the interior of
the inflamed intestine frequently presents more
serious changes than yet noticed.  The villous
surface is then deeply inflamed, and seems abra-
ded or excoriated in parts.  It is sometimes,
in other parts, covered by patches of lymph, or
of an albumino-puriform or muco-puriform fluid,
or by a sero-sanious matter;  and it is often,
also, ecchymosed in numerous points or specks,
or it presents still larger marks of sanguineous
infiltration.  In other cases, portions of a dark,
slate-coloured, or sphacelated hue are observed,
with or without ulcerated specks, or even large
ulcers, which have  nearly penetrated as far as
the external coat in adjoining parts.  In rarer
instances, one or more of these  ulcers have
made their way  through  the peritoneum,  the
contents of the  bowel being partly discharged
into the  peritoneal  cavity.  Occasionally,  the
ulcer has become attached, at its margin, to an
opposite  convolution of the intestines, the  es-
cape of  faecal matters  into this cavity being
thereby prevented.   In  a few cases, where  the
peritoneal surface has been coated with coagu-
lable lymph, in the  progress of the ulcerations
through the membrane, the ulcers have been
covered over by the lymph, so as to prevent the
passage of the intestinal contents  through  the
perforations.   In addition to disease of the  fol-
licles, and to the consequences of such disease,
particularly ulceration and perforation of  the
intestinal parietes (see Digestive Canal, y 37,
40, et seq.), the villous surface, especially after
the forms of enteritis observed in warm climates,
is often excoriated or abraded in parts ; and it
is not infrequently sphacelated in large patches,
particularly in the large bowels.  These chan-
ges, however, as well as those consequent upon
chronic enteritis, especially as respects the  fol-
licles and glands, are more fully described in
the articles Diarrhoea (y 12-22), Digestive  Ca-
nal (y 36), Dysentery (y 58), and Fever ($ 519).
I shall not, therefore, allude to them farther at
this place.
   79. In the forms  of  enteritis in which  the
substance of the intestine or its peritoneal coat
is chiefly affected, either primarily or consecu-
tively,  the whole of the coats  are often very
vascular, red, or of a brick-red colour, and  are
readily torn.   Coagulable lymph is effused  on
the serous surface, either in distinct.clots, or
as a general film, of greater or less thickness,
and gluing the convolutions to each  other>  and
to the adjoining viscera and surfaces.  In these
cases, the omentum has sometimes participated
in the disease, being either more than usually
vascular, or drawn up  irregularly to the arch
and flexures of the colon.   When the examina-
tion is  made within a few hours from death, as
is usual  in warm climates, the  vascularity of
the diseased parts is very great; and, although
the colour may be beginning to change, or  the
parts to assume a gangrenous appearance,  yet
complete gangrene of all the coats of the bow-
el is not often  met with.  It is, however, com-
mon to find the villous surface apparently spha-
celated in places, and the external coat of  the
same part either of a bluish or  brownish hue,
but not altogether deprived of its cohesion, al-
though more easily lacerated than usual.   In
these acute cases, the inflamed intestine is gen-
erally distended  with flatus; but  it is some-
times constricted, and the constricted portions
are occasionally so small as to give the appear-
ance of stricture by the application of a fine  lig-
ature.  Intro-susceptions of portions of the  ile- 
676
INTESTINES—Inflammations of—Causes.
 um, which had taken place subsequently to the
 occurrence  of inflammation, or even just be-
 fore, or at the period of death,  are met with in
 rare instances.
   80.  4. In chronic cases, as well as in the  acute,
 the changes  are chiefly observed either  in the
 villous surface or in the follicles,.or in both.
 Many of the lesions  observed  after  the  acute
 forms of the disease are also met with after the
 chronic states.  In the latter, however, the villi
 are frequently of a blackish tint; and the iso-
 lated follicles and glands are oftener affected
 than  the agminated glands,  which latter  are
 chiefly attacked in the acute.  As respects the
 villous coal,  the  lesions consist of softening,
 thickening, and induration ; with various  chan-
 ges of colour, from the lighter hues to a slate or
 deep-brown colour, and even to black.  While
 softening of the internal coats is most common
 in the  acute, hardening of these parts is most
 frequent in the chronic stajtes  of the  disease.
 With the thickening of the villous and connect-
 ing cellular tissues there is sometimes a very
 remarkable  contraction  of the bowel ; and
 many of the alterations described in the article
 Digestive Canal (y 26-31, 52, et seq.). As re-
 spects the changes of the follicles and glands,
 I can  add but little to  what I  have stated in
 this and the other places 'already referred to.
  81. c. The ulcerations which take place in this
 form  of the disease assume  three  different
 forms : 1st. Those which commence in the ag-
 minated, or Peyer's glands, and are seated lon-
 gitudinally in the intestine ;  2d. Those which
 originate in the isolated follicles and glands,
 and are of a rounded form;  and,  3d. Those
 which  attack the villous  surface, and present
 a transverse direction as respects the canal of
 the bowel.   Either of these may go on to per-
 foration, and the production of acute or chronic
peritonitis.  Occasionally, tubercular matter is
detected at the  margins  of the ulcers.   The
 mesenteric glands are often enlarged^ inflamed,
 or congested, softened, and even suppurated.
  82. d. I have had no opportunity of observing
the appearances after death in the chronic ca-
ses where membranous or tubular exudations
have been voided from the intestines, but such
 appearances have been observed by several au-
thors.   Dr. Monro  states, that when  the vil-
lous coat of the intestines is jnflamed, the di-
 ameter of the part is much diminished by the
 effusion of coagulable lyrnph upon this  coat;
that the quantity of lymph  is very  various,
sometimes being as thin  as a wafer, at  other
times  nearly filling the  affected  bowel; and
that occasionally it  forms only a thin  lining to
the villous coat, or appears in the form of tat-
tered shreds, in  some cases filling the spaces
between the  valvulae conniventes,  in others,
covering these. In a case described by M.  Pail-
loux, the villous coat was covered by a mem-
branous layer, extending uniformly over its sur-
face.   The follicles did not seem to  have any
 share in the production of this membrane, which
he considered as differing only by its continuity
 and thickness  from the  small isolated patches
 secreted by the, villi  in aphthous affections.
 According to the appearances observed by MM.
 Billard and Lalut, these tubular exudations
 and false membranes are produced  from the
 villous surface itself,  and not from the mucus
 secreted by the follicles, or from a diseased ac-
 tion of these follicles.  These exudations have
 been observed in all parts of the  alimentary

 CS83 ' e.  In the acute and chronic forms of enter-
 itis, inflammation of portions  of the mesentery
 is sometimes observed, either with or without
 disease of the glands  ; and an oedematous state
 of this part is occasionally met with.   Other
 changes  are more rarely remarked, both in the
 small and in  the larger intestines ; but they
 are merely incidental, and are described in the,
 places above referred to.  Various  alterations
 are often, also, observed in the related viscera;
 but these are accidental complications, which
 need not be adduced at this place.
  84. VIII. Causes of  Inflammations  of the
 Intestines.—i. Predisposing.—The several va-
 rieties of enteritis occur at all ages, in all tem-
 peraments, and in both sexes;  but they  are
 most frequent in infants during the  first denti-
 tion, and soon after weaning; and in the ner-
 vous, irritable,  and sanguine temperaments.
 They are occasionally more prevalent in some
 families than in others, owing to peculiarity of
 constitution, and have hence assumed, in a few
 instances, somewhat  of an hereditary charac-
 ter,  especially  in  their slighter forms.  Both
 sexes are nearly equally liable to them ; males
 being, however, rather more frequently  attack-
 ed than  females,  probably in consequence of
 their greater exposure  to the exciting causes,
 The several forms of the disease may assume,
 from states of season and weather, or from the
 constitution of the air,  a more or less epidemic
 prevalence.  They are  most common in warm
 and humid seasons, and when the vicissitudes
 of temperature  are sudden and great; hence
 they are  more frequent  in autumn and summer
 than in other seasons, and when cold nights
 succeed  to warm  or hot days.  They are also
 almost endemic in  some countries, partly owing
 to the high range and high daily vicissitudes
 of the temperature,  in connexion  with great
 humidity of the atmosphere ; but partly, also,
 owing to the low_and miasmatous state of the
 locality,  or to  the  circumstances  connected
 with the supply of water.  Inflammations of
 the bowels of an asthenic form, often assuming
 the characters of dysentery,  or chronic diar-
 rhoea, or  chronic ileo-colitis, or a true follicular
 enteritis,  are  very commonly caused,  in hot
 climates, and even in  numerous places without
 the tropics, by water preserved in tanks, or ta-
 ken  from marshes, or abounding with  animal
 exuviae or animalcules.
  85. ih  The exciting causes of enteritis  may
 be divided  into, 1st. Those which  operate di-
 rectly on the  digestive villous  surface;  2d.
 Those which act indirectly, by arresting the se-
cretions and excretions, and by determining the
momentum of the circulation  to the  intestinal
mucous membrane; 3d. Those which act me-
chanically, as strangulations, injuries, wounds,
 &c. ;  and, 4th. Those which act sympathetical-
ly-—A. The causes acting directly upon the bow-
els are the ingesta, whether alimentary, medi-
cinal, or  poisonous—a.  The food often occa-
sions enteritis, gastro-enteritis, or entero-coli-
tis,  by its quality,  quantity, variety, and incon-
gruity.   Heating, stimulating,  or  rich food,
especially in great quantity, frequently produces
muco-enteritis,  and its  several  consequences
and  complications;  while food which  is  un- 
INTESTINES—Inflab
wholesome,  septic,  putrid,  imperfectly pre-
served, or mouldy, or spoiled, or innutritious,
generally occasions follicular enteritis, or en-
tero-colitis, or dysentery.  Too great a quanti-
ty of food, or incongruous or indigestible food,
particularly after prolonged abstinence or fast-
ing, is a frequent cause of the more acute forms
of enteritis.   Thus a quantity of cheese eaten
in these circumstances has, in several instances
which I have observed in the course of my
practice, produced this effect.   Among the ali-
mentary substances most productive of enter-
itis, smoked, dried, and long-preserved meats,
pork, ham, bacon, cheese, stale fish, and high-
seasoned dishes, may be particularized.
  86. b. The  inordinate use  of  spirituous  or
other intoxicating liquors is  among the most
common causes in the  lower classes, particu-
larly in hot  climates and in  warm seasons.
Even a small quantity of spirits,  taken by per-
sons unaccustomed to them, and during disor-
ders of irritation affecting the alimentary canal,
will often develop a state of inflammatory ac-
tion.  Unripe or stale fruit; too large a quanti-
ty of fruit or of vegetables ; most acid and cold
fruits, and particularly pineapples, melons, and
cucumbers ;  cold fluids  or ices taken while the
body is perspiring, or very soon after, or imme-
diately upon a meal; and acidulated beverages,
or cider, perry, &c, often occasion  either en-
teritis, or some one of the disorders of the  di-
gestive organs, most apt to pass into, or to be as-
sociated with this disease. The changes which
the ingesta undergo in the stomach and bcrwels,
especially when excessive in quantity or varie-
ty, or otherwise incongruous,  and when imper-
fectly changed with the gastric juice and bile,
give rise to enteritis, either directly, or consec-
utively to  indigestion, costiveness, colic,  or
diarrhoea.   The  influence of the  secretions,
particularly of the bile, when  redundant or  ac-
rid from the changes  consequent upon inter-
rupted  excretion of it, in  giving rise to ileo-oo-
litis, has already been insisted upon.
   87. c. The frequency of the several  forms
of enteritis in young children, particularly  in-
fants brought up by hand, or after weaning, is
caused  chiefly by the  inappropriate or too
abundant supply  of food  in these circumstan-
ces.  The  digestive organs cannot dispose  of
the food, either from its quality or quantity, and
the undigested part irritates the digestive vil-
lous surface, or undergoes changes producing
the same effect.  In some instances, the disease,
especially the follicular  variety of it, is caused
by the insufficient quantity of aliment obtained
from the food, owing to  its  unsuitableness to
this early period of life, this  cause  combining
with the irritation produced by the undigested
portion.  The milk, also, of some nurses, ow-
ing to the state of their health, and of their di-
gestive organs,  or to their  habits, especially
in resorting to spirituous liquors, occasionally
gives rise to enteritis, or gastro-interitis, in the
infants suckled by them.
  88. The influence of an innutritious  and fluid
diet in causing muco-enteritis and follicular en-
teritis, the latter especially, particularly when
aided by cold and humidity, or by miasmata, or
by foul  or  unwholesome  water,  has been too
much overlooked.  A starving diet and regi-
men not infrequently develop  these forms  of
the disease in an  asthenic form, or in the guise
MMATIONS  OF--CAUSES.                    677

 of chronic diarrhoea or chronic dysentery, par-
 ticularly in persons previously  accustomed to
 live fully or intemperately; and if these dis-
 orders prevail in a  number of persons, either
 crowded  together or shut up in ill-ventilated
 apartments, adynamic or typhoid fevers will be
 generated, complicated with  the  enteric dis-
 ease.  The influence of stagnant and foul wa-
 ter, more especially water long shut up in wood-
 en casks; and river or canal water, containing
 animal  matter or impurities conveyed by the
 sewers running from cities or large towns, in
 producing follicular enteritis,  is much greater
 than  is generally supposed.  The use of im-
 pure water  favours  the production of the dis-
 ease, when other causes are in  operation, and
 imparts a specific, generally an asthenic,  char-
 acter to the malady.   It has the effect of a slow
 poison, and acts on the economy, not merely by
 impairing the tone of the organic  nerves and
 villous surface of the  bowels, but  also by con-
 taminating the  circulating fluids,  and thereby
 producing not only a local, but a constitutional
 disease at the same time.  In this disease, the
 general and local  asthenia is  more prominent
 than inflammatory action, which is limited to
 the intestinal glands and follicles,  and is often
 characterized by a tendency  to ulceration or
 disorganization  rather than to reparation.
   89. d. Medicinal substances, particularly acrid
 purgatives, stimulants, and tonics, injudiciously
 resorted to, are more frequently the causes of
 enteritis than is commonly supposed, the ef-
 fects of these medicines being often mistaken
 for the natural  course of the disease.  Acrid
 purgatives,  given  with the view of removing
 indigestion, colic, or constipation,  and injudi-
 ciously repeated,  in circumstances  requiring
 milder means, have often converted these com-
 plaints into acute enteritis, or have aggravated
 inflammation  where it already existed.  Stim-
 ulants and tonics, prescribed with the view of
 removing debility, and the various forms of in-
 digestion, have likewise developed a latent in-
 flammation, or changed slight  inflammatory ac-
 tion, giving rise  to symptoms mistaken for
 those of debility merely,  to acute enteritis, or
 to gastro-enteritis.  I am, moreover, convin-
 ced, from personal observation, during an ear-
 ly part of my experience, when I had opportu-
 nities, in different climates, of observing, with-
 out interfering with the practice of medical of-
 ficers in charge of hospitals, and from the pe-
 rusal of the journals  kept by others, that nu-
 merous cases  of diarrhoea, and still more of
 dysentery, have been aggravated into the most
 acute forms of enteritis or of entero-colitis, by
 the repeated, continued, and extravagant exhi-
 bition of acrid  or heating cathartics.  I have
 in my possession hundreds of cases of  these
 diseases, written by  the medical  men who
 treated them, in all of which the usual phe-
 nomena of inflammation, when seated in the
 villous surface of the intestines, and attended
 by morbid action of the muscular  coats, were
 viewed as the consequences of the accumula-
 tion and retention  of morbid secretions and
 faecal matters,  and  treated by large  doses of
 cathartics, prescribed not daily only, but at in-
 tervals of a few hours, and thus persisted in
 until the dissolution which they either caused
 or accelerated took  place.  The fire once kin-
 dled, however slightly or  weakly burning, was 
678
INTESTINES—Inflammations of—Causes.
 thus fanned to a blaze, which soon extinguish-
 ed itself in fatal disorganization.   A slight di-
 arrhoea or simple dysentery, arising from  irri-
 tation or determination to the intestinal villous
 surface, has been converted,  by  a continued
 use of the most drastic purges, into inflamma-
 tion, which, in its turn, has been  urged  on by
 the same agents to fatal sero-enteritis and  per-
 itonitis, with sphacelation of the villous coat.
   [We believe that the pathological conditions
 of the intestinal canal above described are  oft-
 ener brought  on, in this country, by the gen-
 eral prevalence of polypharmacy, or over-drug-
 ging, than by all other causes combined.   It is
 Impossible to  calculate the amount  of mis-
 chief thus annually produced by the use of dras-
 tic pills, patented by government,  as  it would
 seem, for the special purpose of preventing too
 great increase of the population.   Physicians
 are beginning  to learn that diseases are  not
 cured by drugs, but by nature; and  that harsh,
 pertUrbating treatment, especially such as irri-
 tates the tract  of the intestinal canal, is gener-
 ally far worse  than no treatment at all.   If ho-
 moeopathy had  done no more than demonstrate
 the curability of most diseases when left to the
 unaided efforts of nature alone, it would be en-
 titled to the gratitude  of mankind  ; and this it
 has done beyond all controversy.]
   90. e. Poisonous  substances are   among  the
 most common causes of enteritis, but generally
 complicated with gastritis—of gastro-enteritis.
 Some poisons, however, pass into  the bowels
 from  the stomach, without affecting the  latter
 in a very sensible manner.  Most  of the min-
 eral poisons, and of the acrid and aero-narcotic
 poisons, inflame the mucous surface of the in-
 testines ; and when they fail of producing fatal
results by the  intensity and the extent  of in-
flammation, by their injurious impression on the
 organic nervous  influence, and by  the change
they produce in the blood—by these effects, in-
dividually and  conjointly—they are generally
the cause of a severe, and often prolonged form
of enteritis, which, however, differs materially,
in its precise  seat, and in its  characters,  ac-
cording to  the particular agent which excited
it.  (See article Poisons.)
  91. B. Those causes which act indirectly,  and
chiefly by suppressing accustomed secretions
or excretions,  and by determining  the momen-
tum of the circulation  upon the abdominal  vis-
cera,  are exposures to sudden  vicissitudes of
temperature, especially in connexion  with  hu-
midity and the  influence of malaria ; sleeping
in damp beds or clothes, or in exposed places,
or on the ground during campaigns; the  ab-
straction of the animal heat from the feet,  the
loins, and abdomen;  unusual heat applied to
the back and loins ; and the drying up, the sup-
pression, or the disappearance, of  accustomed
discharges, evacuations, or eruptions.   Enteri-
tis is  often caused by the suppression of an ac-
customed perspiration of the feet.   Sleeping on
the ground, or  exposed to the night dews, es-
 pecially after a debauch or  the excessive  use
 of spirituous liquors, is a very frequent  cause
 of this disease, and particularly of phlegmonoid
 or sero-enteritis and colitis, among soldiers  and
 sailors, especially in warm or intertropical re-
 gions.  I have seen instances of  the disease
 occasioned by sitting with the back to a warm
 fire at dinner ;  by the suppression  of the cata-
menia,  and by arresting or preventing the re-
turns of the  haemorrhoidal flux, without insti-
tuting such precautionary measures as the cir-
cumstances of the case required.  The repulsion
of gout or of rheumatism from the extremities
has, in  rarer instances, a similar  effect; and
enteritis, appearing in these circumstances, pre-
sents certain peculiarities,  especially  in the
gouty diathesis, or  when  it occurs  from the
retrocession  of gout from the feet.  It is then
always  very  acute, is attended by intense pain,
and  is characterized as much by the extreme
morbid  sensibility of the parts  affected as by
the severity of the inflammatory action, the for-
mer pathological condition requiring more at-
tention  from  the physician than even the latter.
  92. C. Many of the causes  of enteritis are
altogether  mechanical, and act either internally
or externally,  in respect of the canal of the in-
testine.—a. The former consist chiefly of hard-
ened faeces obstructing the tube, or  lodged in
the cells of the colon ; concretions of various
kinds; and the inordinate distention occasioned
by gases or  faecal  accumulations.   Hardened
faeces and  concretions first irritate, and after-
ward inflame the parts in contact with them,
if the muscular action of the coats of the bow-
el fails in procuring their expulsion,  and a some-
what similar effect is produced by retained or
accumulated  faeces and morbid secretions. The
over-distention occasioned by flatus weakens
the coats of the intestines, overcomes their
power of reaction, and favours the  suppression
of the natural exhalations and secretions, and
the  consequent  development  of inflammation
in  the over-distended part.
  93. b.  The mechanical causes of enteritis ex
ternal to the  canal  are hernial strangulations,
and  strictures of any kind which diminish the
diameter of  the canal;  intus-susceptions,  the
pressure of tumours developed within the walls
of the abdomen and pelvis, and injuries, wounds,
or operations.  Every patient who complains
of the usual  symptoms of enteritis, especially
of vomiting  and constipation of  the bowels,
should undergo a strict examination, in order to
ascertain the existence or non-existence of the
several  kinds of hernia.   The presence of her-
nia  in connexion with  enteritis indicates at
once both the nature and cure of the disease;
but hernia or external strangulation may exist
without the lesion  being manifest, or its seat
or cause being detected, or even admitting of
detection, although suspected and carefully in-
quired after ;  and the mischief may be caused
by an old hernia, or in connexion with an old
protrusion, which can no longer be  detected on
examination.   When internal strangulation ex-
ists,  the symptoms of ileus, or of acute enter-
itis,  or of both in succession, are usually pres-
ent.   The  seats and causes  of strangulation
are so numerous, as shown and described in
the articles on Colic and Ileus (v 37), and Di-
gestive Canal (y 56, 57), that we can but sel-
dom come to a  correct  conclusion respecting
them, unless  they are subjected to  our senses,
as in the case of external hernia ; yet we may
occasionally,  lrom a review of antecedent and
concomitant  circumstances,  draw  inferences,
not only as to the  existence of internal con-
striction or  strangulation, but  also  as  to its
source,  that  will approximate,  although they
may not be  altogether the truth.   Either of 
INTESTINES—Inflamm
the many causes which I have enumerated, in
the article just referred to, as productive of il-
eus, may also occasion enteritis, the inflamma-
tion generally commencing at the point of stric-
ture,  or strangulation,  and  in  the  peritoneal
coat,  and extending thence usually to the dis-
tended  portion of intestine  above this point,
and to the rest of the tunics.
  94. c. Intussusceptions produce, as shown at
another place (Colic and Ileus, y 38, et seq.),
either ileus or enteritis, or both, either coetane-
ously or consecutively.   Where enteritis takes
place, it usually proceeds from strangulation of
the intro-suscepted portion of intestine, and as-
sumes a  most acute form,  the inflammation
generally commencing in the serous coat, im-
plicating the rest of the coats, and sometimes
terminating in  gangrene, and even in the dis-
charge of the gangrened portion  of the intes-
tine, the canal being preserved by  the union of
the edges of the divided  intestine.  But this
subject is fully described in the place just re-
ferred to, and also in the article Digestive Ca-
nal (Y 54, 55).
  95. d.  Tumours formed in any part within
the abdomen, may, from the injurious pressure,
or from  the irritation occasioned  by them, or
from  the extension of inflammation from their
surface to  the serous coat  of the intestines,
give rise to enteritis.  Tumours in the omen-
tum,  in the  ovaria, or connected with the ute-
rus, sometimes cause inflammation in either of
these modes, particularly in the former; this
effect being the  more readily produced when
the tumour is hard, cartilaginous, or osseous ;
or when it is very large, so as to  interrupt, by
its size  and pressure, the transit  of the more
consistent contents of the bowels ; or whenan
injury or blow  is received upon, or in the vicin-
ity of the tumour.   The  lymph effused on the
surface of an adjoining viscus will excite  in-
flammation  in whatever portion of the serous
surface of the bowels with which  it may come
in contact;  enteritis thus occasionally appears
consecutively upon  inflammation  of adjoining
organs, from the contact of a morbid secretion
chiefly, and not from extension of the inflam-
matory process over a continuous surface. Ex-
ternal injuries and wounds  are  occasionally
causes  of enteritis, particularly of serous or
phlegmonoid enteritis ; and gangrene of the  in-
jured and inflamed part sometimes takes place.
  96. D.  Mucous and follicular enteritis may
occur sympathetically of some severe disease or
extensive injury of external parts.  Either of
these varieties may be consequent upon burns
or scalds, or upon erysipelas, or uppn disease
of some vital organ.  They constitute, the lat-
ter variety  especially, the most frequent com-
plication  of continued,  and even of periodic
fevers, and  more particularly  of  the  eruptive
fevers;  and they are often sequelae of these
fevers.  My friend, Dr. Abercrombie, of Cape
Town, informed me that, when measles were
lately epidemic  at the  Cape of  Good Hope,
where they  were imported after an absence of
upward  of thirty years,  the great bulk of the
population being,  in  consequence, susceptible
of their infection, enteritis sometimes occurred
upon  the  decline of the eruption, but that  it
appeared  much more frequently during conva-
lescence, or a few days after the patient had
apparently recovered.
iations of—Treatment.                   679

   97. IX. Treatment.—The indications, as well
 as the means  of cure, necessarily vary in the
 several varieties of enteritis, and in the differ-
 ent circumstances in which  they present them-
 selves.   Some reference ought also to  be  had
 to the causes which  produce the disease, and
 to the state of vital tone or energy, especially
 if the complaint appeared in the course, or as
 a sequela of any other.   I  shall therefore de-
 scribe the treatment most  appropriate to the
 principal forms of the disease, and to the chief
 circumstances with which it is usually connect-
 ed.
   98.  i. Muco-enteritis and muco-entero-colitis
 differ only in the extent to which the digestive
 canal is affected in its internal surface, and in
 the different portions of this surface, both va-
 rieties being the same in their natures and mor-
 bid relations.   The means  of cure  are, there-
 fore, equally suitable to both.—A. In the slight-
 er states of the complaint, and in theless robust
 constitutions, local depletions, chiefly by leeches
 applied  to the abdomen, will be generally requi-
 site ;  but in strong, young, or plethoric persons,
 a moderate or full  blood-letting from the arm
 should be premised.  Immediately  afterward,
 small doses of calomel, or of blue pill, or of the
 hydrargyrum  cum  creta, the  last  especially,
 should be given with ipecacuanha, or with the
 compound ipecacuanha powder,  and repeated
 every four, five, or six hours.  If the  bowels
 be insufficiently evacuated,  and if the stools be
 morbid and offensive, mild purgatives, as sweet
 oil, castor oil, or both, may be given, and emoll-
 ient and aperient enemata administered.  After
 these have operated satisfactorily, a warm bath
 or the  semicupium  may be resorted to,  and
 Dover's powder, or the combinations of ipecac-
 uanha just mentioned, may  be exhibited, so as
 to relax the external surface ; and perspiration
 may be promoted by suitable diluents and warm
 mucilaginous  fluids, or by these latter contain-
 ing the liquor ammoniae acetatis with the spiri-
 tus aetheris nitrici, and small quantities of the
 nitrate  of potash.  Or these may be taken in
 camphor julep, or  any other suitable vehicle.
 When there is nausea or occasional vomiting,
 the medicines containing ipecacuanha may be
 laid aside for the  latter preparations, which
 may  be taken in small but frequent doses, in
 any emollient or soothing vehicle most grate-
 ful to the patient.   In such  cases, the stomach
 and bowels should be quieted, and their func-
 tions excited as little as possible until the mor-
 bid action has subsided.   In mild cases, these
 means, aided by a farinaceous, mucilaginous,
 and spare diet, will generally be sufficient; but
 in severer attacks,  a repetition of the more ac-
 tive of  these, and the aid of additional reme-
 dies,  will be requisite.
   99. B.  When the disease occurs in the most
 acute  form,  particularly  among Europeans in
 warm or intertropical countries, and as de-
 scribed above (y 45), a  copious blood-letting
 ought never to be neglected ;  and the antiphlo-
 gistic treatment and regimen should be strictly
 enforced.  In this state of complaint, local de-
 pletions will often be requisite, even after blood
 has been taken freely from the arm, and  will
 sometimes require to be repeated.  Leeches
 may occasionally be applied around the anus,
 preferably to  any  other  situation, more espe-
 cially when any degree  of  congestion of the 
680
INTESTINES—Inflammations of—TREATMKNt.
liver is suspected.  If the  attack be attended
by vomiting, and the large intestines seem but
little affected, calomel or the hydrargyrum cum
creta may be given with opium, and repeated
according to circumstances ; the bowels having
been sufficiently evacuated, and being kept open
by  copious  oleaginous  enemata;  but,  if the
stomach be not irritable, after having evacuated
morbid secretions and ftecal accumulations, ip-
ecacuanha may be prescribed with opium and
the nitrate of potass, as in the original Dover's
powder, in  as large and frequent, doses as the
severity of the  case may indicate.  After de-
pletions have been sufficiently practised, the
warm bath,  semicupium, or hot fomentations,
taking  care  to  keep the bed-clothes perfectly
dry, may be allowed.  In these cases, as well
as  in all the other varieties of enteritis, the
more acute especially, the turpentine fomenta-
tion on the  abdomen, or the liniments  in the
Appendix (F. 295, et seq), employed as embro-
cations in  this situation  by means of warm
flannels, will be found the most serviceable.
As long as evidence is furnished of the pres-
ence of morbid secretions and faecal collections,
the milder mercurials and laxatives or aperients
should be prescribed, and opiates withheld, un-
til the  causes of irritation are evacuated. The
safest laxitives or aperients are sweet oil and
castor oil, if they be perfectly fresh;  but if they
be at all rancid, they will greatly increase the
mischief.  If these means, energetically pur-
sued, do not remove the disease, it generally
passes into  the sero-enteric form, or into  the
second  stage of that form, with marked  ex-
haustion ; a very different treatment being then
indicated, although with little hope of success.
   100. Upon the whole, the treatment of the
milder forms of muco-enteritis should be near-
ly the  same as is  recommended for the more
inflammatory varieties of Diarrhoea (y 27, 28),
and that of the more acute cases, particularly
when  the  large  bowels are  chiefly affected,
ought not materially to differ from what I have
advised for  the inflammatory states of Dysen-
tery (v 82-87);  and the greater part of what
I have stated in these places altogether applies
to the  present subject.
   101.  C.  The Chronic forms of Muco-enteritis,
and of muco-entero-colitis, require merely a mod-
ification of the above treatment, appropriately
to the age, strength, and vascular states of the
patient. Local depletions are sometimes neces-
sary, also, in  these forms of the disease,  and
should even be repeated, according to circum-
stances.  The chronic  state is often  owing to
the indulgence of the patient in too  much or
too rich and stimulating food.  When this is
the case, then a more  rigorous diet and regi-
men are requisite.  A diet consisting chiefly of
farinaceous and gelatinous substances, of milk,
 sugar  [we doubt much the propriety of allow-
 ing sugar,  or  any  other  form of saccharine
 matter, in these cases], chicken or veal broth
 in small quantities, with rice,  etc., warm cloth-
 ing, flannels worn next to the skin, warm baths,
 and assiduous friction of the surface of the
 body,  aided by exercise, travelling, and change
 of air, will generally be found most beneficial
 in these cases.   But the disorder may have
 somewhat  changed  its character in  passing
 from the acute to the chronic form ;  a too rig-
 orous diet, during the former state, may have
favoured the development  of ™'^ar e  ten.
tis upon the subsidence of the inflamrnation of
the villous surface.   Consequently, the pers st-
ence of a chronic disorder after the acute should
lead  to a careful examination of  the local and
constitutional  symptoms, and of the  evacua-
tions ;  and if  these be marked by asthenia, or
cachexia, the stools  being  mucous, muco-puri-
form, or ochrey, and the pulse  weak and  very
quick, the means about to be recommended for
the follicular variety of the disease should be
prescribed.
   102.  D. In infants and young  children—a. the
acute form of muco-enteritis  requires nearly sim-
ilar means to those already prescribed, but with
due  reference to their age and their previous
nourishment.  For them, lopal depletions, the
hydrargyrum cum creta, with  ipecacuanha in
small doses, or Dover's powder, and the warm
or tepid bath or the  semicupium, or stupes or
fomentations, will generally be necessary.   For
infants, however, Dover's powder, and all other
preparations containing opium, ought not to be
prescribed ; nor, indeed, should the alvine evac-
uations be suddenly  arrested by these or other
means  in  young  children.  When the  com-
plaint  is  attended by much irritability of the
stomach, a full dose of calomel will be of ser-
vice, and  if the child be  not very young, a
small dose of opium may be given with it; and
the  bowels, which  are  usually  then  costive,
should  be moved by emollient  laxative enema-
ta.  When the stomach is  not irritable, and the
bowels are much relaxed, the stools being mor-
bid,  I have often found  small  doses of the bi-
borate of soda taken in honey, or in dill-water
with paregoric  elixir and  mucilage, of  great
service, after calomel or the hydrargyrum cum
creta had been prescribed.   In  such cases, also,
the  warm bath, stupes, and emollient  enemata
are  very beneficial.  In older children, when
the  bowels are very irritable, and the stools
contain blood,  small  doses of the sirup of
poppies, or of paregoric elixir, may be  added to
these or  to the starch enema, or to an enema
of thin gruel, or of warm water, or of strained
veal or mutton broth ; local depletions having
been resorted to,  according as they may have
been indicated, and ipecacuanha  or  Dover's
powder given in frequent doses.   On the  other
hand, the bowels ought not to  be allowed to be
costive.  When children will take sweet oil, it
is the mildest and most suitable aperient in this
disease, and it  should  always be employed in
laxative enemata.   In the more severe cases,
or after local depletions,  the  warm  bath, fo-
mentations, and suitable medicines have been
prescribed  without  satisfactory results,  mus-
tard poultices, or the warm turpentine fomen-
 tation  may be resorted to, and be kept on the
 abdomen until smarting  or burning heat is pro-
 duced.   Either of the turpentine liniments  in
 the  Appendix  (F. 296, 311) may be employed in
 this manner,  with the addition of the tincture
 of opium, when the stomach or bowels are very
 irritable.  In grown children, opium with calo-
 mel or hydrargyrum cum  creta, and with ipe-
 cacuanha, or this latter  with nitre and opium,
 in suitable doses, are the  most important rem-
 edies, when employed after vascular depletion.
   103. b. In the chronic cases of muco-enteritis,
 or  of entero-colitis  in children, repeated  small
 doses of hydrargyrum cum creta with ipecac- 
INTESTINES—Inflami
 uanha, or With Dover's powder, the warm bath,
 or fomentations, and, subsequently, blisters on
 the abdomen, if the foregoing means are ineffi-
 cient, are generally necessary.  But in this state
 of the complaint, diet and change of air, espe-
 cially to a high and dry locality, are most ben-
 eficial.   Advantage will be obtained, also, from
 the warm bath, followed by frictions of the sur-
 face, and the application of a flannel roller round
 the abdomen.  The bowels should be duly reg-
 ulated by means of mild  mercurials, rhubarb,
 magnesia, or sulphate of potash,  or of sweet
 oil, castor oil, manna, &c., aided by enemata,
 according to the peculiarities of the case.  - In
 other respects,  the treatment  advised  in  the
 mucous and chronic states of Diarrhoea (y  30-
 36) should be adopted.
  104. c. In both the acute and chronic states
 of the complaint, the utmost attention  should
 be  paid to the diet of infants and children.
 When there is much irritability of the stomach,
 indicating an extension of disorder to the duo-
 denum and stomach, endeavours to give food,
 or even medicine, are more injurious than ben-
 eficial, until the severity of the  attack is  abated
 by local  depletions and external means.  If a
 full dose of calomel, with or without a little cal-
 cined magnesia, is retained, as  it generally will
 be in such cases, nothing ought farther to be
 given for two or three hours, when gum-water,
 with equal parts of the milk of  a healthy nurse
 or of asses' milk, or gum-water slightly sweet-
 ened, may be administered in  small quantity,
 one or two tea-spoonfuls being given at a time.
 In these cases, no other purgative than calomel
 will  be retained in the stomach.   The bowels
 must, therefore, be opened by means of the en-
 emata already mentioned.  The diet and regi-
 men must entirely depend upon the state of the
 bowels.   If they be  relaxed, the milk may be
 taken with  lime-water.   As the acute symp-
 toms subside, more nutritious  kinds of light
 food and farinaceous  articles may be allowed.
 Chicken-broth, or veal or mutton broth, may be
 taken with rice ; and mild tonics, with the alka-
 line sub-carbonates and small doses of ipecac-
 uanha, should be prescribed when the digestive
 functions are much  weakened.   [In chronic
 cases,  a little fat salt pork, or bacon, broiled,
 will produce the most beneficial effects.] The
 means so fully  insisted upon  in  the  several
 forms  of Diarrhoea (see  more particularly y
 35-52) may severally be employed, according
 to the peculiarities of individual cases.   In  the
 sub-acute and chronic states of the disease,
 particularly in recently weaned children, or in
 infants that are attempted to be reared by hand,
 the kinds of milk just mentioned may be given,
 immediately upon being drawn, either with gum-
 water, or with a little cinnamon-water, or with
 lime-water, or with barley-water, according to
 the states of the bowels.
  105.  ii. Treatment of Glandular and Follicular
 Enteritis and Entero-colitis.—A. The indications
and means of cure in the acute states of these
 varieties  entirely depend  upon their exciting
causes,  their  association  with  muco-enteritis,
 and the state of the constitutional disturbance.
The  first object is to  ascertain the cause  or
 causes of the malady ; the next is to ascertain
 the state and stage of the local  and general
morbid action.  It is necessary not merely to
 remove the causes, but also to counteract the
                     86
     s~s of—Treatment.                  681

 poisonous influence they have exerted, both lo-
 cally and constitutionally.  A reference to these
 causes (Y18, 83) will show the necessity of thus
 extending our views in the treatment of these
 varieties.  It must not be overlooked, that many
 of these causes are of a septic or poisonous na-
 ture ; that they consist of putrid, decomposed,
 and decomposing substances, vegetable or ani-
 mal, or both,  which act as a poisonous  or con-
 taminating leaven  upon the digestive mucous
 surface, on the  intestinal glands and follicles,
 and upon the blood; and that  this effect,  al-
 though most demonstratively produced on these
 glands and follicles, does not always, at least in
 its earliest stage, consist  of true or of  sthenic
 inflammation.  The vital condition of these fol-
 licles is changed, but not in  such a manner as
 to develop an excited condition of their capil-
 lary circulation ;  an opposite state—an asthen-
 ic congestion with impairment of their  vital
 manifestations and vital cohesion—more prob-
 ably obtains ;  for it is uniformly observed, that
 when the causes are of the above description,
 or  when  they are such as debilitate, or even
 such as  insufficiently excite or nourish  the
 frame, as inappropriate, innutritious, fluid, and
 unwholesome food, a treatment of a lowering
 or depleting kind is always injurious.  As this
 morbid condition of the glands and follicles  of
 the digestive villous surface often rapidly pass-
es  into ulceration, it has been too generally
 viewed as being altogether of an inflammatory
 nature.  This error has arisen  from two cir-
 cumstances : first, the general belief that ulcer-
 ation, can proceed only from antecedent inflam-
 mation ;  and, second, that inflammation  is  a
 state  of  vascular action  always attended  by
 one and the  same condition  of vital tone  or
 power, and that the tissues affected by it pos-
 sess the same degree of  vital cohesion on  all
 occasions.  Now I have  shown, in other pla-
 ces,  that ulceration  may occur and proceed
 without any appreciable grade of inflammation,
 and more particularly of true or sthenic inflam-
 matory action ; and that inflammations, or, rath-
 er, that, the states  of local vascular action, to
 which the term inflammation has been too gen-
 erally and  often  inappropriately applied,  are
 widely different from  each other, in respect of
 a great variety of both local and constitutional
 phenomena; and that these states vary, as re-
 gards the condition of the tissues and vessels,
 and circulating fluids and vital manifestations,
 not only in each of their more  specific forms,
 but also in each of their progressive periods or
 stages.  It  may,  therefore,  be  inferred that,
 when ulceration is produced in the intestinal
 glands by septic or contaminating ingesta,  it
 assumes somewhat of a phagedenic character,
 and that the state of vascular action preceding
 or giving rise to this effect is either not truly
 inflammatory, or is that to which I have appli-
 ed  the term of asthenic inflammation (see that
 article, y 54, et seq.), and  which requires,  both
 locally and constitutionally,  a  very different
 treatment from that  appropriate to the more
 common inflammatory condition.
   It is not improbable, however, that  inflam-
 mation commencing in the villous surface  it-
 self will extend to  the follicles,  and even  that
 both  it and the follicles may be almost coeta-
 neously attacked ; or that the affection of the
 former may subside as that of the latter is de- 
682
INTESTINES—Inflammations of—Treatment.
veloped ;  but of either of these states of dis-
ease  we  have no  certain proofs at an early
stage, although appearances  after death  fre-
quently show that they  must  have  existed.
The chief difficulty is to  ascertain the symp-
toms  by  which  they are  severally  or  con-
jointly attended and  indicated, more  particu-
larly during  early periods of life, when  this
morbid  association is common ; and  even at
much later periods, so minute a diagnosis as
this is  can  rarely be made with  precision.
When we have reason, from the nature of the
exciting causes,  from the character  of the
symptoms, and especially from the state of the
evacuations,  to infer that disease of the  folli-
cles is associated with inflammation of the vil-
lous surface ; or when the more usual phenom-
ena of follicular enteritis cannot be connected
with the septic and lowering causes mentioned
above (y 18, 85), and when the symptoms indi-
cate more or less of vascular excitement, lo-
cally or generally, local depletions, followed by
the warm bath, by  the semicupium, or by the
rubefacient embrocations or fomentations al-
ready noticed (y 296, 311), will then be requi-
site.  If faecal collections have not been  re-
moved by the natural action of the bowels, calo-
mel with rhubarb, or the latter with sulphate of
potash,  or the compound jalap powder may be
given, and be aided by suitable  injections : af-
terward, frequent doses of the hydrarg.  cum
creta, with Dover's powder, or with  ipecacu-'
anha and rhubarb in small quantity, may be pre-
scribed, according to the circumstances of the
case ; and the turpentine fomentations already
mentioned (y 99) may be  applied on the abdo-
men.   The treatment, in such circumstances,
should not vary  materially from  what is  ad-
vised for the more acute forms of mucous diar-
rhoea (y 99), and for dysentery, according to the
features of individual cases.
   106. After the more acute symptoms  have
subsided,  and in the more asthenic cases, more
restorative, astringent, and antiseptic remedies
may be employed; and more  especially those
recommended for the mucous and chronic forms
of Diarrhoea (y 31, et seq.).   If the  stage of
the disease,  the state of the evacuations, and
the constitutional -symptoms  indicate the  ac-
cession or progress of ulceration, the means ad-
vised in the article just  referred to  (y 32, et
seq.) should be resorted to.   In such cases, as
well as in those which have followed the in-
gestion of septic and contaminating  substan-
ces, I have found the following of more or less
service, with or without the  addition of opium
to either  of them, as circumstances may have
required :
  No. 279.  R Hydrarg. cum creta 3j. ; Pulv. Ipecacuanhae
gr. viij.; Pulv. Rhei 3ij.; Creasoti Ttlxij.; Mucilag. Acacis
q- s. M. Fiant Pilulae xviij. quarum capiat duas ter qua-
terve quotidie.
  No. 280.  R Pulv. Ipecacuanhae gr. xvj.; Argenti Nitratis
Pulver. gr. viij. ; Extracti Humuli 3iv.; Extr. Papaveris
3ss.; Olei Carui q. s.  Tere bene et forma in massam asqua-
lem quam divide in Pilulas xxxij., quarum capiat unam vel
duas ter quotidie.
  No. 281.  R Calcis Chloridi gr. ss. ad gr.. j. ;  Aquie Cin-
namomi  'Six.;  Mucilag. Acaciae 31J. ; Tinct.  Camphorae
Comp., Tinct. Humuli, Tinct. Cardamom. Comp. aa 3J. M.
Fiat Haustus, pro re nata sumendus.
  No. 282.  R Calcis Chloridi Pulv. gr. viij.; tere cum Pulv.
Tragacanth. Comp. 3j. et adde Pulv. Ipecacuanhae gr. viij.;
Bals. Peruv. q. s.  ut Fiant Pilulas xviij. ; quarum capiat
duas ter quarterve in die.

   107.  B. The chronic states of follicular enteri-
tis and entero-colitis, particular!} when^utoera.
tion  has commenced, can  be ameliorated  01
cured only by strict attention to diet and regi-
men, as well as by the appropriate use of med-
icine.  Of the latter, but little can be added to
what has already been stated with reference to
the treatment of chronic mucous diarrhoea (v 31,
et  seq.) and chronic dysentery (y 100,  et seq.).
The  various methods  and  diversified means
there enumerated are appropriate to the states
of the disease now under consideration; and
the treatment recommended for chronic muco-
enteritis is  also partially applicable to them.
In the follicular form, however, of chronic en-
tero-colitis,  the means of cure, both medicinal
and dietetical, should be even more restorative
than I have advised for the other varieties  of
enteritis.   In many cases, both medicines and
diet should be prescribed almost experimental-
ly, the effects of both being carefully watched;
for it is impossible to infer correctly the effects
of the  several means in all, or even in the great
majority of cases. In many instances, and  in
several circumstances in which  they occur,
powerfully tonic and astringent remedies are
most beneficial; while in others, alterative and
absorbent medicines are most useful.  A spare
and farinaceous diet  is usually recommended,
and yet abstinence may be  carried too far, nu-
tritious and digestible  food being often requi-
red,  especially when  the disease is prevailing
epidemically, or when it proceeds from the
more  debilitating  and contaminating causes.
In addition  to the means  already mentioned,
both here and in  the  articles just  referred to,
others  variously  combined, according to the
ever-changing features of individual cases, may
be employed, more especially sulphate of qui-
nine,  or the nitrate of silver,  with camphor
and the extracts of hop and of poppy; the sul-
phates of quinine and of iron with these ex-
tracts, or with catechu, purified  ox-gall, and
capsicum ;  the sulphate of zinc or of copper,
or the acetate of lead, with ipecacuanha and
opium; the tincture of the muriate of iron, or
chlorine-water, with the compound tincture of
camphor  or of cinnamon, and any of the va-
rious astringents, tonics, and absorbents usu-
ally employed.  In this variety of the disease,
the chloride of lime, or the  chlorate of potash,
or any of the  mineral and vegetable astrin-
gents, tonics, and antiseptics, may be prescribed,
according to circumstances ; but those astrin-
gents  which are  also antiseptics  should  be
preferred, and be conjoined with  the  prepara-
tions of bark, or of cascarilla, or of tormentilla,
&c.  When the follicles and glands of the large
bowels are  chiefly affected, and the  disorder
has become chronic, or if ulceration be expect-
ed, many of the substances just mentioned may
be employed in enemata, as the nitrate of sil-
ver, the sulphate  of zinc, lime-water, chlorine-
water (Pharm. Dubl.),  the  infusion or decoc-
tion of bark, with the compound  tincture  01
camphor, or sirup of poppies ;  the chlorate of
potash, or the chlorides similarly combined;
and the various astringent  and tonic infusions
and extracts.
   108. For infants and children affected by acute
or chronic follicular enteritis and entero-colitis,
very nearly the same means as have  been  ad-
vised  for them when  suffering  under muco-
entero-colitis ($ 102,  103) will be found appro- 
INTESTINES—Inflammations of—Treatment.
683
 priate.   As, however, the follicular variety of
 the disease in this class of patients is more es-
 pecially caused by insufficient or unwholesome
 nourishment, by an unhealthy nurse, by a spoon
 diet, by rearing by hand or premature weaning,
 by cold and humidity, and particularly by living
 in a miasmatous atmosphere, or in low, damp,
 and ill-ventilated cellars and apartments, a re-
 moval  of these causes, and attention to suit-
 able diet and regimen, become most important
 parts of the treatment.   The patient should be
 warmly clothed in flannel, and always sleep in
 the arms of  a  healthy  nurse, or have  asses'
 milk warm from the  animal.  The diet should
 be regulated  in other respects as already ad-
 vised (y 104).  In this, and in similar states of
 disease of the  digestive  canal, the jelly pre-
 pared from the  Ceylon moss  is a most appro-
 priate article of food*  In aid of these means,
 change of air, particularly from crowded towns,
 and low, close, or  unhealthy localities, to open,
 airy, dry, and temperate situations, or to the
 seaside, should always be prescribed.
  109. iii. Treatment of Phlegmonoid or. Sero-enteri-
 tis.—When the inflammation either seizes pri-
 marily  upon the substance of the intestines, or
 extends to it, or commences  in the peritoneal
 coat, vascular depletion should be immediate
 and copious, and other remedies promptly em-
 ployed.   If the  patient be  plethoric, young, or
 robust,  blood should be taken very largely from
 the arm, and leeches applied  afterward upon
 the abdomen.  A full dose of calomel and opi-
 um—from fifteen  to  twenty grains of the for-
 mer and two to three grains of the latter, with
 or without a grain or two of  ipecacuanha, ac-
 cording to the state of the stomach—ought to
 be taken  immediately after the bleeding, and
 the hot turpentine fomentation applied over the
 whole abdomen.  This last should be kept con-
 stantly  applied,  or should be renewed until the
 symptoms have abated.   If the stomach be ir-
 ritable,  the calomel and  opium taken after the
 bleeding, and without  the ipecacuanha,  will
 remove this  symptom, and will, particularly
 when aided by the  hot turpentine fomentation,
 determine the circulation to the surface, equal-
 ize the  distribution of blood, and promote per-
 spiration ; and when  the fomentation can be
 no  longer endured, a warm  bread-and-water
 poultice may replace  it, and may be frequently
 repeated.  If these mearis  give relief, with a
 copious and general  perspiration, the patient
 should not be disturbed for a considerable time,
 nor the  stomach and bowels irritated by purga-
 tives or cathartics taken by the mouth ; and as
 soon as it becomes requisite to procure evac-
 uations  and to remove  offending matters, the
 oleaginous or other  mild purgative enemata
 may be  administered.
  110.   If the disease be very severe, or con-
 siderably  advanced before this treatment is in-
 stituted, a repetition  of  both  the general  and
 local bleeding will  often be necessary ; and the
 calomel and opium, in the doses already stated,
 may be  given  once or twice daily, either  until
 the secretions and evacuations become free, or
 until the  mouth is affected, or  the symptoms
 disappear. If the stomach be not irritable, and
 if the bowels have been evacuated, saline med-

  * [Animal jellies, as of isinglass, calfs-foot, &o., or chick-
en and mutton broth, given warm, will be found more gen-
erally beneficial in these chronic cases than vegetable food.]
 icines may be prescribed at intervals ;  and the
 warm bath  may be  ordered, with the  view of
 aiding the preceding means in equalizing the
 circulation and promoting perspiration.   If the
 biliary functions be much disordered, or if the
 disease does  not  yield readily to the above
 means, the mercurial liniment or ointment may
 be  placed upon the surface of the abdomen,
 and covered by a  succession of warm poulti-
 ces, or the  former of these may be laid upon
 the  surface of the poultices that  is to be ap-
 plied next to the abdomen.  If this state of the
 disease be associated  with hepatitis, local de-
 pletions below the right  scapula, or over the
 right hypochondrium, should precede these ap-
 plications.
   111. As to the  use of blisters  in enteritis,
 much discretion is requisite.   If they be em-
 ployed before the disease, particularly this form
 of it, be in a very great degree subdued, they
 either fail of being serviceable, or they aggra-
 vate  the  morbid action; unless they are so
 large as  to  occasion a complete revulsion of
 the  capillary action  to- the blistered surface :
 an effect they can  seldom produce, unless the
 inflammatory action is slight in degree, or small
 in extent, or  has  been nearly altogether re-
 moved by the previous treatment.  In the early
 stages of  the disease,  the turpentine fomenta-
 tion is greatly to be  preferred, as it in  no way
 aggravates the  disease, but, on the contrary,
 remarkably tends  to  abate it, and to prevent
 the effusion of coagulable lymph, and  in this,
 as well as in  other  ways, aids the beneficial
 operation  of  blood-letting  and  mercurials.
 When, however, the  disease is nearly subdued,
 the external inflammation  and  discharge pro
 duced by  a large blister entirely remove the
 remaining morbid action, and prevent an exas-
 peration or a return of it.  In this period of the
 disease, and after  the above fomentation has
 been used, a large  blister may therefore be ap-
 plied, and the discharge from it promoted by
 poultices and other means.
  112. iv. Enteritis with membranous or tubular
 exudations  is generally a chronic disease, and
much less amenable to treatment than any oth-
er variety.  M. IIoche states that M. Burdin,
a physician of large experience in Paris,  inform-
ed him that local  depletions, poultices, warm
baths, emollient enemata,  and a soothing regi-
men,  proved most beneficial in his practice;
and that a mucilaginous, diluent, and fluid diet
was generally injurious ; while  mild, bitter in-
fusions, aromatics, and antispasmodics were
preferred ; and the former physician adds, that
his  experience accords with this  statement.
 However,  he has seen a  case exasperated by
the slightest  stimulus, and cured by a severe
antiphlogistic regimen ; and another cured by
drastic purgatives, after other means had failed.
Dr. Powell observed no benefit from the use
of calomel.  The practice which appeared to
him most  advantageous was the steady use of
a mixture  of the compound infusions of  gentian
and senna, with the addition of from til  x. to ill
xx. of the solution of potash, so as to procure
four or five stools in  the  twenty-four  hours.
 Sir B. Brodie informed me that he has found
small doses  of cubebs  serviceable  in this dis-
ease, aided by  an  occasional recourse to an
active purgative.  The purgative  advised by
Dr. Powell has been most  beneficial  in my 
684
INTESTINES—Spasm of1.
practice ; but I have found it requisite to apply
leeches to  the abdomen,  followed by the tur-
pentine fomentation and  embrocation,  by hot
poultices, and emollient enemata.  A frequent
use of sweet oil, both as an article of diet and
as an  aperient, has also  been of service.   A
light, nutritious, and solid  diet has been  gener-
ally requisite ; at the same time avoiding stim-
ulants  and irritants.  The  treatment, however,
will  necessarily vary, or even be entirely dif-
ferent, in different  cases, as the disease has
always been variously associated or  complica-
ted in the cases which I have seen, these com-
binations often requiring as much attention  as
the intestinal malady.
  113.  v. During convalescence from any of the
several forms of enteritis,  the regular action bf
the bowels is  a matter of the greatest  conse-
quence, and should be  promoted, when defi-
cient, by mild  and cooling aperients  and laxa-
tives.  At the same time, the secretions gen-
erally,  and  particularly the biliary  secretion,
should be collected or promoted whenever they
are deficient or morbid.   For this purpose,  an
occasional dose of blue pill or of the  hydrargy-
rum  cum creta, or of Plummer's pill with soap,
should be taken.   A warm bath,  followed  by
active  friction of the surface with hair gloves,
or with a coarse towel, will  also be of use.
The  utmost attention ought to be paid  to diet.
A returning appetite should be  indulged with
great caution.   Mild broths, in  srtiall quantity,
with toast, or with boiled rice ;  the farinaceous
articles of  food, as arrow-root,  sago, tapioca,
&c, and the jelly of the Ceylon moss, may be
taken at first,  and continued for some time be-
fore  more stimulating and solid articles* are  al-
lowed.  The patient ought to wear flannel next
his skin, and be careful not to expose himself
to vicissitudes of temperature or to  moisture.
He should always preserve his feet warm, and
observe those articles of  food which agree or
disagree  with his digestive  organs,  carefully
avoiding  those which  have the latter  effect.
In all respects, his diet and regimen  should be
regulated in the  manner advised in the article
Indigestion (y 69, et seq.).
  114.  X. Of Spasm, etc., of the Intestines.
—A. The muscular  coats of the intestinal tube
possess a very perfect degree of muscular pow-
er, and may be contracted in a very remarka-
ble manner, even so as to propel quicksilver
along its canal contrary to the specific gravity
of this substance.  The extent of spasmodic
contraction  of the intestines is  rarely demon-
strated to the  sense of sight, even after death.
But in  dissections performed a few hours after
dissolution,  it  has been observed so extreme
as very nearly to obliterate  the canal.  The
spasmodic  contraction of circular fibres, and
of the muscular  coats of hollow viscera,  is
shown by the action of the urinary bladder,  of
the intestines, and of the  sphincters ; and the
extent of relaxation of these structures is dem-
onstrated by the state  of  these  parts, both  in
health  and disease.   The  healthy contractions
of the intestinal  canal push onward its con-
tents ;  but this contraction is speedily followed
by relaxation.  The passage  of substances
more or less stimulating along the villous sur-
face excites the action of the muscular coat,
and  this action ceases in  one  part as soon  as
the  stimulus passes onward to a continuous
nart  Where, however, the muscular coats are
spasmodically contracted, there is, at least for
JZ!S considerable time, no consequent
Xation, as in the healthy state.  It is very
difficult to determine the extent to which spas-
modic  constriction takes place, in respect ei-
ther of the amount of the obliteration of the
canal it may occasion, or of the length to which
it may affect the intestine, and  the  particular
bowel  affected.   The  spasm, there is every
reason to infer—indeed, it is sometimes dem-
onstrated—-may  attack  several  parts  at  the
same time, more or less remote from each oth-
er, the intermediate portions being remarkably
dilated ;  and it may proceed along the intesti-
nal canal, either continuously or interruptedly,
from the stomach downward, or even in an op-
posite direction, as in colic, hysteria, and ileus,
in which it may follow either of these direc-
tions.  We can hardly suppose that the spasm
extends, at the same moment, to the whole
line of the canal, but merely to  portions of it,
which  may be thus affected for a very varying
and indefinite period.   This affection may pass
with rapidity from one part to  another;  and,
as respects duration and recurrence, it may be
continued, almost permanent, intermitting, re-
mitting,  periodical, and  slight  or- tremulous.
Some portions of the bowels are more subject
to spasmodic action than others, as the duode-
num, the lower portion  of the ileum,  and the
lower parts of the large bowels.
  115. B. Intestinal spasm is generally associa-
ted  with disorder  of the secreting functions of
the  liver and of the digestive villous  surface,
and often, also, with inflammatory action in this
surface.   There is always more or,less of irri-
tation of this tissue, or, rather, of the nervous
fibrils supplying this and the muscular coats;
and this irritation is attended by a more or less
remarkable alteration of the sensibility of these
nerves, which is roused often to the most acute
pitch of sensation.
  116. i. Symptoms.—The symptoms of spas-
modic  constriction of the intestines necessarily
vary with  its seat, degree, extent, duration,
causes, and concurrent changes.   In the great
majority of eases they constitute the disease
denominated colic -. and in their moie extreme
or prominent state, particularly when spasm is
associated with farther change, or consists of
a succession of retrograde actions emanating
from a part  more permanently contracted or
obstructed, they constitute, or very  nearly ap-
proach, the iliac  passion, which,  however, is
often dependant upon obstruction from some
other cause,  and is-frequently associated  with
inflammation.  Pain is the most general attend-
ant upon spasm,  and, like it, is  usually felt in
paroxysms, or is exasperated, or is  recurrent,
intermittent, remittent, and more or less acute
or violent.  In some cases it is  slight  and ir-
regular,  or it assumes the  above forms in  a
much less acute grade, as in the spasmodic in-
testinal contractions of hysteria.  The pain char-
acteristic of spasm is often more or  less allay-
ed  by pressure, unless  the spasm be excited
by inflammatory action, or associated with it.
When  the spasm  affects the small intestines,
there is  commonly pain  about the navel; and
when it is attended with flatulent distention of
the parts unconstricted, there is a tympanitic
state of  the  abdomen, with borborygmi, and a 
INTESTINES
sensation of the passage of air from one part
to another, the pain often, also, shifting its sit-
uation.   Spasm of the duodenum has been sup-
posed to be indicated  by pain in  the right side,
stretching to the back, and occasionally to the
right shoulder, but often changing its place upon
the expulsion of air ;  by distention of the abdo-
men, slight yellowishness of the  conjunctiva or
countenance, and deficiency of bile in the evac-
uations ; and by a soft, and sometimes an  ir-
regular pulse.  These symptoms, however, do
not furnish sufficient evidence either of the seat
or of the nature of the affection, although  they
are attendant upon it in  most instances ; for
they also accompany other complaints, more
especially torpor and other functional disorders
of the  biliary organs.   When the pain accom-
panying  them is eased by pressure,  and when
none of the  signs of inflammatory action  are
present,  then the existence of spasm  is  ex-
tremely probable ; but its seat is not the more
certainly indicated by this circumstance.  Nor
does pain in the right side, extending from the
caecal region to the right hypochondrium, suffi-
ciently prove the existence  of spasmodic  con-
striction of the commencement of the .colon,
although it is a sufficient reason to suspect the
presence of this affection in this part.  Both
Sauvages and Monro admit the difficulty of the
diagnosis as respects the seat of spasm.  This,
however, is of the less importance, as the treat-
ment is the same, whatever may be its exact
seat.   But it is of the utmost moment to ascer-
tain whether or not  the  spasm be caused by,
or  associated  with,  inflammatory  aqtion  or
structural lesion ;  and this can  be  detected
only by a careful examination of the previous
history and present state of individual cases.
The disposition, particularly in young subjects,
of intestinal spasm,  to  be  followed by intus-
susceptions, and by inflammation or ileus  from
this circumstance,  should always be  kept in
recollection.
   117. ii. The causes  of spasm  of the intestines
are also those  of spasm in other parts. — a.
The nervous temperament, and the delicately
or weakly constituted, owing either to original
conformation or to  the  operation of the usual
causes of debility during infancy, puerility, and
puberty, are most predisposed to this affection.
Dr. Gregory has very correctly  and briefly sta-
ted the predisposing causes as follows :  " Hab-
itus corporis nimis sentiens, et nimis  mobilis,
homines spasmis opportunos reddit; hinc ma-
lum fceminis, infantibus,  debilibus, luxuriosis,
desidibus, sanguine plenis, familiare."
   118. i. The  exciting  causes  are principally
those which irritate the villous  surface of the
intestines, as all acrid, poisonous, or unwhole-
some ingesta;  flatulence, acrid bile, retained
or morbid secretions  and excretions, mechan-
ical  irritants, calculi or concretions,  foreign
bodies, worms, biliary calculi, either passing the
biliary or other ducts, or lodged in the intes-
tines, exposure  to cold, &c.   Intestinal spasm
is often caused by inflammation of the bowels,
or by organic lesions implicating their coats;
by  the  poison  of lead, and by the numerous
causes mentioned in the article  on the several
forms of Colic and Ileus.  It is also frequent-
ly occasioned sympathetically,  by the irritation
of dentition ; by irritation or inflammatory ac-
tion in the uterine organs, or in the urinary pas-
!—Spasm of.                              685

sages;  and by affections of the mind, especially
the  more violent  emotions.   It is a frequent
attendant upon hysteria, upon  calculi  in the
kidneys or ureters; and it occasionally appears
in the course of disorders of distant parts.  It
is also apt to  occur in the gouty diathesis, ei-
ther as misplaced  gout, or in consequence of
disorder of the biliary or intestinal secretions.
   119. iii. The treatment of intestinal  spasm
does not differ from the  treatment of colic and
ileus, and it should be conducted according to
the principles  there detailed.   The chief inten-
tions are,  1st.  To remove the cause or causes,
whether those acting directly on the bowels, or
those exerting a  sympathetic  effect.   2d. To
remove the immediate attack.  3d. To combat
associated or contingent disease, whether in-
flammatory or structural; and, 4th. To prevent
a recurrence of the affection by such means as
will prevent accumulations of morbid secretions
and  excretions, and promote a  healthy condi-
tion  of the secretions, while they restore the
tone of the parts and of the system generally.
It is unnecessary to describe the modes in which
these indications may be carried into effect, as
they are already stated in the article just refer-
red to, and as they necessarily differ according
to the peculiarities  of each case.  I may, how-
ever, remark, that the use of opiates, or  of oth-
er narcotics, should not be long persisted in,
with the view of accomplishing the second in-
tention, without alternating or combining them
with mild purgatives or  laxatives, or with de-
obstruents ; taking care, at the  same time, to
remove inflammatory action, if it be present in
any  degree.   Narcotics, especially  opium or
morphia, interrupt the biliary and intestinal se-
cretions and excretions ; and, although the lat-
ter is extremely efficacious in removing spasm,
yet it counteracts the other indications.  Much,
however,  will depend upon the modes of com-
bining or prescribing it, and upon  the other
means employed.   Hydrocyanic acid is often a
most efficacious remedy in this affection. In
the violent forms of it which sometimes occur
in the  gouty diathesis, opiates and the  hydro-
cyanic acid have been most efficacious in my
practice, particularly when given with camphor
and an alkaline carbonate, or with the carbonate
of magnesia or of  ammonia, due attention be-
ing paid to the excretions, both faecal and uri-
nary.  Belladonna  is frequently of service, giv-
en either internally or applied by means of a
plaster over the abdomen.  The administration
of narcotics or anodynes in enemata is occa-
sionally beneficial; but I have seen  the doses
of those medicines recommended by some wri-
ters produce very serious effects.  The spirit
of turpentine  thus employed is an efficacious
remedy, especially when much flatulent  disten-
tion is associated with spasm, and particularly
when its  antispasmodic operation is aided by
the external application of it, in the form either
of epithem, embrocation, or liniment, over the
abdomen.  Numerous other means may be re-
sorted to  in the different states of intestinal
spasm.   But they are fully noticed in the arti-
cle on  Colic  and  Ileus (6 50, ct seq.).  The
fact of spasm  being not infrequently a  conse-
quence of congestion of blood, of local deter-
mination, and of inflammatory action, either
latent or manifest, ought never to be overlook-
ed in the treatment of these  affections, more 
686
INTESTINES—Palsy op.
especially  in the  young  and plethoric, and  in
those who live fully and  take insufficient exer^
cise.*
   120. XI. A Paralytic state of the intesti-
nal canal occurs, but only in respect of portions
of it, and much more rarely than the affection
just noticed.   Palsy even  of a portion of the
intestines  is seldom complete.   It is  rather a
state of over-distention,  or of inflation, during
which the  usual vermicular or peristaltic  con-
tractions of the bowel do not take place for a
time ;  but  this state is more rarely permanent:
it generally disappears either gradually or after
the use of medicine or stimulating articles of
diet.   In its more extreme forms, it  is occa-
sionally  consequent upon permanent  or spas-
modic constriction, or incarceration, or stran-
gulation, or other obstruction of a portion of
bowel, and is commonly  seated above the  con-
striction ;  the inordinate distention caused ei-
ther by flatulence, or by faecal accumulations,
or by both, as wTell as by the unceasing efforts
to propel the contents of the distended intestine
onward, ultimately terminating in a  loss of
contractile power. In addition to these sources
of partial palsy of the intestines, hysterical af-
fections, irritation  of the  uterus, and more
particularly diseases of the spinal chord or its
envelopes,  causing more or less  of paralysis
of voluntary parts, may be mentioned.
   121. A  paralytic state of a portion of the
intestines, particularly when consequent upon
permanent contraction of a part  immediately
below it, is often followed by serious changes
in the palsied portion.   The secretions of its
villous surface are suspended, and inflamma-
tory action, quickly passing into ulceration,  or
even sphacelation, soon  supervenes.   Indeed,
these consecutive changes may take place even
in those parts which are not completely para-
lyzed,  but  which, having  lost  much of their
contractile power, continue more or less dis-
tended ; this condition, in  connexion with the
influence of accumulated  and  pent-up flatus,
arresting the secretions of the part, and favour-
ing the occurrence of inflammatory action and
its usual consequences.  In cases where  per-
manent contraction, or obstruction of a portion
of bowel exists, from changes  about to be no-
ticed (y 127, 128), the parts immediately above
the contraction are generally found inordinately
dilated, ulcerated, ruptured, or even sphacela-
ted ; and others  still  higher up the bowel are
occasionally spasmodically constricted—chan-
ges resulting from the inordinate efforts made
to propel  the contents of the intestines.   A
partially paralyzed  state of the bowels may
likewise proceed from inflammation of the part
thus affected, the  muscular coats being  thereby
rendered incapable of contracting.
   122. i. The symptoms of palsy of the intesti-
nal canal are  chiefly constipation, distention,!

  * [A very successful mode of treatment in these cases is
that of gradually forcing up, by injection, a large quantity
of  some bland fluid until it reaches the seat of obstruction,
or of spasm, when a speedy evacuation and relief will gen-
erally follow.   In many instances several quarts will be re-
quired before this result takes place ;  but in all curable
cases, if seasonably applied, more speedy relief may be ex-
pected from this means than almost any other.  It shoud be
succeeded, however, by some mild laxative, as olive oil, in
a large  dose, and the  diet for some time afterward be of a
light and fluid nature.]
  t In some  cases of lead colic I have found the colon So
enormously distended, from flatus and loss of contractile
with a tympanic state of a part or of the whole
of  the  abdomen upon percussion ;  a  weak,
quick, small, and often  an irregular pulse, and
occasionally vomiting.  The other symptoms
vary with the changes either occasioning or
associated with the palsied condition;  with the
presence  of inflammation, of disease  of the
spine or spinal chord ; with uterine or urinary
irritation, or with hysterical affections.   When
the  spinal chord is  seriously affected,  and in
certain severe forms of hysteria,  the urinary
bladder is often also paralyzed; and the volun-
tary muscles,  particularly those of the  lower
extremities, and sometimes those of the abdo-
men and superior limbs, are similarly affected.
   123.  ii.  The treatment should  be conducted
with a strict reference to the source of the af-
fection, and to the disorders attending or com-
plicating it; and this can be accomplished only
after a strict examination of the  history  and
existing state of each case.  If the loss of con-
tractile power proceed from a  more or  less
permanent  contraction, or from incarceration
or strangulation  of a portion of bowel, or from
pressure or some other mechanical cause of
obstruction, the  removal of the source of mis-
chief is the primary object of treatment.   Other
associated lesions just  mentioned  also require
immediate attention, as either causing or  per-
petuating the  palsied state.   It is compara-
tively rare that this  affection of the intestines
is primary and uncomplicated ; and it  is conse-
quently but seldom that  the means of cure
should be solely  directed to it.  But when  it is
thus primary and simple, or dependant upon
disease or injury of the  spine, warm purgatives
and carminatives, given by the mouth, and ad-
ministered  in  enemata, are  then beneficial  ;
and these may be combined with various anti-
spasmodics, more particularly those just men-
tioned (y 119).   If, however,  there is  any rea-
son  to suppose that the  loss of contractile
power is either a consequence of, or associated
with inflammation of the bowel, or even that
the  distended portion of intestine  has passed
into this state, then these means may be more
injurious than  beneficial,  and the usual reme-
dies for enteritis, according to the state of local
and general action, and of constitutional power,
should be resorted to.   In such cases,  a careful
examination of existing symptoms, and the pres-
ence of those already shown to attend the sever-
al forms of enteritis, will guide the practitioner,
both in the diagnosis and in the treatment.*
power, that I could distinguish its form and course, in the
different abdominal regions, by the eye when standing at a
considerable distance from the patient; and yet the bowel
has been restored to its healthy state by repeated injections
containing turpentine, castor oil, <fec, aided by stimulating
frictions on the spine, abdomen, &c.
  * Uncases of a paralytic state of the intestinal canal, which,
we believe, is a not unfrequent cause of obstinate constipa-
tion, galvano-magnelism, applied by placing one button of
the conducting wires over the spinal vertebrae and passing
the other gradually over every part of the abdomen in suc-
cession, will be found, perhaps, the most successful of all
means to rouse the  nervous energy, on which both the
healthy peristaltic action and intestinal secretions depend.
One button may occasionally be placed on the tongue, and
the other in contact with a metallic bougie, introduced into
the rectum or passed over the abdomen, as in the former
case, or placed in a tub of water, in which the feet are im-
mersed : we have been m the habit of employing all these
modes of application, and with very gratifying success   A
combination of quinine, or piperine, with some preparation
of aloes, as the compound decoction, or pill, will aid and sus-
tain the effect of the galvanism, which, without some in-
ternal stimulant of this kind, might only be temporary ] 
INTESTINES—Contraction op a Portion op.
687
  124.  XII.  Rupture of  the Intestines is
generally a consequence of pre-existing disease
of the ruptured  part or its vicinity.  It never
takes place in the healthy bowel, unless when
caused  by external violence, as the kick of a
horse, or the passage of a carriage-wheel over
the  abdomen.—A. The symptoms vary in these
cases according to the amount of haemorrhage
which takes place from the ruptured part.  But
the  vital powers always  evince great depres-
sion from the shock and the nature of the in-
jury ; the features becoming pale and collapsed,
and  the pulse feeble,  small, or slow, and the
surface  and extremities  cold.  There is also
very acute pain in the abdomen, with vomiting
or syncope, in most cases.  When the rupture
proceeds from softening or  ulceration, there is
seldom  any haemorrhage, and the  symptoms
are  nearly those which arise  from perforation
of the intestines ; great and general distention,
pain and tenderness of the abdomen, a small,
frequent pulse, vital depression, vomitipg, con-
stipation, decubitus on the back, with the knees
drawn up, and the other, symptoms of peritoni-
tis,  from effusion into the peritoneal cavity, be-
ing  present.
  125. The treatment in the above circumstan-
ces  consists  chiefly of the exhibition of full
and  frequent doses of opium and of perfect
quiet; but it  is more fully stated in the article
Peritoneum.
  126. XIII. Thickening  and permanent Con-
traction of a Portion of  Intestine.—These
lesions, whether consequent upon inflammation
orrproduced by constitutional vice, and impair-
ed organic  nervous power,  have been fully de-
scribed in the articles Digestive Canal (y 48,
et seq.), and Colic and Ileus  (y 33).  In their
slighter forms and earlier stages, they are not
always,  or  even generally attended by such
symptoms as will enable the physician to form
a correct  idea  of their  nature, or to infer
whether or not they are simply obstructive, or,
in addition, of a malignant character.  In many
cases, where this latter, character exists, the
malady is far advanced  before the symptoms
marking its nature become fully manifested;
and in some it is even neither supposed nor de-
tected until disclosed by an examination after
death.
  127. i. Thickening and permanent contraction
of the coats of a portion of intestine are usu-
ally conjoined.  It is but rare  that the one ex-
ists without the other.   They are much more
rarely observed  in the small than in the large
bowels.  They  are usually attended, in their
early stages, ,by costiveness, or by constipation,
alternating with diarrhoea and  colicky pains.
The symptoms, however, vary according to the
seat of a partial, or of a  more or less complete
obstruction.  (See Colic and Ileus, §32, etseq.)
When they are seated in the small  intestines,
vomiting frequently recurs with twisting pains,
occasionally  with  a gurgling  noise  about  the
umbilicus,  and the matters vomited are often
more or less digested.   When they implicate
the  ileo-caecal valve, or the  vicinity, pain is
generally felt in the caecal region ;  and if the
pbstruction be not complete, the faecal matters
which have  passed  into the  large bowels, to-
gether with the  decretions and excretions from
their surface, generally form scanty and costive
evacuations.  When the obstruction is more
complete, the  sufferings  of the  patient are
greater, the evacuations are scantier, and the
bowel above the obstruction becomes more di-
lated and tympanitic, ultimately inflamed, and
occasionally ulcerated,  or  even lacerated or
gangrened.  In such cases, the abdominal ten-
sion, tenderness, and pain, the frequent  small
pulse, vomiting, &c., indicate the existence of
inflammatory action;  and the appearance of
the vomited matters, and the seat or commence-
ment of the suffering, suggest the portion of
intestine affected.  In most cases, the abdomen
is very resonant on percussion ; but if the ob-
struction be eaused by much thickening of the
coats of the intestine, there is  marked dullness
of sound on percussion in the situation of the
part  thus affected.  The parts most liable to
thickening and  constriction of  the coats are
the sigmoid flexure  and the arch of the colon.
When this change exists low in the colon, the
fits of vomiting are less frequent, and the evac-
uations at stool much scantier and less frequent,
than when it is  seated either  in the small in-
testines or at the commencement of the colon.
Even when the disease is in the sigmoid flex
ure of the bowel, as much faecal matter may
pass into the rectum, as long as the canal is at
all open, although remarkably constricted, as
will form a consistent  stool, by its accumula-
tion and retention at the termination of the co-
lon and in the rectum.  Thickening and per
manent contraction  in the small or large  intes
tines may be distinguished, with some proba-
bility,1 by the seat of pain and  swelling, and of
the gurgling noise caused by the passage of
matters through the straightened part.   If the
contraction be in the  colon, its situation may
often be detected by observing how much fluid
can be thrown up, and by consulting the feel-
ings of the patient while it  is being thrown
up, in addition to the other indications  just no-
ticed.
   128. ii. Wh6n scirrus  or  carcinomatous  or
other malignant chronic  disease attacks the intes-
tines, either primarily or consecutively (see Di-
gestive  Canal, y 48, et seq.), it is generally at-
tended not only by great  thickening or hyper-
trophy of the  coats, particularly of the sub-vil-
lous or cellular tissue,  but also by  very marked
constriction of the canal.  Tumours of various
sizes,  or  fungous  excrescences, sometimes
sprout out from the diseased or ulcerated sur-
face, which tend still farther to lessen the aper-
ture through the diseased part.  The larger in-
testines, and  particularly  the  caecum,  the ileo-
caecal  valve, the sigmoid flexure of the colon,
and, still more, the upper part of the rectum,
are more frequently the seat of cancerous  or
malignant chronic disease than the small intes-
tines.
   129.  iii. The symptoms of these  changes are
generally obscure, for  they always come on im-
perceptibly and slowly. Distention of the bow-
 els ; more frequent calls to stool than usual,
 with difficulty and  pain in passing the faeces ;
 colicky  pains, and stools consisting chiefly  of
 frothy  mucus,  often  tinged  with  blood, are
 among the earliest symptoms  of the disease.
 The evacuations are  only in  small quantities
 at a time, are thinner than natural, and, when
 consistent, are much  narrower, or mixed with
 a frothy or slimy  mucus.   Emaciation takes
 place, and the pulse becomes quick and feeble. 
688
INTESTINES—Softening
of the Villous Membrane.
As the disease proceeds, very acute lancinating
pain is felt in some  part of the abdomen, com-
monly the seat of lesion.   When the patient is
at stool, flatus passes through the diseased part,
sometimes with a hissing sound and tremulous
motion. As the contraction increases, the quan-
tity of faeces discharged is diminished, and ab-
dominal distention, pain, and tension are  in-
creased.   Occasional vomitings supervene, and
become more and more frequent, the matters
ejected being more digested, or more nearly ap-
proach the faeculent appearance, as the malady
advances to a fatal termination.  In some cases
a distinct  tumour may be felt, or its  seat indi-
cated by a dull sound and pain on  percussion.
I was lately consulted in a  case of carcinoma,
seated a little above the sigmoid flexure of the
colon, which  occurred in a medical man aged
about 40,  where the seat of the disease was
thus indicated.  The other circumstances also,
already noticed, will farther  aid  in forming
an opinion as to the seat of mischief.  The
malady usually follows a slow but uninterrupted
course, during which the swelling of the abdo-
men, pain, vomitings,  and constipation  in-
crease.  The countenance and general surface
in this last stage commonly present the cachec-
tic appearance usually observed in  Cancer (y
11).  At last, inflammation, ulceration, or even
rupture or -.gangrene, often  takes place in the
over-distended portion of bowel above the can-
cerous part, and the patient rapidly sinks ; syn-
cope, cold  sweats,  singultus, feeble, intermit-
ting  pulse, cold extremities,  &c,  ushering in
dissolution ;  but the disease occasionally ter-
minates in fatal  exhaustion, without these  al-
terations supervening, and  without the  symp-
toms of ileus taking  place  in a very  violent
form.
  130. iv.  Of the treatment of these changes but
little can be  said more  than will be found in
the articles Colic and Ileus (y 71, et seq.), and
Constipation (y 21).   I have seen  temporary
benefit derived in some cases from small, but
frequent  doses  of Castile  soap, ipecacuanha,
and  hyoscyamus; in others, from the purified
extract of aloes, conjoined with the biborate of
soda and conium.   The frequent use of small
quantities of sweet oil,  so  as  to preserve the
bowels in  a freely open state, or the adoption
of the oil instead of  butter, as an article of diet,
has been of service  in several instances.  The
injection of considerable quantities of it into the
large bowels has  also proved beneficial in the
advanced  states of the disease.   A liniment
consisting of the mercurial and compound cam-
phor liniment, with  opium, may be rubbed over
the part of the abdomen  chiefly affected, or the
ammoniacal and mercurial plaster may be worn
over this part.  The diet should consist of such
articles as  are the least excrementitial, or fur-
nish the smallest proportion of faecal  matters.
  131. XIV.  Softening of the Villous Mem-
brane of the Intestines.—Maladie Grastro-in-
testinale avec Disorganization Gelatiniforme, Cru-
veilhier.—This  lesion is fully described in the
article Digestive Canal (y 34, et seq.).   It oc-
curs chiefly in infants and young children, and
is distinct from the softening caused by inflam-
matory action.   Softening, as shown  in that
article, may be primary and idiopathic, and, in
this form, is not unfrequently seated in the vil-
lous surface of the  stomach and intestines, or
of either  more especially.  It generally pro-
ceeds from causes which greatly depress  the
organic nervous power, and rarely takes place
in adult persons,  in whom, however, M Cru-
veilhier, who first correctly described the dis-
ease, met with several instances.   Of 50 cases
observed by Dr. Romberg, 6 occurred from the
1st to the  3d month, inclusive ; 17 from the 4th
to the  6th month ; 7 from the 7th to the 11th ;
14 from the 12th to the 24th month ;  and 6 from
the 2d to the 5th  year of age; the  periods of
weaning and teething being those during which
it is most  frequent.
  132. i. Symptoms.—The  earliest  indications
of this disease are frequent, watery, greenish,
slimy or mucous stools, often  mixed with yel-
lowish flakes, and having a peculiar offensive,
acid, or putrid odour ; occasional vomitings of
acid, ropy, or mucous  matters, and extreme
thirst; acute sensibility, perpetual restlessness
and fretfulness, and screaming or crying on be-
ing touched, or upon being roused from the state
of exhaustion or of lethargy into which the in-
fant generally sinks.   Fever is observed at the
commencement of some cases, but  it is slight,
and of short duration, and more commonly the
skin is cool from the  beginning.  The surface
becomes  cool, or soon cold, pale,  flabby,  and
sickly, as  the disease  proceeds ; and the coun-
tenance is also pale, cold, sickly, and sunk.  At
an advanced  stage there are a slight or short
cough ; remarkable exhaustion  or  sinking; a
short or interrupted respiration ; frequent cry-
ing and moaning ; much apparent  anxiety  and
restlessness ; coldness of the extremities, with
rapid emaciation  and  extreme debility;  an ir-
regular, languid,  small, and  weak  pulse; a
white, pale, or slimy  tongue; a soft, relaxed,
sometimes inflated, but never a tender or pain-
ful state of the abdomen ;  and pale or whitish
urine.
   133. The duration of this malady varies from
a few days to several  weeks, or even to two or
three months.   When the patient is carried off
more rapidly, disorder of a slighter form  has
existed for some  time previously.   When  the
disease proceeds  unfavourably, a violent exa-
cerbation, or  a gradual exhaustion  or sinking
of the vital  energy,  usually  terminates life.
The sensorial functions, in these cases, are  not
oppressed by  sanguineous  congestion, or by
aqueous effusion,  but  cease in consequence of
the general vital depression and the extensive
lesion of the intestinal canal.
  134. ii.  Diagnosis.—If this disease have been
ushered in with fever,  it closely resembles, and,
indeed, is intimately allied to, both in its symp-
toms and pathology, the Choleric Fever of in-
fants.  (See that  article.)  The greater sever-
ity of the attack, the presence of fever, and  the
more frequent vomiting and purging, are  the
chief symptoms which characterize this latter
malady and distinguish it from that  now under
consideration.   The diarrhoea, the unoppressed
state of the cerebral functions, the extreme ir-
ritability, fretfulness, and restlessness, and the
cerebral symptoms generally, fully  distinguish
this disease from inflammation of the brain or
of its membranes, and from acute hydrocephalus.
  135. iii. Causes.—The predisposing causes are
chiefly a weak or delicate  development of the
constitution, originally deficient vital energy, a
poor or unhealthy  state of the nurse's milk,  and 
INTESTINES—Bibliography and References.
689
the numerous other causes lowering the pow-
ers of life in early infancy.   The more common
exciting causes are principally unwholesome, in-
appropriate, or  insufficient food ; weaning,  or
bringing up by  hand,  or premature weaning;
and living in low, damp, or miasmatous locali-
ties, or in close, ill-ventilated, crowded apart-
ments or cellars, or in warm, damp, and low
districts.   I have seen this disease  prevalent
in low, humid, and miasmatous places, in warm
countries,  and within, the  tropics, particularly
among the children of European parents. Many
of the diseases  of the infants or  children of
white parents residing in  these  countries are
more  or less intimately related to this malady,
especially while they continue to reside in them.
M. Cruveilhier observed  it to assume an epi-
demic form in some districts of  France ; and,
when thus appearing, as well as when occurring
sporadically, it is often complicated with soften-
ing of the villous coat of the stomach.   When
it proceeds from the state, quantity, or kind of
food or  other ingesta, it is  generally thus asso-
ciated ;  but, when it arises from the climate,
air, and locality, it is frequently uncomplicated.
   136. iv.  The structural  change constituting
this malady is  fully described in  the  article
Digestive  Canal (y 34).   Dr. Droste consid-
ers that the softening  process may be divided
into three stages: in the first, the  villous sur-
face preserves its appearance and texture, but
loses its natural consistence, either in parts or
patches, or more or less  extensively.   In the
second stage, the villous membrane is converted
into a thin, soft, gelatinous, and nearly trans-
parent substance, which may  be wiped off by a
sponge  from the adjoining tissue, or even wash-
ed off by a stream of water poured  upon  it;
yet it seems still to be continuous with, or ad-
herent to, the subjacent coats, which are also
much softened.   In the third stage, no trace of
organization is  left in any of the coats, the
intestines  being  either perforated in  various
places, to a greater or less extent, or showing
such perforations on being washed bya sponge
or stream  of water.   It is obvious that these
stages are merely arbitrary  divisions of the
progressive advance  of disorganization.   As
this malady consists of a  loss of the vital co-
hesion of the coats of the intestines, it will ob-
viously  follow  that the  capillary circulation
will indicate, in  these  situations, some degree
of congestion, or sanguineous exudations, in
the form of ecchymoses and spots of extrava-
sated  blood.  Softening may take place in any
part of the alimentary  canal.  I have observed
it  most frequently in the  stomach and  ileum,
and, as respects the latter, in the lower portion
of it.
   137. v. The nature of this  change has been
discussed by several Continental pathologists,
and chiefly by Cruveilhier, Camerer, Andral,
Droste, and Pommer, all of whom admit that
softening  of the intestinal villous membrane
may be  an idiopathic change, and independent
of inflammation.  Camerer, however, supposes
that it proceeds from inflammation of the nerves
supplying the  intestinal canal, terminating  in
paralysis of them.  From the history and phe-
nomena of several cases which I have observed,
as well  as from the appearances  after death, I
believe  that the  softening here  described de-
pends upon innervation, or insufficient power,
    II.               87
of  the intestinal nerves,  in  consequence of
which condition the villous surface  first, and
the  other coats  consecutively, lose their vital
cohesion.   This view is confirmed, moreover,
by  the effects of  the remedies  employed in
cases  manifesting the usual symptoms of the
disease.
  138.  vi. Treatment.—The causes  and circum-
stances connected  with  the production of the
complaint should be ascertained and  removed.
The health of the  nurse, and  the  state of her
milk, ought to receive attention.   If the infant
be weaned, the diet must be  duly  regulated as
to  quantity and quality.   Thirst,  which  is  a
general feature of the  disease, should be  al-
layed  by  frequent  sippings, and never by full
draughts.  Asses' milk, or  milk and  water, or
lime-water, may be given  often, but  in small
quantity ; and if any additional food be allowed,
it should be' suited to the reduced  state of di-
gestive and assimilative power, and to the age
of the patient.   The medicines most  appropri-
ate to  the  disease are the preparations of iron
and of lime, and the more permanent and astrin-
gent vegetable tonics.  Of the  former, the  sul-
phate and muriate of iron  are the most  servicea-
ble ; and of the latter, the powdered Cascarilla
bark.  At the Infirmary for the Diseases of Chil-
dren, I usually gave this bark with either of these
salts in the form  of powder, and very generally
with the best results, when the patient came
under  the  treatment in  any of the earlier pe-
riods of the disease.  This practice  has  been
adopted in this institution since  my earliest
connexion with  it  (in  1820); and a similar
treatment  has  been found  successful in  Ger-
many  by Drs. Pommer and Droste.  In addi-
tion to these  means, I  have  frequently  pre-
scribed warm  salt-water bathing,  and assid-
uous frictions, with stimulating liniments along
the spine; and I have  occasionally employed
the iodide of potassium  with  advantage.   An
improvement  in the pulse and  other symptoms
has  often been observed on the  second  and
third day after this course of treatment  has
been adopted.   In this complaint, as in all oth-
ers  depending  upon vital depression, particu-
larly when occurring  in large towns,  and in
other unhealthy localities,  change  of air,  par-
ticularly to the seaside, is a  most important
part of treatment;  and, when aided by suitable
diet  and  regimen,  and  by  appropriate medi-
cines, will generally remove the disease, if ac-
tual disorganization have not taken place.
 Biblioo. and Refer.—Fernelius, Pathol., lib. vi., cap.
ix.— Tulpius, Observ. Med., lib. iii., cap. 18.—Horslius, De-
cus  Problematum  de Morbo  Intest. Mesent.  et Omenti.
Giess., 1609.— V. de Petrone,  Duellum Literarium inter
Medico-Salernitanos et Neapolitanos de Phlegmone Intesti-
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de Gland. Intestinorum, earumque Usu et Affectibus, 8vo.
Schaffh., 1677.—Amatus Lusitanus, Cent, vii., cur. 93.—G.
E. Stahl, De Intestinis, eorumque Morbis ac Symptomatibus
cognoscendis et curandis, 4to.  Halle, 1684.— G.  Thomasius
Ephemer. Med. Phys. German., dec. iii., an. iii., obs. 190
p. 319.—C B. Behrens, Ibid., dec. iii., an. v. et vi.,obs. 34
p. 77.—J. M..Hoffmann, Ibid.,  dec. iii., ann. ix. et. x. obs.
60, p. 124. —E. Camerarius, De Vitus Machinae Humana;,
Diss. iv.  Tub., 1726.—D. J. A. Fischer, De Morbis  Intes-
tini Coli ex Anatomia dijudicandis, 4to. Erford, 1728.__A.
F. Walther, De Intest. Angustia ex obfirmato eorum Habi-
tus Vitio. 4to. Leips., 1731.— Morgagni, De  Sedibus et
Causis Morb., Epist.  xxxi., 19, xxxiv. et xxxv.—Buechner,
De Spasmo Intest., 4to.   Erf.,  1741.—De Consensu Pedum
cum Intestinis, 4to. Halle, 1747.—De Consensu Primarum
Viarum cum  Perimetro Corporis Humani, 4to. Halle, 1764.
—C. Leurinck, De Morbis a Situ Intestin. Crassor. penden-
tibus.  Gott.. 1756.—/. G. Bauer,  Epist. de Malis Intest.,
in Halleri Disp. Med., t. iii., p. 461.—C. F.  Kaltschmidt, in 
690
IRRITABILITY—Source of.
Halleri Disp. Med., t. iii., No. 99.—C. G. Ludwig, in Schle-
gel, Thesaur. Semeiot., t. ii., No. 8. —/. Quarin, Method.
Medendi Inflammationes, 8vo.   Vien., 1774. — Stoll,  Rat.
Med., vol. i., p. 262 ;  et vol. iv., p. 1\.—Percival, Mem. of
Med. Society of Lond., vol.  ii., p. 60. — W. Dougall, Edin.
Med. Comment., vol. ix. — A. S. Nevinson, Qbserv. on the
Use of Crude Mercury in Obstruct, of the Bowels, and on
Castor Oil, 8vo.  New., 1787.— W. Stark, Works consisting
of Chemical and Anatomical  Observations, 4to. Lond., 1788.
—G. F. Hildebrandt, Geschichte der Unreinigkeiten im Ma-
gen und in den Gedarmen, 8vo.   Brunow., 1790.— W. Hen-
ning, Beschriebung von der Entziindung des Magens und
der Gedarme, 8\o.  Copenhag.,  1795.—B. Vogel, Methode
den Ileus von Eingekkemmten Durmbruuhen zu Heilen.,
8vo.  Numb., 1797. — F. Duncan, Letter on a Particular
Affection of the Bowels in  the  East Indies, 8vo.  Lond.,
1801.—E. Peart, Practical Information on Inflammation of
the Bowels, 8vo.  Lond., 1802.—/. Sanden, in Annals of
Med., vol. vi., p. 293.—/. A. Gaitskell, Essay on Catarrhal
Iuflamm. of the Bowels from Cold, 8vo.  Lond., 1812.—F.
J. V. liroussais, Histoire des Phlegmasies Chroniques, 8vo.
Paris. 1807, 2 vols.; 3d edit., 1822,3 vols., sect, ii., Inflam.
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—C. R. Pemberton, A Practical Treatise on Diseases of the
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veilhier, Med. Pratique eclairee  par PAnatomie et la Phys.
Patholog., cahier  1, 8Vo. Paris, 1824. — Chomel, Diet, de
Medecine, t.  viii.—J. F. Meckel, Journ.  Complem. du  Diet.
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Gen. de Med., t. ix.—Goldmann, in Archives Gen. de Med.,
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xvii., p. 111.—Fuschius, Ibid., t. ix., p. 116.— Louis, Ibid.,
t. xiv., p. 185.—Buet, Ibid., t. xiv., p. 230.—Rost'an,  Ibid.,
t. six., p. 332.—Corbin, in Ibid., t. xxiv., p. 214; et t.  xxv.,
p. 36. — Trousseau, in Ibid., Jan. et Fev., 1826. — Breton-
neau, in Ibid., Sept., 1829.—Leuret, in  Ibid., Oct.,  1828.—
Gendron, Ibid., Juin et Jul., 1829.— Toulmouche, Ibid., Mai,
1830.—J. Abercrombie, Pathol, and Practical Researches on
Dis. of the Stomach, the Intestinal Canal, the Liver, and
other Viscera of the  Abdomen, 8vo. Edinb., 1828, 3d ed.,
1837.—Camerer, Versuche ueber die Natur der Krankhaften
Magenerweichung,  <fec, 8vo.   Stuttg., 1828.—J. Johnson,
On Morbid Sensibility of the Stomach and Bowels, &c, 8vo.
Lond., 1828; and Med. Chiruig. Review, vol. ii., p. 1.—/.
Armstrong, The Morbid Anatomy of the Bowels, Liver, and
Stomach, 4to.  Lond., 1828.—A. Bompard, Traite des Mal-
adies des Voies Digestives,  8vo.   Paris, 1829.—Roche-, Diet.
de Med. Prat., t.  vii. — Billard, in Edinb. Med. and  Surg.
Journ., vol. xxviii., p. 163. — Lesser, Entziindung und Ver-
schwarung derVerdanngs organe.  Berlin, 1830.— CloqUet,
Nouv. Journ. de Med., t. i. ; et  Lond. Med.  Repos., vol. x.,
p. 332.—Schmidtmann, Observ. Medicin., t. ii., p. 98, 181.—
Mollison, Transact, of Edinb. Med. and Chirurg. Soc, vol.
ii., p. 249.—Droste, in British and Foreign  Med. Review,
vol. ii., p.  551. — Gendrin, Hist. Anat. des  Inflam., 8vo.
Paris,  1826,  vol. i. — Hutin, Biblioth. Med., Juil., Sept., et
Nov., 1826.—Scoutetten, in Journ. Complem. du Diet, des
 Sc. Med., 1827 et 1828.—J. O.  Beirne, New Views on the
 Process of Defecation, and their Applicat. to the Pathol.
 and Treat, of Dis. of the Stomach, Bowels, &c, 8vo.  Dub-
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 son, Edin. Medical and Surgical Journ., vol. xlvi.,p. 102.—
 W. Stokes,  Cyclop,  of Pract.  Med., vol. ii., p. 54; and
 Lond.  Med. and Surg. Journ., vol. v., p. 70.—Griffin, Dub-
 lin Med. Journ., vol. vi., p. 384.—R. J. Evanson and H.
 Maunsell, A Practical Treatise on the Diseases of Children,
 8vo.  Dubl., 1836, p. 233.  — Cruveilhier, Anat. Pathol, du
 Corps Humain, fol., fascia, iv., vii., xiv.  Paris, 1837.—7.
 Bouillaud, Clinique Medicale, 8vo. Paris, 1837, 3 tomes.—
 F. Hodgkin, Lectures ou the Morbid Anatomy of the Serous
 and Mucous Membranes,  8vo.   Lond., 1838, 1840, 2 vols.,
 vol. ii., passim.  See, also, Biblioo.  and Refer,  to ar-
 ticles  Colic and Ileus, Constipation, Diarrhosa, and
 Digestive Canal.)
   [Am. Bibliog. and Refer.—S. D.  Gross, Elements of
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 and 250 wood-cuts ; et Experimental and Critical Inquiry
  into the Nature and Treatment of Wounds of the Intestines,
  2d ed.,8vo.  Phil., 1845, p.822.— W. E. Horner, A Treatise on
  Pathological Anatomy.  Phil., 1829.—E. Bartlett, The His-
  tory, Diagnosis, and Treatment of Typhoid and of Typhus
Fever, &c, 8vo.  Phil., 1842.  (See Bibliog. and Refer, of
Typhoid Fever.)-Am. Journ. Med. Sciences  -Host.
Med. and Surg. Journal.-Western Journal of Med. and
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Cincinnati and Lexington, 1844.]
INTUS -SUSCEPTION. — See art. Colic anh
  Ileus, y 38.
IRITIS.—See art. EYE.
IRRITABILITY.— Svnon.  Irritabilitas;  vis
  irritabilitatis; vis insita,  Haller.    Vis vitalis,
  Gorter.    Irritabilite,  Fr.   Die  irritabilit'dl,
  Reizbarkeit, Germ.   Inherent power, Myotility,
  Muscular Pou\er, Contractility, Muscular Con-
  tractility, Excitability, &c, of various authors.
     Classip.—General Pathology.
   1. Defin.—A power  or properly of organized
bodies of being acted upon by stimuli, so as  to give
rise to movements, manifested chiefly by muscular
or fibrous tissues.
  2. This very important and generally diffused
property of animal bodies was first investigated
by  Dr.  Glisson. .  He applied the term " irrita-
bility^ to all the sensible and insensible movements
of  animals.    Baglivi,   Gorter, Winter, and
Hoffman  used this term  in  nearly  a similar
manner to Glisson, and it  was thus commonly
employed until Haller restricted it to the sus-
ceptibility  of  movement  in muscular tissues, and
carefully  investigated  its  laws  in  those parts.
In  this latter sense' it was employed by physiol-
ogists, until  Girtanner  rejected the restricted
sense of Haller, and  used it in the  compre-
hensive sense adopted by  Glisson.
   3. i.  Of the Source of Irritability.—The source
of this property soon  became  a subject  of dis-
cussion.  Most  physicians recognised it  as a
manifestation of life in organized  bodies; but
the circumstance of its being called into activ-
ity by  nervous influence readily suggested the
question  as to its dependance' upon,  or inde-
pendence of this influence.  Haller and  his
disciples, with Fontana, Metzger, Bichat, and
others, considered irritability to be, sui generis,
inherent in  the  muscular fibre, altogether  in-
dependent of nervous  influence, and  only sub-
jected, in muscles governed by the will, to the
action  of the nerves, which, in  this case, serve
as conductors of the stimulus intended to excite
contraction.   They founded their opinion  on
the facts, that muscular power is altogether dif-
ferent  from the  power of living nerves in  its
manifestations, the former consisting of visible
 oscillations  and movements not perceivable in
 nerves; and that destruction of the brain and
 spinal chord, or division of the voluntary nerves
 supplying the muscles, does not annihilate the
 power of muscular movement, when subjected
 to  irritation.   On the other  hand,  Whytt,
 Monro, Unzer,   Prochaska,  Legallois, &c,
 regarded the nervous power as  the  principle
 upon  which  all muscular  contractions depend,
 and, consequently, irritability to be communica-
 ted to the  muscles   by the  nerves, because
 nerves enter into the composition of all mus-
 cles ;  because the latter contract quite as well
 when  the  former are irritated as when  the
 stimulus  is applied to  the  muscles themselves ;
 because irritability is  extinguished by substan-
 ces subversive of nervous power ; and because
 the destruction of the brain and spinal chord,
 and section or ligature of  the nerves, cause  the 
IRRITABILITY—Source and DependaNce  of.
691
disappearance of the  power of contraction on
applying irritants to the muscles.  It is obvious,
as Tiedemann has  remarked, that both parties
have pushed  their  arguments too far, and, in-
deed, have over-stated or exaggerated the facts
from which they argue.  Haller and his dis-
ciples were wrong, and went counter to every
idea  of an organized body, in  which  all the
manifestations of life  are mutually connected,
in attributing to the muscles a faculty altogether
independent of the influence  of the nervous
system.  But his opponents were equally wrong
in attaching  too great  an  importance  to the
part which  the cerebro-spinal nervous system
performs in the  phenomena of muscular con-
tractility.
  4. In the year 1820,  and subsequently (see
Lond.  Med.  Repository, for May,  1822, and my
Notes and Appendix to Richerand's Elements of
Physiology, &c,  edit. 1824, 2d ed. 1829, p. 690),
I showed, as  the result of my researches into
this subject, that  irritability is  not dependant
upon the  cerebro-spinal  nervous  system, al-
though it is excited by this system ; but that it
proceeds from the organic  or ganglial system
of nerves*—that this  latter system bestows on
  * As respects the more perfect manifestationsof this prop-
erty, by means of muscular structures, I there stated, " that,
as irritability is present in parts which do not receive vol-
untary nerves, this faculty cannot  be attributed to them.
To what other species of organization can we refer it 7  We
observe it, in the more perfect animals, displayed chiefly by
muscular parts.  Is it from this circumstance  an attribute
only of muscular parts, and the jpure result of their confor-
mation? One class  of physiologists answers this question
in the affirmative.  But irritability is manifested in the low-
est orders of the animal creation, as well as in some of the
higher, by parts in which a  muscular structure cannot be
detected ; therefore, although a property of the muscular
structure, it is  neither altogether restricted to it,  nor is it
strictly the  result of the organization of this structure, in-
dependently of some other.  Consequently, this property
must be referred to a conformation still more general than
the muscular tissue, as respects both the entire scale of an-
imal creation and  the organization of individual species ; al-
lowing, at the same  time, that a particular structure is re-
quisite to the full  and perfect manifestation of this property,
but that this structure depends upon a different source than
itself for the property which  it displays.
  "Having  arrived at the conclusion that irritability, al-
though a property of muscular parts, is not the result of
muscular organization merely, but is derived from  a differ-
ent and more general system, supplying the muscular struc-
ture as well  as other structures, we must next inquire what
this system  is.  It has been already shown that the organic
or ganglial nervous system is distributed in various propor-
tions te all  the textures and organs of the body ; that this
system is similarly distributed throughout all the individu-
als composing the-animal kingdom ; that in some animals it
is the chief nervous  system ; that not  only is  it  present
wherever irritability is manifested, but it is the most gen-
erally diffused of  all the tissues; that no other structure
than this exists  which can be shown to be present  in every
species of irritable or contractile parts, in all orders of ani-
mals ; and, consequently, that to no other source than this
can irritability be  assigned.
  " Having  inferred  that the muscular fibre is only the in-
strument of contraction in its more perfect condition—that
it performs the function in consequence of a certain confor-
mation, and  owing to that conformation being endowed by
another still more generally diffused than itself—and that
this property is derived from the  ganglial, or soft nervous
system—we are led farther to infer that the cerebro-spinal
nerves are distributed to muscular parts for specific purposes,
but  that these  parts do not derive their innate properties
from these  latter nerves —  these nerves  merely  exciting
them, or acting as conductors of a stimulus to properties
which proceed  from a different source.  I have contended
that these properties  are not innate, or the consequence of
the  conformation  of the muscular fibre itself; but are de-
rived from  a conformation more general, surrounding or
otherwise connected with the  muscular fibrils, and that
this more general  conformation is  the organic nervous sys-
tem.  Conceiving, therefore, that this system, in  its state
of ultimate distribution and dissemination in the texture of
* muscle, whether in the form of unarranged corpuscles or
muscular or fibrous tissues the power of con-
traction, while the  spinal nerves  simply con-
duct  or convey the stimuli  to   contraction.
This statement, with the proofs and arguments
in its favour, appeared at the time  just stated;
and in  1835—fifteen  years subsequently—Dr.
Fletcher published lectures  (in Lond- Med. and
Surg. Journ., vol. vii., p. 327, et seq.), in which
not only the same statement, but also the iden-
tical proofs and arguments  which  had  been
urged by me  in  the works above  referred to,
were  adduced by  him  as  his  own  original
views, and in  some parts in nearly the same
words as I  had there employed.  In the  repub-
lication, however, of these lectures,  and in a
different form,  some reference was made to
the originator of these  views, but in  such a
manner  as  showed that  the act  was one  of
compulsion rather than of inclination.
   5.  As expressed  in my published  notes  on
this subject, and on others connected  with it, I
have suggested that the  different  departments
of the  nervous  system   have been   hitherto
viewed  in a much too restricted manner; and
that, instead of considering the different  orders
of nerves as ramifications shooting forth  from
the large nervous masses, it would be equally,
if not more correct,  and consistent  with the
gradual  rise in the scale of animal  creation,
and with the  development of  the tissues and
organs in the  higher animals, to view them as
originating in  the different structures and or-
gans in which they, have hitherto  been said to
terminate.*   The  reasons  which I  assigned
of minute and variously arranged fibrils resulting from the
regular distribution of these corpuscles, is the chief source
of the property evinced by muscular parts of every denomi-
nation,  I farther conclude that the cerebro-spinal nerves do
not produce their specific effects on muscular fibres, owing
to a  nervous fibril being ramified to each muscular fibril,
for this does not take place ; nor do these effects proceed
from the direct influence of these nerves upon the muscular
fibril, for the muscular fibre has been shown to derive its
property or faculty of contraction from a source different
fi;om itself and from the voluntary nerves which occasion-
ally excite its 'contractions; but that these  nerves seem to
act directly upon the ultimate distribution or corpuscles of
the  organic nervous  system in the  muscle, which system
bestows on it the faculty of, or disposition to, active con-
traction, on the application of a stimulus ; and this faculty
all muscular parts possess, although some of these parts
only  are supplied with voluntary nerves, and are liable  to
be acted upon  by cerebro-spinal influence.  The mode of
termination of  voluntary nerves in muscular parts also fa-
vours the opinion now stated.  These nerves terminate, as
already noticed, in such a manner as leads me to infer that
they become, in the textures which they supply, gradually
identified, as it were, or  amalgamated, with the ultimate
distributions of the ganglial nerves ; and the history of the
embryo and the progressive development of the nervous sys-
tem in the lower animals lead me to  believe that the volun-
tary  nerves originate in the textures which they supply;
that  they proceed from the ganglial system ; and that their
larger branches, the spinal marrow, and  encephalon are
successively formed.'y
  * u Viewing the nervous system throughout the numer-
ous classes of animals, and tracing the process of its forma-
tion  from the embryo up to the period of perfect foetal ex-
istence in  the  higher animals, I am led to infer that this
system is not originally formed from  the centre towards the
circumference, but that the origin of its ramifications com-
mences in the mucous or cellular tissues, when the embryo
is yet but in an apparently homogeneous state ; and that as
the textures become, in the process of  foetal growth, more
and more developed, so the corpuscles composing the rudi-
mental nervous system, and chiefly those of the ganglial
system of nerves, are arranged into  chords of communica-
tion, chiefly in the course of the vessels, for the purpose of
preserving a connexion between the organs, and re-enforcing
each of the textures with the influence which those systems
generate in their perfect states of  development.  As the
embryo is formed, the nervous  ramifications advance to-
wards centres, which vary in their characters according to
the genus  of the  animal: in those which are more perfect 
692
IRRITABILITY—Source and Depenuaxce  or.
for this mode of investigation, and for adopt-
ing it in addition  to  the  one-sided mode  of
viewing this subject hitherto pursued, need not
be  here  repeated.   I  may, however,  briefly
state, that the lowest grades of animal bodies,
and the earliest stage of animal formation, dis-
play merely  minute granulated  or nucleated
globules  or corpuscles, more or less abundant-
ly disseminated  throughout the cellular and
other tissues; and that, as these  tissues are
more visibly developed, and  assume a more
truly  cellular and fibrous  conformation,  from
the almost albuminous state of the earlier stage
of their formation, so  the gray fibres constitu-
ting the organic nervous ramifications become
visible in connexion with these corpuscles.  In
the fully-developed state of animal organization
these granulated  corpuscles are numerous and
demonstrable in the tissues, particularly in the
ganglions in  connexion with the gray organic
fibres, and in the muscular fibrils,  both invol-
untary and voluntary.  But,  whether  these
corpuscles are formed before the large nervous
masses connected with sensation, volition, &c,
or contemporaneously with these masses, is of
little consequence.  The most important ques-
tion is, what is the function performed by these
corpuscles 1  When we recollect  that  these
bodies are found  disseminated through  the  al-
buminous and  otherwise  almost inorganized
structure of polypi, and throughout the tissues
of others of the lowest animals, which manifest
irritability as> their most .important function,
and when we  know that  these animals are
capable  of being multiplied by  division, and
that parts cut off from them have separate
existences,  it seems highly probable that the
vital  functions they display — that irritability
proceeds from this peculiar organization.  Hav-
ing farther observed these  granulated corpus-
cles disseminated through  other  tissues,-in an
abundance proportionate to the amount or grade
of vital function—having detected these corpus-
cles in great numbers within the delicate mem-
brane investing the primitive fasciculi of volun-
tary muscular fibrils, and  in the flattened fib-
rils  of involuntary muscular parts — having
seen  still greater numbers of them comprised
in the structure of the organic nervous fibres,
and constituting  the chief part of the ganglia;
and having, moreover,  found them giving origin
to  the gray and  solid filaments  of organic
nerves, as well as comprised in or embraced by
these filaments,  it  may be inferred  that they
are mainly concerned  in the production of the
various  grades  of irritability  or contractility
manifested by the  tissues in  which they* are
thus disseminated, and to which  they are thus
supplied.
   6. The views which I  published in  1820,
1824,  and 1829, respecting the constitution,
those centres are numerous, and almost  each differs more
or less sensibly from the other, both as to appearance and
function."— See Author's Notes, <fcc, to  M. Richerand's
Elements of Physiology, &c, p. 1.
  * Schwann and  more recent  microscopic observers and
physiological writers, both foreign and British, suppose that
these granulated corpuscles  are  merely  the nuclei of the
cells from which, according to him, all the tissues are de-
veloped. That this, however, is not the case, and that these
corpuscles are intimately connected with the performance
, of important functions, are shown by their higher and more
complex organization, and  by the circumstances of their
constituting the principal part of the composition of the
 ganglia and of the organic nerves.  I would therefore de-
nominate them the organic corpuscles.
connexions, and  functions  of the organic  or
ganglial nei vous  system, have been  more re-
cently (from 1831 till 1840)  confirmed by the
researches of Retzius,  Giltay, Muller, and
Valentin.  The  organic, or gray nerves, do
not consist, as the motor and sensitive nerves
of the spino-cerebral axis do, of parallel tubes
containing a liquid matter,  but  are altogether
homogeneous, pale, almost  transparent,  and
peculiar in their form, distribution,  and  con-
nexions.   They are  intimately connected with
the granulated or nucleated corpuscles dissem-
inated throughout the  tissues, and they either
enclose,  or  are  otherwise  associated with,
these-corpuscles or globules in great  numbers,
both  in the  ganglia and in  the  plexuses  and
ramifications.  The gray, or ganglial nerves,
thus seem to arise from  the organic globules
just described, especially from those  contained
in the ganglia.  The ganglia should therefore
be regarded as the central organs of the organ-
ic nervous system ;  and the  white fibres which
run to and through them, especially in the lat-
eral chords  of sympathetic  ganglia, without
having any intimate connexion with the gran-
ulated corpuscles of the ganglia, and merely
passing between these corpuscles, are the sen-
sitive  and motor fibres  of  the nerves derived
from  the cerebrum and spinal chord.   The or-
ganic, or gray portions of" the nervous system,
and more especially of those parts of it lodged
in  the abdominal, thoracic, and cervical re-
gions, preside over the organic and truly vital
functions  ; and their connexions with the cere-
bro-spinal centres are such  as evidently show
that they are ramified  thither in order to en-
dow these centres with  the organic nervous
power in common with other parts of the econ-
omy ;  nerves proceeding from these centres
also  being ramified to the  ganglia  to supply
them with the sensitive and motor influences.
The  nervous connexions or ramifications be-
tween the ganglia and cerebro-spinal axis thus
consist of the solid or homogeneous gray fibres
of organic nerves conveying the strictly  vital
or vegetative influence to the brain and spinal
chord, and of the whitish tubular fibres of mo-
tor and sensitive nerves transmitting the influ-
ence  of these organs in various degrees to the
viscera engaged in the strictly vital operations.
In those parts which perform complex functions,
as  the organs constituting the face, mouth,
throat, &c, and the organs of generation, which
are endowed with  the  functions  of  secretion,
sensation, and motion, the  nerves proceeding
thither consist both of the gray fibres of organ-
ic life, and the white tubular fibres of sensitive
and motor nerves.
   7.  From  what has  been  here stated, from
the most recent researches, and from the con-
formation detected by microscopic observation,
the  results  of  my  own investigations many
years since, as published in the works already
referred to, have been fully confirmed, namely,
that  the  organic or ganglial nervous system
presides over the strictly vital functions, and
that all the grades and manifestations of irrita-
bility or contractility proceed from this source.
It  is  extremely probable that  the  organic or
nucleated corpuscles disseminated throughout
the structures, and particularly in fibrous and
contractile  parts, bestow a  certain  share  or
grade of contractility upon  them,  and that  an 
IRRITABILITY—Grades op.
693
additional or  even  a principal share  of this
property is contributed by the  ganglia  and or-
ganic nerves distributed to them.  Indeed, this
is  shown by numerous observations made by
me in 1812 and 1813, when it was proved that
the hearts of fishes continued to contract for  a
considerable  time  after  they  were removed
from  the animals,  and  from all  the nervous
structures external to themselves ; while influ-
ence of the ganglia  on the involuntary muscles
was proved by the application of powerful stim-
uli  to the coeliac ganglion having  caused in-
creased peristaltic movements of the intestines
that continued for some time.  (See a notice of
these experiments in my " Notes," &c, already
referred to.)
  8. In  the organic muscles, which  possess ei-
ther a power of almost continued action, or  a
certain  rhythm of action, as the heart  and ali-
mentary canal, the  organic  nerves  are plenti-
fully distributed,  and abound with the  organic
corpuscles above described ; showing that the
unexhausted irritability of these parts is chief-
ly owing to this  organization.   The facts and
arguments adduced so many years since by me,
in  proof of the dependance of irritability upon
the organic  nervous system, have  been  very
recently urged, with little Variation, by  Doctor
Fletcher, and  by several  German writers ;
but what they have  advanced merely confirms
what I had published, fully explained, and made
even the basis of a system of general and spe-
cial pathology, many years previously, in the
works above stated.  Among  others, the sub-
joined  remarks* of Mueller, from the able
translation of his Elements of Physiology, by
Dr. Baly, may  be  adduced in illustration  of
what I  had stated  long since respecting the
functions of the organie or ganglial  nervous
system, and  the source  of irritability.  After
stating  the same facts as have been advanced
by me, he draws the same  inference,  namely,
"that the organic  nerves  distributed in the
muscular substance have a principal share in
the production of their automatic movements,
and that the rhythmic  contractions of  the or-
ganic muscles  are  not independent   of the
nerves,  as Haller  believed."  (P. 913.)  The
error of those who contended that irritability
was independent of nervous  influence arose
from the circumstance of their confounding the
  * " It has been proved that the automatic movements of
the organic muscles, like all muscular motion, depend pri-
marily on the influence of the nervous principle ; that the
cause of the rhythm of these automatic motions is not con-
nected with the nature of the muscular fibres, but with the
peculiarity of the nervous system of the organic muscles ;
and that the cceliac ganglion has the property of exciting,
when irritated, the peristaltic motions of the intestines.  It
appears, moreover, that the sympathetic nerve retains its
ganglionic structure even in its more minute ramifications;
and the poweT of the intestine to perform its peristaltic mo-
tions is found to be preserved even when it is separated from
the mesentery.  From  these facts, then, I conclude that
even the minute branches of the sympathetic, which ramify
in the intestinal coats, have the same power of causing pe-
riodic contractions as the cceliac ganglion was proved to
possess.   The explanation which applies to the peristaltic
movements of the intestines has the same force with rela-
tion to the rhythmic motion of the heart, the first observed
motion of which, in its simple tubular condition, is indeed
of a peristaltic nature.   Since, therefore,  not merely the
larger ganglions of the sympathetic, but even its ultimate
ramifications in the tissues of organs, seem to possess the
power of giving rise to periodic motions, we can understand
how the rhythmic  movements of the heart, intestine, and
oviduct of the turtle are enabled to continue when these
organs are removed from their connexions in the body."—
Mueller's Physiology,   Baly, p. 914.
cerebro-spinal  nervous influence, or sensitive
and motive function, with organic nervous pow-
er, or  the strictly vital manifestations.   Hal-
ler, believing  that there was only one species
of nervous influence, and that it proceeded from
the brain, considered the irritability of muscu-
lar parts to be  what it really is, independent of
this part of the nervous system ; but his argu-
ments and  facts left entirely unaffected,  or,
rather, confirmed the  view, first advanced and
supported by me, that this property of animal
bodies proceeds from the organic nervous sys-
tem, which  system I showed to  be  altogether
distinct from the cerebro-spinal nervous sys-
tem, its functions being different from those of
the other system, and altogether of a strictly
vital character.*
  9. From what has been now  stated,  it will
be inferred that  irritability,  according to  the
sense  in which it has been viewed by Haller
and others, is the contractility, or power of con-
traction, possessed by muscular parts, and dis-
played by them when  aeted upon by stimuli or
irritants.  In the wider sense of the word,  ac-
cording to Glisson  and others, it is the  power
of sensible and insensible contraction possessed
by most living  tissues.  The molecules of mat-
ter, composing  the  living structures,  are pre-
served in a state of cohesion, varying in grade
in the different tissues. This variation in grade
depends  upon  the  organization of the tissue,
and  upon the  state of its vital  endowment.
That the organization affects the cohesion of a
particular structure, does  not  require proof;
and that the  state  of vitality exerts a marked
influence upon the cohesion of the tissues gen-
erally, is  shown by the gradual loss of cohe-
sion, as vitality departs, and as it becomes  re-
duced  in the progress of diseases characterized
by exhaustion.  The state of the blood also af-
fects the cohesion of  the structures, but most
probably by first reducing vital power.  From
this intimate  dependance  of structural cohe-
sion upon vitality, the term vital cohesion of the
tissues may be  used  with reference  to some
of the most important conditions presented by
them in  health and in disease.   As  the pow-
ers of life are perfect  and strongly manifested,
so cohesion  is  perfect; and, as  these powers
are reduced, so it also  is reduced.   Hence it
becomes an  index, in many diseases, of  the
degree to which this reduction has taken place,
the firmness and tenacity of the tissues, and
the  duration  of these  properties  for a time
after death, varying with the reduction of vital
energy.
  10.  ii. Of the Grades of Irritability.—The vi-
tal cohesion of the tissues is one of the earliest,
the most generally diffused, the lowest, and  the
most persistent of vital phenomena.  It fur-
nishes, as it were,  the basis for all the other
manifestations of life ; and as it becomes weak-
ened, or ceases, these manifestations more or
less completely disappear.  As long as the  tis-
sues  are endowed -with life, vital  cohesion
continues, varying, however,  in grade with  the
circumstances just  stated.  Of the  parts pos-
sessed of vital cohesion, a very large proportion
  * On this subject the reader is referred to the London
Medical Repository, vol. xvii., p.  370, et seq.; and to the
Author's Notes and Appendix to M. Richerand's Elements
of Physiology, where will be found the same facts and opin-
ions stated as early as 1820, 1822, and 1824, as. hare  been
espoused by MUELLER, and others much more recently. 
694
IRRITABILITY—Conditions necessart to.
present certain graiies and modes of contractili-
ty which  have been  variously denominated.
Contractility is essentially a vital phenomenon,
and results  from changes  in the vital endow-
ment of a structure affecting the relative posi-
tion of the molecules composing such structure.
Vital contractility may be divided  into grades,
commencing with the lowest and tbe most gen-
erally diffused grade of this property of living
parts—with that grade the next above simple
vital  cohesion,  in  the  scale of animal mani-
festations.
  11. 1st. Insensible organic contractility, or that
state usually denominated tone or tonicity, is,
like  vital cohesion, not confined to  the animal
kingdom : it is a property of vegetables and of
animals not possessed of a heart.   It is dif-
fused  throughout  the  tissues, and  may be
viewed as  merely  a  higher  grade of vital co-
hesion, or, rather, this latter may be considered
as the lowest manifestation of life in organic
structures, insensible  organic  contractility or
tone being the next in the scale.  This  prop-
erty,  equally with  the preceding, results from
the vital influence  with which the  structures
are  endowed—is perfect,  as this influence is
perfect, is impaired as it is weakened, and al-
together disappears soon after life has depart-
ed.  Insensible contractility or tone is manifest-
ed by the vascular system more especially, and
by the soft  solids generally ; and it is more or
less exerted in all  the vital operations—in the
circulation,  in secretion, in nutrition, and in ab-
sorption, the perfection  of these functions de-
pending upon its due manifestation.  The or-
ganic nervous system seems to be instrumental
in its production and preservation in the animal
kingdom, as I have contended  in the works al-
ready referred to.
  12. 2dly.  Sensible organic contractility, or irri-Ji
tability, is that  property of contraction which
exists in fibrous and muscular parts.  It  is ex-
cited by the application of an irritant or stimu-
lant, and depends,  as I have shown above (§ 4,
et seq.), upon the ultimate organization and dis*
tribution of the organic or ganglial nervous sub-
stance or corpuscles to these parts.
  13.  Both  these species of organic contractil-
ity result from one species of influence  with
which animal bodies are endowed—they are the
proximate  results  of vitality,  and differ from
each other, owing  to the intimate structure of
the parts in which they are  seated, and to the
extent to which each of the parts  manifesting
these properties is supplied with the  organic
nervous globules and ganglial  ramifications.
   14.  3dly.  Cerebro-spinal contractility  is  the
contraction of those muscles which is occasion-
ed  by volition, and by stimulants  acting upon
their motive and  sensitive  nerves.  It  takes
place  only  in such muscles  as receive nerves
from the spinal chord, medulla oblongata, and
encephalon ; and results  from this conforma-
tion and connexion with these centres of voli-
tion  and sensation.   Although produced  and
directed by volition,  it may  also be excited by
irritations acting upon, or conveyed to, the cer-
ebro-spinal  axis, or the nerves proceeding from
any part of this axis.
   15. The first and second species of contractil-
ity proceed from the organic  nervous system
 and influence; the third from the  super-addi-
 tion of the  nerves of voluntary motion and of
sensation.  This last form of contractility, how-
ever, may take place in voluntary muscles, in-
dependently of volition, by  a "reflex sympathy,
as shown by me in the places already referred
to ;* and  independently, also, of sensation,  as
subsequently contended for by Dr. M. Hall, by
means of what he has denominated a  " reflex
function," with which he  supposes  the  spinal
chord to be endowed.
   16.  As the various grades of contractility are
dependant upon vital energy, and as  the higher
grades  of it  are  influenced, moreover,  by the
states of the nervous systems—sensible organic
contractility, by the organic nervous system;
and cerebro-spinal contractility by the cerebro-
spinal  system—so it  must necessarily follow-
that they will  vary in their grades and condi-
tions  with the vital  manifestations  generally,
and with those more particularly evinced  by
these systems.  Hence irritability may be im-
paired or exalted, either throughout the frame,
or in  one Or more tissues or parts.   Irritable
structures, moreover, are  not only liable to al-
terations in the grades of  action, but they also
evince a greater or less disposition to be acted
upon by the ordinary stimuli.   The susceptibil-
ity of irritation as well as the degrees to which
the consequent contraction takes place in living
structures, vary in different constitutions and
temperaments, and  in different diseases, and
even in the same disease, owing to various cir-
cumstances connected with diathesis and habit
of body, and with the nature of the exciting
causes.
   17.  iii. Conditions requisite to the healthy man-
ifestation of the several grades of irritability.—
From what  has been  stated,  it is obvious that
these manifestations will be  perfect  according
as the vital  endowment is perfect.   That form
of  contractility  with which  the involuntary
muscles are endowed, being altogether depend-
ant upon the ganglial nervous system, will ne-
cessarily be influenced by the conditions of this
system ; and that which is displayed by volun-
tary muscles will vary, according to  the states
of the cerebro-spinal  axis and nerves, chiefly
in respect of the degree in which these mus-
cles will still continue subjected to  the influ-
ence of volition ; injury or destruction of these
parts  of the nervous system leaving  the volun-
tary muscles still possessed of their  contractil-
ity, although in a more or less impaired form,
owing to the loss of an accustomed stimulus to
contraction ; and, as I have stated many years
ago in my physiological notes, it is reasonable
to suppose " that  the voluntary nerves convey
to the organic or vital nerves a natural stimu-
lus or influence ; and that, if the latter nerves
were  deprived of this additional influence, the
parts supplied with them would necessarily suf-
fer an impairment of function."
   18. A.  A strong proof of the influence of the
nervous systems upon irritability is furnished by
  * See, also, several articles in the first -volume  of this
work, which were published twelve months before the ap-
pearance of Dr. M. Hall's views.  Jn these articles (p. 322.
« 23, p. 331, <> 16, p. 424, v 46, and p. 576, v 81) I have ac-
counted fo» the occurrence of involuntary movements, con-
tractions, and spasms in voluntary muscles, in several dis-
eases, by showing that they proceed from irritation propa-
gated to the roots of the spinal nerves, or to the spinal chord
itself, and thence reflected, by means of the spinal nerves,
upon the voluntary muscles.   (See articles Cholera Cho-
rea, <fcc, Convulsions, Disease, Epilepsy, and'lRRi-
Tation, at the sections just referred toj 
IRRITABILITY—Conditions necessary to.
695
the operation of these agents, which either ex-
haust or directly depress the nervous power.
Galvanism,  electricity,  mechanical  irritation,
&c, exhaust this  property, and narcotics de-
stroy it, or, at least, greatly impair it.  These
effects are produced upon both voluntary and
involuntary muscles, and whether the  agents
be applied to the muscular tissue directly,  or to
the nerves distributed to them.  In the former
case they affect chiefly the organic corpuscles
or vital nerves actuating the  muscular struc-
ture ; in the latter, they produce a nearly sim-
ilar effect through the medium of the voluntary
nerves terminating in it.   Many of the exciting
causes of disease,  and the majority of our me-
dicinal agents, produce these effects in a sim-
ilar manner; the several manifestations of con-
tractility being thereby  impaired, exalted, or
exhausted, or specifically modified, according
to the natures or properties of such causes and
agents.  From what has been  stated, as well
as from obvious phenomena coming under the
cognizance of every observer, it may be infer-
red that the several grades of irritability of this
property, viewed  in the sense  entertained by
Glisson, are the  most general and important
of the several endowments of life,  and the most
requisite to the continuance of  life.  I  have
also stated, and more fully attempted to  show
many  years since, that  this property results
from a peculiar organization—from the distri-
bution of the organic or vital  nervous  fibrils
and corpuscles to the  tissues  displaying this
property;  and that the  apparent dependance
of it, in voluntary muscles, upon  the cerebro-
spinal nervous system is owing to the termi-
nation  of  motor  nerves  in these muscles, in
order to bring  them under the influence of vo-
lition ;  the high grade of irritability which they
possess being, however, derived  from the or-
ganic or vital  nervous system ;  and probably,
also, re-enforced  by the influence proceeding
from the spinal chord.*
   19.  It follows from the foregoing, that while
the several manifestations of irritability are all
directly dependant  upon the  organic or vital
nervous system—are expressions  of life through
the  medium of this system—one  form only of
this property, namely, voluntary motion,  is un-
equivocally influenced  by the cerebro-spinal
nervous system ;  this  form,  however,  being
chiefly derived  from the former source, although
excited and directed by the latter.  Moreover,
it may be  inferred that these manifestations
being dependant upon this source, the several
changes to which they are subject chiefly pro-
ceed from changes in the condition of the or-
ganic or vital nervous energy ; and that altera-
tions of that form of this property,  which is more
intimately connected with volition, equally with
other forms, also proceed from the  same source;
a healthy  state of the cerebro-spinal nervous
system, and of its ramifications, being requisite

  * " It appears, from the effects of agents upon voluntary
or other muscular parts, when directly applied to the gan-
glial or vital nerves—from the intimate organization of con-
tractile parts—from the distribution of these nerves to the
vascular system, to the extreme capillaries, and to volunta-
ry as well as to involuntary muscles—that the ganglial or
vital nervous system gives rise, in both these kinds of mus-
cles, to the phenomenon called irritability ; the  different
manifestations of this property, as it is displayed in volun-
tary and involuntary muscles, resulting from the accessary
supply of the spinal nerves which the former muscles re-
ceive.— (Notes, &c, 1824,)
to the due excitement, direction, and determi-
nation of this particular manifestation of irrita-
bility.   These  influences, indeed, are daily  il-
lustrated by the  phenomena of disease, more
particularly of  those  diseases which implicate
the vital endowments manifested through the
medium of the ganglial or vital nervous sys-
tem, or which affect the integrity of the cerebro-
spinal system.   In the former class of these
diseases,  the irritability of vital organs is af-
fected co-ordinately with the disorder experi-
enced by the ganglial system ;  and that  of vol-
untary organs  is also either imperfectly mani-
fested, or incapable of being determined or di-
rected.  In the latter class, on the other hand,
the organic nervous system is entirely unaffect-
ed, its functions being quite healthy, and irrita-
bility also perfect throughout the frame ; yet,
owing to lesion  in some part of the cerebro-
spinal system, the contractions of voluntary
muscles are either not excited, or not directed,
or  uncontrolled,  although the power  derived
from the  ganglial system still  continues to  be
possessed by them.
   20.  B.  The influence of the blood upon the irri-
tability of parts is demonstrable.   Stenson, Ar-
nemann, Bichat,  Emmert, Segalas, and  others,
have proved this influence, and shown that the
presence of blood in irritable textures is neces-
sary to the continuance, even for a  short time,
of the property  of contraction; and that the
power of  volition over voluntary  muscles is
lost when blood  is no longer sent to them.  It
is also fully proved that arterial blood is requi-
site to the due performance  of the  several
grades of contractility, and that, while the con-
tinued action of this  blood on  irritable parts is
necessary to  their functions,  this  blood  loses
something by this action, or undergoes changes
 in the course of it, that give this fluid  the ve-
 nous character.  That venous blood  is incapable
 of supporting irritability in its healthy and more
 persistent states, is shown by the blue disease,
 and by the several modes of producing asphyxia.
 The state of the blood in respect,  also, of the
 presence in it of either stimulating, depressing,
 narcotic, or specifically alterative materials, has
 also a most important effect upon  the  several
 forms of irritability.  Many of the causes of dis-
ease, many remedies, and many  poisons,  act
 upon  the frame by passing into the  circulation,
 and affecting, by their presence in the blood, the
different  grades of this property, their influence
being exerted in this way, either upon the organic
 and cerebro-spinal nervous systems, and through
them upon  the  irritable structures, or  upon
 these structures directly, or even  upon  these
 systems and structures conjointly and coetane-
 ously. The changes, also, which take  place in
 the blood, in the course of diseases, particular-
 ly contaminating maladies and fevers, owing
 either to the absorption of morbid matters into
 the circulation, or to interrupted elimination of
 effcete and injurious materials from it, affect the
 several forms of irritability, and even the vital
 cohesion of the tissues, in the manner now ex-
 plained ;  the absorption or accumulation, how-
 ever, of these excrementitious matters gener-
 ally having a similar effect to that produced on
 the frame by animal  poisons.   Contractility is
 affected  by the various stimuli   or  irritants
 which may act  either directly on  irritable or
 contractile parts, or on nerves supplying them, 
696
IRRITATION—Preliminary Remarks.
or on the central nervous organs ;  but remarks
on  this part of the  subject, as well as on the
varying  susceptibility of irritation in  different
persons  and diseases, will  find  a  more appro-
priate place in the article Irritation.
  Bibliog. and Refer.—Glisson, De Ventriculo et Intes-
tinis, 1678, p. 239.—Baglivi, De Fibra Motrice, &c, Opera,
an. 1703, p. 261.—De Gorter, Medicine Compendium, 1731.
— Winter,  De  Certitudine in Med. Pract., 1746.— Haller,
Deux M6 moires sur les  Parties Sensibles  et Irritables.
Lausanne, 1756 ; et Elementa Physiol., 1. iv. et 1. xi.—Zim-
merman, De Irritabilitate, &c, 1751.—Bordeu, Recherches
Anat. sur  les Glandes, &c. Paris, 1751. — Senac, De  la
Structure  de  Cceur, <fec.  Paris,  1749. — Whytt, Phvsiol.
Essays.  Edin., 1755 ; Works, &c, p. 274. —De Haen, De
Sensibilit.  et Irritabil. Hum. Corp., 8vo, 1761.—Battie^De
Princip. Anim. Exercit.   London, 4to, 1757.—Farr, on An-
imal Motion, <fec.  Lond., 1771. — Monro,  Structure and
Functions  of the Nerv. System, fol. ed., 1833.—/. Brown,
Elementa  Medicinae, cap. 11, 12.—G. Blanc, On Muscular
Motion,  Philos.  Trans.,  1788. — Cruickshank,  Philosoph.
Trans.,  1795. — /.  L. Gautier, De Irritabilitatis Notione,
Natura  et Morbis, 8vo.  Hall., 1793; et Physiologie und
Pathologie der Reizbarkeit, 8vo.  Leips., 1796.—E. B. G.
Hebenstreit, Doct. Physiol, de Turgore vitale brevis Expo-
sitio, 4to.  Lips., 1795.—G. Prochaska, De Came Muscu-
lari, Opera Minora Anat. Physiol, et Pathol.,  &c, vol. i.
Vien., 1800; et Bemerk. ueber den Organismus d. m. Kiir-
pers, 8vo.  Wien.,  1810.—G. R. Treviranus, Ueber Leben-
sturgescenz, in Phys. Fragm., th. i., s. 57-102.-iJr. Gregory,
Conspect. Med. Theoretics. <fec, passim. —Legallois, Ex-
periences  sur le Principe de la Vie, p. xvi.—Bichat, Re-
cherches sur la Vie et la Mort.  Paris, 8vr>, passim:  et
Anatomie  Generale, 8vo.  Paris,  passim. — /. Copland, in
Lond. Med. Repos., vol. xvi., p. 370.—Richerand, Elements
of Physiology, <fcc, with Notes and Appendix, by J. Cop-
land, 8vo.  Lond., 1824, and edit. 1829.—Fournier et Begin,
in Diet, des Scienc. Med., t. xxvi., p. 94.—Adelon, Physi-
ologie de I'Homme, 4 vols., 8vo.  Paris edit., 1829, passim.
—D. B. Mojon, Laws of Physiology ; trans, by G. R. Skene,
8vo.  Lond., 1827.—R. A. Rudolphi, Elements of Physiolo-
gy, &c.; trans, by W. D. How, 8vo.  Lond., 1825, p. 207.—
'M.Hall, Phil. Trans., 1833. — F. Tiedemann,  Systematic
Treatise on Comparat. Physiol, <fcc. ; trans, by J. M. Gully
and J. H. Lane, &c, 8vo.  Lond., 1834,  p. 289.—/. Muller,
Elements  of Physiology; trans, by W.  Baly, 8vo.  Lond.,
1840, vol. i., passim.—(A. Walker), Documents and  Dates
of Modern Discoveries in the Nervous System, 8vo.  Lond.,
1839, p. 155.—(See, also, the numerous recent works on Phys-
iology.)
IRRITATION.—Syn.  Opyacr/ioc, epediofioc, Gr.
   Irritatio, Irritamentum, Lat.  Reizung, Germ.
  Irritazione, Ital.
     Classif.—General  Pathology—Special
       Pathology and Therapeutics.
  1. Defin. An exaltation of the vital actions of
a particular tissue or system relatively to the vital
states of other parts.
  2. I. Preliminary Remarks.—Next  to in-
flammation, the morbid condition to which the
term irritation has been applied is the most im-
portant,  both to the  pathologist and to the ra-
tional  practitioner.  Notwithstanding this, the
term has been  vaguely employed, and the ex-
istence of the morbid states which it has  been
used to designate has been as loosely  inferred.
This has arisen, in a great measure, from the
neglect  of these states, until a comparatively
recent period, by most writers on general and
special pathology;  from the want of any pre-
cise ideas respecting the  nature, extent, and
relations of the morbid actions to  which the
term irritation is applicable ; and from the dif-
ficulty of determining the modes, grades, tran-
sitions, and consequences which these actions
experience.   The  varying  characters, also, of
irritation with  the tissue or part primarily or
chiefly affected, and  with  lesions  of adjoining
or of functionally associated parts, and the su-
perinduction  of other  morbid changes,  more
particularly of increased exhalation, secretion,
and inflammatory action,  have given rise  to
much  perplexity,  in respect  not  only of the
meaning  attached to the word, but also of at-
tempts of ascertaining its existence, seat, and
extent.   Hitherto irritation, as a primary mor-
bid condition, has been inferred more frequent-
ly from the absence,  during disease, of more
manifest  alterations than  from any positive
proof of  its presence ; and to it have been  re-
ferred by many  those disorders and maladies
which could not be imputed to any  more palpa-
ble lesion.
  3. It has been shown, in the article Irrita-
bility, 1st. That irritability is the  chief mani-
festation  or expression of life  in the tissues and
organs of a living body.  2d. That it exists in
various grades and modes, according to  the  or-
ganization  and connexions of different textures
and systems, the functions of organs being dis-
charged in great  measure by such agencies.
3d. That  the modes and grades of this property
ascend from  simple vital cohesion up to that
form Of muscular contractility which is deter-
mined  and regulated by the  will.* 4th. That
in this, its highest grade, it interests and is  as-
sociated with conscious sensibility.!  5th. That
it is variously affected by the states and chan-
ges of the nervous system,  more  particularly
by  the  organic or vital nervous system,  and by
the conditions of the blood.   6th. And that such
affections constitute the principal alterations in
numerous constitutional maladies.
   4. To these fundamental principles of pathol-
ogy, which were fully developed by me many
years  ago  (London Med. Repository, vol. xvii.),
others may be added, having  a stricter refer-
ence to the subject now under consideration.
The grades and modes of irritability thus vary
not only  in different  organs or parts, but  also
in different epochs of life, in  different tempera-
ments and habits of body, and under the influ-
ence of numerous  physical agents and  various
moral influences.   Depending, as it does, upon
the amount or condition of vitality, so  it must
necessarily vary with the states of this actua-
ting and controlling principle.  Where this prin-
ciple is powerfully or largely imparted, irrita-
bility  will  also  be energetically evinced,  and
long exerted  ; but Where life is depressed,  ex-
hausted, or feeble from the earliest endowment
of  it in the structures,  then  irritability will be
feebly expressed, readily excited in its  highest
grades, and speedily dissipated.   With weak-
ness  or  vital depression, irritability  becomes
more easily roused—the susceptibility increas-
ed—or, in  other words, the  disposition  to con-
tract upon  the application of irritants  is great-
er ; but the contractions are weaker, and  the
sooner cease  altogether.  Yet this increased
susceptibility of parts thus weakly endowed is
not general, and exists chiefly in  parts which
manifest  the  higher grades of irritability.
  5. Another important circumstance  which

  * " The lower grades of contractility depend entirely upon
the organic  or ganglial nervous system and influence ; the
highest form  only upon the super-addition  of the nervous
system  of  voluntary motion  and sensation." — (Author's
Physiol., Notes on.)
  t " Conscious  Sensibility is confined chiefly to certain
parts and textures of the body, and is  dependant  upon the
part of the  nervous system of which the encephalon is the
centre.   Contractility exists throughout the whole animal
structures,  although in  different grades, and is, with  the
exception of its highest grade or species, entirely'independ
ent of sensibility and volition : contractility is a general ex-
pression of  life, sensibility of the higher functions only of
this principle."—(Notes, &c.) 
ological Relations of.                     697
                       IRRITATION—Path(

may be  noticed is the increased disposition of
local irritation to extend itself in proportion to
the increase of susceptibility, or, in other words,
to the diminution of vital power.  This aug-
mented  disposition  to the  extension of  irrita-
tion, and to the manifestation of several of its
effects in different and remote parts, evidently
depends  upon the same primary condition to
which I have attributed increased  susceptibili-
ty, namely, weakened organic nervous energy
or vital power.  Hence an increased  disposi-
tion to be affected by irritants generally is asso-
ciated also with a disposition to extend their
effects to distant parts.  The extension of irri-
tation, or, rather, of its effects,  far beyond its
primary seat, evidently depends  upon, or, rath-
er, takes place through the medium of the or-
ganic or vital and the cerebro-spinal nervous
systems, the  former especially ; but this topic
will be more fully considered hereafter.
  6. Illustrations of the foregoing pathological
facts are daily presented in practice.  We con-
tinually  observe, in  persons originally and or-
ganically feeble, in those who have become fee-
ble from the exhaustion consequent upon ex-
cessive  or repeated excitement, and in  those
depressed by disease, all contractde parts, more
particularly muscular structures, to be readily
acted on by irritants, especially  by sueh as are
novel; but the excited action  is  weak, or is
soon exhausted,  and rapidly sinks the principle
upon which the contractility depends.  In con-
nexion,  also, with this  local susceptibility, an
increased disposition to experience the effects
of the local and primary irritation in distant
parts is also developed ;  and these distant parts
often manifest the  principal amount  of  disor-
der, evincing both its nature and primary seat.
In these  cases, irritable parts become  more
susceptible of irritation,  or morbidly irritable,
not only locally,  but generally also, as respects
the nervous  systems,  especially  the  organic
cervous system, upon which the several grades
of irritability have been shown to depend. And
here it should be recollected that the-term irri-
table admits  of  two meanings, which  should
not be confounded with each other : some parts
are naturally and healthily irritable; and  these,
as well as some other parts, become morbidly
irritable, owing to numerous causes—to excess
or deficiency of stimuli, to the operation of nox-
ious agents, or of most of the causes of disease
A morbid state  of irritability may be  either
more or less local or limited, or extended and
constitutional; but  in either case,  the suscep-
tibility of contraction is increased, while the
power and duration of it  are  the sooner ex-
hausted.   Mr. Hunter defined morbid irritabil-
ity to be " an increased disposition to act with-
out the  power to act with," with  much  truth,
although with insufficient precision ; but  it will
generally be found,  as I have just  stated, that
the amount and duration of "power" will  be de-
ficient in proportion to the  " increased disposi-
tion."  In all cases of morbid irritability, wheth-
er local  or constitutional, the intrinsic and ex-
trinsic causes and  circumstances connected
with it should be considered;  and this  state,
moreover, ought  to be  carefully distinguished
from irritation ; for  the former may exist with-
out the latter, owing to vital depression merely,
or to this state associated with others ; and the
latter may be induced and continued  by local
    II.               88
agents, where the former can hardly be said to
be present, more particularly with reference to
the constitution generally.  Physically as well
as morally, irritation may be caused, and  yet
morbid irritability may not be present, although
the one  will favour and aggravate the  other
mutually.  Both states are  frequently associa-
ted, but they are not necessarily connected.
  7. II.  Of the  Pathological  Relations of
Irritation.—If an irritant or stimulus act upon
a living tissue or organ, certain changes, hav-
ing reference to the nature of the functions
discharged by the tissue or organ which is act-
ed upon; and to the properties of the agent em-
ployed, are thereby produced.  If the digestive
canal be  acted upon by one particular irritant,
certain of its actions are augmented or modifi-
ed; if a  different irritant is employed, others
of these actions are increased ;  and if the irri-
tant be more powerful or in excess, the effects
are locally heightened  and extended to remote
parts.  If the external structures  and organs
be irritated, sensibility is excited,  and all the
functions of the part more or less increased or
otherwise affected. Whatever may be the  func-
tion of a  part* such function will be exalted by
a moderate irritant; but it will be  disordered,
or even overturned altogether, by an excessive
one, owing to the effects thereby produced in
the circulation and organization of the part upon
which the irritant has acted.  Seeing that the
operation of irritants  is  thus different as  re-
spects their actions individually, and as regards
the tissues chiefly affected by them, and, con-
sequently, that  irritation is various in its  char-
acters, extent, relations, and consequences,  ac-
cording to its cause and seat, it becomes requi-
site to the due  investigation of  this important
department of  pathology to analyze  it  more
fully.
  8. i. Relations of Irritation to the  Ner-
vous  Systems.—A. To the Organic or Vital Ner-
vous System.—The vital actions of a part, and
contractility  in  particular, have  been  shown,
both here and in the places already referred to,
to depend upon  this  system.  When  a tissue
is irritated, these actions are affected, and it
may therefore be reasonably inferred that the
cause of irritation acts chiefly upon the system
by means of which these actions are produced,
and that, in consequence of changes in the parts
of this system distributed to the tissue or struc-
ture which is irritated,  the effects of irritation
are developed.    If a portion  of the intestinal
canal be irritated, either by mechanical or chem-
ical stimuli, its contractility is first  augmented.
If the irritating cause, or the irritation, howev-
er excited, continue for a time, the secreting
functions and the circulation are affected  ; and
if it be energetic or excessive,  these  are still
more increased,  and sensibility, so obscurely
bestowed on this part, is acutely roused.  In
addition, also, to these changes, the irritation,
which was  limited, while it was slight, to  the
parts more immediately subjected to its causes,
now  extends itself, influencing different sys-
tems  and parts ;  and, owing to the  connexions
of the organic  nervous system with the  cere-
bro-spinal, not only is sensation acutely affect-
ed, but also the contractions of voluntary mus-
cles  are  violently excited,  without either the
influence or the control of the will.
  9. Irritation thus originating in parts endow- 
698
IRRITATION—Pathological Relations of.
ed chiefly by tne organic or vital nervous in-
fluence, will either continue more or less limited
in its sphere, or extend itself to various parts, ac-
cording to the general susceptibility of this sys-
tem, to the predisposition or susceptibility of
particular organs, and to various concurring or
determining causes.—a. Where the irritation
is slight relatively  to the amount of  organic
nervous power, or  where the susceptibility is
not increased, the limitation of it to its original
seat may be long continued ;  but where it is
more considerable,  organic nervous power be-
ihg low, and the susceptibility, either general
or local, consequently high, it will extend itself,
or manifest its effects, more or less prominent-
ly, in remote situations.  The limitation of irri-
tation  may be so complete that one function
only of one organ is affected ; but this seldom
is of long duration without other functions and
organs experiencing disorder.  Thus, owing to
mental emotion acting as an  excitement to the
cardiac nerves, palpitation or excessive action
of the  heart is produced ; and  in consequence
of the  irruption of  bile  into  the intestines, in-
creased action of their coats is occasioned ; but
this discharge  seldom  is  great*or continued
without producing  augmented  secretion from
the  intestinal mucous surfaces  generally, and
increased  determination  of  blood and other
changes of the vascular system, consecutively,
as will be hereafter shown.
  10. b. The extension of irritation, particularly
when seated in an internal or vital part or vis-
cus, takes place either directly, by means of the
communicating ramifications of the organic or
ganglial nervous system, or indirectly, and by a
reflex operation of the ganglial nerves, convey-
ing the morbid impression or  action to tbe roots
of the spinal nerves, or to the  spinal cord  and
brain,  and thereby exciting  the sensations or
actions of parts supplied with  nerves  by the
cerebro-spinal system, or in  both these modes,
either   consecutively  or  contemporaneously.
These two distinct ways, by which irritations
or impressions are transmitted to parts remote
from the  seat of impression, were pointed out
by  me many years  ago, and described by the
terms  direct and reflex sympathy.   (See Physio-
logical Notes, &.C., 1824.)  ,
  11.  a. The direct transmission  of irritation
may take place  either along parts  or tissues
similarly  constituted, as mucous or serous tis-
sues, or from one organ to another, by means
of.the  organic nerves with which they  are sup-
plied.   In  this manner,  irritation of one part of
the  intestinal mucous  surface  often proceeds
along it;  or irritation of one part of the mus-
cular coats of the bowels frequently  extends
along the tube, or affects it to a greater or less
extent, as in colic  and  hysteria.  The morbid
impression, also,  made  upon the organic or vi-
tal  nerves  of one tissue or viscus, is often
transmitted thence to an adjoining, but differ-
ently constituted organ,  through  the  medium
of  these  nerves, which are  supplied to both.
Thus  the  irritants  which affect the nerves of
the duodenum or of the stomach primarily, ex-
tend their operation in many cases also to the
liver and pancreas ; and stimuli which excite
the stomach raise the action of the heart and
vascular system.  Irritants of  the kidneys fre-
quently render the  urinary bladder more irrita-
ble, or excite  this latter viscus; and those of
the rectum often extend their influence to both
the urinary and genital organs.   In cases of
this description, it may be asked whether irri-
tants or stimuli applied to an involuntary part
excite the contractions and vital actions of such
part by producing an impression on the organic
nerves which is conveyed  to their correspond-
ing ganglia, and reflected thence by these nerves
upon the muscular fibres which they actuate ;
or whether they act directly, and without the
intervention of  the ganglia, independently of
any reflex  operation, and  simply  by affecting
the state of the nerves themselves—by affect-
ing the organic corpuscles and fibrils  entering
into the organization of the part.   I would in-
cline to this latter alternative;  although I ad-
mit that the ganglia may generate an addition-
al vital  influence,  re-enforcing that with which
the tissues and  organs  are endowed.   The
truth of this inference is confirmed by the fact,
often observed by me and  others, that involun-
tary contractile parts, as the heart and portions
of  the intestinal canal, may be excited to con-
traction even when  removed from their con-
nexions with the ganglia.
   12. /3. As I  have shown,  when treating of
various diseases originating in the nervous sys-
tem,  irritations commencing in  the  organic
nervous system are often propagated to the
cerebro-spinal system, and thence reflected upon
external and distant parts, either affecting the
nerves of sensation, morbid sensation or pain
being felt  in parts  to  which such  nerves are
distributed, or  exciting those of voluntary mo-
tion, so as to remove them out of the due control
of  the will.  In this manner I explained, in the
early parts of the work (published in  1832 and
1833), the origin of several spasmodic and con-
vulsive diseases; and  insisted that the irrita-
tion thus conveyed to the roots of the spinal
nerves, by means of the communicating rami-
fications of the gray or ganglial nerves, either
might reach the spinal chord and brain, thereby
exciting involuntary or automatic  motions  of
involuntary parts and  conscious  sensation, or
might affect the nerves of motion  and sensa-
tion, and  the parts supplied by them;  the cer-
ebro-spinal axis being only contingently impli-
cated.*
   13. B.  Relations of Irritation to  the  Cerebro-
spinal  Nervous  System.—That  irritation of  a
part,  as of an  extremity, will excite  contrac-
tions of the muscles of the same or of an adjoin-
ing part, independently of sensation or of the
intervention of the brain, has been illustrated
by Dr. M. Hall ; but, instead of attributing this
to  a " reflex function," as he  has  done, it  may
be  explained  as  I  have  many years ago at-
tempted,  in a  work  already referred to,  by
means of a "reflex  sympathy."  Dr. Hall and
.Mr. Grainger, in  endeavouring to establish the
existence  of this as a distinct function, have
attempted to connect  it  with a particular or-
ganization of the spinal chord; and  to  show
that there are not only nerves of sensation and
voluntary motion, which have an intimate con-
nexion  with the brain, and are actuated  by  it,
  * The reader is referred to the articles Cholera, y 23,
Chorea, v 16, and Convulsions, t) 42-46, the last espe-
cially, for remarks upon reflected irritation, which  were
Written in 1830 and 1831, and published in 1832, long be-
fore the appearance of Dr. M. Hall's views on the subject,
and explained by him by means of a " reflex function." 
IRRITATION—Patho
 but also a distinct class of nerves which are
 independent of this organ, and arise from the
 spinal chord.  This class he has denominated
 the  " excito-m.otory"  and  " reflecto-motory"
 nerves.  Dr. Hall limits the phenomena of re-
 flex action  to this class of nerves, and denies
 the cerebral nerves of special sense the power
 of producing  them.  He supposes the  reflex
 motor actions to  be in no case excited by sen-
 sation, nor even by means of the sensitive ner-
 vous  fibres.   He  maintains  the  existence of
 spinal nerves, endowed with the " excito-moto-
 ry" function ; and the reflex action he supposes
 to be conveyed, not by the nerves of sponta-
 neous motion, but  by special fibres, which he
 calls  "reflecto-motory."  This theory of ex-
 cited  and reflex movements being produced by
 nervous  fibres which are distinct  from  those
 which reach the centres of sensibility and voli-
 tion in the brain, has been  supported by  Mr.
 Grainger  and,Dr. Carpenter.   The former
 believes  that the  fibres of the roots' of the spi-
 nal nerves, which pass into the chord, and are
 lost in the gray  matter, as demonstrated by
 Weber,  Bellingeri, and himself, are the true
 excito-motory and reflecto-motory fibres.  Such
 may or may not  be the  case ;  or  the nerves
 which thus originate in the gray matter of the
 chord may be destined to transmit to the  gang-
 lial system the influence generated by this part
 of the chord, thereby re-enforcing,  and, in cer-
 tain places or ganglia, modifying  the influence
 proceeding from  the  organic nervous system
 itself.  Thus, the ganglia supplying the heart,
 the genital organs, and the outlets of mucous
 canals, are re-enforced by nerves from the spi-
 nal chord ;  and it seems much more probable
 that the  gray matter of the chord gives origin
 to them, and generates an influence necessary
 to the due performance  of the  functions of
 these parts, than  that it gives origin to a class
 of nerves,  the existence of which, as well as
 of their  imputed  functions, is altogether  hypo-
 thetical.
  14.  The  chief phenomena adduced in favour
 of an " excito-reflecto-motory" function,  of its
 independence qf  sensation,  and o.f the gray
 matter of  the chord  giving  origin to nerves
 destined to perform this function, are: 1st. That
 reptiles and various others of the lower ani-
 mals,  when decapitated,  may still  evince mo-
 tion of a part when  its surface is irritated ;
 2d.  That an apoplectic or paralyzed person may
 refract or move the paralyzed limb when it is
 pinched ; and, 3d. That infants, when asleep,
 may clinch  their hands when the palms are ir-
 ritated.  The same explanation applies to these
 several phenomena.  But as long as they ad-
 mit of explanation without calling in to our aid
 the existence of  a new and  special apparatus
 for this purpose, the material presence of which
 is not demonstrated or even rendered probable,
 we  are bound to refer them to the organization
 which is generally admitted, as parts of the
 offices discharged by it.  In reptiles, and evert
 in higher orders  of animals, it has not been
 ascertained how   far  sensation  is extended
throughout the nervous system, or how closely
it is confined to the brain, or the  ganglia serv-
ing  the offices of  the brain.   The distinctions,
moreover, existing between conscious and in-
conscious sensations have never been attempt-
ed to  be drawn;  unless, indeed, in the  brief
logical  Relations of.                    699

manner I have attempted, many years ago, in
my physiological notes.   That the brain is the
seat of conscious sensation, in the higher ani-
mals especially, will not be denied ; but that a
species of sensation—a susceptibility of motion
and action, particularly of such motions and
actions as have become  habitual, is  retained
and exerted under the influence of certain stim-
uli or irritants, when the brain is no  longer
conscious, or  even  after its removal in  young
or  in the lower animals, cannot be  doubted.
The mere turning  in bed while  a  person is
soundly asleep is a proof of this ; and the mo.
tions of a limb, upon  irritation of it, in apoplexy
or in paralysis, is of a similar description.   In
these cases, the brain is not in a condition to
manifest consciousness ; but, with the rest  of
the nervous system, it may still be so impress-
ed  by an obscure feeling of uneasiness  as to
give  rise to  motion or  change of position.
The explanation given of these phenomena by
Dr. M. Hall would have been more convincing
if a different one equally, if not more conclu-
sive, could not have been offered. For, if the
facts and  arguments adduced in the article
Irritability,  and  elsewhere, be  received, it
will necessarily follow that  the  irritation of
parts acted on by volition will give rise to con-
tractions  of them,  as  in  involuntary parts ;
seeing that  the nerves of volition are merely
superadded, in the former, to the organic  or
ganglial nerves, which supply them in common
with all other  contractile parts ;  and that con-
tractions will thus take place in them independ-
ently of the transmission of the irritation by
means of excitory fibres to the chord, in order
to be reflected back again by means  of other
fibres.  Even granting that the irritation  is
conveyed by nerves of sensation, it does not
follow that it shall reach the chord itself, for it
may only proceed as far as the ganglia on the
roots of trie nerves, and there  partially affect
the motory fibres corresponding with the sensi-
tive fibres, without  giving  rise  to conscious
sensation.
   15. Moreover, as the nerves of general and
special sensation may be viewed as originating
in the tissues and organs  they actuate, and the
parts they endow, as shown to be the case in re-
spect of the organic or vital nerves, and  as
converging to the spino-cerebral axis—being,
in fact, centripetal nerves—it may reasonably
be expected that, irritation of a part will often
give rise to motions of corresponding or asso-
ciated parts, without the  brain, or even the
spinal chord, under certain circumstances,  co-
operating in the act, or taking cognizance of it.
These nerves  are thus expanded in the tissues
and organs, so that an impression or irritation
in any one  point, however minute, is  trans-
mitted from them to the central organs of per-
ception and volition, where it gives rise to con-
scious sensation, if it  be sufficiently strong,
and if these organs be in a state capable of dis-
charging these functions; but when they are
incapable  of consciousness, as in sleep, apo-
plexy, &c, or  when the impression is so weak
as not to excite this function, still motions of
voluntary muscles may follow, owing to " re-
flex sympathy," as explained in my Physiological
Notes, already  referred to.  When the bronchial
secretion rises to the larynx, it there  irritates
the nerves of sensation supplying this part; 
iological Relations of
tOO                    IRRITATION—Path

and the irritation, if the patient be awake, gen-
erally becomes an object of consciousness, giv-
ing rise  at  the  same time, and by a reflex
sympathy,  to  increased or spasmodic  action
of the muscles of respiration : in such cases, as
I have pointed out in my "Notes," the irritation
is conveyed by the  nerves of sensation to  the
cerebro-spinal axis,  and thence reflected by the
associated nerves of motion upon the muscular
apparatus which the latter nerves supply.  In
many of these instances, the reflected motions,
consequent upon the  irritation, take place, al-
though in a much less degree, when the brain
is incapable, as in sleep, of taking  due cogni-
zance of the primary  irritation ;  yet this is no
sufficient proof, either that  the brain is unne-
cessary to their production, or that the spinal
chord alone performs them, or that a particular
organization of both  the chord  and nervous
system is destined  for their performance.  In
the particular illustration now adduced, it is
just as probable that the irritation excites  the
nerves of motion, independently of  both brain
and spinal chord, as that it acts through the in-
tervention of one or both of them.   To  infer,
then, that the chord contains, or is  the centre
of an apparatus destined  to discharge certain
offices, which  offices may  be readily performed
by the agencies, and  in the modes  previously
conceived, and which consist merely of the re-
ception and transmission of irritation  or  ex-
citement, by sensitive and organic nerves, and
reflecting such irritation by means of motory
nerves upon voluntary muscles—the gray mat-
ter of the chord receiving the fibres supposed
to convey the  irritation, and originating those
transmitting or reflecting it upon the muscles—
is to suppose the existence of an organization
too important for the  amount of function to be
performed — is to assign a means of much  too
wide  and great extent, for a contingent  or an
occasional  office ;   and  one, moreover, of  the
existence of which  there  is no visible, or pal-
pable, or demonstrative proof.
   16.  If the apparatus argued for  by Dr.  M.
Hall and Mr. Grainger really did exist, no
reflex  action  could possibly occur when  the
spinal  chord is destroyed ;  yet, nevertheless,
the destruction of the chord could not be a sat-
isfactory proof that  reflex actions depend sole-
ly on it,  seeing that the vitality of the animal
receives  such  a shock from an injury so very
extensive as this, as  would prevent these  ac-
tions  from being manifested.   Indeed,  some
experiments which  I have made induce me to
infer that reflex  motion may take place inde-
pendently of the  spinal chord  itself,  and  by
means of the connexions subsisting between
sensitive and motive nervous fibres, in the vari-
ous ganglia and plexusus, and that the isolation
of those and all other sympathetic actions in a
single part contended for by these writers is
not consistent with  the connected and recipro-
cative  functions of  the different parts of the
nervous system.   Moreover, it should be recol-
lected that it  is not motion alone that is thus
reflected from the seats of irritation.   In some
cases, more especially when the irritating cause
affects the organic nerves, or when parts chiefly
supplied with them  are affected, pain or morbid
sensibility, either  alone or in connexion with
disordered  muscular  action, is  manifested in
remote or corresponding parts.   Hysteria and
various spasmodic affections furnish sufficient
illustrations of this.
   17. In convulsive  and spasmodic diseases,
which have received specific but conventional
appellations according to the  forms they as-
sume, we observe that irritation  of sensitive
and ganglial nerves gives rise to abnormal ac-
tions  of the muscles, without  any  sufficient
proof being furnished of the spinal chord being
actively engaged in the circle of morbid action ;
and when the spinal chord or its membranes
have  presented  any  lesion after  death from
these diseases, there is every reason to infer
that   such  lesion was  merely  an occasional
contingency, the irritation being conveyed by
these nerves to the  plexuses and  roots of the
motory nerves, and reflected thence by the lat-
ter nerves upon the muscles, without the spinal
chord being necessarily  brought  within  the
sphere of morbid action.
   18.  Irritation, therefore, whether of sensitive
or of  organic nerves, gives rise," in the erebro-
spinal nervous system, owing either to the prop-
agation  of the morbid impression in a direct
manner, or to the transmission of it in the first
instance to the roots of the spinal nerves, or to
the spinal chord itself, and  the reflection of it
thence,  1st. To spasmodic or convulsive  actions
of voluntary muscles, as shown  in the articles
Chorea, Cholera, Convulsions, Disease, &c. ;
2d. To pain or altered sensibility of  some part
of the surface of the body, or of particular
nerves,  or of a limb.  Irritation,  also,  of one
portion  of the cerebro-spinal nervous system
may directly affect distant parts,  or indirectly or
mediately and by a reflexed sympathy, as already
mentioned.  When the irritating cause is in the
brain  or medulla oblongata, the functions of
sensation and perception may be deranged, ei-
ther solely,  or in  connexion with morbid voli-
tion and muscular action or motion.  In such
cases, the irritation  is central, its  effect direct
and immediate, and  manifested chiefly in the
functions performed by, or intimately connected
with the tissue most seriously affected.  When
the irritation is seated in the spinal chord, and
is unattended by effusion  or other  cause of
pressure on the chord, muscular action  only
may be  excited,  but  generally excited in such
a manner, or to such an  extent, as  to be no
longer amenable, or to be imperfectly amenable
to the control of the will;  or sensation  only
may be  affected in various  grades, the spinal
irritation manifesting itself in the ramifications
of sensitive nerves,  and the morbid sensation
becoming an object  of consciousness through
the instrumentality of the  medulla  oblongata
and brain ;  or both muscular action and sensi-
bility  may  be  conjointly disordered.  Illustra-
tions  of irritation of the central parts  of the
nervous system  are  constantly appearing  in
practice.  When irritation is seated in portions
of the gray  or effective portions of the brain,
the states of the mind, the sensations, and spe-
cial functions  of sense are  chiefly disordered.
When it extends to or affects the fibrous struc-
ture, muscular actions are deranged.  When it
commences  in the medulla  oblongata, general
sensibility, the respiratory functions, and volun-
tary  motion are disordered, according  to  the
extent and grade of the primary morbid condi-
tion.  When it implicates the spinal  chord, the
consequences vary with its seat, or as the gray 
IRRITATION—Pathological  Relations of.
701
 or fibrous structure, or the anterior or posterior
 columns are solely or chiefly affected by it.
   19. It has lately been  supposed,  as  above
 stated, that the sympathies which 1 have called
 reflex, and those  irritations which are propa-
 gated to the spinal chord, and reflected thence
 to remote  parts of the  external surface or to
 the extremities, with  the tonic contractions of
 the sphincters, are essentially dependant upon
 the gray substance of the  chord ;  but there is
 much more reason to believe that this substance
 is chiefly concerned in generating an  influence
 necessary to re-enforce and increase  that pro-
 duced by the ganglial nervous system ; and that
 this influence is conveyed  by nervous fibres to
 the plexuses and ganglia of this system, and to
 the muscles of  voluntary  motion.  Irritation,
 therefore, of the gray  tissue of the spinal chord
 will thus affect the thoracic and abdominal vis-
 cera obscurely, indirectly, and through the me-
 dium of the ganglial system ; but more directly
 and obviously the muscles of voluntary motion,
 the actions of which  will  be thereby  removed
 more or less from under the control of the will,
 and thus become involuntary or automatic.   It
 is very probable that the  continued action of the
 sphincters  very much depends  upon this part
 of the chord ; but in this case the action is di-
 rect— is immediately  dependant upon this or-
 ganization, and not merely reflex; but it may
 be allowed  that, in common with all other mus-
 cular actions admitting  of being influenced by
 volition, irritation  in the vicinity of sphincters
 will induce,  both  directly  and  indirectly, as
 above explained, increased contraction  of the
 sphincters.
  20. It has likewise been supposed  that the
 spinal chord, and more especially the gray sub-
 stance  of  it, is the source  of  irritability.   I
 have already ascribed this very important, and,
 indeed,  chief manifestation of life, to the or-
 ganic or ganglial nervous  system, whether  as
 manifested in the  voluntary or in the involun-
 tary muscles—in hollow muscles or in sphinc-
 ters ; the  fibres proceeding from the  spinal
 chord conveying the influence generated  in this
 quarter  to  these parts, and re-enforcing, in-
 creasing, or otherwise influencing that  which
 is produced by the ganglial system ; this latter
 system being, however,  the chief source of the
 tone and irritability of these several orders of
 muscles.   It is, moreover, very probable, al-
 though the  fact cannot be satisfactorily demon-
 strated by experiment, that the gray matter of
 the chord  is that part  only which generates
 the power  thus destined to re-enforce and in-
 crease  the  power conferred by the organic  or
 ganglial system, and especially to augment the
 energy which the ganglial system confers upon
 the generative organs.  Thus, while these or-
 gans have large ganglia and plexuses of organic
 or vital  nerves (of gray and non-tubular fibres),
 with large  communicating branches  running
 between them and the other ganglia, very con-
 siderable branches of  nerves (of white tubular
 nerves)  are also sent from the  sacral spinal
 nerves ;  but, instead  of ramifying directly  in
 these organs, they always proceed by  the most
 immediate  or direct routes to the ganglia which
 supply these  organs.  The sphincters, also, are
supplied  with organic or ganglial  nerves, and
with spinal nerves ; the latter, however, par-
ticularly as  respects  the  sphincter  ani, &c,
 proceeding directly to this muscle ; so that, al-
 though the tonic contractions of the sphincters
 depend upon the organic nerves, these contrac-
 tions may be exalted by volition, through the
 instrumentality of the spinal nerves.
   21. Whatever energy may thus  be supplied
 by the spinal chord to the genital  organs  and
 sphincters is most probably generated by the
 gray substance of the chord, while  the  will
 merely stimulates this energy, and develops it
 in a more or less active and sensible manner.
 If we analyze the phenomena manifested by
 the  generatiye organs, we shall  find that the
 essentially vital  and  insensible  changes  and
 functions of these organs  are dependant upon
 the  organic nerves  with  which they  are so
 abundantly supplied,  and  upon the connexion
 of these with the rest of this system;  while
 the excitation of these functions, and the sen-
 sible changes  attending such excitation, take
 place through the medium of the organization
 of the spinal chord and of the nerves proceed-
 ing from it.  The former of these classes of
 phenomena require little remark, farther than
 that  they are performed with  a degree of per-
 fection proportionate  to the strength  and con-
 stitution of the individual.   The latter phenom-
 ena are produced in one or other of two modes
—either  by the influence  of the mind upon
the nerves of these organs, through the medi-
um of the chord, or  by the local irritation of
these nerves ;  the influence of such irritation
 extending not only to  all these organs, but also
 to the  spinal chord, and to the brain, whence
 it may be again reflected back upon them and
 upon other parts.
  22. While  thus the tone, irritability, and
 strength of contractile and sensitive parts are
 furnished by the organic nervous system, and
 augmented by the influence  generated  by  the
 gray substance  of the chord, irritation, impli-
 cating either of these parts of the nervous or-
 ganization, excites and  removes  from under
 the control of the will the functions of the parts
 which  receive nerves from the part irritated ;
 and  while irritation of the parts  giving origin
 to nerves necessarily  exalts the functions per-
 formed by these nerves, whether these be sen-
 sitive or motory, yet,  if it be either carried to
 too high a grade, or  continued too long, vital
 exhaustion will succeed.   The vital tone and
 irritability of contractile parts will also be  ex-
 hausted by the  excitement caused by volition,
 when either  energetic or  prolonged  beyond
 what is necessary to  the healthy development
 of these functions.
  23. ii. Relations of Irritation to, and In-
 fluence on, the Vascular System and Blood.
 —There can be  no  doubt of the commence-
 ment of many  of the diseases, both local and
 constitutional, of which the vascular system is
 the seat, in the nerves, more especially in  the
 ganglial or vital nerves supplying this  system,
 and  the several  tissues and secreting struc-
 tures.  I have attempted to show that this must
 necessarily be the case in respect of many mal-
 adies, both in the article on Disease generally,
 and  in  those on specific  affections.   At  the
 same time, I have not only admitted, but even
 demonstrated, that the blood may be either pri-
 marily or consecutively altered from its healthy
 constitution ; and that it may, moreover, pre-
 sent such states as,  although they  may  not 
702
IRRITATION—Pathological Relations of.
amount to actual disease, may strongly predis-
pose to it, and contribute much to the develop-
ment of it, as soon  as the nervous system is
subjected  to  any shock, irritation, or morbid
impression; or as soon  as  some vital, or se-
creting, or excreting viscus experiences any
interruption of its functions ; the morbid  con-
dition  of the blood,  in  its turn, affecting the
nervous systems of organic and animal life, and
exasperating or perpetuating disorders primari-
ly seated in these systems.
  24. The influence of irritation on the vascu-
lar system is well demonstrated by the changes
consequent upon irritating the nerves of erect-
ile,  glandular, and mucous  tissues.   We ob-
serve excitement of  the nerves of these parts
produce expansion of the capillaries, increased
action of the arteries, and turgidity of the veins.
The irritation is thus  generally followed  by
what has been  variously denominated turgor
vitalis,  vascular  turgescence, vital  turgescence,
&c.; and this condition, especially when  fa-
voured by the tissue, as in irritation  of mu-
cous surfaces, or by the temperament, consti-
tution, or diathesis,  or  by states of the blood,
may readily pass into active congestion or deter-
mination of blood—its common consequence ;
or into inflammation, or sub-inflammation ; or
it may give rise to  haemorrhage.  As respects
mucous surfaces, cellular tissues, and glandular
structures, the usual consequences of irritation
are increased exhalation, secretion, and vascu-
lar  determination or flux ; which, if allowed to
proceed, or if the irritating cause act violently,
is followed by some state or other of inflamma-
tory action and its various consequences.
  25. A.  The relations of irritation to the several-
states  of inflammation are more intimate than
have been  generally admitted  by pathologists.
Irritation seated in any tissue, or in a secreting
surface or organ, can be viewed, at its  com-
mencement, only as  connected with the nerves
of the part;  and in this stage, as well  as in
those which  follow,  it is attended  by more or
less of altered sensibility.  In some structures,
morbid  sensation may  be  the  chief  disorder
throughout its course ;  but in parts which per-
form a secreting function, or which are highly
vascular, augmented and otherwise altered se-
cretion, and  increased vascular determination
and action, very generally  supervene.  In  se-
creting surfaces and glands, an augmented flow
of  their natural products usually follows  the
commencement of irritation ; and, as the irri-
tation proceeds, or as it increases, these  prod-
ucts  generally become  not  only augmented in
quantity, but  also changed in quality; and  the
vascular determination also is increased, or it
assumes  an  inflammatory  form, or  one very
closely allied to the  more chronic or sub-acute
forms of inflammation, several of the changes
usually consequent upon inflammation also ap-
pearing in the advanced progress of the  disor-
der, thus.originating  in, and chiefly consisting of,N
irritation in its earlier stages.   Diarrhoea, from
irritating ingesta, or from cold  and  simple ca-
tarrh, or catarrhal bronchitis, often furnish il-
lustrations of this course of morbid action ;  and
the more simple, as well as the more complex
of the glandular structures, are liable to similar
changes.  A disorder of function, consisting
of  irritation  or exaltation of the  organic ner-
vous endowment of the part, is gradually con-
verted into  structural disease,  owing to  this
disorder having affected the secreting, and con-
secutively  the circulating  functions, morbid
capillary and arterial action ultimately passing
into organic change.  Many of the forms of in-
flammation, particularly those which are chron-
ic and sub-acute, originate in irritation, or  in a
change in the state of the organic nervous in-
fluence of the part, the liability to the vascular
disease, as  well as the grade of action, depend-
ing upon the susceptibility of the  system in
connexion with the state of the blood, and with
the nature of the tissue  or structure in which
the irritation is seated.
  26. B. The relations of irritation to hemorrha-
ges and serous effusions are very similar to those
just  instanced in  respect of inflammations.
The  irritation which in one constitution would
produce  some form of the latter will produce
in others some one of the former, the particu-
lar effect being, in a great degree, influenced
by the states of organic, nervous, or vital pow-
er, of the irritability of capillary tone, and of
the blood ;  these  states  themselves being, in
some measure, dependant upon  those viscera
chiefly engaged in  the functions of assimilation
and  excretion ; or, in other words,  these  sev-
eral  morbid conditions  often acknowledging
one source, namely, the state of the vital  ner-
vous influence. Haemorrhages,particularly those
taking place from  mucous surfaces, are often
traceable to local  irritation, in connexion with
impaired tone of the extreme capillaries, and
often with  vascular  plethora ;  but  something
is also to be imputed to  the constitution, or in-
dividual conformation, as shown by "the  dis-
tinctive  characters by which it is marked, and
by its  hereditary disposition.   Many of  the
phenomena, also,   preceding  haemorrhage, as
well  as some of those attending it,  are refera-
ble to irritation, this  primary  morbid condition
of the  organic nerves  of the part  influencing
the states of vascular determination and action
in the same manner as the irritation or excite-
ment of the sensitive nerves of the sexual 6r-
gans and of erectile  tissues affects the  blood-
vessels of these parts. Serous effusion, although
occasionally a consequence of irritation, is much
less frequently so than  either inflammation or
haemorrhage, and  is met with, as a result of
this  state, chiefly in  leucophlegmatic or  lym-
phatic temperaments, or in persons whose as-
similating and excreting functions are impaired
or interrupted.
   27. C. The relations of irritation to the production
of morbid nutrition and  secretion, although  con-
tended for by Broussais, and most of the pa-
thologists  of his  school, are not so manifest
nor  so  uniform, or even general as they  con-
tend.  Viewing irritation as simple exaltation
of the organic nervous influence of the affected
tissue, increased nutrition and secretion might
be supposed to be legitimate consequences of
it ;  and as  irritation is  not merely a simple,
Jiut  also a morbid exaltation  of this influence,
 so these consequences  might be also inferred
to be morbid.  These inferences are doubtless
 correct  as regards many cases of morbidly in-
 creased nutrition and  secretion,  especially
 when the  irritation is  exerted chiefly  upon
 muscular or contractile parts, and on secreting
 organs  and surfaces.  Irritation affecting the
 nerves  of  a hollow  muscle will, if protracted, 
                       IRRITATION—Path.

ultimately cause  hypertrophy of this muscle ;
and a similar change in the state of the nerves
of the liver, or of the  digestive mucous sur-
face, will both increase and otherwise change
the secretions of  these parts.  Morbid nutrition
and  secretion, however, although  very fre-
quently proceeding from irritation, do not al-
ways thus arise.;  for either or both these more
palpable changes cannot, in many  instances,
be traced to any obvious grade or  form of irri-
tation, so far as irritation can be viewed as ex-
altation of  the organic nervous power: they
must, therefore, be considered, as regards these
instances especially, as consequences of a per-
version of this power,  as I have endeavoured
to show in the   article Disease.   (See § 87,
et seq.)
  28. D. That irritation should affect the state of
the  blood, particularly when prolonged  or ex-
~£3sive in any important organ or tissue, may
readily be admitted. The usual effects of irrita-
tion upon the vascular system, especially in pro-
ducing a febrile state, and in thereby impeding
the functions of digestion, assimilation, and ex-
cretion, must necessarily, more or less, change
the blood from its healthy constitution.   Even
in cases where local irritation  does not pro-
duce  marked febrile excitement,  or merely a
remittent or intermittent form of  it, the quan-
tity, as well as  the healthy condition  of the
blood,  may be affected nevertheless.  When
irritation of a particular tissue or  viscus takes
place in plethoric persons, febrile excitement
or reaction may  be Very fully manifested, and
a consequent  change in its  constitution may
take place with a rapidity co-ordinate with the
grade  of excitement;  but, when  the blood is
deficient in quantity,  or in the proportion  of
haematosine, the  febrile excitement  may be of
either a low, remittent, or obscure form, or be
identical with hectic, and the blood may expe-
rience still farther changes  in its  quantity and
constitution.  But, in  all cases, much  of the
effect  produced by irritation on  the  blood will
depend upon the temperament and circumstan-
ces of the individual,  as will be shown here-
after.
  29. While, however, this  condition thus af-
fects the blood, the states of the blood, in their
turn, exert an equally  marked effect upon the
local consequences or  products  of morbid se-
cretion and nutrition depending  as much  upon
the conditions of this  fluid as upon  the  irrita-
tion which, existing in a particular viscus, has
determined  these changes  to take place in it.
Indeed, the materials  furnished by  the blood
often constitute  and characterize  these  chan-
ges, the local irritation causing either a dis-
charge of a portion of these materials in the
secretions of the part, or their deposition in its
structure, thereby giving rise to  various organ-
ic lesions, more  fully  described in the article
Disease (y 93, et seq),  and in  the  various arti-
cles more particularly devoted to each of these
lesions.
  30. iv. Of the Propagation,  Reflection,
Reaction,  and other  Consecutive  and  Sym-
pathetic Phenomena  of Irritation.—Irrita-
tion may act in various modes, or may have its
effects limited or  extended, in various grades,
in different persons, in  diversified circumstan-
ces, and according to the kind, nature, or degree
of the irritating cause.  It may thus be, 1st. Sim-
logical Relations of,                    703
pie or direct, its effects being either local, ex-
tended, or propagated ; 2d. Reflected, or con-
veyed to some portion of the nervous centre or
axis, and thence  reflected upon distant parts ;
and, 3d. Consecutive, sympathetic, or reactive,
and constitutional.   As to each of these modes,
it requires a more particular consideration.
  31. A.  Simple and direct irritation  is (a) at
first local; and, in  this state, it may continue
for some  considerable time, or for a period so
short as hardly to admit of appreciation ;  and
(b) it may extend or propagate itself, or its effects,
to more distant parts.  The extension of the
morbid action, condition, or impression, of which
irritation  consists, varies,  1st. With the nature
and intensity of the cause producing it ; 2d.
With the  state  of organic nervous or vital pow-
er ;  and, 3d. With the conditions of the blood
and of the excreting or depurating functions.
When the cause is intense in its operation, and
at the  same time  contaminating,  vitally  de-
pressing, or poisonous, relatively to the state
of vital power  or resistance, the irritation or
local effect produced by such  cause  is rapidly
extended, by means chiefly of the organic ner-
vous and  vascular systems, to adjoining parts,
and  even to  the whole frame.  On the other
hand, when the cause is merely mechanical, or
simply irritating,  without  being depressing or
contaminating,  the constitutional energies con-
tinuing unimpaired and the blood uncontami-
nated, the irritation may be long in producing
more extended effects, or materially injuring
the frame. It is chiefly when the organic ner-
vous influence  is weak, the secreting and  ex-
creting functions are already impaired, and the
blood more £>r less .morbid, that irritation is
rapidly followed by severe local and constitu-
tional disorder.  When the  blood  is  supera-
bundant as to quantity, and especially as to the
quantity of haematosine, or fibrin and albumen,
relatively to that  of serum; when the blood is
thus rich and inflammatory, and the tempera-
ment and diathesis are sanguine and phlogistic,
then the irritation,  unless its cause be poison-
ous or contaminating as well as irritating, soon
assumes  an  inflammatory  character, and is
quickly followed by all the local and  constitu-
tional effects of inflammation.
  32. When  the  irritation is  slight  or mod-
erate, the blood being neither superabundant
nor rich, or even somewhat deficient or thin,
and the temperament being phlegmatic or lym-
phatic, then it  may not produce great change,
either locally or constitutionally, until it  has
continued  long, or  affected the secretions of
the part; but when these  states of the vascu-
lar  system are  coexistent with the nervous or
irritable temperament, the local, and especially
the remote and constitutional effects of irrita-
tion will be quickly and severely manifested,
particularly on the nervous  system, and  on
muscular or contractile parts.  Illustrations of
these facts occur frequently  in practice,  and
are  met with in many of the affections char-
acterized by extreme pain and spasm.  Irrita-
tion is influenced,.as to grade and consequen-
ces, not only by the temperament,  diathesis,
and states of the blood and of the secretions,
as  just stated, but also  by organic nervous
power,  and by whatever tends to depress or
vitiate this power, or to contaminate the blood.
  33. In depressed states of vital power, irri- 
logical Relations of.
704                    IRRITATION—Pathi

tation more rapidly develops its effects, other
circumstances  being  equal,  than when  this
power is unimpaired, the resistance exerted by
the constitution to the morbid impression or
irritation being weaker, and  consequently the
less capable of overcoming this primary affec-
tion, which increases and extends itself with a
rapidity co-ordinate with  the vital or  the or-
ganic nervous depression or exhaustion.  Mor-
bid conditions  of the blood,  arising  from the
passage of contaminating matters into it, or
from the accumulation of effcete materials in
it, owing to deficient  or interrupted action of
eliminating organs, exert an equal, if not a still
more remarkable influence, in favouring and in
accelerating the extension and  consequences
of local irritations.  Punctures, external abra-
sions, local injuries, the  acrid, contaminating,
and animal poisons, and numerous other caus-
es acting locally, or even on the minutest point
of the  organism, produce effects of the most
severe and deleterious character in  these cir-
cumstances  of organic nervous power, and of
the circulating fluids ; and, although these caus-
es are  often deleterious  in  the most  healthy
conditions of the frame, yet are they very much
more so in the circumstances just now stated,
occasioning the worst forms  of erysipelas, dif-
fusive  inflammations  of the  integuments  and
subjacent cellular tissue, the  most violent  con-
stitutional disturbance, contamination of the
blood and soft solids of the body, with effusion
into  shut cavities and other  lesions, and,  ulti-
mately, death.
   34. B. Reflected irritation  may  be of  three
kinds; namely, (a) The irritation may occur in
a  surface or part  of  a viscus supplied either
chiefly or solely with organic or gtnglial nerves,
and be transmitted to the ganglion by the ner-
vous fibres first affected, and thence reflected
upon these fibres themselves, or upon others
supplying different structures, or communica-
ting with other parts of this system,  or  with
the cerebro-spinal axis.—(b) The irritation may
commence as  in the  preceding  variety,  and
extend to either the roots of the spinal nerves,
or the chord  itself, and thence  be reflected, in
the form of pain or spasm, to superficial parts,
or to the extremities.—(c) The irritation  may
commence in, or affect the nerves of sensation
in these last  situations, be transmitted to the
spinal chord, or to the roots  or ganglia of the
spinal nerves, and be  reflected thence  by  sen-
sitive and motory nerves, occasioning altered
sensation, morbid sensibility, or convulsive or
irregular movements.   These  several modes
of reflected irritation  occur most frequently in
nervous and  irritable temperaments,  and in
persons neither plethoric nor robust.
   35. a. The first of these often attends visceral
disease, both functional and  organic, hysteria.
the several forms of colic, constipation, gastro-
intestinal disorders, visceral neuralgia,  or, pain-
ful affections of the abdominal organs, and dis-
eases  of the  sexual  and urinary organs, but
generally in  irregularly, or  imperfectly mani-
fested states.   Irritation of the nerves of the
uterus or ovaria, or exaltation  of their sensi-
bility, may be  extended to the ganglia, from
which  these  nerves depart,  and be reflected
thence, not only upon these organs themselves,
but also upon the intestinal  canal, giving rise
either to irregular movements of its muscular
coats and to borborygmi, or to altered sensibili-
ty, or to abdominal pains, such as I have de-
scribed  in  the article  Hysteria,  or to  both
spasm  and pain,  as  in  hysterical colic.  The
irritation of calculi in the pelvis of the kidney
may be extended to the renal ganglion,  and
be thence reflected upon the digestive tube in
the form either of colic, or  of nausea or vom-
iting.  The irritation of calculi inthe bile-ducts
may, in a  similar manner, be reflected upon
the  duodenum, stomach, or  other  abdominal
organs.
  36. b. The second variety  of reflected irrita-
tion, or that extending to  the cerebro-spinal
nerves, and from thence expressed upon super-
ficial or distant parts, may exist either alone or
in conjunction with the  foregoing variety, as in
the several forms of hysteria, especially  the
more irregular forms of it, in chorea, in ver-
minous complaints, in  symptomatic epilepsy,
cholera, &c.   In these  affections, as  shown in
the articles devoted to  them, irritation affects
a certain portion of the  organic nervous circle,
and extends to corresponding ganglia, and is
thence reflected upon the fibrils of gray nerves
supplying other viscera, or upon those commu-
nicating  with the roots of the cerebro-spinal
nerves, occasioning either altered sensibility or
extreme pain in the extremities of the nerves
of  sensation, or  spasmodic or uncontrolled
movements of the voluntary rauscles, through
the medium of the nerves of motion.  The con-
vulsive affections of infants and children  are
frequently  thus produced without any disease
of the brain, although  the  circulation  in this
quarter generally is affected in the course of
the convulsion, owing to the disorder of the re-
spiratory processes attending it, and to the im-
peded passage of blood through the lungs and
heart.   The irritation of worms in the intesti-
nal mucous surface gives rise not only to vari-
ous painful and spasmodic states of the canal,
and to palpitations of the heart or of the ab-
dominal aorta, but also to convulsions and spasm
of voluntary muscles in the manner just  ex-
plained, and as I have stated in the article Cho-
rea (§ 16,17).  In 1820 I treated at a dispensa-
ry a case characterized by constant clonic spasm
or convulsive movements of the abdominal mus-
cles.  The  cause was instantly  recognised;
spirits of turpentine was prescribed, and  im-
mense accumulations  of faecal  matters  and
many hundreds of lumbrici were  evacuated  ;
and then the convulsions of 4;he voluntary mus-
cles ceased.  This case  was published  (see
Lond. Med. Repos., vol. xvii, p. 242) soon after
its  occurrence, and was  explained as above.
Other illustrations of this form of reflected ir-
ritation might  here be adduced, but they are
unnecessary ;  others will be noticed hereafter.
  37. c. In the third variety,  or when the irrita-
tion implicates, or is seated in, the cerebro-
spinal  or sensitive nerves,  and is  transmitted
either  to  the  plexuses  of nerves,  or to their
roots, or through these to the spinal chord, and
even to the brain itself,  and is reflected thence
so as to manifest its effects in the  form either
of spasm  or convulsion, or  of pain or altered
sensibility  of some superficial or distant part
or limb,  then consciousness is frequently af-
fected," in some way or  other, in the course of
the process; and, consequently, the  functions
of the brain are co-ordinately implicated.  Still, 
IRRITATION—Pathological Relations of.
705
the brain may be no farther  affected than in
being cognizant of either the primary affection,
or of its sympathetic effects, or of both.   In
this case, only one of the functions of the brain
is  acted  upon, and all the  other functions are
unimpaired and unaffected.  But in other in-
stances, the irritation, owing either to its inten-
sity and extension to the  cerebro-spinal axis
itself, and more especially to  the brain, or to
the latter organ being implicated in the course
which it takes in developing its effects, may so
affect the brain as completely to overpower its
functions;  yet this  result rarely takes place
without being attended by convulsions.
  38.  On a careful examination  of disorders
characterized by convulsions, spasms, or irreg-
ular muscular actions, we  shall find that they
may be divided into, 1st. Those which are at-
tended by consciousness;  and, 2d. Those  in
which consciousness is  suspended.   The one,
however, may pass into the other, but in com-
paratively rare instances.   In the  former of
these, the brain retains the power of sensation,
and is not  incapable of exerting its functions
during the paroxysm ; in the latter, conscious
sensation is for a time altogether overwhelmed,
and is restored, more or less rapidly,  after the
attack has ceased.   It may reasonably be in-
ferred that, in  the one, the primary irritation is
propagated to the roots of the spinal nerves
only, or to the spinal chord, and reflected thence,
by the motor nerves, upon  the voluntary mus-
cles, the braiu being still capable of discharging
all its functions, excepting that of  controlling
the muscular movements ;  in the other, the ir-
ritation extends to the brain, or affects it or its
circulation, in such a manner as to  suspend or
to extinguish  consciousness and all its modifi-
cations for a time.  In many,  if not all the lat-
ter class of cases, the medulla oblongata seems
to be the part more immediately implicated ;
as soon  as the affection extends  to it, con-
sciousness and the other subordinate manifest-
ations of mind being suspended for a  time.  (See
article Convulsions, y 42, et seq.)
  39.  b. Severe or neuralgic pains are  often caus-
ed by irritation, the source of which may be in
the trunk of the nerve whose terminations are
thus affected, or in  the spinal  chord, or in vis-
ceral or ganglial nerves passing to the roots of
the spinal nerves, or to the  spinal chord itself.
In this latter case, the primary irritation mani-
fests its effects in distant parts by a reflex sym-
pathy,, as already described, and as long since
insisted upon in the works  already referred to.
In all  instances of pain from irritation, whether
the irritating cause be seated in the nerve itself,
or in  the chord, or  in other or distant nerves,
the effect being reflected by means of either
the chord or of ganglia, it is expressed chiefly
in the ultimate  ramifications or smaller branch-
es of  nerves.   When the pain is seated in the
trunk  of a nerve, it will generally be found that
the sheath or neurilema of such nerve is infla-
med, either in the seat  of  pain or near it.   In
a case recorded by Dr.  Denmark,  where  ex-
treme pain was felt in the points of the fingers
and thumb, the limb was amputated,  and a small
portion of a ball, which had been detached from
it when it struck against the bone, was found
imbedded in the fibres  of the median nerve.
In several  cases which  have  occurred in my
practice, as well as in others recorded by au-
   II                89
thors, irritation  and chronic inflammation of
the spinal chord or of its membranes have been
attended by pain in nerves, chiefly of their ex-
tremities, given  off from the parts of the chord
chiefly affected.  Numerous illustrations of this
are given in the article Neuralgic Affections.
In nearly all cases where the pain is caused by
irritation merely, it is intermittent or periodic,
or  returns  only after  distant intervals.  But
when it  is produced by inflammation, or by ir-
ritation of an intense and permanent kind, it is
either continued or  remittent only.   When it
proceeds from the former cause, it is sudden in
its accession, intense in grade, often brief in du-
ration, and it generally ceases suddenly.  When
it arises from the latter cause, it is more grad-
ual in  its increase and subsidence, and more
permanent than  in other circumstances.
  40. The cases of pain  from  irritation,  ex-
pressed in distant parts by reflected sympathy,
furnish  some very singular phenomena, which
fall more particularly  under consideration in
other articles.   These are characterized chiefly
by their seat, intermittency or remittency, and
by the non-febrile and  non-plethoric states of
the vascular system, in the very great majority
of instances.  Thus, irritation of the stomach
or bowels, by accumulated matters, or by acid-
ity, or  by flatulence, or by morbid  secretions,
often causes severe pain in distant  and super-
ficial parts, or even in less remote organs.   A
gentleman  was seized  suddenly with a  violent
pain in  the heart.   I was  called to him, and,
while I wrote a  prescription,  I directed  him to
swallow two or three  small  pods of Cayenne
pepper,  which were at hand in a bottle of pick-
les.  He instantly afterward eructated much fla-
tus, and the pain as instantly ceased.  Pains
of short duration, but of great severity, are oft-
en experienced during disorders of the  digest-
ive organs,  in various parts of the body far re-
moved from the seat of irritation.   Thus, pain
at the vertex, or in the temple, or in a limb, or
in other parts,  is  sometimes felt;  but it in-
stantly ceases upon the escape of accumulated
flatus, or upon the neutralization of acid in  the
prima via, or after the  operation of an  emetic
or of a brisk cathartic.   (See article Neuralgic
Affections.)
  41. C. Reactive,  Consecutive, and Sympathetic
Irritation. — In  certain  circumstances  of  the
ceconomy, especially those which will be noticed
hereafter, irritation gives  rise to general vas-
cular reaction, or  to various consecutive anu
sympathetic effects,  having a more or less ob-
vious relation to the state and grade of the pri-
mary affection.   In most instances, the first ef-
fect of irritation is displayed in the vessels of
the part, in one or other of the modes described
above—in either inflammatory action or haem-
orrhage ; but in some cases, the irritating cause,
owing to its nature, or to the part  irritated, or
to the constitution and diathesis of the individ-
ual, gives rise  to very severe febrile commo-
tion, or to various consecutive phenomena of
either a painful, or a spasmodic or  convulsive
kind, without the local vascular disturbance
being remarkable;  and these effects may be
general as respects the ceconomy, or more or
less limited in extent, or may change their seats
and character.  Chemical irritants, and vari-
ous vegetable and animal poisons, produce these
effects,  which usually present a very marked 
ological Relations of.
706                    IRRITATION—Path

speciality, their  characters  varying with the
cause which produced them, and with the cir-
cumstances in which they are developed.  Thus,
the irritation of  the digestive mucous surface,
or of some part of it, by worms, by acidity, by
flatulence, by noxious ingesta, or by accumula-
ted soides, frequently is followed by spasmodic
movements of the voluntary muscles, by pain-
ful affections of the joints, by neuralgic or rheu-
matic pains, by  gout,  and by various visceral
affections of a painful of of a functional  kind.
  42. The presence, also, of morbid elements
in the blood, or the accumulation of those ma-
terials in it which require to be eliminated, will
not only occasion irritation of some portion of
the organic nervous system, but more especial-
ly of that portion which is supplied  to or actu-
ates the organs destined to the elimination of
these materials,  but will, at the same time, fa-
vour the  rapid development of the reactive and
sympathetic effects of the more local affection.
Gout, erysipelas, and several other diseases,
illustrate this  principle; indeed,  most  of the
disorders which are seated principally  in the
excreting organs furnish proofs of the truth of
this  view.  From the foregoing, it may be safe-
ly stated that the  sympathetic effects of local
irritation are to be traced by means, 1st, of the
nervous system  of organic and animal life ; 2d,
of the vascular system and blood ;  and, 3d, of
the excreting viscera as influenced by the or-
ganic, nervous, and vascular systems.  But the
consideration of these, if farther pushed, leads
to the following part of the  subject, which  is
very intimately connected with the foregoing
general views.
  43. v.  Constitutional Effects  of Irrita-
tion.—The principal and most serious  effects
of irritation are ascribable, 1st, to  the  nature
of the irritating  cause ;  2d, to the state of or-
ganic, nervous,  or vital power, especially as
manifested by  the irritability of  contractile
parts ; 3d, to the state of the circulating fluids,
particularly as respects the accumulation of ex-
crementitial or noxious  materials in the  blood;
and, 4th, to the functions of eliminating and
depurating organs.—a.  Of the influence  of the
causes in determining the evolution, as well as
the kind  of constitutional commotion produced
by irritation, sufficient notice will be taken here-
after ; and I have already shown (§ 31) that the
effects of irritation are, caeteris paribus, more
extensively, more rapidly, and more severely
propagated throughout the frame, the more the
organic nervous or vital power is depressed at
the time when the irritating cause is in  opera-
tion.
  44. b. When the circulating fluids are  loaded
with noxious elements or materials, in  conse-
quence either of interrupted excretion or of the
absorption of injurious matters, not  only is the
vascular  system  the more readily excited there-
by to increased  action,  but the vital power  is
also greatly impaired  at the same  time ; and
hence, although  vascular action is augmented,
power is  diminished, and the sooner altogether
exhausted.  The impeded or interrupted action
of depurating or  excreting organs, in first caus-
ing a morbid state of the blood, exerts, accord-
ing to the extent of this primary effect, a simi-
lar influence in  developing, accelerating, and
aggravating the  constitutional operation of lo-
cal irritants; and hence the necessity of bring-
ing our means of cure to act upon these organs
in all cases of local as well as of constitutional
irritation.   The influence apparently arising, in
connexion  with  irritation, from a  superabun-
dance  or deficiency of blood, and from a too
rich or a too poor or watery state of this fluid,
has been already noticed, particularly with ref-
erence to  the supervention of inflammations,
haemorrhages, and various spasmodic and ner-
vous affections ;  but these conditions of the
vascular system seldom give rise to so rapidly
developed,  so severe, or so dangerous  commo-
tions of the whole ceconomy, as when the blood
is loaded with excrementitious  materials,  and
when important emunctories are interrupted or
impeded in their functions.   It may be, there-
fore, inferred, as a pathological axiom, that,
other circumstances being the same, the con-
stitutional  effects  of local irritants will' vary
with, and be proportionate to, especially in the
rapidity of their development and in the sever-
ity and acuteness of their characters, the gTades
of vital power and  of vascular purity, and the
states  of the several emunctories.  In propor-
tion as power is reduced, and the blood is im-
pure or changed from its healthy state, so the
brain becomes oppressed, the soft  solids con-
taminated,  the vital cohesion of the tissues
weakened,  and the depurating organs impeded ;
effusions of  serum, sero-sanguineous  exuda-
tions,  haemorrhages, and various structural
changes ultimately supervening, with more or
less rapidity.  Erysipelas, local irritants giving
rise to diffusive inflammation of the cellular
tissue, wounds or injuries, and  punctures  fol-
lowed  by severe disturbance,  and  many acute
affections consequent upon irritating and mor-
bid poisons,  furnish sufficient illustration  of
these inferences.
  45.  vi.  Of the  Continuity, Periodicity,
Duration,  and Terminations of the Effects
of Irritation.—A.  The effects of irritation are
seldom continued, or of equal severity through-
out, unless they be aggravated by morbid con-
ditions of the blood, or by impeded action of the
emunctories.  In such cases they may be pro-
gressively acute or severe, until they terminate
fatally, without any appreciable intermission or
even remission.  The blood may also be more
or less contaminated, particularly by the absorp-
tion into it of morbid  secretions, and yet the
effects will still assume a periodic or remittent
form, as in  cases of hectic fever ; but very gen-
erally the constitutional effects of irritation are
continued when  the blood is much contamina-
ted either by absorbed matters  or by unelimi-
nated elements, as shown by most of the forms
of erysipelas, by the consequences of punctured,
poisoned, or contaminated wounds, and by nu-
merous irritating causes acting locally in these
states of the vascular system.
  46. B. The effects of irritation, whether they
be spasmodic, or neuralgic, or painful, or con-
stitutional,  are most commonly  periodic, or re-
cur after intervals, or become  aggravated  by
paroxysms, if they do not cease altogether for
a time.  The recurrence or aggravation of these
effects generally observes no regular periods,
unless intermittent and remittent fevers be con-
sidered as constitutional manifestations of irri-
tation  of the organic or ganglial nervous sys-
tem, in which point of  view, indeed,  I have
chiefly contemplated them in their more sim- 
                       IRRITATION—In Ri

pie slates.   As  long  as irritation extends no
farther than the nervous systems, and while the
excreting organs and vascular system and blood
are not greatly disturbed, it generally thus man-
ifests itself more remarkably at one time than
another.   In  many cases,  the irritation seems
to proceed or to exist in a latent form, or  the
irritating cause seems to  have  ceased to pro-
duce any results after its  more immediate ac-
tion, until some adventitious circumstance oc-
curs, or some change  takes place  in the states
of organic nervous or  vital power, or of the ex-
creting viscera, favourable to the  development
of its effects ; and these effects may  either in-
crease progressively or recur more frequently,
or they may soon cease altogether, owing either
to exhaustion or to the subsidence of the  pri-
mary morbid  condition.
  47. In  cases  of neuralgic pains, the  effects
of irritation  manifested in distant  parts, as
above shown, by either a direct or reflex sympa-
thy, as well as  in cases of spasmodic  or con-
vulsive movements .similarly produced, we ob-
serve certain phenomena  or circumstances of
an  important and  practical  kind :  1st. That
these attacks are immediate, severe, and con-
tinued, in proportion to the intensity of the irri-
tating cause relatively to the grade of constitu-
tional or vital power;  2d. That they are favour-
ed and aggravated by whatever lowers the or-
ganic nervous energy and vital  resistance, the
intervals between them becoming shorter or
less marked, and the  seizures longer or more
frequent  the more this power is reduced;  3d.
That these attacks are similarly affected by im-
paired excretion and evacuation, and by impure
or morbid states of the blood;  and, 4th. That
they are  influenced  in the same way by mental
depression, and by directing the mind either
frequently or for a lengthened period to them.
  48. C. As  to the cause of the periodicity, or
of the recurrence of the effects of irritation, no
farther or more satisfactory information can be
given than by assigning this character to a law
of the animal ceconomy, which is observed as
long as these effects  do not extend  much be-
yond the nervous systems, or implicate  the
more important emunctories and the blood and
vascular  system.  If  we  attempt to  proceed
farther in our research, we can infer only that
all causes exciting or irritating the source of
irritability and  the  sentient system,  produce
their  effects  on sensibility and on  muscular
movements in a more or less remittent or par-
oxysmal manner, the intermissions being com-
plete and prolonged in proportion  to the slight-
ness of the cause relatively to the susceptibility
of the nervous system and state of vital power.
Even the most violent of painful and spasmodic
diseases, as neuralgia and tetanus, are charac-
terized by exacerbations during the attack; and
these exacerbations exhaust,  for a  time,  the
sensibility and irritability, which, however, are
quickly restored  under the  influence  of  the
causes which continue to excite  them; or, in
other words,  irritation  being once excited in
any part  of the source of irritability or of the
sentient system, explodes itself in fits or shocks
on those  parts  most immediately connected
anatomically  and  physiologically  with  these
sources ;  and when the cause of irritation con-
tinues in action, or when the irritation is in-
tense, although the cause which excited it may
                                        707

have been removed, the effects may continue
until the vital energies are exhausted, or may
even increase with the  vital exhaustion, until
life is extinguished, unless some powerful agent
be employed capable of fortifying the nervous
power  and  vital resistance, and thereby ena-
bling them to overcome  the morbid impression
which has been produced, or to resist the oper-
ation of the causes which are present, until the
parts become accustomed to their influence.
  49.  D. The  duration  of  irritation depends
chiefly upon the same circumstances as have
just been shown to influence the character or
type of its effects (<J 45): these circumstances,
however,  tend more  especially to render the
disease  more acute,  and of shorter duration
than it  would  otherwise prove.   In general,
irritation is prolonged in  proportion to its slight-
ness relatively to the degree of vital  or consti-
tutional power ; and it may continue or recur
for an indefinite period, as long as vascular ac-
tion  and the states of  the  blood, and  of the
emunctories, are not  very materially affected
by it.   As these become deranged or remarka-
bly  diseased, so the duration  of the resulting
malady is equally short; and this is  especially
the case when muscular contractility is either
inordinately excited or very greatly  impaired.
Tetanus, rabies, poisoned wounds, &c, are il-
lustrations of the short  duration of the effects
of irritation when  its action is energetic, and
when its consequences are extensive  in respect
of the nervous, vascular,  and muscular systems.
  50.  E. The terminations of irritation have
been partly  noticed (§ 23) when remarking the
effects or consequences  of it upon the vascular
and muscular systems, and upon the secretions
and nutrition.   The effects of it on these parts
of the ceconomy are often intermediate between
an advanced stage of its development and  its
termination ; but still, irritation may  arise and
subside, or  terminate in  health, without any of
its more palpable consequences or strictly struc-
tural lesions having been produced, sensibility
and contractility having been only temporarily
disturbed.   It may terminate in death in a very
short time, owing to the intensity of its action,
or to its violence,  as expressed chiefly on the
sensibility or on the muscular and vascular sys-
tems, and previously to any very marked effect
upon the organization, although  generally the
secreting and excreting functions, and the chan-
ges in the blood requisite to the continuance of
life, are either impaired or arrested before death
is occasioned.  Irritation may also produce va-
rious lesions, already alluded to (§ 27-29), these
lesions  either superseding, extinguishing,  or
merely masking the original mischief;  or then
greatly increasing both it and its effects. Most
frequently  when irritation terminates fatally,
this result is owing more to the changes, often
numerous  and consecutive, produced  by  it,
than to the violence of this state, as expressed
merely on the sensibility and irritability of the
frame, although the  changes in these latter
properties may either altogether, or only partly,
produce this last result.
  51.  III. Of the Influence of  the Agents
or Causes on the  States and Characters of
Irritation.—i. Of predisposition to irritation.—
An  increased susceptibility of irritation may
arise  from  a great variety  of circumstances.
The influence, however, of several of these is
lation to its Causes. 
ELATION TO ITS CAUSES.
708                     IRRITATION—In R

not satisfactorily  established, or, rather, hardly
admits of proof.  It appears very probable that
the usual causes  of irritation act more readily,
and  with greater intensity, (a) On  the irrita-
ble,  nervous,  and  sanguineous,  than on the
phlegmatic, bilious, melancholic, and lymphatic
temperaments; (b) On the scrofulous and gouty
diathesis, and the  delicate and enfeebled consti-
tution, than on the  sound and robust;  (c) On
the young than on the old, and more particular-
ly on infants and children ; (d) On  the female
than on the male sex.   Besides  these  causes
of predisposition, others may be enumerated,
as hereditary or original constitution;  unwhole-
some diet and insufficient food ; modes of liv-
ing calculated to  weaken and to impede the di-
gestive, assimilative, and depurating functions ;
confinement in-doors, insufficient exercise, sed-
entary occupations, and deficient ventilation.
All the depressing passions and emotions ; soli-
tary confinement, suppressed feelings, and pri-
vation of light, sunshine,  and fresh air ; debility
and pre-existing disorder, more particularly tor-
por of the bowels, and of the excreting  organs
generally; the superabundance of excrementi-
tial matters in the blood, or the absorption into it
of morbid secretions; and either too great ful-
ness or extreme deficiency of the blood, or vital
depression and vascular  plethora, or inanition,
or contamination, either individually or  vari-
ously conjoined,  favour  the  operation  of the
more immediate  causes  or agents of irritation
on the frame.
  52. ii.  The Exciting Causes.—The operation
and  nature of these, conjointly with  the state
of predisposition, influence and determine the
form and character of irritation.—A. The nature
and amount of external injury, especially in con-
nexion with the shock sustained by the cecono-
my on the infliction of it, often produce irrita-
tion of a serious  kind, both locally and consti-
tutionally ; and the particular nature  and  rela-
tions of this effect are often misunderstood and
unsatisfactorily treated.  Among these injuries,
surgical operations may  be classed.   The na-
ture and character  of the irritation  also  vary
much with the nature of the tissue or part pri-
marily affected or injured. Thus, a puncture or
laceration of a tendon, or of an aponeurotic ex-
pansion,  will  more readily induce tonic spasm
or tetanus than neuralgia ; and the  spasm will
more readily be produced in a person predispo-
sed  by a combination of  circumstances ; by an
irritable or nervous  temperament;  by depres-
sion of organic nervous and vital power;  by
accumulations of  morbid  secretions in the bow-
els ; and by the depressing passions,  than in a
healthy individual.  An irritating body, lodged
either between the fibrils of a nerve, or upon
its  sheath, may so alter the sensibility of its
sensitive  fibrils as  to occasion acute pain  in
their ramifications and terminations, even with-
out  affecting  the motor nerves, or  affecting
them only slightly and occasionally.   In many
external injuries the cerebro-spinal nerves may
entirely escape, and yet the extent of mischief
and the shock to  the system may be great.  In
such cases, the other structures may be serious-
ly injured, and especially the organic nerves :
these latter affect the circulation in the vessels
of the injured part, and consecutively the vas-
cular system generally;  and thus extreme suf-
fering, shock to the constitution, and vascular
reaction—unless the vital powers are entirely
overwhelmed  by the amount of injury and  the
attendant shock, so as to prevent  reaction-
are  successively  produced.   In perusing  the
numerous instances of surgical operations  de-
tailed in various works, the physiological  pa-
thologist will readily recognise, in many of the
phenomena  attending these  cases, the effects
of irritation caused by the operation.   A man
is operated  upon for axillary or subclavian  an-
eurism, and the ligature placed upon the sub-
clavian artery necessarily  produces not only a
shock to the constitution, but also irritation as
the  shock subsides, owing chiefly to the cir-
cumstance of the organic  nerves surrounding
the vessel in a closely reticulated plexus being
enclosed, strangulated, or irritated by the liga-
ture.  Hence  the oppressed breathing, general
coldness, and  sinking of the vital powers, fol-
lowed by febril commotion and various painful
spasmodic and sympathetic affections, accord-
ing to  the peculiar circumstances of the case,
so frequently consequent upon such operations.
  53. B.  Numerous mechanical and chemical ir-
ritants  produce  not only great local, but  also,
consecutively,  much constitutional irritation.
These, however, are generally no farther inju-
rious than by disordering or inflaming the parts
to which they are  applied, unless they are so
energetic as to disorganize  the structure,  as
concentrated acids, alkalies, &c.  Much of the
local and constitutional irritation produced  by
these,  unless  they  are thus  energetic, or are
brought in contact  with an extensive surface,
is owing to the states of the system, and espe-
cially of the organic functions—deficient  vital
power, impure states of the  circulating fluids,
and  impaired secretion and excretion, particu-
larly favouring the effects of these agents.
  54. C. Many substances combine, with much
local irritation, a  narcotic or alterative  effect
upon the nervous  and  vital  properties.—a.
These  acro-narcotics exert  a decidedly poison-
ous  effect, characterized  not  merely by  local
and  general irritation, but also by a specific
condition of the vital functions.   There are
both a local irritation or inflammation produced
by them, and a change in the states of sensibil-
ity, of irritability, and of secretion and excre-
tion, having  a special reference to the agent or
cause.   Most of these substances are derived
from the mineral and vegetable kingdoms, and
constitute, owing to  their peculiar  modes  of
action, the principal part of our means of curing
disease, when judiciously employed.
  55. b.  Numerous animal substances occasion
either  local or general irritation, or both,  or
combine with  this a contaminating or poison-
ous effect.  In some instances, their operation
locally and constitutionally, is chiefly of a sep-
tic nature, dissolving the  vital cohesion of the
tissues, and contaminating the circulating flu-
ids ;  in others, their action  is more strictly irri-
tant, in respect either of the organic or of the
cerebro-spinal nervous system, or of both, but
generally of the former especially ; and again,
in others their influence is both septic, as  re-
gards the tissues and fluids, and depressing, as
respects the vital  endowment.   Thus, putrid
animal matter acts principally in the first of
these modes, yet partly, also, as a local, and,
through the medium of the blood and vascular
system, as a constitutional irritant.   The virus 
IRRITATION—In Relation to its Causes.
709
 of rabies affects chiefly the nervous systems,
 irritating, first, the part inoculated with it, and,
 consecutively, the organic nervous functions,
 and,  lastly,  the  cerebro-spinal actions.  The
 venom of serpents and insects both dissolves
 the vital cohesion of the  tissues to which it is
 applied, contaminates them and the fluids, and
 remarkably depresses the vital manifestations.
  56.  c. Acid or excrementitious matters passed
 into, or accumulated in the blood, are more fre-
 quent causes of constitutional commotion or
 irritative fever than is generally supposed.  Va-
 rious secretions and excretions, when accumu-
 lated or retained, are partially absorbed, and
 render the blood impure (see art. Absorption,
 $ 15); others, when interrupted or  suppressed,
 are followed by a redundancy in the blood of
 the materials forming them, which materials
 are the causes of irritative fever, of excessive
 action and greatly depressed vital power.  Uri-
 nous fever, or the constitutional commotion oc-
 casioned by suppressed or interrupted secretion
 and excretion of urine, is one of the forms  of
 irritative fever caused by the accumulation  of
 excrementitious or morbid matters in the blood.
  57.  d. The passage, also, of morbid secretions
 into the circulation is often productive of the
 worst forms of constitutional irritation.  If
 these substances pass gradually, so that  their
 elimination  from the  blood is as rapid as  their
 introduction into it, the consequent  irritative
 fever is comparatively slight, and generally as-
 sumes a hectic or remittent form ; but when it
 passes more abundantly and rapidly, as in cases
 of phlebitis  and of diffusive inflammation of the
 cellular tissue, the constitutional disturbance
 is very much more serious and acute, and very
 closely resembles the worst forms of putro-
 adynamic fever.   In  lying-in hospitals, where
 the vital powers are reduced, first, by the shock
 attending parturition, and, secondly, by the im-
 pure  air of the ward, and  when, in conse-
 quence of these circumstances, the  uterus con-
 tracts imperfectly, or  allows a considerable
 quantity of the bloody sanies escaping from the
 vessels on its  inner surface to accumulate in
 it, a portion of this sanies is absorbed or im-
 bibed by the veins into the circulation, and irri-
 tative fever  or constitutional irritation of the
 worst and most rapidly fatal  form  is soon de-
 veloped.  In many of these cases,  as I  have
 proved by repeated observation and post-mor-
 tem research, the imbibition or absorption  of
 the matter from  the cavity of the uterus, and
 the consequent contamination of  the blood,
 takes place without producing uterine phlebitis,
 or, at least,  without occasioning that form  of
 phlebitis which is attended by the production
 of coagulable lymph in  the veins  (see Veins,
 Inflam.  of);  while  in others the  uterine and
 spermatic veins are inflamed, either primarily
 or coetaneously, owing  to  the irritation of the
 matters retained in the uterus at the mouths
 of the veins  or sinuses left exposed by the sep-
 aration of the placenta, or as they  pass  along
 the  veins,  during the process of  imbibition.
 The most adynamic and rapidly fatal cases are
of the  former description, the more inflamma-
tory and prolonged instances are of the latter;
but this important subject is fully discussed in
the article on Puerperal Diseases and Fevers,
where the results of long and extensive expe-
rience are given.  The rapid absorption of fluid
 effused into the cellular tissue, as in phlegmasia
 dolens, edematous erysipelas, diffusive inflamma-
 tion of the cellular tissue, and in cases of non-
 encysted abscesses, is generally followed by con-
 stitutional irritation of a most remarkable kind,
 vascular action being excessive, but devoid of
 power or tone, and all  the  vital and nervous
 functions being remarkably depressed.  In a
 case of phlegmasia dolens of both thighs, under
 my care in 1832, the swellings very rapidly sub-
 sided, but we're soon followed by all the symp-
 toms of adynamic or  typhoid  fever, requiring
 the  free use of restoratives and  antiseptics,
 which produced a most beneficial effect and
 rapid recovery.
   58. e.  All  the animal poisons, and all the ema-
 nations produced from dead and living organized
 bodies, seem  to act first as local, and  more or
 less rapidly  as constitutional irritants.   The
 most remarkable of these is the virus or fluid
 sometimes inoculated when examining recent-
 ly-dead bodies.  This poison produces excess-
 ive irritation of the nervous systems, locally
 and  constitutionally, with extreme prostration,
 weakness,  and  rapidity  of the heart's action,
 &c, soon followed by fatal exhaustion.  But,
 while these  animal or-morbid  poisons irritate
 more or  less  the organic nervous and  vascular
 systems, they likewise depress their vital man-
 ifestations  and contaminate  the blood and se-
 cretions.  They act as a kind of leaven which
 infects the whole  ceconomy, and imparts to it
 the power of developing a poison, like itself in
 all respects, capable of producing the same ef-
 fects, and  thereby perpetuating itself.  (See
 arts. Infection ; Poisons, Animal,  &c.)
   59. /.  Numerous substances irritate the sys-
 tem  when received into the stomach or bowels,
 or passed into the circulation, each producing
 an effect having a strict reference to its nature
 or peculiar properties, and to the quantity of it
 taken or introduced into the blood.   Indeed, the
 operation of a large proportion of medicines
 depends  upon this specific influence, modified,
 however, by  a variety of circumstances, duly
 considered and taken advantage of by the ob-
 servant  and  experienced physician.  In cases
 of irritation  from these  causes, the local and
 constitutional effects vary with the tissue or
 viscus upon  which they individually act, with
 their absorption or non-absorption into the cir-
 culation, with  the quantity  of the substance
 employed, and  with their specific influences on
 the different  emunctories.  Substances which
 are absorbed, or which otherwise pass into the
 blood, exert, according to their nature or pecu-
 liar properties, more or less of irritation of the
 vascular system, and of the organs by which
 they are excreted from the blood, modifying, at
 the same time, the functions of the mucous and
 cutaneous surfaces, and  the  states of nervous
 influence. Owing to these circumstances, these
 agents produce more or less constitutional com-
 motion,  or irritative fever, unless  their influ-
 ence is  slight or is limited to some excretory
 organ or surface.
  60. g.  The sensations,  when acutely  excited,
 are often causes of irritation, more especially
of those parts of the cerebro-spinal  nervous
 system with  which they are in the  most inti-
mate correspondence.  Thus, inordinate excite-
ment or irritation of the organs of sense is oft-
ten followed by inflammatory excitement of the 
7i0                           IRRITATION-

brain, or of its membranes ; and of the nerves
of sensation in the  extremities, or in the gen-
eral surface, by convulsions.   Morbid sensation
occasionally exerts a similar  influence, or re-
acts upon and augments the primary irritation
producing it.  Acutely  excited sensation may
occasion, by either a direct or  reflex sympathy,
morbid sensations in distant parts, or spasmodic
or convulsive  movements, or, by exciting the
vascular system or impairing the  excreting
functions, constitutional disturbance  of a more
or less severe  nature.  Indeed, this cause, par-
ticularly in connexion with the excitement of
a pleasurable feeling, as in sexual irritation, is
a much more  common  source of the diseases
of irritation, or, at least,  of those which are thus
characterized  at their commencement, than is
generally supposed ; and  it is almost equally
prevalent and  mischievous in  both sexes.  Its
consequences are manifested both by direct and
reflex sympathy, giving  rise to disordered func-
tion, morbid sensation, disordered or uncontrol-
lable muscular movements, and  ultimately to
constitutional disease.  If we trace the progress
of the mischief, we shall detect the effects, first,
in the weakness of the  various digestive func-
tions, through the medium of  the organic ner-
vous system;  next, in the cerebro-spinal ner-
vous system, as evinced by morbid sensibility
of the spinal nerves and weakness of the men-
tal faculties, or by  affections  of the voluntary
and involuntary muscles, or  by  convulsions;
and, lastly, in  the  augmented disorder  of all
these, in disease of the vascular system,  in de-
ficiency and poverty of the blood, and in various
nervous, cachectic, and even  structural  chan-
ges, terminating in  some instances in death.
   61.  h. Various moral  emotions and intellectual
powers, when  inordinately excited or  exerted,
and especially the malevolent passions, anxiety,
and some  of  the depressing  feelings, excite
more or less of irritation, disturb the circula-
tion in the brain, and disorder the actions of
the heart.   In addition to their  more strictly
local effects, particularly in respect of the ner-
vous  system,  they may also  produce violent
constitutional  commotion, and derange all the
secreting, assimilating, and excreting functions,
this latter effect increasing still farther the vas-
cular or febril disturbance.  The mental emo-
tion may even  irritate particular organs, accord-
ing to its nature, as the heart, the urinary,  and
genital organs ;  and the physical  effect may in
its turn be  a source of irritation to other  parts.
The mental emotion, also, may be of so violent
a nature as to  give rise to convulsions, or alter-
ed sensibility  of remote  parts,  previously to
vascular or other disorder of a  general kind
having been produced.
   62.  In estimating the influence of moral or
physical causes in exciting local or general irri-
tation, too great importance  should  never be
attached to one, or even two causes only, with-
out endeavouring to detect others, or compri-
sing the various predisposing circumstances in
our pathological estimate.  Every influence or
occasion ought to oe recognised and duly weigh-
ed ; for, upon  the evidence we obtain of each,
must a principal part of our indications of cure
be founded.
   63.  IV.  Treatment of Irritation.—The in-
dications, as well as the means of cure,  or of
alleviation, of both local and general irritation,
-Treatment or.

must entirely depend upon the knowledge that
is obtained of the causes,  of their individual
and conjoint influence in producing the existing
effect, and of the extent of functional or struc-
tural disease which has already resulted.   It is
manifest, from these and other considerations,
that the indications and means of cure of irri-
tation must, in order to be appropriate and ben-
eficial, have strict reference to the several pre-
disposing and exciting causes, and to the exist-
ing morbid conditions of each case.   However
closely observant,  however  experienced the
writer may be, he cannot state these so  as to
apply to all the circumstances of such cases as
they are  daily occurring in practice.  He can
only assign those which are the most important
and the most applicable to the more usual oc-
currences, leaving the reader to  modify them,
or even to add to them, according to the emer-
gencies or the variations presented  by particu-
lar instances.
  64.  There is no class of diseases in which
the  fundamental principle in  therapeutics, of
avoiding or removing, subduing or counteracting
the causes, is so necessary  to  be observed, or
so difficult to be practised, as  in this very im-
portant and numerous class ;  and none which
requires greater physiological knowledge, or a
more sagacious recognition of healthy and mor-
bid sympathies than this does. Thus  impressed,
I have been led into a fuller exposition of the
pathological relations and  causes of irritation
than may appear necessary to many.  It seems,
however, that this procedure was not the less
necessary that it was difficult, and either avoided
by nearly all preceding writers, or treated of in
a most empirical manner, or, at least, with a less
strict reference to the early, the intimate, and
the consecutive changes characterizing the dis-
eased condition in question—with a  less regard
to the actual procession of morbid phenomena
than the existing state of physiological knowl-
edge warranted.   In entering, therefore, upon
the  treatment  of a case of local or constitu-
tional irritation, it is necessary not  only to as-
tertain fully, and to estimate justly,  the predis-
posing and exciting causes, with the view of
removing or counteracting them, but  also to
trace the origin, the various relations, and the
obvious and probable effects of this condition,
and to consider them  in connexion with the
states of vascular action and purity, and of vital
power or resistance, and with the sympathies ex-
isting between distinct organs and distant parts.
  65.  i. Treatment'of Irritation with  reference to
removing,.subduing, and counteracting the Caus-
es.—Many of the causes admit of removal, oth-
ers can be counteracted merely ; and  where the
former cannot be accomplished, the latter must
be attempted.   In many eases, certain only of
the causes may  be removed, and the others may
be either  counteracted  or subdued—a circum-
stance which should not be overlooked in fra-
ming our plan of cure.  The first part of this in-
dication requires no remark, but the latter de-
mands farther notice. In order to subdue or to
counteract irritation, the means should be applied
with strict reference to the nature of the causes,
to the  state of the  ceconomy, and to the seat
and state of irritation.   The means  which are
to be  thus employed  may be  divided into /ieo
classes.  1st. Those which are strictly localt or
topical; and, 2d Those which act more or less 
                             IRRITATION—

constitutionally, or upon one or more of the gen-
eral systems of the frame.
  66.  A. Of the means applicable to the seat of
Irritation.—These  consist chiefly of emollients,
anodynes, or sedatives, and narcotics; in  some
instances of refrigerants, of stimulants or irri-
tants, and of evacuants.   The  former of these
admit of being variously  combined.   It  is in
comparatively few cases of irritation that these
means can be applied to the part primarily af-
fected ;  but where this may be done, it should
never be neglected.—a.  Under the  head  emoll-
ients may be comprised all the modes of em-
ploying  moist heat, or of  conjoining moderate
warmth with humidity ; as the use of fomenta-
tions, warm vapour, and  poultices.—b.  Ano-
dynes and narcotics are indicated chiefly in con-
nexion with the former, the particular agent be-
ing suggested by the nature of the cause and
the seat of affection.  This combination exerts
a more sedative influence on the local disorder
than either would if employed singly.   Thus,
warm water, vapour, fomentations, or poultices,
with  henbane, conium,  belladonna, poppies,
camphor, &c, are more efficacious than those
emollients used simply.   It should not be over-
looked, that protection from  the  action of the
air aids many of these in their beneficial opera-
tion.—c. Refrigerants are  much less efficacious
than the foregoing in removing local irritation,
although they act, like them, chiefly upon the
sensibility of the part; and, in order to be useful,
they should be constantly applied.  Refriger-
ants are most  beneficial when  irritation is
about to excite either haemorrhage or inflam-
mation, and they may then especially be con-
joined with various astringents and sedatives, as
the preparations of lead, of zinc, of opium, &c.
   67. d. Stimulants, or even irritants, are some-
times useful in subduing local irritation, but it
is often difficult to determine the particular cir-
cumstances in which they should  be resorted
to.  When  the irritating cause is of a poison-
ous, septic, infectious, or contaminating or spe-
cific nature, then stimulants, or even the more
powerful  irritants,  are  generally  beneficial.
Thus, camphor, ammonia, the turpentines, the
chlorides, the nitrate of silver, and numerous
other vegetable and mineral substances, are
often of service when applied to a part  irrita-
ted by any of these causes.   In  such  cases,
the artificial irritant, if sufficiently energetic,
supersedes the action of the morbid one,  espe-
cially if it be employed before the organization
of the part and the vital powers have suffered,
or before morbid sympathies have  been  devel-
oped ; and even in  these circumstances they
may greatly aid the  constitutional means of
cure.   The stimulus, even of dry heat, may be
useful  in relieving irritation when judiciously
employed,  or  conjoined with  other agents.
When heat is indicated purely as a stimulant,
or even as an antispasmodic and sedative, these
will often be most useful when applied in a dry
form.  The  combination  of  stimulants with
narcotics is sometimes of use, even locally, in
many cases of irritation, attended by pain or
spasm, and it will be seen  in the sequel that this
combination is still more  beneficial when pre-
scribed internally, or constitutionally.  In most
cases of irritation manifested  chiefly in the
nervous systems, this combination is especially
indicated,  and is  often  not  less  efficacious I
-Treatment of.                           711

 when topically than when constitutionally  em-
 ployed.
   68. e. Evacuation of the vessels of the part
 affected, or of fluid effused in the areolae of the
 tissue, is often of great service in an advanced
 period of irritation.  In such cases, distention
 of the capillaries and of the tissues by the ef-
 fused fluid, consequent upon  the action of the
 irritant, perpetuates the morbid state, or even
 increases it; and in every instance it heightens
 the constitutional and  sympathetic effects of
 the local affection.  This is more  particularly
 remarkable where joints, fibrous or sero-fibrous
 structures, or deep-seated  parts,  or tissues
 bound down by aponeuroses, are so irritated as
 to give rise  to  capillary distention or serous
 effusion.  In cases of this description especial-
 ly, the use of emollients, anodynes, and narcot-
 ics, will often beneficially follow the judicious
 local evacuation of the distended vessels, or of
 the effused serum.
   69. B. The constitutional or more general treat-
 ment of irritation consists chiefly of the use,  1st,
 of agents calculated  to lower or  subdue,  not
 only the local affection, but also its sympathetic
 and constitutional effects, by their direct or spe-
 cific operation ;  2d, of such means  as  will  ex-
 cite irritation in a particular part or viscus,  and
 thereby supersede or reduce the primary affec-
 tion ; 3d, of  those medicines which stimulate
 or impart tone to the nervous and vascular sys-
 tems, and thereby either subdue the local mor-
 bid condition, or enable the constitutional pow-
 ers to resist it until it subsides, either naturally,
 or from the disappearance of its causes, or from
 the influence of local  treatment;  and, 4th, of
 remedies  which remove injurious materials
 from  the  system, which promote  the excre-
 tions, and preserve the  circulating fluids in  a
 state of purity.  It is obvious that, in the more
 severe and intense states of irritation especial-
 ly, these several means require to be variously
 conjoined, and to be aided by the topical meas-
 ures already advised.
    70. a. The means most useful  in reducing local
 or sympathetic and constitutional irritation are the
 usual antiphlogistic remedies ;  as low  diet, ab-
 stinence, vascular depletions, refrigerants, sed-
 atives, and physical and moral quietude.  These
 are more particularly indicated when  irritation
 affects the sanguine, the plethoric, and the ro-
 bust, or when it has superinduced a  state of
 sub-inflammation, or  of active congestion, or
 of active haemorrhage, or of simple sanguine-
 ous determination to  an important  viscus.   In
 opposite circumstances, especially in the debili-
 tated ; in the nervous, melancholic, lymphatic,
 and irritable temperaments ;  in persons with a
 poor, or deficient, or morbid state of the blood ;
 and for those who have long suffered, or who
 are  suffering from depressing influences,  the
 lowering measures now enumerated generally
 increase the  local irritation, and even hasten
 and augment its sympathetic and constitutional
 effects.  By lowering the constitutional pow-
 ers, resistance to the extension of the  disorder
 is equally weakened.   In cases of this kind, the
 more restorative measures about to be noticed
 (() 76) are required.  Where the remedies com-
 prised under this head are indicated, the choice
 of them must altogether depend upon the causes
 and nature of the case ; but generally  they
I should be cautiously prescribed, and they should 
712
IRRITATION—Treatment of.
 be neither repeated nor persisted in, even when
 indicated, without being combined with narcot-
 ics, or with antispasmodics, according as mor-
 bid sensibility or spasm may be the consequence
 of irritation.  In cases where want of sleep or
 mental irritation attends this affection, the state
 of circulation in the head should receive atten-
 tion ;  and if these symptoms are clearly not ref-
 erable to increased vascular action in this quar-
 ter, then narcotics or anodynes, sometimes con-
 joined with alkalies, are of great service, and
 reduce both the local irritation and the nervous
 affections consequent upon it.  In  cases  of
 spasm, as well as of morbid sensation, anodynes
 and narcotics are nearly equally serviceable;
 but, in the former especially, a combination of
 them  with  those stimulants commonly  called
 antispasmodics  is productive of great benefit.
 When these symptoms are violent, without vas-
 cular determination to the brain, antiphlogistic
 and lowering means are generally prejudicial,
 the opposite measures about to be noticed being
 the more appropriate.  In  the  circumstances
 just noticed, a recourse to alkalies or their sub-
 carbonates, with anodynes, is often of service,
 particularly when the  urine is thick,  deposites
 a sediment, is acid, and when the stools are of-
 fensive, and the skin foul.
   71.  b.  Irritation artificially produced in  an  or-
 gan or part remote from the primary seat of mor-
 bid irritation sometimes  supersedes this latter
 state.  The  principle of counter-irritation,  of
 vascular  derivation,  of artificial  irritation, &c,
 has been long recognised in medical practice,
 has been variously denominated, and various
 means have been used in carrying the principle
 into effect.   It is, when  judiciously prescribed,
 more serviceable in disorders of irritation than
 in any other class.   The agents employed with
 this intention may be divided into, 1st. Those
 which irritate internal organs, and are servicea-
 ble in  consequence, chiefly,  of this mode  of ac-
 tion ;  2d. Those that are applied  externally with
 this intention.—a. Of the former, (a) drastic pur-
 gatives are the most commonly used, and  some-
 times most beneficial.   They not only give rise
 to  an  amount of irritation occasionally suffi-
 cient to  supersede  the  original  affection, but
 they evacuate accumulated morbid secretions
 or  faecal matters which either predisposed to
 or otherwise contributed to  cause the disorder.
 Their good effects may partly, also, be imputed
 to the  vascular determination to  the  digestive
 canal, and consequent  derivation  from the seat
 of irritation produced by them.   It is princi-
 pally, however, when disorder is seated in parts
 intimately sympathizing with the intestinal ca-
 nal that they are the most useful.   If it is seat-
 ed in the nervous centres, or if it  affects sensa-
 tion or muscular motion, cathartics energeti-
 cally employed afford great  relief, as shown in
the articles on Neuralgic Affections, Teta-
 nus, &c.—(b) Emetics are, upon the  whole, less
 serviceable than cathartics ;  yet they are of
much use for irritation  of  the respiratory or-
gans,  especially for  hooping-cough, asthma,
eroup,  and for all spasmodic affections of the
larynx and bronchi  consequent upon irritation
of the nerves of these parts.   Of cathartics and
 emetics it may  be  remarked, that  a  cautious
 recourse  to them—in  some cases  a  frequent
 repetition of them—is often necessary to the
 removal  of the  irritation produced by morbid
 secretions accumulated in the gall-ducts  and
 bladder, or even in the cells of the colon, or in
 the Ccecum. — (c) The more  irritating diuretics,
 as turpentine, cantharides, &c., are sometimes
 decidedly beneficial in many disorders of irrita-
 tion ;  and, according to my experience, they
 are most so when the  irritation  gives  rise to
 spasmodic or convulsive actions, as in trismus,
 convulsions, hooping-cough, &c. ; but, in order
 to be  thus useful, they  should be given so as
 to produce a marked operation on the urinary
 passages.  I have frequently seen a very man-
 ifest improvement of states of these diseases
 as soon as the urinary organs became irritated.
 —(d) Salivation may  be considered as one of
 the modes of internal irritation and  derivation,
 especially  when  maintained for a considerable
 period.  Mercurial salivation is, however, more
 appropriate  to inflammatory diseases than to
 disorders depending upon irritation, unless, in-
 deed, the latter tend to the former character,
 and affect  the  states  of vascular  action either
 generally or locally.   Irritation, also, when pro-
 ductive of haemorrhage, is often most success-
 fully combated by mercurial  salivation of a
 slight form, when it  may be readily produced,
 and without  having recourse to a too free ex-
 hibition of this mineral.   In the slightest forms
 of irritation, especially those affecting parts
 about the  face,  mouth, &c, artificial excite-
 ment of the salivary glands by pyrethrum or
 other sialogogues may be of use.
   72.  B. External derivation or irritation has al-
 ways been prescribed for disease ;  but in recent
 times it has  been resorted  to by empirics  and
 impostors, who have employed it injudicious-
 ly, and often injuriously.  It is appropriate in
 most cases of irritation, in some form and mode
 or other; yet much discrimination is necessary
 to a beneficial recourse to it, in the choice both
 of the irritant  and of the situation to which it
 should be  applied.  The stage of the  disorder
 in which it is most likely to be serviceable, and
 the other means of cure which should be pre-
 scribed iii aid of it, also  deserve consideration.
 In the more acute and continued cases of dis-
 order, and  when it is desirable to produce  an
 immediate  effect, then  the  external  irritants
 which are  most  energetic, as hot  turpentine
 epithems and embrocations, mustard poultices,
 blisters,  moxas,  stinging by  nettles, mustard'
 pediluvia, &e, are also the most  useful; but,
 in the more chronic, remittent, or intermittent
 states, it will  be necessary either to repeat
 these  applications  oftener  than  once,  or  to
 have recourse to others which, although slower
 in their operation, are more permanent in their
 influence on  the  complaint, as setons, issues,
 and artificial  eruptions, produced by  croton oil,
 by tartar emetic ointment, or by other means.
 Some of these modes  of producing external  ir-
ritation require a few  remarks.
   73. a.  Epithems of warm flannels, soaked in
spirits of turpentine, produce an almost imme-
diate  redness and a burning  sensation of the
part on which they are applied, and are espe-
cially beneficial in irritation of internal organs,
in painful or spasmodic affections,  and particu-
larly when there is risk of inflammatory action
or haemorrhage being induced.  They may  be
frequently repeated in  some cases, and they
then usually slightly vesicate or excoriate the
surface of the part, the external inflammation) 
IRRITATION—Treatment of.
713
 thus produced soon subsiding, and they often
 procure  a copious perspiration.   Stinging by
 nettles was formerly much used, and is an im-
 mediate and often very efficacious mode of ex-
 ternal  derivation, and is applicable to the cases
 for which mustard poultices are prescribed.
 Mustard  pediluvia,  or  mustard manuluvia, the
 water  being as warm as it may be endured, and
 mustard poultices, are of service chiefly in cases
 of slight  irritation, and before vascular excite-
 ment  has been produced, or after it has been
 in great measure subdued.  These means are
 seldom of much service when vascular excite-
 ment is considerable.
   74.  b. The external irritants which are slow
 in their action are beneficial  in  consequence
 rather of their  permanent influence, and  the
 discharge they occasion, than of the amount
 of irritation or inflammatory  action produced
 by them.   This is especially the case with se-
 tons and issues, in all the various forms in which
 they are  made  or kept in action.  One of the
 best modes of  forming an issue is by applying
 the decorticated bark of mezereon, previously
 moistened, over the part selected, and  by re-
 newing the application daily, or by placing the
 common issue-pease under the plaster covering
 the denuded or ulcerated part.  When it is de-
 sirable to  produce a free discharge and much
 artificial irritation at the same time, then open
 blisters, large issues, or the antimonial ointment
 may be prescribed.  Croton oil, employed so as
 to occasion free pustulation,  and other appli-
 cations calculated to excoriate the surface and
 to give rise to a free discharge from it, as vari-
 ous combinations of concentrated acetic acid
 and oil  of turpentine, or preparations of ammo-
 nia, are severally of use when judiciously pre-
 scribed and applied, and when aided by appro-
 priate  internal means.
   75. c. Most of these  modes of producing ex-
 ternal irritation and derivation from the primary
 seat of disorder are indicated, either before vas-
 cular action has been excited by the  primary
 affection,  or after it has been  subdued,  or  in a
 great measure  subdued by suitable treatment.
 As long as inflammatory action exists, or as
 long as the primary irritation  may be greater
 than the amount of external irritation that can
 be prudently excited, but little benefit will re-
 sult from  the practice, unless the discharge
 procured by its  means  assist  its influence, or
 compensate for the deficiency in the  amount
 of irritation.  In such  instances the artificial
 irritation is seldom productive of  that amount
 of vascular afflux or determination capable of
 being decidedly beneficial.  When, however, a
 copious discharge is produced and maintained,
 the internal affection will often be removed, if
 it does not amount to disorganization or serious
 structural  change ;  but when these changes
 have taken place, the amount of discharge will
 often  only hasten  the  unfavourable progress
 of the malady, and sink the patient. In all such
 cases it is important to watch carefully the ef-
 fects of this mode of treatment. When morbid
 irritation has given rise to increased vascular
 excitement, external irritation and derivation
 are seldom successfully procured.  In  these
cases they only augment the  morbid vascular
action, and are prejudicial, or, at least, ineffica-
cious, in proportion to the degree in which the
vascular system is excited.
    II.               90
   76. C. The remedies which stimulate the ner-
 vous energy and impart tone to the vascular sys-
 tem—a, are generally of service  in diseases of
 irritation when the vascular system is not ma-
 terially disturbed, or when it is  excited to in-
 creased action, with a diminution of power, and
 with evidence of a morbid state of the blood.
 When  irritation has  been followed by great
 frequency of the heart's action, irritability and
 muscular power being much impaired, and the
 pulse soft and open, or expansive, then the
 more energetic stimulants  or tonics, selected
 with reference to the circumstances of individ-
 ual  cases, and  conjoined with  means which
 may promote the  action of the emunctories,
 and counteract  morbid changes in the circula-
 ting fluids, are generally of the greatest service.
 They increase the vital resistance to the exten-
 sion  of the sympathetic  effects of irritation,
 and enable the vital energies to overcome the
 primary morbid condition, or to resist its inju-
 rious influence until it subsides under the local
 or other means of cure,  or from other influ-
 ences.  The several preparations of cinchona,
 or of other tonic barks, quinine, camphor, am-
 monia,  the chlorate of potash,  the chlorides,
 the alkaline carbonates, the hydro-chloric acid
 and  ether, wine, opium, alcoholic preparations,
 the  turpentines,  Cayenne pepper, cajeput oil,
 &e, and the numerous remedies  more particu-
 larly mentioned  in the Treatment  of Typhoid
 Fevers (<J 530),  and of Diffusive Inflamma-
 tions (■$ 236), are more especially indicated in
 this  state of disease.
  77. b. When irritation gives rise to extreme
 pain, to  the more violent forms  of neuralgia,
 or to convulsive  or  spasmodic actions, the most
 energetic and  permanent tonics, variously com-
 bined, according to the states of  the excreting
 viscera, are also then more beneficial than a
 lowering treatment; but these remedies  should
 be aided by the  most  active narcotics, and by
 suitable  local means.  In  such  cases,  brisk
 cathartics, followed by quinine, or the prepara-
 tions of iron, or of arsenic, camphor, the alka-
 lies, or alkaline carbonates in large doses, am-
 monia, &c. ; and these, aided by opium, mor-
 phia, henbane, colchicum, aconite, &e,  pre-
 scribed  either internally or externally,  or  en-
 dermically, according to circumstances, are the
 most efficacious  remedies,  particularly when
judiciously combined with one another, or with
 other medicines.  Whenever pain  or convul-
 sion is  violent, inflammation is  not present;
 but the irritating cause evidently acts most en-
 ergetically upon the nervous system ; and  the
 means employed to  overcome or  remove it
 should be equally energetic, and so selected
 and combined as to act upon the source and
 seat of irritation, and to  remove the  morbid
 impression made by the cause of it.  In some
 cases, particularly those of extreme pain, al-
 ways affecting the  same  nerve,  treatment is
 not permanently efficacious, although it is gen-
 erally of temporary service, because the affec-
 tion  depends upon mechanical or  irremoveable
 irritation, near the origin, or in the course of
 the nerve.   In severer cases of  spasm, or of
 convulsion, it is, upon the whole, not much more
 successful; and is  even almost  equally hope-
 less when the  complaint depends  upon similar
 causes, or upon structural changes in the head,
or spinal column. In all such cases, the means 
714                           IRRITATION-

of cure should not be too weakening, and san-
guineous evacuation should be cautiously prac-
tised, even although local plethora, or vascular
determination to the nervous centres may ex-
ist.  Local depletions, or small bleedings, coun-
ter-irritation and derivation, both internal and
external,  tonics,  anti-spasmodics,  narcotics,
&c., are more beneficial than other measures.
Some years since, a gentleman was sent to me
from the country by his medical adviser on ac
count of neuralgia  of the occipital nerves;  I
considered it, from  the history of the case, to
be dependant on a  permanent cause of  irrita-
tion  about  the base of the skull.  External
derivation, and the other means already ad-
vised, were prescribed, and he continued to im-
prove for two or three years.  During a visit
to town, he was exposed to  several sources of
disorder,and in the  evening he was seized with
violent  convulsions.  The surgeon  called to
him bled him to a very large amount; and on
the following day, when I saw him. his pulse
was very quick, irritable, extremely compressi-
ble, and furnishing  all the indications of much
excitement, with  defect of power.   His man-
ner and answers to  questions were hurried,
quick, and unusual.   I expected a return  of the
seizure, or paralysis, or apoplexy,  in the course
of a few  days; but he continued to improve
slightly for some months, when hemiplegia, fol-
lowed by apoplexy,  soon terminating life, took
place.   Numerous  other illustrations  of this
principle might be adduced if my limits could
admit of them.
  78. D. Remedies which remove Injurious Mat-
ters, promote Excretion, and correct Morbid States
of the Blood.—Many of the substances  that evac-
uate excrementitial irritating matters also ex-
ert a salutary derivation, as  respects the vas-
cular afflux  or determination.  The  old doc-
trine, " ubi irritatio ibi fluxus," is correct in all
situations, and in every sense, and particularly
when the  irritant is  applied to mucous surfaces,
and acts upon excreting glands.   During many
states of irritation, particularly when vascular
action is materially excited by it, absorption is
remarkably active, and morbid secretions accu-
mulated, either in the biliary passages or in the
intestines, especially in the  cells  of  the colon
and  caecum, are  more rapidly than  in  other
circumstances conveyed into the circulation,
thereby either favouring the production of, or
actually  producing  constitutional disturbance
of a serious nature  consecutively upon  the lo-
cal irritation. The more stomachic, tonic, and
alterative purgatives are essentially  necessary
in such circumstances, particularly  combina-
tions of the compound infusions of gentian and
senna, with alkaline carbonates ;  the spirits of
turpentine, with or without castor oil; and oth-
er medicines which produce a restorative, as
well as  an evacuant effect.  In all instances of
impaired excretion, or of excrementitial ac-
cumulations  in the circulating  fluids,  either
contemporaneous with, or consequent upon lo-
cal or constitutional irritation, the exhibition of
stomachic purgatives, and the alternation of the
more powerful tonics,  are extremely servicea-
ble.  In this 6tate of actual disease, the chlorate
of potash, chlorides, hydrochloric aether, cam-
phor, ammonia, the alkaline carbonates, and,
when vascular action is excited,  the nitrate of
potash, the solution of the acetate of ammonia,
-Treatment of.

and other stimulants, either separately or pref-
erably, in conjunction with quinine, or with ton-
ic infusions or decoctions, or with one another,
according to tneir several compatibilities, will be
found most beneficial, provided that the actions
of the emunctories be  at the  same time duly
promoted,  and morbid  accumulations evacua-
ted.   In cases where irritation is attended by
accumulations of excrementitial matters in the
blood,  not only should the  bowels  be  freely
acted upon by the means just  mentioned, but
the kidneys ought  to  be excited by the more
energetic diuretics, as the turpentines, the al-
kaline carbonates, the  nitric or hydro-chloric
aethers, &c.  When local, or even constitution-
al irritation is attended by deficiency of blood,
or by a deficient proportion of haematosine, then
the preparations of iron, with  alkaline solutions,
as the mistura ferri composita, or the ferri am-
monio-chloridium,  the  ferri potassio-tartras,
&c, will be requisite, in  addition to the other
means which the circumstances  of individual
cases will  suggest.
   79.  E.  Alteratives  and deobstruents,  either
alone, or  conjoined with gentle  restoratives,
or with mild tonics, or with  laxatives or ape-
rients, are of the greatest service in the more
chronic  and slight forms of  irritation.  The
most useful of these are Plummer's pill, either
alone or with soap  and extract of taraxacum ;
the  hydrargyrum  cum  creta, similarly pre-
scribed ; the liquor potassae, or Brandish's al-
kaline solution, with any of the  concentrated
preparations  of  sarsaparilla, or  with taraxa-
cum ; and  the solution  of potash, with the hy-
driodate of potash.   The sub-borate of soda,
either alone or with the bitartrate of potash,
or both  these with taraxacum, are of service
for irritations of the  biliary organs.  A com-
bination of several of the foregoing medicines
with  camphor,  henbane, belladonna, or coni-
um, or with any of the preparations of opium,
according  to the peculiarities of particular ca-
ses, is  often  beneficial,  especially  when  irri-
tation is  attended  by increased sensibility.
When there is much irritation of the cutane-
ous surface, the alkalies  and their carbonates,
camphor, prussic acid,  the narcotics just enu-
merated, with emollients, &c,  employed both
internally and externally, should never be over-
looked.
   [In nothing is the skill of  the practical phy-
sician more clearly manifested than in  distin-
guishing irritation from inflammation, and suc-
cessfully combating it with appropriate  reme-
dies.   Dr.  B. Travers, in  his able work on
" Constitutional Irritation," led the way to cor-
rect views on this most important subject; and
Marshall Hall, in his more recent essay, en-
titled " Researches on  the Effects of Loss of
Blood,"  brought forth  facts  and  observations
of the  highest  practical import, which  have
been also confirmed by the publications of Drs.
Abercrombie, Gooch, and others.  With these
views,  American  physicians, we believe, are
very generally acquainted ; but yet we have so
frequently  witnessed erroneous treatment, from
incorrect pathology—from mistaking simple ir-
ritation  for active  sthenic inflammation, that
we deem  it proper to  add a few remarks on
this subject, supplementary to  those of our au-
thor.  We have found, in a practice  of many
years, that it is not always easy to discriminate 
IRRITATION-
I—Treatment.
715
in these cases, from the fact  that excessive
irritability,  as maintained by Broussais, very
often depends on  inflammation, or hyperaemia;
it may be latent or chronic, and the  irritation
hence arising will accordingly  be successfully
combated by antiphlogistic measures, as evac-
uants,  revulsives, and  contra-irritants.   We
do not, however,  believe that blood-letting, ei-
ther general or local, is as beneficial, or as fre-
quently applicable in  the treatment  of these
cases as is generally supposed.   We are to
bear  in mind the remark of  Mr. Travers,  that
" extreme susceptibility, and consequent over-
activity, are invariably coupled with, and most
probably dependant on weak and insufficient
powers of constraint and resistance.  The same
principle which renders a  part  over-irritable
renders it  over-active."   Medicines are not
anti-irritant in proportion to their antiphlogistic
effects, and therefore,  as  Dr. Williams  has
remarked, where  irritation  predominates over
inflammation, those are to be preferred which
act on  the  nervous as well as on the vascular
functions.   Physicians, especially those of the
younger,class, are in danger of regarding pain
as necessarily indicative of inflammation,  and
hence calling for depletory measures ; whereas
it oftener  is  the  result  of nervous  derange-
ment, and calls for soothing and anodyne rem-
edies.
   The first  rule to be laid down in the manage-
ment of this  affection, which can scarcely be
called a specific disease,  is to remove the  irri-
tating cause.  This  will generally suffice for
the perfect  cure of the patient.   Thus, emetics
are successfully employed to remove irritating
matters from  the stomach  ; purgatives from
the bowels  ;  acidity is  relieved by an alkali;
the irritation of dentition by lancing the gums ;
of worms, by  anthelmintics ; of a deep-seated
abscess, by the escape of the purulent matter;
of hernia,  by  a division of the  stricture  ; of
stone in the bladder, by its removal, &c.   But,
unfortunately, as  every practitioner must have
observed, irritation, when  once  established,
propagates  itself,  so as to become independent
of its first cause,  and we here  have a compli-
cation more difficult to manage.   If now we
are ignorant of, or cannot reach the cause, we
must endeavour to diminish the irritability of
the system, which is to be done by corrobora-
ting measures, as pure  air, exercise, cold  and
shower bath; vegetable and mineral  tonics,
with  anodynes and other soothing remedies.
As irritation results from a preponderance of
nervous mobility,  those agents which give tone
and strength to the muscular system will un-
doubtedly prove the most efficient remedies for
its removal.  As  a late writer has observed,
under the influence of tonics, disposition  and
power to act will  go together, and within  due
bounds produce the harmonious balance of even
health.   Whether certain of them possess a
specifically  sedative property towards the  ner-
vous  system, or whether this is their secondary
effect, after  their tonic and astringent influence
on the vessels, is beyond our means of decis-
ion ;  but the fact  is not  less ascertained than
important, that the continued use of nitrate of
silver or sulphate of copper will cure the  epi-
leptic convulsions independent of organic caus-
es, and often  diminish them where the cause
is irremoveable, by lowering in the nerves their
susceptibility  to its impressions.  Thus, like-
wise, bark, carbonate of iron, arsenic, sulphate
of zinc,  or sub-nitrate of bismuth sometimes
remove the painful or spasmodic irritations of
tic  douloureux, hemicrania,  sciatica,  chorea,
and gastrodynea, which the most powerful ano-
dynes,  antispasmodics,  and  counter-irritants
fail to effect.   The stomach and intestinal ca-
nal, also, under the influence of a bitter  tonic,
will often lose various signs of irritation, which,
however  they may occasionally be  accompa-
nied by slight hyperaemia or fancied inflamma-
tions, owe their being to weakness and want
of tone.  The cold shower or  plunge  bath, or
cold ablution, is another efficacious tonic; the
more eligible,  often, because, without loading
the system with medicine, it rouses it to the
exertion of its own powers in  a vigorous vas-
cular reaction, under the habit of which  nervous
mobility is physically forgotten, and ceases.
  It  is  highly necessary that  practitioners
should be cautioned against  resorting  to anti-
phlogistic measures in  these cases, although
temporary relief sometimes follows  their em-
ployment.  When local pain returns after bleed-
ing,  it  will often yield to  fomentations and
morphia,  or hyoscyamus internally, when the
repetition of the bleeding would entirely fail in
procuring relief.  We believe, with Williams,
that there are  frequent pseudo-inflammations
arising in irritable states of the system which
are best relieved by sedatives, a judicious sup-
ply of nourishment, and  an exclusion of all ex-
citing or disturbing agencies  ; and that we oc-
casionally meet with diseases following excess-
ive evacuations which put on  the semblance
of violent pleurisy, pericarditis, arachnitis, or
hydrocephalus,  and  which  may be completely
subdued by hyoscyamus or opium, with a sus-
taining  nourishment, such as  sago, arrow-root,
or jelly, with small quantities  of brandy  or wine.
The state of the circulation, as  indicated by the
pulse, is here  to be our guide ; and the  local
pains, palpitations,  disturbance of the  mind,
with beating or noises in the  head, should be
viewed  as partial reactions,  to  be subdued by
opium or hyoscyamus, rather than by  the lan-
cet and evacuants.*]

  * [In illustration of some of the preceding views, we quote
the following case  from the New-York Jour, of Medicine,
vol. iv., p. 300, by Luther Ticknor, M.D., of  Salisbury,
Connecticut. " Mrs. A., about the  middle of November,
1844, in washing  some small articles of dress, pierced the
end of the middle finger with the head of a threaded needle,
which she supposed penetrated the ball of the ringer to the
depth of one third to one half inch. The first sensation was
that of numbness instantly following the infliction, extend-
ing up the arm to the axilla and front part of the shoulder.
This was followed immediately by numbness of the fingers
of the other hand, and next with faintness and vertigo, which
brought her pretty soon to her bed. Some mitigation of
these symptoms was produced by laudanum, so  that I did
not see her until severe pain and  febrile symptoms, op-
pressed respiration and gastric sinking, excited some alarm
for her safety, about forty-eight hours  after the  injury.  I
found her with hurried, anxious breathings, very frequent,
obscure pulse, a moist surface, with temperature but little
increased, almost constant chilliness, and what the patient
called faintness.  These two  latter symptoms continued,
with very little variation, for five or six weeks.   A diffused
swelling, not easily defined, occupied the upper  portion of
the ' pectoralis major muscle,'  extending upward to the ar-
ticulation of the  shoulder; certain points on this tumefac-
tion were excessively painful and  tender to the touch.
These  tender points changed their  location from time to
time, so as to encourage the hope that some improvement
was going forward.
  *' The local treatment consisted of dry-cupping, epispas-
tics, fomentations, anodyne poultices,  anodyne  liniments,
&c, with very little  apparent benefit; and yet anodya* 
3ATH0L00Y.

  tate Morborum Genitrice. Jen., 1772. —.4. Grant, Obser
  vat. on the Use of Opium in Dis. of Irritability, 8vo.  Lond.,
  1785.-7. L. Gaultier, De Irritabilitatis Notione. Natura et
  Morbis, 8vo.  Hal., 1T93 ; et Physiolog.e und Pathologie
  der Reizbarkeit, 8vo.  Le.ps., 1796. - Marcard, Beschre.-
  bung von Pyrmont, b. i... p. 107.-.V. Maraudal, Essa, sur
  les Irritations, 4to.  Paris, \807.-Consbruch, in Hufeland,
716                                   ITCH—P

  80.  F.  The diet and regimen of diseases of
irritation require much attention.  While vas-
cular action continues excited, the diet should
be mucilaginous, or farinaceous, light and cool-
ing,  and suited to the powers of digestion  and
assimilation.   If, however, the vascular system
be not materially affected, and the functions of
the  stomach are not much impaired,  a small
proportion of light animal food may be allowed.
In the more serious states of constitutional  irri-
tation, especially where there are marked asthe-
nia,  and a disposition to change*  in the state
of the blood, wine, and even alcoholic stimulants
are often necessary, in aid of  the  means above
recommended, in order to limit, or to  prevent
the extension of the mischief, by exciting the
several vital endowments.  In these cases, the
diet  should  consist  chiefly of such articles as
are desired or relished by the patient, as being
the most likely to be digested  without disorder-
ing the system.
  81.  Change of air: residence in a pure  air,
exercise taken regularly and  short of  fatigue,
travelling, the use of those mineral waters, both
internally and externally, that contain the alka-
lies  and alkaline carbonates and carbonic acid;
the waters of Bath,  Ems, &c, are usually ben-
eficial ; but mineral springs should be  prescri-
bed with a strict reference to the specific forms
of these complaints, after a due experience of
their operation, and without being  influenced by
prejudices, by fashion, by guide-books, or by lo-
cal interests.  In many diseases of irritation the
factitious mineral waters prepared at Brighton
Iiave proved of great benefit, even in the range
of my own experience, having frequently  pre-
scribed them since 1824.  In  most cases, how-
ever, much  discrimination is  requisite to  the
procuring all the benefits they are calculated to
afford.   In most instances, the  milder waters,
as those of Ems, of Saratoga, or of Salsbrunnen,
should be  first  prescribed; and  subsequently
f.he more tonic waters of Kissengen, Marienbad,
and  Carlsbad,  or of Eger,  Pyrmont,  or Spa,
having recourse occasionally  to the waters of
Seidschutz or Pulna, when the bowels  are tor-
pid,  or the  biliary functions  impaired or ob-
structed.   Several of these  waters, also, may
be procured in London ;  and  at Brighton their
effects may be  aided,  in the cases that require
it, by warm salt-water bathing.
  Bibliog. and Refer.—De Magny, An a Vasorum aucta
aut imminutalrritabilitate omnis Morbus 1 8vo. Paris, 1752.
— G. Verschuir, De Arteriarum et Venarum Vi irritabili,
ejusque in Vasis Excessu, et inde oriunda Sanguinis Direc-
tione abnormi.  Groning., 1766.—Baldinger, De  Irritabili-
poultices did the best.  Internally, opium in some form, and
in large quantities, was indispensable throughout her treat-
ment.  Profuse perspiration, subsultus, and incipient de-
lirium pretty early suggested the use of tonics, of which
sulph. of quinine was preferred, and freely and with advan-
tage. About six weeks after the injury, a slight fluctuation
was felt under the edge of the tendon of the pectoral muscle
within the  axilla.  Forty-eight  nours after it was discov-
ered, a spontaneous discharge, of at least eight ounces, of
rather thin purulent matter took place, and continued pro-
fuse from this  orifice, and  one made subsequently a little
lower down upon the chest, for about  two weeks, when
constitutional and  local symptoms gave place to returning
health.  Immediately after  the fluctuation was discovered,
Mrs. A. made free use of London porter, it being the only
stimulus of a diffusible kind her stomach would bear, and
this it bore to good purpose.  Mrs. A. is now entirely well,
[ believe, though, perhaps, the shoulder droops a little, from
the awkward position in which the arm was kept for a long
time, rather than from any imbecility in the muscles.  A
deep depression marks the  site of the abscess, showing a
pretty extensive condensation, or loss of cellular tissue.']
Journ. der Pract. Heilkunde, b. mi., * si., p. ■«•—'■ £• *•
Henning. Ideen  ubcr Idiosyncrasie  und Krankliche Reiz-
barkeit; 8vo.  Gotha, 1812.—Humboldt, in Memoires de la
Soci.'te Medicale d'Emulation, t. i., p. 302 ;  t. 11., p. 323.—
Monfalcon, Diet, des Sciences Medicales, t. xxvi. — P.I.
Mongellaz, Essai sur les Irritations  intermittentes, 8v».
Pans, 1820. — F. T. V. Broussais, Traite de Physiol, ap-
plique a la Pathologie, 8vo.  Paris, 1822;  et  Examen de
Doctrines Medicales generalement  adopte, 8vo.  Paris, 2d
ed., 4 vol., 1829 ; et de l'Irritation et  de la Folie, 8vo. Paris,
1828.-7. AT. Gouvil, Exposition des Principes de la nou-
velle  Doctrine Medicale, 8vo. Paris, 1824.— Charpenlier,
in Journ. Gener. de Med., t. lxxxvi., p. 6, 145.— /. Butler,
Remarks on the Irritative Fever of Plymouth Dock-Yard,
8vo.  Devonport, 1825. — Coutanceau, Diet,  de Medecine,
8vo.  Paris, t. xii.—V. Prus, De l'Irritation et de la Phleg-
masie, 8vo.  Paris, 1825.—B. Travers, Inquiry concerning
Constitutional Irritation, 8vo.  Lond., 1826.—Also a Far-
ther Inquiry concerning Constitutional Irritation, and the
Pathology of the  Nervous System, 8vo. Lond., 1835.—Roche,
Diet, de Med. Pratique, t. x. — R. Williams, Elements of
Medicine, vol. i. ; On Morbid Poisons, 8vo. Lond., 1836.—
C. B. Williams, Cyclop, of Pract.  Medicine, 8vo.  Lond.,
vol. ii., p. 875.
  [Am. Bibliog. and Refer.—Various Treatises on Phys-
iology and Practice of Medicine, and occasional Essays in
different Medical Journals.]
ISCHURIA.   See Urine.
ITCH.—Syn. Psora, ^Tupa  (from  -fau,  I rub,
   or scratch), Scabies (from scabo, I scratch).
   Phlysis scabies,  Young.    Ecpyesis  scabies,
   Good.   Scabiola, Auct., Lat.   Kr'itze, jucken
   der haut, zaude, Germ.   Gale, rogne, Fr.  Rog-
   na,  Scabbia, Ital.   The Scab.
     Classif.—iv.  Class,  viii.  Order (Cullen).
       6th  Class. 3 Order (Good).   III. Class,
       I.  Order (Author in Preface).
   1.  Defin.—An  eruption  of distinct,  slightly
acuminated vesicles, accompanied  with constant
itching,  caused  by contagion,  the  eruption  being
occasio-nally modified in  character at its appear-
ance, or during its progress,  and unattended  by
constitutional  disturbance.
   2.  Recent  writers have  supposed  that  the
eruption mentioned by Galen, under the  name
of iropa, was really the itch ;  but his descrip-
tion of it is more applicable to squamous  than
to vesicular eruptions.   The description, also,
which Celsus  has  given of scabies is  by no
means distinctive of itch, and is more charac-
teristic of  prurigo  than of it.  Neither these
writers  nor  Avicenna  mention contagion  as
attending the eruption  thus named by them.
Guy de Chauliac, according to Rayer, was the
first to point  out this important  feature of the
disease.  Subsequent writers  have generally
noticed  it,  although several  of them have not
distinguished between  itch  and  prurigenous
affections.  More recently, Willan, Bateman,
Biett, and Rayer have given  the history of
this  eruption  with much precision.
   3. The modifications  occasionally presented
by the itch, both  on its  appearance and during
its progress, have led to some difference in the
classification of  it.  Thus,  it sometimes  as-
sumes from its  commencement a papular form,
and  during  its  course  a  pustular character.
Hence Willan and Bateman arranged its vari-
eties accordingly, and placed it among the pus-
tular eruptions,  the varieties  being the Papuli-
formis, Lymphalica, Purulanta,  and Cachetica.
MM.  Biett and Rayer, however,  have  more
accurately  classed it with  vesicular eruptions,
the vesicular form being its primitive and most 
ITCH—De
common state ; still it sometimes appears as a
papular eruption,  and as such  Dr. Paget  has
arranged it.  I shall here consider the disease
as commonly vesicular, and the modifications or
varieties  presented  by it as accidental or con-
tingent upon the peculiarities or circumstances
of individual cases.
  I.  Description.—This eruption generally ap-
pears first on the hands, between the fingers,
on the wrists, on the flexures of the joints, on
the abdomen, and on the insides of  the limbs.
It is most commonly confined  to a surface of
no very great extent; and, in some cases, con-
sists only of a few  vesicles dispersed between
the fingers and over the wrists ; but it may af-
fect the skin very generally.  It does not occur
on the face or on the scalp.  It is essentially a
contagious disease, and is neither epidemic nor
endemic.
  4. 1st.  Of its  common vesicular form.—The
eruption generally takes place in children at the
end of four or five days from the period of con-
tagion ; but this  is uncertain,  for in weak or
delicate children it  may be delayed beyond this
period, while, in the plethoric and sanguine, it
appears  even  earlier.   It  seldom  occurs in
adults  before eight or ten days have elapsed,
in spring and summer, or  before fourteen or
twenty days in winter.   If is longer  in appear-
ing in the aged than in the young or middle-
aged, and it attacks in preference the situations
where the skin is most delicate.
  5. The eruption commences with  itching, at
first slight, of the parts which have been expo-
sed  to contagion.   The  itching  is  increased
through the night by the warmth of the bed, by
indulgence in stimulating food, beverages, and
spices, and by whatever heats or determines
the blood to the  surface.  A number of small
points or  spots,  very slightly  elevated  above
the  surface, now appear,  and present a  pale
rosy colour, with small acuminated vesicles on
each point or spot.   If the vesicles be few, they
occasion but little pruritus, and preserve longer
their primitive form ; but if they be  numerous,
the skin between each  participates in the irri-
tation, and the itching becomes urgent.  The
vesicles are then usually torn by the nails, and
allow  their viscid serous  contents  to escape,
which concrete  and form  small, thin scabs,
slightly adherent to the skin.  If the scratch-
ing has been violent, the scabs are  black, and
resemble  those of prurigo.
   6.  ii.  Varieties or  Modifications.—Owing to
peculiarity of constitution, "to the amount of in-
flammatory action  attending the  eruption, to
the depth  to which it  extends in the tissues
composing the skin, and to the existing state
of health of the  patient, itch presents certain
modifications  which  have been arranged  into
species by Willan and Bateman.—A. The va-
riety denominated by them  the Scabies Papuli-
formis, or rank itch, is  that in  which the erup-
tion  is more papular and inflamed  at the base,
hut still presents a transparent apex, indicating
its vesicular character.  When much irritated
by scratching, long red lines are left here  and
there,  and the  fluid exuded  from  the abraded
vesicles concretes into  little brown or blackish
scabs.   In sanguine temperaments, and when
much irritated, a few of the vesicles assume a
pustular form, from the fluid contained in them
changing to a purulent matter.
;ription op.                               717

   7. B. The Scabies Lymphatica, oi watery itch,
 differs from the foregoing chiefly in the ab-
 sence of the papular character and of inflam-
 matory redness, and in the larger  size of the
 vesicles.  When the vesicles are ruptured by
 scratching them, moist excoriations often form,
 and, after  a time, dark scabs.   This variety
 usually presents three stages, viz., the entire
 vesicle, the excoriation consequent on its rup-
 ture, and the  scab covering the  excoriated
 part.  It is  not so frequently observed as the
 former variety  on the  trunk, but is most com-
 monly found collected on  the  lower parts of
 the extremities, as the fingers, wrists, backs of
 the hands, and sometimes on the feet and toes.
   8. C. The Scabies Purulenta, or pocky itch, is
 more distinct than the other varieties.   The
 round pustules into which scabies, in a few in-
 stances, forms  itself, resemble  the  pustules of
 smallpox.   They occur chiefly in children  and
 young persons who have been living on a heat-
 ing  diet,  and who have  been inattentive to
 cleanliness.  These pustules are distinct,  with
 an inflamed base, and considerably elevated ;
 they maturate and break after a few days, hav-
 ing then often  attained a diameter  of two or
 three lines.   The itching occasioned by them
 is attended  by more tension and smarting than
 that of the  other varieties.  After they break
 they often leave a cracked excoriation or ul-
 ceration behind, or small fissures between the
 scabs, the stiffness and heat of  which cause
 considerable uneasiness.  The pustules rarely
 appear on the trunk, but usually on the hands,
 between the fingers,  or  near their flexures,
 more rarely on the feet and at  the bends of
 the arms.   They are largest on the hands and
 between the knuckles, especially between the
 index finger and thumb;  they often  coalesce,
 and in these situations more especially, slight
 fissures or cracks form in the concretions cov-
 ering the excoriations or seats of pustulation.
 This variety, in  plethoric  children, is some-
 times attended by slight febril commotion.
   9. D. The Scabies Cacheclica, or scorbutic itch
 of Willan, is not, strictly, a variety, but mere-
 ly an imprecise modification, produced by de-
 bility and general cachectica, in  consequence
 of intemperance, poor living, and unwholesome
 food, that assumes no very distinct or unvary-
 ing character.   As may be expected, from the
 circumstances in which it occurs, it is the most
 aggravated  state of the eruption ; and is more
 frequently than the true varieties, either  form
 of which  it may assume, complicated with oth-
 er eruptions, particularly with lichen, prurigo,
 ecthyma, and impetigo.  When itch occurs in
 the dark races,  it generally presents this state,
 and is severe  and obstinate—is  rank and ex-
 tensive, spreading rapidly  over the  body.  As
 thus met with, it has been  noticed by Bontius,
 and by Sauvages, who called it Scabies Indica.
   10. E. The complications of itch often render
 the  diagnosis difficult.  Ecthyma  is sometimes
 associated with it, and more rarely eczema, but
 is chiefly cured by the use of stimulating wash-
 es or ointments.   Scabies  is most frequently
 complicated with papular eruptions,  particular-
 ly with lichen, in the young, and when the vesi-
 cles are generally or abundantly disseminated.
 Prurigo is  often  associated with itch in the
 more prolonged cases.  Boils occasionally ap-
 pear in the more severe instances. These com- 
josis—Causes.
 718                            ITCH—Duo:

 plications, as well as a pustular state  of  the
 eruption,  are favoured by living on salt, acrid,
 and fat meats, and by acrid applications to  the
 surface.  Disorders  of  the  digestive  organs
 sometimes prevent the full evolution of itch ;
 or  persons  subject to these disorders, who
 have caught this affection, often readily recov-
 er from it when such disorders are aggravated
 by errors of diet.   Scrofula does not materially
 modify scabies.   In very unhealthy or cachec-
 tic subjects it sometimes assumes a livid hue;
 and, when its vesicles are crowded in any part,
 they are occasionally associated with ecthyma
 cachecticum.
  11. F. The duration of this eruption depends
 upon treatment.   If left to itself it never gets
 well, and  may even continue  through life when
 thus neglected.  In southern climates, and in
 spring and summer,  and in  young,  plethoric,
 and  robust persons, the vesicles of  itch  run
 rapidly through their successive changes, when
 not broken by scratching ; but their progress is
 much slower in the north, in winter and autumn,
 and in the bilious, melancholic, and cachectic,
 and in the aged  and infirm—in  whom, also, it
 is longer in appearing after infection.  When
 it is judiciously treated, and with strict atten-
 tion to cleanliness, and to the state of the  lin-
 en and clothes, it may be cured,  in very recent
 cases, in  five or  six days, and in the worst
 cases  in from ten to fourteen  days  to three
 weeks; but it may be protracted beyond  this
 period in  the old, infirm, and  cachectic,   or
 when it has been long in  appearing.   In some
 rare instances, it  disappears on an attack of
 an internal inflammatory disease, and returns
 again when that disease is removed.   This  cir-
 cumstance, however,  has been doubted, some
 other eruption having been  mistaken for  the
 itch.   In general, this eruption exerts no influ-
 ence upon internal complaints, nor do they pro-
 duce  any effect on it;  although an  opposite
 opinion has been long held by pathologists, and
 is still entertained by  a few.
  12. II.  Diagnosis.—It is of importance,  not
 only as respects the  reputation  of the  practi-
 tioner, but as regards the speedy recovery of
 the patient,  and  the  protection of the other
 members  of the family to which he  belongs,
 that a correct diagnosis between this eruption
 and those which so closely resemble it  should
 be made.—A. Prurigo is most frequently con-
 founded with the  itch; but, independently of
 the former being  papular, while the  latter is
 vesicular,  prurigo is usually seated on the back,
 shoulders, and on the outsides of the limbs, or
 on the  surfaces  of extension ;  while the  itch
 is observed chiefly on those of flexion, on  the
 wrists, and between the fingers.  Prurigo, also,
 occurs more  frequently in adults and elderly
 persons than  itch ; its papula are flat, and when
 abraded, a black spot of blood concretes on
their centres.   The itching attending prurigo is
more vehement than that of scabies, more
 stinging or smarting, and less pleasurable. The,
 former, also,  is not contagious.
  13. B. Lichen simplex most closely resembles
the papuliform variety of itch.   In the former
 no vesicles can be detected in the summits of
 the papula?, which pass away in a scurvy exfo-
 liation,  and  do not give rise to dark  scabs.
 Lichen appears on the backs  of the hands and
 on the external surface of the limbs, and hard-
ly ever between the fingers.  The itching at-
tending it is not severe, and the papulae preserve
the tint of the skin, while the vesicles of scabies
are of a pale pink;  the former being  generally
crowded together, the latter being much more
distinct.    Lichen is commonly accompanied
with some constitutional disturbance ; but  it is
not contagious.   The lichen urticatus is more
acute, and sometimes presents a  few vesicles
among the papulae ; but its inflamed, wheal-like
papulae, and the deep tingling, rather than itch-
ing, sufficiently distinguish it.
   14. C.  Eczema, particularly C. Simplex, may
be confounded lvjth itch ; but in the former the
vesicles are flattened and agglomerated in great-
er or less numbers,  while in the latter they are
acuminated and generally distinct.  The itching
of eczema is a kind of  general smarting,  or
stinging, very different  from  those exacerba-
tions characterizing itch. The former is usu-
ally produced by  exciting or irritating causes,
the latter by contagion only.
   15. The association of scabies  with  other
eruptions is  of importance in the diagnosis.
Such complications may be  merely accidental,
but they occasionally arise  from the  irritation
of scratching, and of applications  to the erup-
tion.  Vesicles of itch, pustules of impetigo or
of ecthyma, and  furunculi are sometimes met
with in the same patient.   The papulae  of li-
chen, also, may be either contemporaneous with
itch, or consequent upon it.  Scabies may even
coexist with syphilis, without  having its char-
acters thereby modified,  farther than  has been
noticed when mentioning the variety called ca-
chectica.   These  combinations generally retard
the cure, as well as often increase the difficulty
of diagnosis.
   16. III.  Causes.—The great, and,  perhaps,
only cause of  itch, is  contagion.   The only
questions are, whether it does, in any circum-
stances, arise spontaneously,  and  what is  the
nature of the  infecting substance,  or  body.
These will be answered in the sequel, as far as
the state of our knowledge admits of answers.
Scabies is one of the most universally dissem-
inated contagious diseases, the momentary con-
tact of the fluid secreted by its  vesicles  being
sufficient  to communicate the  infection.  It oc-
curs in every climate, in every season,  in all
ranks and ages;  but is  most common in  the
poor  and wretched,  in  persons negligent  of
cleanliness; in sailors, soldiers, in work-peo-
ple, dealers in old clothes, in tailors ; and espe-
cially in those crowded in jails, hulks,  barracks,
workhouses, and factories.   It rarely is observ-
ed in  tanners, in  dyers, and  blacksmiths, or in
the families of the affluent.  It always spreads
in consequence of contact, immediate or  medi-
ate ; and of want of cleanliness.
   17. Several instances  of itch  transmitted
from animals to the  human  species have been
cited ; but most of the diseases thus named are
inaccurately described, and are of a very doubt-
ful character.   M. Mouronval adduces  cases
of the communication of itch  from the dog to
man ; but M. Rayer states that M.  Leblanc
showed MM. Sabatier,  Littre, and  himself
dogs labouring under a disease called itch, con-
sisting of a number of small acuminated vesi-
cles, resembling those of scabies in the human
subject; and stated that the  man who  attended
them had  not been infected  by them,  although 
ITCH—T
they communicated  the disease to their own
species.   This, however, is  no  satisfactory
proof of the non-communicability of the affec-
tion from the dog to  man.  Mr. Youatt, whose
authority in this matter is  the best possible, in-
formed the author that  the  itch may be com-
municated  to the dog, and by the dog to man
and other animals, but that it is never sporadic
in the canine race.
   18. Avenzoar, and, long  subsequently,  In-
grassias and Jobert, hinted at  the existence
of an insect in the vesicles of itch ; but Mouf-
frt first mentioned  it in his Theatrum Insecto-
rum, in a particular manner.   Several recent
authors have described it under the name of
Acarus  scabiei.   Hauptmann first published a
figure of it, and represented it  with six feet.
Redi put the existence of this  insect beyond
doubt, and, aided by G.  Lorenzo and  H. Ces-
toni, examined numbers  of them, having re-
moved  them from the  vesicles.   Dr.  Bonomo
gave the following description of it: This in-
sect moves with great vivacity ;  has six legs,
and  a pointed  head, armed  with two  small
horns, or antennae, at the extremity of the mouth.
It is, he remarks, difficult  to distinguish  these
insects  on the surface  of the body, owing to
their minuteness,  and to  their  colour resem-
bling that  of  the  skin.   They first insinuate
their pointed heads, and then move about, gnaw-
ing and pushing, until they have buried them-
selves under the  cuticle, where they form a
kind of covered way of communication between
one  point and another, so  that the same insect
generally causes several watery pustules. The
above physicians also discovered the eggs of
these insects, and even observed their extru-
sion from the hinder part of the animal.   The
eggs are white, nearly quite transparent,  and
hardly  visible.  These insects,  they remark,
pass readily from one  person to another, by
mere contact, for,  being very active, and often
on the surface of the skin, they readily attach
themselves to whatever they touch.
   19. Morgagni, Linnaeus,  De  Geer, Wich-
mann, Waltz, and  others confirm the above
description ;  but,  nevertheless,  the existence
of these insects having been called in question,
M. Gales took up the subject, and his investi-
gations, which were witnessed by many mem-
bers  of the  Institute,  farther  confirmed  the
above statement.  The  circumstance of Gale-
otti, Chiarugi, Biett, Lugol, and Mouronval
having failed in  finding these insects occasion-
ed fresh doubts of their  existence ;  but their
failure arose from having sought for  them in
the vesicles.   Mouffet had long before stated
that they are not found in the pustules, but by
their sides ; Casal had made nearly a similar
observation ; and Dr. Adams remarks, that they
are not found in the vesicles, but in a reddish
line going off from one of its sides, and in the red-
dish and firm elevation at  the extremity of this
line, and at a little distance from the vesicle.
Mr.  Plumbe supposes that the insect is unable
to live in the fluid of the  vesicle, which is the
result of the irritation it causes, and therefore
escapes from it.  Finally, M. Renucci, a med-
ical  student from Corsica, showed, in 1834, the
physicians of Paris the mode of discovering this
insect, which is the  same as tliat formerly sta-
ted by Dr. Adams.   Since this time, M. Rayer
remarks, the existince of  the acarus of the itch
IATMENT OF.                              719

has been placed beyond a doubt.  MM. Lemery,
Gras, and Renucci had each shown him the
mode  of detecting  it, and he had himself ex^
tracted several.   M. Raspail has given an ex-
cellent description and figures of it;  and M. A.
Gras  has entered  into researches  as to the
share  it has in producing this  eruption.  Al-
though it has been proved that, in almost all
who are affected with scabies, and who have
not been subjected  to treatment, a certain num-
ber of sub-epidermic furrows, containing acari,
are to be discovered, it is also undoubted that
the number of these furrows and of these in-
sects  bears no proportion to that of the vesi-
cles.   It is, farther, rare to discover these in-
sects  on the abdomen  and groins, where the
eruption is, nevertheless, very common and ap-
parent ;  and, moreover, scabies  is  known  to
continue where no  more acari are to be found.
The experiments made to ascertain whether  or
not the acarus be the cause of the itch, or a par-
asite  produced by' it, are not altogether conclu-
sive.
   [Dr. Watson remarks (Pract. of Physic), that
" there is good  reason for  believing that the
parasitic animal is not merely a casual  com-
panion, but the veritable cause of scabies.   Va-
rious  attempts have been made, and made  in
vain,  to produce  the disease by inoculation of
the fluid from the vesicles.   On the other hand,
transportation of the acarus has always excited
the eruption.   These facts explain  how it  is
that the itch, though readily communicable by
direct contact or by fomites, is not  communi-
cable through the medium of the air; that fo-
mites long retain the contagious property ; and
that the disease is curable by whatever destroys
the acari."]
   20.  IV. Treatment.—As  the itch is never
spontaneously cured, but may continue even for
many years, the  treatment  should be decided
and unremitting.  The experiments lately made
by M. Gras have thrown much light upon this
subject.  They prove that a concentrated solu-
tion of the hydriodate of potash kills the acarus
of scabies in the shortest time—in from four to
six minutes ; and he considers that an ointment,
consisting of half a drachm of this substance to an
ounce of axunge, is the best remedy for the itch.
I have prescribed this ointment in several in-
stances, and have  found it  the  most speedily
efficacious.   This  physician states  that the
itch insect lives sixteen hours in the vapour of
burned sulphur, three hours in water, two hours
in olive oil, one hour in the acetate of lead, one
hour  in pulverized brimstone, three quarters of
an hour in lime-water, twenty minutes in vine-
gar and spirits of wine, and twelve minutes in
a solution of sulphuret of potash.
   21.  Where scabies is uncomplicated and re-
cent, its cure is  readily accomplished by local
applications, and without  any preparatory  or
constitutional means; but where it  is of old
standing, and associated with other  eruptions,
or with an inflammatory state of the skin, and
particularly if the patient be young  and pleth-
oric, a bleeding from the arm, soothing lotions,
and simple baths may be premised.   Frictions
with   the sulphur ointment  (sulph. sublim. loti,
 §viij. ; adipis prep., ibj.), or with either of the
compound sulphur ointments (sulph. subl., 3ij. ; po-
tassce subcarb., 5J.; adipis, fj.; or sulphureti calcis,
l).;  adipis, ?j.), usually cure scabies in ten  or 
tEATMENT of.
720                               ITCH—Tr

fourteen days.  The compound sulphur oint-
ment is the next to the ointment with hydrio-
date of potass in efficacy.   M. Rayer advises
the compound sulphur ointment in the quantity
of two ounces daily, to be rubbed over all the
parts affected, the patient's skin having been
well cleansed with soap and water.  The rub-
bing should be continued diligently for about
half an hour, morning, midday, and at night.
If this be continued unremittingly, the eruption
may be cured in  six  or seven days.   Helme-
rich  prescribed four  ounces of the compound
sulphur ointment to  be assiduously rubbed on
the parts affected in the twenty-four hours.  An
ointment, consisting of sulph. sublim. loti, f iij. ;
ammon. hydro-chlor., 3ij. ; adipis prcepar. jxiij , is
also an efficacious application.  M. Derheims
has found the solution of chloride of lime, jj. in
water Oj., and used twice or thrice daily, very
efficient.
  22. The plan of M  Pyhorel, to add half a
drachm of the sulphuret of lime to a little olive
oil, and with  this  to rub the palms of the hands
during a quarter of an hour night and morning,
is also efficacious.   Sulphureous washes, as that
composed of potassce  sulphureti jj., aqua Ibiij.,
of which an ounce is to be added to four ounces
of warm water, and applied to the affected parts,
also speedily effect a cure.  These washes do
not soil the  clothes  like  ointments, but they
often cause  vesicular and papular eruptions.
Should these eruptions appear, or complicate
the itch,  irritating frictions and applications
must be suspended, and tepid emollient baths
prescribed.   In all cases of scabies, a few tepid
baths should follow the removal of the eruption.
  23. Alcoholic saponaceous  washes,  acid oint-
ments and washes, artificial sulphureous baths, sul-
phureous fumigations, &c, and  various other
means,  have  been recommended for the cure
of itch; but they are less certain than the above,
require  a  longer period, and are more expen-
sive.  Washes and   ointments, the basis of
which are  nitric acid and  mercury, have occa-
sionally produced salivation  and disturbance of
the digestive  organs.  The  internal use of sul-
phur, or this  conjoined with its external appli-
cation, has been long employed in this country,
and is efficacious and well suited to the puru-
lent form of  scabies,  as met with in children.
Hellebore and  tobacco have also been recommend-
ed for the cure of itch, and are doubtless effica-
cious ; but they are hazardous substances, par-
ticularly where there  is much excoriation, and
when prescribed for children.
  [We have  never found any difficulty in  cu-
ring the itch, however severe, by sulphur oint-
ment.   We mix with it a small quantity of oil
of bergamot,  to disguise the smell, and a little
vermilion, to conceal the  colour, and then di-
rect the patient to be rubbed all over carefully
at bedtime, especially over the parts affected,
and to sleep  in a flannel dress. A repetition
of this  practice, night and morning, for three
days  will suffice  for a cure.   The patient is
then to be thoroughly washed with warm wa-
ter and soap, and the treatment is completed.]
  24.  Where  itch is  associated with  general
cachexia, and is modified by  this circumstance,
a judicious internal  treatment should  be con-
joined with  external  applications, and with
warm or tepid baths.  In these cases the liquor
potassa may be taken with sarsaparilla, or the
alkaline  carbonates may be given  with mild
tonics; and an alterative dose of a mild mer-
curial may be prescribed occasionally  at bed-
time.  This treatment, in addition to the spe-
cific external  measures already  mentioned, is
also requisite when itch attacks the dark races,
among whom it generally proves a much more
severe and obstinate affection than in the white
races.
  25. During the treatment, the diet should be
digestible and in moderate quantity.   All acid,
heating, and fat articles, as  well as stimulating
beverages, should be avoided.  In order to pre-
vent a return of the eruption, and its spreading
in a family, the body and bed-clothes of the pa-
tient ought to be subjected to disinfecting pro-
cesses, as the fumes of sulphurous acid gas.
The linen should  be changed frequently, and
the greatest attention paid to cleanliness.
  [There is need of caution  on one point: mer-
curial preparations of every  kind should be laid
aside in the treatment of scabies, as they often
produce  very  dangerous consequences.  Be-
sides the accidental eruptions to which they
often give rise, they are liable to occasion sali-
vation, engorgement of the  salivary glands, or
even inflammation of the tongue.  Cazenave
regards the sulphuret of lime to be the most
generally beneficial application in these cases :
3ss., mixed  with  a little olive oil, and  rubbed
twice a day over the part affected.  The mean
duration  of the treatment with this remedy is
fifteen days; but  it is  only useful where the
eruption  is limited and recent.  We have known
Dupuytren's lotion prove very successful: this
is composed of sulphuret of potassa, jiv.; sul-
phuric acid,  jss. ; water, Ojss.: mix.  The af-
fected parts to be washed with the lotion twice
a day.  The hellebore ointment, in the propor-
tion of one  part to eight of lard, will usually
accomplish a cure in about  two weeks.   Hel-
merick's ointment will, in a large majority of
cases, cure  in about ten days.  This is the fa-
vourite remedy of M. Biett, composed as fol-
lows : Sublimed sulphur, 31J. ; sub-carb. potass.,
3i. ;  lard,  51. ;  M. ;  jss. to be rubbed in night
and morning, and occasionally a tepid bath.  In
children, soap water and artificial sulphur baths
are very  appropriate remedies ;  also sulphur
fumigations, especially as auxiliaries.  Where
the itching is very troublesome., alkaline baths
usually afford very decided relief.  Dr. Bulke-
ley states (Am. ed. of Cazenave and Schledel
p. 108), that the combination of sulphur with
soap, of a kind and quality to suit the taste and
the means of the  patient, forms a convenient
and  effectual mode of applying  that remedy;
and that  he has combined it with the common
soft  soap in dispensary practice with good ef-
fect.  Emery gives the  following recipe for an
ointment  used at the  St.  Louis Hospital:
$ Brown soap, ji. ;  table salt, Jss. ; alcohol, 3L;
vinegar, 31J. ; chloride of lime, 3SS. ; M.  He says
that it causes no irritation, does not soil the
clothes,  has no  unpleasant  smell, cures in  a
short time, and is cheap.  (Bull. Gen. de Ther-
apeutique. May, 1836.)
  Extensive experiments have  recently been
made in  the Berlin hospitals (Brit, and For.
Med.  Rev., July, 1841), by  which it  is found
that a slight modification of the ordinary sul-
phur treatment accomplishes a cure with more
speed, certainty, and economy than any other. 
KIDNEYS—Diseases  of the.
721
One part of the flowers of sulphur was mixed
with two parts of soap, and sufficient warm wa-
ter to make into an ointment.  The patients, af-
ter a warm bath of soap and water had been ap-
plied, were placed, undressed, in a chamber kept
constantly at a temperature of 95°  Fahr., and
well rubbed with the ointment  over all the parts
affected, three times a day, and then made to
sweat profusely by putting  them into warm
beds.  This  system was continued for three
days and nights ;  on the  morning of the fourth,
each patient had a warm bath, and then, if not
cured, was provided with clean bed and body
linen, and  put in a  ward of ordinary tempera-
ture,  in which the  suspicious parts  were still
rubbed  with  the  ointment, and  a  warm bath
taken every other day.   In general, no internal
medicines  were given; but the diet allowed was
reduced to a  fourth  portion,  and  water only
given to drink.  In this  manner, with but one
short interval, 1981  were  heated  and  cured
between September, 1839, and February, 1840,
making the total number of days of treatment
15-890, which gives, on the average, 8 days and
a fraction  for the cure of each patient, and for
the expense of each  about two dollars.  The
exact result  was, that in 3  days  there were
cured 42; in 4 days, 161 ; in 5 days, 333; in
6 days, 376 ;  in 7 days, 207;  and in more than
seven days, 589.
   The treatment of these last was  prolonged
by many circumstances which can  hardly cast
discredit  on  the  remedies.   In  many among
them, the itch was soon cured, but they re-
mained under treatment for  the ulcers which
had come  on from  long  neglect of it, or were
kept  in the  hospital till there was no chance
of the ulcers communicating the disease. Oth-
ers among them, after being  cured of the skin
disease, had to be treated for other affections ;
and others, again, had their cure delayed by an
obstinate  refusal to adopt all accessory treat-
ment.  In the whole 15 months there occurred
only 8  cases of relapse  ; less than i of 1 per
cent, of the cases treated, and in most of these
there was reason to suspect  a fresh infection.
In no case did the treatment give rise to  any
general  disorder, or  to  the  inflammations or
congestions  which some have described as re-
sulting from it.]
  Bibliog. and Refer.—Celsus, lib. v., cap. 28.—Novus
Index in omnia quae extant Cl. Galeni Opera, fol. Basil,
1562 ; art. Psora, Scabies.— Guy de Chauliac, Des Signes de
Scabie, &c, trad, par /. Canappe,  8vo.  Lyons, 1609.—
Willis, Pharrnac. Ration., Par. I., s. 3, cap. 6. — Mouffet,
Theatrum Insectorum,fol.  Lond., 1634.—Bontius, De Med.
Indorum, lib. iii.. cap. 17.—G. C. Bonomo, Sur les Cirons
ou Insectes  de la Peau des Galeux, in Collect. Academ.
Etrangercs,  4to, t. iv., p. 574.—Bonomo by Mead, in Phil-
osoph. Trans., vol. xxiii., 1702. — Plenck, Doct. de Morb.
Cut., p. 42. — Roederer, De Scabie, 1710. — Ettmuller, De
Scabie Programma, Svo, 1731. — Helmxch, De Usu Interim
Olei Vitrioli  dil. in nonnullis Scabiei Speciebus. 4to, 1762.
—G. Casal, Historia Natural  y Medica de  el Pnncip. de
Asturias, 4to. Madrid, 1762.—Morgagni, De Causis et Sed.
Morb., lib. iv., ep. 55.—De Geer, Mein. pour servir a l'Hist.
des Insectes, 4to. Stockh., 1778.—Turner, Treat, on Dis.
of the Skin, ed. 4, p. 58. — Pentzlin, in Brit, and Foreign
Med. Rev., Oct., 1837, p. 514.— Wickmann, ^Etiologie der
Kratze, Svo.  Hanover,  1786.—Adams, On Morbid Poisons,
4to.  Lond.,  1807, p. 299.—F. I. Becu, Mem. sur la Decoc-
lion du Tabac, empl. au Trait, de la Gale, vide Recueil Pe-
riodique, &c, t. i., p. 60. — Ranque,  Mem. et Observ.  Cli-
niques sur un Nouv. Procede pour la Cuerison de la Gale,
Svo.  Paris,  1811 —Le Roux, Traite sur la Gale, &c, 12mo.
Paris, 1809. — J. P. Frank,  De Cur. Horn. Mob., t. iv., p.
165.—Gale, Essai sur le Diag. de la  Gale, sur ses Causes,
&c, 4to.  Paris, 1822. — T. Bateman, Pract. Synopsis of
Cutaneous Diseases, 7th ed., by A. T. Thompson, p. 280.—
Mouronvel, Recherche et Observ. sur la Gale, &c, 8vo.
     II                91
Paris, 1822. — Lugol, Rech. et Observ. sur la  Gale, 8vo.
Paris, 1822.—Helmerich, Methode pour guerir la Gale  en
deux Jours, par /. Burdin, 8vo.  Paris, 1822.—Plumbe, On
Dis. of the Skin, 8vo.  Lond. ed., vol. ii., p. 300— Cazenave
et Schedel, Abrege Pratique des  Mai. de la  Peau. 8vo.
Paris, 1828. — Derheims, Journ. de  Chim. Medicale, Dec,
1827.—Houghton, in Cyclop, of Pract. Med., vol. iii., p. 633.
—J. Green, Pract. Compendium of Diseases of the Skin, 8vo.
Lond., 1835, p. 63.—P. Rayer, Theoretical and Pract. Trea-
tise  on Dis. of the Skin, trans, by  R. Willis, tivo.  Lond.,
1835, p. 387. — Remuir, in Lond. Med. Gaz., Oct., 1834, p.
29. — Raspail, Mem. comparatif sur l'Hist. Natnrelle  de
Tlnsecte de la Gale, 8vo.  Paris, 1834.—A. Gras, Rech. sur
l'Acarus de la Gale de  1'Home, 8vo.  Paris, 1834.—Fanto-
netti, in Archives Gener. de Med., t. xxx., p. 407.

  KIDNEYS.—The Diseases of. —1. Our
knowledge  of the diseases of the kidneys has
been  recently very much advanced and render-
ed  more precise by the  researches  of  Drs.
Bright, Prout, Christison, Gregory, Willis,
Osborne, Rayer, and  others.  In the present
article will be  discussed the diseases  of which
these  organs are the only or principal seats; and,
in that devoted to the consideration of the urine,
those  disorders in which the  kidneys and other uri-
nary organs are functionally disturbed.  The great
importance of an early attention to the disor-
ders,  and more especially to the actual  diseases
of these organs, especially in relation to several
consecutive maladies, and to various pre-exist-
ing changes of the  digestive  and assimilative
functions and of the circulating fluids, has be-
come very manifest since the researches of Dr.
Bright disclosed to us some of the most  inter-
esting, most common,  and  most fatal of the'
lesions to which the kidneys are liable.
  2.  The causes of diseases of these organs do
not, for the most  part, act immediately upon
them.  Intimately associated with the digestive
and assimilative viscera, through the medium
of the ganglial or organic  nerves, with the cir-
culating organs by the states of the blood, and
with  the  cerebro-spinal  nervous  system,  by
means of the spinal nerves communicating with
the renal ganglia and plexuses, the kidneys are
liable to be deranged sympathetically, or indi-
rectly, during  the  progress  of the various dis-
orders and maladies by which these important
parts of the human frame are affected.  As the
chief emunctories of effoete  and hurtful materi-
als, the  ultimate product  of assimilation, that
are liable  to  accumulate  in, and require to  be
carried out of the circulating fluids, the kidneys
are disturbed by the  superabundance and pecu-
liarities of these materials.   Eliminating these
various  elements and substances existing in the
blood circulating through them, by means  of
the nervous influence conferred on them, chiefly
by  the ganglia and plexuses which supply and
endow them; and combining these  elements
into new forms,  frequently of an irritating and
hurtful nature, they  are liable to disorder from
causes  which may diminish, excite, or  other-
wise modify this influence, or interrupt the ex-
cretion of the fluid and saline matters that they
are destined  to  accomplish.  Intimately asso-
ciated, moreover, with the  other organs elimi-
nating from the circulating  mass, materials  of
an irritating  or  otherwise hurtful tendency,
they are liable to disorder,  sometimes of a  vi-
carious  character, from causes acting upon the
organs  thus associated with them in  function,
although in other respects remotely connected
with them, and from diseases affecting the or-
ganization or functions of those parts: thus
are the  kidneys affected by  causes acting upoa 
722                         KIDNEYS—Inflammation of thk.
the skin, lungs, liver, digestive canal, and gen- I
erative organs ;  by diseases affecting the func-
tions and organization of those several viscera ;
and by morbid conditions of the system in gen-
eral, or of the nervous and vascular systems in
particular.
  3. These are circumstances calculated to in-
crease the difficulty of the study of the diseases
of the kidneys ;  and  it should not be concealed
that there  are  causes which add to this  diffi-
culty.  Among these, the low degree of sensi-
bility with which the internal structure of these
organs is endowed :  their situation—protected
in one direction by a firm and unyielding mass
of muscles, &c, and surrounded in  all the rest
by various viscera;  and  the changes which
their secretion  undergoes in the parts through
which it passes or accumulates, deserve due
consideration, and should impress the mind of
the physician with the importance of a diligent
investigation of the phenomena, and of caution
in forming his opinion as to the nature of the
affections referrible to these organs, as the only
guides by which the indications and  the means
of cure can be safely directed.
  4. It is, perhaps, owing to these  causes of
difficulty that the  disorders and morbid  chan-
ges to which the  kidneys are liable, the signs
and symptoms by which they are indicated, and
the means most efficacious in their removal,
have made so little progress until recently, and
still require, notwithstanding the  advances
which have been lately made, so much farther
elucidation.  In the present consideration of
the diseases of the  kidneys, I shall first describe
the inflammatory diseases, and their pathological
and therapeutical  relations, and afterward no-
tice the  changes, chiefly structural,  consequent
upon these and upon other disordered states.
I. Inflammation  of  the Kidneys. — Synon.
  Nephritis.—Ncdpi-ic, Hipp., Galen (from Nt-
  0pof, the kidney).—Renum Inflammatio, Sen-
  nert.   Phlegmone  renum,  Prosper Alpinus.
  Cauma Nephritis, Young.   Empresma Nephri-
  tis, Good.  Inflammation des Reins, Nephrite,
  Ft.  Nierenentziindung, entziindung der Nie-
  ren, Germ.  Nefritico, Inflammazione di reni,
  Ital.
     Classif.—1. Class; 2. Order (Cullen).  3.
      Class; 2. Order (Good).  III. Class, I.
      Order (Author in Preface).
  5. Defin.—Pain in  the  lumbar region,  often
extending anteriorly through the abdomen, or de-
scending to the groin and testes, with retraction of
the latter, disordered state of the urinary secretion
and excretion,  febrile disturbance, sometimes numb-
ness of the thigh, and nausea or vomiting.
  6. These symptoms are the most  character-
istic of inflammations of the kidneys ; yet they
are not all present, unless in some of the more
acute cases, or when the inflammation extends
to the greater part of the tissues composing the
organ ; and they may  be  attended  by various
contingent and much less constant phenomena.
In the slighter and more partial cases, particu-
larly when the disease commences  insidiously
and  proceeds slowly,  any one, or  more  than
one, of these  symptoms may be absent; a dis-
ordered state of the urinary secretion and ex-
cretion being the most constant.
  7.  Until very recently, all the inflammatory
and painful affections of the kidneys, whatever
may have been  the particular tissue affected,
[ were  comprised  and  confounded under the
 term nephritis.  Late investigations have, how-
' ever, shown that inflammations differ, both asre-
 spects their seats in the particular tissues com-
 posing these organs, and as regards their na-
 tures, in relation to the states of the constitu-
 tion, and the causes which produced them.  J
 shall therefore describe, 1st.  The inflammations
 seated in the cortical or vascular, and in the tubu-
 lar structures of the organ, with the modifications,
 and complications, and lesions usually presented
 by them;  2d. The  inflammations  seated  in the
 calices and pelvis of the viscus, in connexion with
 thrir  modifications  and  complications ; and, 3d.
 Inflammation of the investing structures  of the
 organ.
    8. i. Inflammation  of the  Vascclak  and
 Tubular Structure of the Kidneys.—Synon.
 Nephritis   propria,  Author.—Nephrite  simple,
 Rayer.—Nephritis proper.
    9. A. Causes.—a. The predisposing causes of
 nephritis are, chiefly, hereditary conformation ;
 the middle, advanced, and matured periods of
 life ;  the male sex, sanguine temperament, and
 plethoric habit of body; indulgence, long at a
 time, in soft, warm beds ; the use of much an-
 imal  food, and  of highly  seasoned or  spiced
 dishes, of too much food, and fermented liquors;
 addiction  to venereal pleasures ;  riding much
 on horseback, or in a carriage ; chronic disor-
 ders of the digestive organs ;  sedentary occupa-
 tions, indolence, and a neglect of due exercise ;
 and the superabundance of excrementitious mat-
 ters in the blood, more particularly of urea and
 its combinations.  The calculous, gouty, rheu-
 matic, and scrofulous diatheses, and diseases
 of the  bladder, prostate gland, and urethra,
 whether these depend upon hereditary descent
 or upon acquired disposition  and advanced age,
 especially  predispose to nephritis, and modify,
 more or less, the characters and course of the
 disease, the varieties and complications which
 result from their influence requiring a particu-
 lar notice.
    10. b. The exciting and concurrent causes of
 nephritis  are injuries, blows, contusions, con-
 cussions, or wounds of the region, or in the vi-
 cinity of the kidneys, or of the spine;  sudden
 jerks experienced on horseback, or  in  a car-
 riage, or occasioned by missing a step on de-
 scending stairs ; falls on the back or thigh ; too
 long retention of the urine ; the improper use
 of irritating diuretics, of emmenagogues, or of
 aphrodisiacs; too  long a course, or  too large
 doses of the preparations of iodine, of nitre,
 &c.;  indulgence  in spirituous liquors; vene-
 real or other excesses; the presence of calcu-
 li in  the kidneys, or in the ureters;  calculi in,
 or inflammations of, the urinary bladder; the
 sudden  suppression of the perspiration, espe-
 cially when inordinately increased; sleeping in
 the open  air, or on the ground; sleeping in
 damp beds or sheets;  cold  and  moisture ap-
 plied  to the  loins  or  lower extremities ; cold
 and humid states of the air ; currents of cold
 air striking against the loins ; sitting with the
 back to a hot fire;  the sudden interruption of
 accustomed discharges, as the haemorrhoids,
 catamenia, fluor albus, sudor pedum, &c.; the
 retropulsion  and  drying up  of chronic erup-
 tions and old ulcers by external treatment; the
 sudden transfer of morbid action from the uri-
 nary bladder, genital and sexual organs, from 
KIDNEYS—Acute Inflammation of the.
723
the psoae  muscles, or  from the organs of di-
gestion and respiration, or interruptions to the
healthy functions  of those organs; retroces-
sion or misplacement of  gout, metastasis  of
rheumatism ; paralytic affections, diseases and
injuries of the spine or spinal column, and es-
pecially paraplegia ; fevers characterized  by a
low state  of the vital energies, and oppression
of the nervous functions, with coma, &c.; the
presence of animal poisons, purulent or sanious
matters, or other  hurtful  excrementitial  sub-
stances in the circulation, however introduced
there, whether  by absorption,  or from morbid
changes in the  chyle or blood  during the prog-
ress of other diseases.
   11. From the above enumeration of the caus-
es of nephritis,  it will be manifest that this dis-
ease, in some one or other of its forms, will ap-
pear, 1st.  As a primary and simple affection, the
result of causes influencing the vascular state
of the kidney  or  kidneys, without any  very
manifest pre-existing lesion of this or any oth-
er organ, either in function or structure ;  2. As
consecutively upon some other malady, affecting
either this particular organ, or some  other,  or
even the  constitution  generally ; as upon the
formation of calculi in  the kidney itself, upon
inflammation of the bladder or testis, upon
gout, or upon disease of the prostate gland  or
urethra, or during  the progress of fevers;  3.
When appearing secondarily, it may either form
the chief or only lesion, or constitute  one of a
complicated state of disease, as when the neph-
ritis is  complicated with gout, rheumatism,
or with other diseases of the urinary organs ;
4. Whether occurring  primarily or secondarily,
it presents various  grades  of activity, from the
most acute to the most chronic, and gives rise
to changes which have some relation to the se-
verity and duration of the  attack; the circum-
stance of one  or both kidneys being affected ;
the constitution and diathesis of the patient;
the  nature of  the predisposing and exciting
causes, and of the  disorders which have prece-
ded, or become associated with  it,  although
such relation may not be obvious, nor admit of
being traced with ease and certainty, numerous
circumstances  occurring  and modifying the
march and consequences of the disease.
   12. B. Description.—The symptoms of neph-
ritis vary extremely, according to the severi-
ty of the  attack and the particular part of the
organ inflamed ; to the  circumstance of one
only, or of both kidneys being affected, and to
the mode of attack.  Inflammation seizes  on
either one or  both organs, according to the
predisposition of the patient and the nature of
the exciting causes ; but in either case it may
appear with great severity and suddenness, or
in a mild, slight, and insidious  manner;  or it
may commence in this  latter manner, and
quickly  pass  into  an  acute and very severe
form.  On the  other hand, a  sudden and  an
acute attack may degenerate into a very obsti-
nate and  chronic  form,  notwithstanding the
best efforts of the physician.
   13. Not only may inflammation of the vascu-
lar and tubular structures of the kidneys assume
any grade of intensity, and hence be acute, sub-
acute, or chronic, but it may also be modified in
character by the nature and combinations of  its
causes ; by the diathesis, constitution, and age
of the patient;  and by the states of the circu-
lating fluids.   I shall therefore consider, firstly,
its simple form, and as usually observed in a
previously healthy constitution ; and,  secondly
the moditications  arising from  those circum-
stances.
  14. a. The symptoms of simple nephritis, of
primary or idiopathic nephritis, of inflammations
of the vascular and tubular structure of the
kidneys, which are independent of diathesis,
of constitutional vice, or of animal  poisons,
vary with the severity of the attack, and with
the age and irritability of the patient.—a. The
acute form of the disease  is generally attended,
at its  invasion, with chills, horripilations, or
distinct rigours, and one or  other of them oc-
casionally, sometimes daily, appear during its
course.  A  sense of heat,  which augments
rapidly, is at first felt in one  or both lumbar re-
gions.   This soon is  accompanied  with  pain,
at first tensitive, afterward lancinating and pul-
sating, in the same situation.   The pain  is at
first not aggravated by pressure from behind,
nor from before, unless  it be applied firmly ;
but it is generally  increased, upon a full inspi-
ration, and on coughing or  sneezing, particu-
larly when pressure is  made  upon the abdo-
men at the same time.   The pain is also mo-
mentarily aggravated by efforts to pass a cos-
tive stool, or to expel the urine, and at the time
of turning  suddenly around, or from side to
side, and upon sitting down, especially upon a
low seat.  A very warm bed increases it, and
a chill of the surface has generally a similar
effect.   The  pain  extends anteriorly through
the abdomen, stretching, in  the course of the
ureters and spermatic vessels  and nerves, to
the hypogastric region, often with extreme vio-
lence, to the testes, which are drawn closely to
the abdominal ring, and descends to the ex-
tremity of the penis,  which is  small and re-
tracted.  Numbness is frequently felt in one or
both thighs, according as one or both kidneys
are affected ; and this feeling is sometimes ac-
companied with  painful  lancinations  in the
thighs, descending often as low as the  knee.
The pain, posteriorly, ascends  as high as the
shoulder-blades ; it is increased in the region
of the kidneys, and is  attended by an augment-
ed sense of heat and pain after lying for  some
time on the affected  side,  when one kidney
only is inflamed, or on the back when both are
affected, although  these positions give at first
slight ease.
  15. The urine is generally passed frequently,
and with aggravation of the  pain.  It is at first
limpid and colourless, but is much  diminished
in quantity, becomes  deeper in colour, and  is
voided more frequently and  with more pain as
the disease increases  in severity.  In the most
acute  cases, particularly when both kidneys
are affected, the urine is in  very small quanti-
ty,  is  voided with the  most  painful efforts,
sometimes only in drops, is of a reddish, or
sanguineous, or brown colour, or  with  small
brownish flocculi; and it is  often nearly, if not
altogether suppressed, so that the bladder  is
found empty upon the introduction of the cath-
eter.  The chief changes presented by the urine
in simple nephritis are:  1st. It contains some
blood or albumen  ; 2d. It is but slightly acid,
or neutral, or alkaline ; 3d.  It sometimes con-
tains a little purulent matter, or muco-puriform
matter, particularly when the inflammation ex- 
724
KIDNEYS—Acute Inflammation of the.
 tends to the calices or pelves of the kidneys, or
 when the disease is associated with inflamma-
 tion of the mucous surface of the bladder, or
 of other parts of the urinary passages.  Where
 nephritis is caused by cantharides, turpentine,
 or  cold, the  urine very commonly contains
 blood.   In the simple form  of nephritis,  the
 presence of albumen in  the  urine is not con-
 stant, as is the case in the granular disease of
 the  kidneys, or albuminous nephritis, as it is
 called by M. Rayer.
  16. Soon after the accession of rigours, at the
 invasion of the disease,  nausea and vomiting
 are  often present.  In the most  acute  states,
 retching continues throughout, although  no-
 thing may be rejected, and  is renewed after
 taking fluids, so that the patient refuses every-
 thing.   He often complains, also, of severe col-
 icky pains in the abdomen, which is sore upon
 firm pressure ; particularly towards the lateral
 and epigastric regions. There is generally con-
 stipation, frequently with repeated  desires to
 go to stool, and occasionally  with tenesmus ;
 all these  symptoms  depending upon intimate
 consent  of parts.  The pulse  is hard and fre-
 quent,  and full during the remissions of pain ;
 but in  the paroxysms or accessions of pain it
 is smaller and contracted.  The skin is at first
 hot,  dry,  or burning; but, as the disease  ad-
 vances, it becomes more  moist, is partially and
 irregularly covered by a disagreeable perspira-
 tion, and, in cases characterized by a partial or
 total suppression of urine, the perspiration has
 a urinous odour.
  17. When  the disease extends to  the investing
 membrane of the kidneys, the symptoms are then
 very acute, the pain severe, the pulse hard and
 contracted, and the urine is less changed from
 the natural state, relatively to the severity of
 the  pain  and constitutional   symptoms, than
 when the secreting structure is chiefly affected.
 But  the disease is more  rarely limited to one
 or other structure, although either may be its
 principal seat.  When it commences in the se-
 creting  and more internal  textures, or  in  the
 calices or pelvis of the organ, the urine con-
 tains much mucous or muco-puriform matter,
 and  is very scanty; and the pulse is softer, the
symptoms are milder, and the course of the dis-
 ease  slower than that above described, which is
seldom prolonged beyond a fortnight, frequently
not beyond six  or seven days, without  giving
rise to some one of the changes or lesions which
will be noticed in the sequel.  When the attack
is occasioned by the irritation of calculi in the
kidney,  there  are commonly more numbness
of the thigh and painful retractions of the tes-
tes,  and  severe pains, shooting at intervals to
the hypogastrium or in the course of the ure-
ters, than in the more primary  and simple states
of the disease, which states are of less frequent
occurrence than this,  and of shorter duration ;
this particular cause, and the  complication pro-
duced by it, being generally a chronic disease,
liable, however, to  assume an acute or sub-
acute form, as will be noticed hereafter.
  18. Acute  and sub-acute nephritis most com-
monly implicates one kidney, both organs being
more rarely affected, especially in the same de-
gree, at the same time.  While total suppres-
sion  of urine  may be considered as distinctive
of severe disease of both kidneys, yet both may
 be inflamed, and a scanty secretion take place,
 for a portion of either organ may be still  ena-
 bled to perform its functions.   These states of
 nephritis commonly present themselves as fol-
 lows :  1st. Mild acute or sub~acute: the pain in
 the loins slight; little diminution or change of
 the urine; slight symptomatic fever, and speedy
 subsidence  of the  disease  under treatment.
 2d. Simple acute and sthenic nephritis ;  greatei
 severity of the pain and of the other symptoms ;
 inflammatory fever, preceded.by rigours; mark-
 ed diminution of the urine, with the morbid ap-
 pearances and disorder attending the discharge
 of it, described  above ($ 15).  3d. Acute neph-
 ritis, with ischuria, and disturbance of the  cerebral
 functions:  suppression  of urine  altogether or
 nearly complete ;  vomitings  or retchings from
 the commencement; pain in the loins, in some
 cases severe, in others obscure; lethargy, so-
 por, or coma, supervening in the worst attacks.
 4th. Asthenic or malignant acute  nephritis:  in-
 flammation of the structure of the kidneys oc-
 curring during states of cachexia, or coincident
 with morbid states of the blood and depression
 of vital  power, or appearing in the course of
 low fever or  scarlatina, attended by a lurid,
 dusky, and offensive odour of the surface of the
 body ; little or no pain in the back or loins, un-
 less firm pressure be made ; the supine posture
 in a state of stupor,  or sopor, the patient  an-
 swering questions with difficulty and imperfect-
 ly ; suppressed, scanty, or involuntary excre-
 tion of  urine ; frequent occurrence  of slight
 rigours; the  tongue  dry, loaded, and brown;
 little or  no thirst; stupor, coma,  and  an offen-
 sive odour proceeding from the surface.
  19. /3. Sub-acute Nephritis.—When inflamma-
 tion of the secreting structure of the  kidney
 takes place slowly in a mild and sub-acute form,
 the patient complains of dull or shooting pains
 in the lumbar  region, occurring at  longer or
 shorter intervals, with disorder of the secretion
 and excretion of urine, aggravated by  errors of
 diet and regimen.  These  symptoms  are con-
 nected with more or less disturbance of  the
 system  generally, and of the functions of  the
 digestive organs ; frequently presenting peri-
 ods of aggravation and amelioration, and occa-
 sionally assuming suddenly, especially after the
 operation of one or more of the causes above
 enumerated ($ 10), a very acute form.
  20. This state  of the  disease is  of very
 uncertain duration.   Sometimes  it continues,
 with intermissions, for several weeks, or even
 months,  when it may assume a very acute or
 hyper-acute form, or may subside into a less se-
 vere and more chronic state.
  21. When sub-acute nephritis passes  into a
hyper-acute state, the disease  may reach its ut-
most severity in two or three days, and if  cir-
cumstances favour its continuance, or  insuffi-
cient means be adopted to subdue it, the symp-
toms assume, in one, two, three, or four days
more, the most dangerous character.  The pain
 becomes sometimes  insupportable; the pulse
 small, contracted, unequal, or intermittent, fre-
quently slow ; the extremities become cold, or
 are kept warm with difficulty ; the countenance
 assumes a leaden  or murky hue, and the fea-
tures are otherwise  much changed; hiccough
 supervenes, and a cold, foetid, or urinous per-
 spiration covers the surface of the body. The
 urine, if any be voided, is  usually now very
 dark-coloured, filamentous, passed drop by drop, 
KIDNEYS—Chronic Inflammation of ths.                     725
ewd  of a cadaverous odour.  The muscular
force sinks rapidly:  fainting delirium, convul-
sions, stupor, and coma supervene, and the pa-
tient dies.
  22. y.  Chronic  Nephritis.—Inflammation of
the substance of the kidney may exist in either
(he acute or sub-acute form, and gradually lapse
into the chronic state.   Or, inflammatory action
may commence in a slight and mild form, pro-
ceed gradually and insidiously, and be so ob-
scure as  not to awaken the fears of the patient,
and as to escape the observation or detection
of the  physician.  In these cases,  pain,  if at
all present, is often slight or obscure ; disorder
of the quantity and states of the urine ; a dim-
inution  of acidity, and a neutral or alkaline
slate of it; disorder connected with the  evac-
uation of it; a feeling of weakness or of slight
numbness in one or both lower extremities, are
the symptoms most commonly observed.   The
urine is  generally turbid, occasionally only al-
buminous, generally abounding with the  phos-
phatic salts and with  mucus, and often depos-
iting sediments, or containing more or less of
gravelly matters.   It is always voided frequent-
ly, but in very small quantity at a time.   Pain
in the loins is often not felt unless on firm pres-
sure, and on taking a full inspiration.  It some-
times extends in the course  of the ureters, but
seldom to the testes.   When it is not associa-
ted with disease  of the bladder or prostate,
there generally is  little or no fever, unless at
night, or when the patient is heated by a  warm
bed.  This state of nephritis is often excited
or perpetuated by disease of the urethra, or
prostate gland, or urinary  bladder.  In  some
cases this form of the disease approaches  a suc-
cession of slight attacks of acute or subacute
inflammation, each subsiding for a time or re-
turning,  or affecting circumscribed  portions of
the organ.  When both kidneys are affected,
the chief symptom may be the gradual deterio-
ration  of the constitution, and development of
cachexia, favouring the occurrence  of  other
maladies, especially dropsy.
   23. Many of the organic lesions found  in the
kidneys upon dissection, as  well as the forma-
tion of calculi in the  organ, proceed from this
slight and slow state of inflammatory action of
its secreting  structure; and,  whether passing
into more active forms of  disease, or giving
rise to  suppuration, it  frequently  renders the
future life of the  patient irksome, especially
when affecting old persons, even without pro-
ducing the latter effect; but when it occasions
this, the patient, particularly if he be advanced
in life, but rarely escapes.    The  chronic as
well as the acute  forms of  inflammation gen-
erally attack one kidney only, and more  rarely
both at the same time, or in the same  degree ;
hence the urine is very rarely suppressed, al-
though it is often much diminished in quantity.
Richter (Therapeia Spccialis, t.  i., p. 534) says
that the  left kidney is more  frequently inflamed
than the right; and a similar opinion has been
stated  by other pathologists; but  this is not
satisfactorily proved.
  24. 6.  Nephritis in the female is a less fre-
quent and less  dangerous disease than in the
male, but it is often more  difficult of detection,
in its chronic forms especially ;  and it is liable to
be mistaken for affections of the uterine organs,
with which, also, it is occasionally complicated.
The existence of pain in the lumbar region ex-
tending to the abdomen, and shooting towards
the bladder and groin, with numbness  of the
thigh and disorder of the secretion and  excre-
tion of the urine,  are, however,  sufficient to
prove the existence of nephritis  in this class
of patients.   Two cases of the disease in fe-
males  have come  before me which  had been
mistaken for disease of the colon, and one for
inflammation of the bowels.   This  wrant of
knowledge  of so very important a disease has
evidently arisen from the very slight attention
paid to diseases of the kidneys by systematic
writers, and to the careless way  in  which the
urinary secretion  is examined  by too  many
practitioners. Nephritis is not infrequent among
females recently  confined, but is then  com-
monly  associated  with inflammation  of the
veins  of the uterus and ovaria, or  with peri-
tonitis.
  25.  G. Terminations, &c.—a.  When reso-
lution takes place,  the severe symptoms abate
from about the fourth to the ninth day,  in the
more  acute cases;  and, in the sub-acute,  fre-
quently not until the twelfth or fifteenth of the
attack.   When this change occurs, the urine
becomes more abundant, paler, is voided with
less uneasiness, and deposites a sediment; the
pulse becomes more natural; occasionally full-
er,  softer, and even quicker than previously,
especially if it have been  slower during the
acute  state ; a general perspiration breaks out,
and critical discharges, particularly the haemor-
rhoidal and catamenial, sometimes appear, es-
pecially when the disease has arisen from  sup-
pression of these evacuations.   In some cases,
particularly in persons  advancing in age, reso-
lution is imperfect, the  urine continuing scanty
and albuminous, other symptoms  remaining in
a slight form.   In these there is reason to sus-
pect that slight depositions of coagulable lymph
have taken place, during the acute state of the
disease, in  the tissues  composing the body of
the organ, and are giving rise to granular de-
generation.
  26.  b.  Suppuration or abscess  does not so
often occur during inflammation of  the  vascu-
lar  and tubular structure  of the  kidney as is
supposed.  The presence of purulent or muco-
puriform matter in the urine is no proof of sup-
puration of these parts, but merely shows that
the inflammation has extended to the  calices
and pelvis of the organ.  Abscess  of the kidney
maybe the  consequence of inflammation, either
unconnected with, or depending upon calculi in
the tubular structure.   It may  also proceed
from slight, or chronic, or sub-acute inflammation
in scrofulous subjects, and more commonly it
is in  them unconnected with calculi, and as-
sumes a more chronic  character.   If the  very
acute form  of  nephritis continue,  without ma-
terial alleviation, beyond seven or eight days,
or  the sub-acute  persist longer than  fifteen
days,  the formation of matter may be dreaded,
especially if, about  this time,  several  of the
following symptoms appear : when the disease
passes from an acute into a more chronic state,
or  milder character, the pain and heat being
abated, but still continuing ; when the pain be-
comes  dull and  pulsating, with a  sense  of
weight or  embarrassment in the lumbar re-
gion,  and increased numbness of  the thigh cor-
responding with the organ affected ;  when rig- 
726                 KIDNEYS—Inflammation of the—Terminations.
ours occur irregularly or at different hours of
the day; and when perspirations become fre-
quent and copious, the pulse small, weak, and
soft, the symptomatic fever assuming an ady-
namic, and subsequently a typhoid character,
cerebral symptoms  supervening, we may then
conclude that  an abscess  has  formed in the
structure of the kidney.
  27. In the more chronic or sub-acute cases ter-
minating in abscess, an cedematous fulness or
swelling, without change of colour, is  some-
times observed.  In  several instances, firm
pressure of the lumbar region occasions acute
pain, extending  to the  groin ;  and the urine
contains either blood or gravelly matter, or a
whitish purulent matter more or less intimate-
ly mixed with  it, and  rendering  it thick and
turbid.  In these more chronic states, the con-
stitutional symptoms are nearly those of hectic
fever.   The symptoms may truly indicate the
existence  of abscess, and yet no pns be seen
in the urine, which  may even remain  clear.
But, after a considerable time, the matter finds
its way into the pelvis of the kidney, and a large
quantity of pus, with some  blood,  is evacuated
with the urine, often occasioning, by its acri-
mony, much irritation of the bladder and ure-
thra.  In other cases, little or no pus is evac-
uated in the urine, owing to the passage along
the ureter  being obstructed, either at the pel-
vis of the kidney, or in some part of the ure-
ter, by a large calculus, which  most probably
induced the inflammatory action giving rise to
abscess, and which now prevents the passage,
not only of the matter, but  also of the urine to
the bladder.  In some  of these cases, the ab-
scess points externally in the back or loins, or
even in the side or above the groin, the patient
either sinking  under the affection, or partially
or altogether  recovering.  The abscess may
burst internally into the peritoneal cavity, and
it then  proves quickly fatal; or it may open
into the colon, and  the patient either recover
or sink.  Of these occurrences, numerous in-
stances are recorded in the works contained in
the Bibliography to this article.
  28. In the greater  number of  cases of ab-
scess, " the ureter remains more or less pervi-
ous, and the patient continues  at intervals to
discharge  pus, and sometimes small calculi,
blood, &c, with the urine for a long  time"
(Prout).  When the abscess opens externally,
the aperture continues for a considerable time
to evacuate purulent matter of an urinous odour,
or pus mixed with urine, and sometimes urine
only.  When the abscess discharges pus mere-
ly without any urinous odour, or without  any
intermixture of urine at any period  of the dis-
charge, it  is then very doubtful whether the ab-
scess is connected with the kidney or no.  It
may proceed from caries of one of the  verte-
bra;, from which it is necessary to distinguish
the abscess now under consideration.
  29. When the fistulous opening,  leading from
an abscess of the kidney, becomes obstructed,
either by granulations or by a calculus, the dis-
charge ceases, and  a  pulsatory pain generally
returns  in  the  lumbar region, followed  by in-
creased heat of skin, accelerated pulse, or even
delirium, which continue or increase until the
obstruction gives way before the  accumulated
matter.  When  at  last the external  opening
heals up, without the immediate return of the
previous dangerous  symptoms, a relapse may
take place at a more remote period, owing to
the return of the inflammation, probably again
induced by a calculus formed in the kidney.  In
the majority of cases, especially  in the ear-
lier stages of abscess, one kidney is only af-
fected ; but this may be altogether  destroyed
by it.  In protracted cases, particularly in aged
persons, the other kidney generally participates
in the disease, to a greater or less extent, be-
fore the one first attacked is altogether disor-
ganized.  Although suppuration is a conse-
quence of inflammation, whether unconnected
or complicated with  calculi in the kidney, yet
the origin of the calculi is a matter  of impor-
tance.   It is very probable that they may be a
result of slow inflammatory action of the tubu-
lar structure, and that, when they are formed,
they heighten this action,  and give rise to sup-
puration.  (See Urine, &c.)
  30. When the chronic states of nephritis oc-
cur in scrofulous persons, abscess often results,
even independently of calculi, with which, how-
ever, the abscess may be associated.  When
abscess takes place in  the strumous  diathesis,
the symptoms attending its formation and mat-
uration are  much more obscure than in other
constitutions,  and the disorganization of the
kidney generally is more complete.  In the lat-
ter stages of the disease, and in the more chron-
ic cases, Mr. Howship has remarked that the
patient refers his complaints more  to the neck
of the bladder than to the region of the kidney;
but in recent cases this is not so generally ob-
served.  Dr. Prout has  met with  instances
where  the pain referred to the lumbar region,
as in ordinary  cases, and  the nrine was acid,
and, abstracting the pus,  not  very unnatural.
I agree with Dr. Prout in imputing the suffer-
ings in the bladder,  in the more  chronic cases
of this  form of abscess, to the exceedingly fee-
tid, acrid, and  unnatural  state of the  urine,
which is usually alkaline,  and evidently  of so
irritating a nature as probably not to  be retain-
ed in a healthy bladder for a moment, without
producing great pain.  Mr. Howship, however,
mentions instances of this form of the disease
where the urine appeared  natural, and yet the
pain was referred to  the bladder, nevertheless.
But there was very probably, in these  cases,
disease of the prostate gland, or inflammation
of the parts  in its vicinity, or of those adjoin-
ing the openings of the ureters, complicated with
the disease of the kidney ; for I have observed
such complications in cases which  occurred in
my practice, where the symptoms were chiefly
referred to the bladder, and yet the urine seem-
ed nearly natural.   Dr. Prout remarks, that
the cases of this scrofulous affection of the kid-
neys that he has seen have also been attended
with indolent tumour and  abscess of the ingui-
nal glands, and by occasional pain and swelling
in the  testicles.  They were accompanied by
great extenuation of the body, and derangement
of the general health ; and in all instances ulti-
mately proved fatal.   (On Diseases of the Uri-
nary Organs, p. 216 )
   31. c.  The termination  of nephritis in gan-
grene is very rare ; the change actually taking
place, and often mistaken for gangrene, as some-
times approaching this state, is softening, more
or less marked, of portions of the inflamed tis-
sues, with purulent infiltration, in a greater or 
KIDNEYS—Inflammation of the—Lesions from.
727
less number of points.   If gangrene take place,
it is indicated by the symptoms usually attend-
ing it in other organs, especially  by sudden
sinking of the vital powers, and cessation of
pain; singultus, vomitings, anxiety,  restless-
ness,-coldness of the surface  and extremities;
small, thready, and weak pulse ;  wanderings of
the intellects, and delirium.   The  urine  also
becomes altogether suppressed, or remarkably
scanty and foetid.
  32. d.  Some degree of either  induration  or
softening may follow  acute nephritis, particu-
larly the former;  and the patient  may either
apparently recover, or the disease may assume
a chronic form.  Some  degree of induration of
the substance of the organ consequent on the
acute state of the disease may not be incon-
sistent with the discharge, to some extent, of
its  functions; and when one organ only is af-
fected, the urine may not be materially altered,
or even not at all diminished.   In these cases,
the quantity  secreted by the indurated organ
cannot be ascertained,  as the function  of the
healthy kidney is increased.  The albuminous
state of the urine in these cases seems to  indi-
cate that the indurated kidney still performs
some part of its  functions.
  33. D.  Changes observed after  death from
inflammation of the vascular and tubular structure
of the Kidney.—a.  At an early stage  of the acute
form of the disease, the volume of a part, or of
the whole of the organ, according as the affec-
tion is general or partial,  is  more  or less in-
creased.   In  a few cases the kidney may be in-
creased to twice, or even thrice its natural bulk.
At  this period, and before the  parts inflamed be-
come infiltrated with pus, they present a morbid-
ly red tint, generally a deep or dark red, and some-
times a brownish ecchymosed appearance.  The
vessels of the cortical structure, and the more
superficial veins, are enlarged and more than usu-
ally distinct.   Besides these, M. Rayer remarks,
that a number of small points of a lively red, not
elevated above the surface, may be seen  with
the unassisted eye in the exterior of the organ.
These small  red points are also found in the
first stage of ganular disease, or inflammation
of the kidney—of the  nephrite albumineuse  of
this writer—and are  often intermingled  with
black points and with small  vesicles.  These
latter points  are often  surrounded  by a  very
delicate  network of vessels.   On division, the
vascular or cortical tissue of  the inflamed kid-
ney presents  a similar congeries of  red points,
distinct from  the  orifices of divided vessels ;
these points   are  disposed in lines or  series,
very rarely in groups, and are the glandules  of
Malpighi—the corpora Malpighiana—highly in-
jected.   Sometimes these glandules, especially
at the exterior of the organ, assume  the appear-
ance of dark  or black  spots, either isolated and
distinct, or approaching each other  in a series,
or in groups.  The surface of the organ,  also,
presents  an irregularly red tint, with scattered
spots of a livelier red than that of the surround-
ing  tissue.   The substance inflamed  is, more-
over,  dotted  with true ecchymoses, disposed
either in lines or in bands, which probably be-
come the bases of the purulent infiltrations ob-
served at a farther advanced  stage.
  34.  When  the  acutely  inflamed  kidney is
augmented in  volume  and weight, it often,  also,
presents  a red induration of  the vascular and
tubular tissues.  This  induration and redness
are commonly general  as respects both these
tissues ;  and the  glandules of  Malpighi  are
also highly injected and very apparent.  Upon
pressing the divided parts of an indurated, red-
dish brown  kidney between the fingers, a lar-
ger quantity of blood escapes than in the healthy
state ; but not with that facility observed in the
passive  congestions of the organ consequent
upon intercepted circulation through the right
side of the heart.
  35. In some states of simple acute nephritis,
M. Rayer has observed  portions of  the organ
in a state  of anaemia interspersed  between
other parts which are morbidly red, and ecchy-
mosed, or infiltrated with pus.  This associa-
tion of anaemia of  some portions of the kidney
with inflammatory injection, &c., of other por-
tions, is also often found in cases of chronic
nephritis which  have  passed into the acute
form previously to  death.
  36. Purulent infiltration is more  frequently
remarked  in the vascular than in the tubular
tissue of the organ ; the former portion being
more commonly and severely inflamed than the
other.  The infiltrated  pus appears in the form
of grains of white sand,  or of minute depots
of the size of pins' heads, surrounded  by a
brownish red tissue.  In  some cases, the puru-
lent formations are much larger,  although less
numerous, being of the size of pustules, or of
small peas, and,  in rare instances, as large as
nuts. It is comparatively rare to find abscess-
es,  or purulent  collections, in the substance
of the kidney larger than these, most of  the
cases of large abscesses in  this organ being
purulent  collections of the calices and  pelvis
consequent  upon inflammation of these parts,
and obstruction  of the ureter.  These collec-
tions are surrounded by a deeper redness than
that of the adjoining  parts,  even when  the
whole of the organ is inflamed.  The small ab-
scesses, seen at the surface of the kidney, pen-
etrate more or less deeply into its substance,
and often  infiltrate the  tissue immediately
around  them, so  that drops  of pus may be
squeezed from it  by the  point of the scalpel.
Some parts of the organ are softened  and infil-
trated with  pus,  and are of a yellowish white
colour, drops of pus being squeezed from them
when divided ; these have not yet proceeded to
the  state just described, or are merely in  the
course of passing into  that of small abscesses ;
they are met with in the vascular as well as in
the tubular structure.   Gangrenous softening is
very rarely observed in these structures, and is
characterized by its brownish  hue, by their to-
mentose aspect when they are plunged in wa-
ter,  and by the odour exhaled by  them.
  37. b. The chronic forms of nephritis present
various changes, some  of which  are very oppo-
site in their natures.   When the whole of the
organ has been chronicajly inflamed, atrophy of
it is much  more frequently observed than hy-
pertrophy, which also occurs.   In some instan-
ces, the vascular tissue of the organ presents a
species of hypertrophy occasioned by a deposi-
tion on it of lymph, which has assumed subse-
quently a fribro-cellular character.  In others,
patches of a yellowish colour are seen exterior-
ly, and are found to consist of a somewhat sim-
ilar  substance, manifestly produced from coag-
ulable lymph long  previously thrown out.   Al- 
728
KIDNEYS—Inflammation of the—Diagnosis.
ter the chronic states of inflammation, the sub-
stance of the organ is more or less indurated,
denser, and  specifically heavier than natural.
The external surface is often granulated, or ru-
gous, or it presents a variously-coloured,  or
marbled  appearance.  Deep redness is seldom
observed, unless an acute state of inflamma-
tion has  supervened on the chronic shortly be-
fore death, and then it is seen both on the sur-
face and  more or less through the substance of
the organ.   An anaemic condition, either par-
tial or general, and commonly associated with
induration or increased density of the textures,
is one of the most frequent lesions produced by
chronic simple nephritis ;  and is generally far-
ther associated with a granulated and marbled
state of  the  surface, and  with atrophy.  This
anaemic  state commences in the vascular tis-
sue, and  extends to the tubular texture, both
of which may become ultimately pale, indura-
ted, and  atrophied  in a very remarkable man-
ner.  When atrophy takes place in several dis-
tinct points or parts of the organ, the external
surface often presents an unequal, rugous, or
mammalated appearance.   The papilla of the
cones or tubular  structure  undergo  various
changes  consequent  upon  their induration.
Sometimes the cones are  very acute,  and of a
whitish yellow colour.  The papillae are occa-
sionally  eroded or infiltrated with pus, more
rarely they are ulcerated.
   38. c.  The  membranes external to the organ
often participate in the  inflammation  of  the
more internal textures, and present the usual
consequences of this  participation, especially
vascular  injection,  exudation of coagulable
lymph, and, in the chronic cases, thickening of
the  membranes and increased  adhesions  of
them over the parts inflamed.  In some cases
they also experience various changes of colour,
chiefly of a brownish or blackish hue ; and oc-
casionally they are changed, in places, to fibrous,
fibro-cartilaginous,  or  even  to a  cartilaginous
or osseous state.   Besides these  lesions, oth-
ers  hereafter to be described take place  as a
consequence of inflammation, and various in-
flammatory changes are also  observed in  the
calices and pelvis of the organ.  The veins of
the kidneys are sometimes inflamed, but inde-
pendently of  this  form of nephritis.  Renal
phlebitis  is more  frequently  associated with
granular degeneration of the kidneys or albu-
minous nephritis.
   39. E. Diagnosis of the simple states of
Nephritis.—a. The distinctions between these
and the other forms of nephritis will  be made
more manifest when  the latter  come under
consideration.  I shall, therefore, merely  re-
mark very briefly that, in  the gouty variety of
nephritis, the  urine  deposites  crystals of uric
acid, which are never  observed in the simple
form of the disease ; and that the granular de-
generation  of the  kidney  is  always either ac-
companied  with or followed  by  dropsy,  and
characterized  by a constant and marked albu-
minous state  of the urine, this latter change
being only accidental and evanescent, although
sometimes  recurring in the  simple forms of
nephritis.  The inflammation of the substance
of the kidneys, occurring in the course of low
and exanthematous fevers, arises from the mor-
bid poison in the blood, or, rather, from the ac-
cumulation of excrementitial matters, and the
consequent alterations  in this fluid in connex-
ion with the state of organic nervous power;
and, from  being thus  a  consecutive disease,
and attended by certain  features hereafter to be
noticed, cannot be confounded with the prima-
ry and simple nephritis  just described.
  40. b.  It  is often  impossible lo distinguish
the acute form of simple nephritis from inflam-
mation of the  investing  membranes of the kid-
neys, on the one hand, or from inflammation of
the pelves and calices of these  organs, on the
other; because  the  disease is seldom limited
altogether  to  either of these  structures, al-
though  it be  seated in one or other chiefly.
When the  urine contains much mucus, or  a
muco-puriform matter, the urethra and urinary
bladder being  sound, then the morbid secretion
can proceed only from the pelves and ureters.
But, in these cases, it is  almost impossible to
say  that  the bladder  is  healthy.  However,
when inflammation of the pelves and calices is
so severe as to produce an abundant secretion
of mucus, it is very  rare that the substance of
the kidney  does not participate in the inflam-
mation-.  When, in  addition to this secretion,
there is severe pain felt in the  loins, attended
by vomiting and other acute symptoms, it may
be inferred that the disease extends to both the
substance and the pelves  of the organ.   It is
much more difficult to distinguish the chronic
states of inflammation of the substance from those
of the pelvis of the  kidney, even although the
morbid action be confined  to either  structure ;
but such limitation often does  not exist, both
parts being implicated, although one  or other is
more especially affected.   Still, in the simple
chronic nephritis, the quantity of muco-puriform
matter in the urine is much less than when the
calices and pelves are chronically inflamed, and
the  phosphates are more frequently found in
suspension.   Most of the cases  usually denom-
inated abscess of the kidney are nothing more
than accumulations  of pus in the pelvis,  owing
to the obstruction caused by a calculus distend-
ing it and the surrounding parts, and transform-
ing the organ into a large multilocular tumour
containing puriform matter.  When the inflam-
mation is seated chiefly in the calices and pel-
vis of the  organ, and  especially when  it is
caused and perpetuated by calculi, then more
irritation is felt in the bladder, especially about
its neck, and more  pain  in the course of the
urethra, than  in other cases.   The  irritability
of the bladder is sometimes so  great in  these
cases as to almost amount to incontinence of
urine.
  41. c.  Inflammation of the surrounding cellular
tissue, or of the investing membranes of the kid-
neys, very closely resemble acute  nephritis;
but there are not such remarkable changes in
the quantity and character of the urine, or such
disorder  connected  with the excretion  of it,
correspondent with the  acuteness of the local
and constitutional symptoms, as are observed
in true nephritis.  When the membranes  espe-
cially are inflamed, the  sense of heat and the
pain  are  very great, while  the  diminution of
urine  and the difficulty of excreting are not
so remarkable.  When the surrounding cellular
tissue suppurates, and a considerable abscess is
formed, the lumbar region becomes full and dis-
tinctly oedematous, and  ultimately even fluctu-
ation may be  detected.   Inflammation of  the 
KIDNEYS—Inflammation of the—Modified states of.             729
ttllular tissue surrounding the psoas muscle—pso-
itis, or the commencement of lumbar abscess—
may be mistaken for nephritis;  but in the for-
mer disease the pain is  much  increased  upon
flexure of the thigh upon the  trunk, while the
secretion  and evacuation of urine are either
not disordered or but slightly disturbed.
  42. d. Nephritis  is  distinguished  from the
Bimple irritation consequent upon the passage
of a calculus along the ureter, chiefly by the fever
which accompanies the pain of  nephritis  from
its commencement, and by the  pain never be-
ing altogether absent,  although  it is generally
characterized by remissions and  exacerbations.
Nephritis can  hardly  be confounded  with ne-
phralgia', this  latter affection is very rare  ; the
pains constituting  it  are much  more violent
than those of nephritis, are sudden in their ac-
cession and disappearance, and are unattended
by fever or heat  of skin.
  43. e. From acute rheumatism  nephritis will
be readily distinguished by the nausea, vomit-
ing, colicky pains  in the abdomen, the numb-
ness of the thigh, the extension of the pain  to
the hypogastrium and groins, and to the testes,
with retraction of  them to the abdominal  ring,
and the disorder of the secretion and excretion
of urine which characterize the latter disease,
but  which  do not attend the  former unless
rheumatism attacks or extends  to the invest-
ing membranes of the kidneys, as will be more
particularly  noticed hereafter.   Lumbago can
hardly be mistaken for nephritis, as, besides
the absence of the above symptoms in the for-
mer disease, it is seldom attended by any feb-
rile action ; and the pain on  bending the back,
upon rising from a seat, or exerting the dorsal
muscles, is distinctive  of the rheumatic nature
of the affection.
  44. /.  In females, nephritis is often distin-
guished with difficulty from  colic, from inflam-
mation of the psoae muscles,  from  enteritis,
from obstruction and inflammation of the colon,
and from inflammation of the internal iliac vein
or artery.   Numbness  of the thigh, pain in the
lumbar region, extending in the course of the
ureters to the groins, insides of the thighs, and
urinary bladder, and being referred more to the
posterior regions of the abdomen than to its
anterior aspect,  with  absence  of tenderness
upon slight pressure,  and the disorder of the
secretion and excretion of urine,  are generally
sufficient to mark the nature of the disease.
  45. g. It is often more difficult to distinguish
nephritis from  uro-cystitis than is generally sup-
posed.  It should, however, be recollected that
both diseases  are  often associated ;  and  that
both simple  nephritis and inflammation of the
pelvis of the organ, caused by the irritation of
a calculus, may be attended by more severe
symptoms referred to  the bladder and urethra
than those felt in the lumbar region ; while uro-
cystitis may be attended by pain in  the loins,
and various other symptoms of nephritis.  The
great irritability  of the bladder, the appearance
of the urine, the  pain behind the pubis, and the
absence of numbness  of the thigh, or of pain
and retraction of  the  testes, unless when the
kidneys are also affected, will generally  indi-
cate the seat of  the disease.   But this subject
will be noticed more particularly hereafter.
  46  ii Modified States of Nephritis.—In-
flammation  of the kidneys presents various

    II               92
 modifications or varieties proceeding from the
 diathesis of the patient, and the  nature of the
 exciting causes.
   47. A. Of Gouty Nephritis—of Nephritis in the
 Gouty Diathesis.   The  fact of gout attacking
 the kidneys  was first remarked  by Aret^eus,
 and  more  particularly by  Wepfer,  Specht,
 Sydenham, Bonet, F.  Hoffmann,  Morgagxi,
 De Haen, Stoll, Van Swieten, Chopart,  and
 by other practical writers of the last century.
 Modern authors,  especially  Barthez,  Home,
 Guilbert, Prout, Scudamore, Brodie, Rayer,
 and others, have  farther shown that inflamma-
 tions  of the  kidneys, either with  or  without
 gravelly and calculous formations, but most
 frequently in connexion with them, are very
 liable to occur  in gouty constitutions,  or in
 connexion with gouty attacks, and to assume
 peculiar features.
   48.  a. Symptoms.—These  vary remarkably,
 according as the  inflammation  is  associated
 with uric acid gravel in the vascular and tubu-
 lar structure, or with calculi in the pelvis or
 other  parts of the organ, or with disease of the
 bladder or prostate gland.   Gravel  or  some
calculi may exist long in the substance of  the
kidney, without any of the symptoms of disease
of the organ being felt, or, at least, felt so as to
attract particular notice. It is only when these
produce irritation,  or when various circum-
stances occasion  vascular  determination  or
congestion of the kidneys,  or when a calculus
is  arrested in the  ureters, that indications of
disorder in this quarter present themselves.
In these cases, the disease  assumes features
more  particularly noticed in the article Urine,
and gives rise to those painful affections usual-
ly called nephritic colic. When these painful
attacks  occur in  a gouty person, and are  ac-
companied by a frequent desire, especiafly  du-
ring the night, to pass the urine,  this fluid
containing more  or less albumen,  and blood-
globules, with acid, they probably depend upon
calculi in the pelvis of the kidney, or in  the
ureter ; and this will be still more probably  the
case, if the pain exist in, or extend to the lum-
bar region, and is attended by great irritability
of the bladder, by incontinence of the urine, by
pain about the neck of the bladder and in  the
urethra, and by uneasiness, numbness, &c, in
the thigh, testes, &c.   Whenever the urine of
a gouty person presents crystals  of uric acid,
 sometimes  with  a little blood, or  mucus, or
 muco-puriform matter,  then  the  existence of
 calculi or gravel in the kidney may be suspect-
 ed, although the  symptoms referable to this
 organ itself may not  be very severe  or well
 marked.  When  these morbid states of  the
 urine  are more  decidedly  characterized,  the
 existence of calculi may be inferred with  much
 certainty,  and is  often  proved by their escape
 with the urine at no very distant period.  When
 calculi do not exist in the kidneys, pains in the
 lumbar  region are not constant, or are merely
 passing. The circumstances, however, which
 more  especially distinguish gouty nephritis  are
 the occurrence of the inflammation in the gouty
 habit, and in  connexion with gravel and calcu-
 li ; the  very acid  state of the urine, which  im-
 mediately presents or deposites crystals of uric
 acid, and the antecedent and attendant symp-
 toms  of gout in the system.   On the  other
 hand, in simple nephritis, the urine is most  fre- 
730
KIDNEYS—Inflammation of the—Modified states or.
quently neutral or alkaline, deposites an amor-
phous sediment, usually composed of the phos-
phate of  lime, or of the urates, or of the  am-
moniaco-magnesian phosphate.  In proportion
to the acuteness of the attack, to the diminu-
tion and other changes of the urine, and to the
predominance of the  symptoms more  strictly
referable to  the  kidneys  and bladder, is the
constitutional or febriie disturbance  usually
great.  When the urine is suppressed or nearly
so, bloody, remarkably  scanty, or very dark-
coloured, and the pains in the loins, &c, and
the attendant fever severe, either inflammation,
or extremely active congestion of the vascular
and tubular structure, or obstruction of the pel-
vis at the commencement of the ureters of both
kidneys,  has taken place.  When this attack
occurs somewhat suddenly, or upon the  pre-
mature disappearance of gout from the lower
extremities, or after the usual premonitory in-
dications of gout, if it appear either  as sup-
pressed,  or metastatic, or misplaced gout, then
acute inflammation, or very active congestion
of the substance of the kidneys, may be inferred
to exist.   I  have lately treated a case of gouty
nephritis, in  which the urine  was of a black,
inky tint, and remarkably scanty; this colour
having arisen from the action of the acid in the
urine upon the blood exhaled from the inflamed
organ.
  49. b. On dissection of fatal cases of gouty neph-
ritis, numerous particles  of crystallized  uric
acid may be  detected at the surface, or in the
substance of the  vascular structure of the kid-
ney.  This substance is generally more or less
inflamed in  parts, and altered in structure, as
already described when stating the lesions pro-
duced by simple chronic nephritis (§ 36). Grav-
el or small  calculi are also found in the papil-
lary structures, in the calices, and in the pelvis
of the organ ; those in the latter situations be-
ing commonly larger than those found in the
tubuli.  The investing membranes  of  the kid-
ney are rarely materially altered.
   50. B.  Of Rheumatic Nephritis.—a. The occur-
rence of nephritis in connexion with rheuma-
tism in different parts  of the body has been
noticed by several writers ; and, in very recent
times, also in connexion with rheumatic peri-
carditis and endocarditis,  or  antecedently or
subsequently to these diseases.  I have seen
nephritis supervene  upon  rheumatism  of the
lower extremities, and upon rheumatism of the
testes  after  sleeping in a damp bed; and  I
have observed in a female rheumatism of the
limbs, of the ovaria, and of the kidneys, nearly
contemporaneous, owing to the same cause, the
affection, however, of the  former parts subsi-
ding as that  of the latter became more promi-
nently developed.  This variety of nephritis is
generally very obscure.  Pains in  one or  both
loins, in  the limb of the same side, and in the
testes, are  very equivocal symptoms,  particu-
larly in a rheumatic  subject, as they may be
either simply rheumatic, or symptomatic of in-
flammation  of the kidneys ; but when they are
attended by ischuria, or by a very marked  dim-
inution of the urine, while there is not a  very
copious perspiration, and by an albuminous and
acid state of the urine, which  is voided fre-
quently,  and in small quantity, with increase
of pain, and which is either very deep coloured,
or deposites a rose-coloured sediment, it be-
comes probable that  the  kidneys are  actively
congested or inflamed.
  51. b.  It is not infrequent to  find extensive
organic changes in the kidneys of persons who
have died of diseases of the heart, consequent
upon rheumatism ;  and who have recently, or
at no very remote period,  complained of disor-
der of the urinary functions or organs.   These
lesions have consisted chiefly of the infiltration
of coagulable lymph,  at several points of the
vascular structure of the kidneys.  These near-
ly solid deposites have given rise  to  marked,
unequal prominences  on  the external surface
of the organ, where they appear as yellowish
patches.  These deposites of lymph are of va-
rious sizes ;  sometimes sinking deeply into the
vascular structure,  and approaching nearly the
size of a nut or bean.  Their limits  are dis-
tinctly marked  by a dark reddish  tint of the
surrounding tissue.  The membranes external
to the kidneys, particularly the portions of them
corresponding with the deposites of lymph, are
generally injected ; the calices and pelves are
also  inflamed,  presenting numerous vascular
arborizations and red  points.  Small collections
of pus are sometimes observed in the vascular
and tubular structures ; and the organ is gen-
erally increased in weight and volume, and oc-
casionally,  also, more  or less  indurated.   In
the more chronic cases of this variety of nephri-
tis, or when the nephritic disorder has preceded
dissolution a considerable time,  eminences and
irregularities of the external surface of the or-
gan are observed ; and what  had manifestly
been, in the acute stage,  deposites of coagula-
ble lymph, are now changed into a firm yellow-
ish substance,  of the  consistence of condensed
cellular tissue.  In the pits or depressions  on
the  external surface, the fibrous and cellular
membranes of the kidneys are so firmly united
with each other, and with the subjacent corti-
cal  substance,  as not to be separated unless
with the greatest difficulty.  These membranes
are  sometimes thickened throughout, but much
more frequently only in  patches or partially,
where they are  also much more opaque.  Sim-
ple  serous cysts are  occasionally found in the
vascular and cartilaginous bodies in the tubu-
lar structure.
   52. C. Consecutive Nephritis—Symptomatic or
Secondary Nephritis — Asthenic Nephritis.— In-
flammation  principally of the vascular and tubu-
lar structures of the kidneys often arise in the
course of febrile and  exanthematous maladies,
especially those which assume an adynamic or
malignant form, or in which the  blood becomes
more or less contaminated.  In many  of these
cases, it is a state of active congestion of the  or-
gan rather  than  that  of inflammatory  action
which takes place  ; or if it be  the latter, it is
inflammation of the asthenic kind, described in
the  article  Inflammation (y 54,  et seq.), and is
produced by the morbid state of the blood, or
by the superabundance in it of those injurious
elements or materials  which require  elimina-
tion from it, and which are usually excreted by
the kidneys.   M. Rayer  has described these
consecutive diseases of the kidneys under  the
 head of nephritis from morbid poisons; but  the
 affection of these organs  is merely an  accident
 or contingency occasionally occurring in  the
 course of certain  contaminating maladies, or
i rarely only  in the course  of others, and as  fre- 
KIDNEYS—Consecutive Inflammation  of the.                   731
quently takes place during paraplegic diseases
or after  injuries  of  the spine, as during the
progress  of those maladies.
  53. a. During the continuance of adynamic or
typhoid fevers, and particularly when the  ner-
vous  manifestations  are  prostrated  or de-
pressed,  and where the blood  becomes altered
either by the accumulation in it of excremen-
titious matters, or from the insufficient supply
of salutary  elements, congestion, or asthenic
inflammation,  not infrequently occurs  in the
kidneys.   In these circumstances both  organs
are generally affected.  The pain in the loins
commonly complained of during fevers, and at-
tributed to other  causes than to inflammation,
or to congestion of the kidneys, often misleads
the physician, and, when really proceeding from
the vascular condition of these organs, is not
generally ascribed to it.  In  other  cases the
sensibility is so much impaired before this af-
fection supervenes, that the state of the urine
itself, and the phenomena attending its  evacu-
ation, are the chief indications of its  existence.
In these  especially, the suppression of the urine
may be the  first  indication  of it; and then it
may be difficult to determine whether  or not
the suppression be the cause or the consequence
of the inflammation ; for it may be either.  The
circumstance of its so being recognised by the
physician will  generally enable him to infer
correctly the alternative ; if the suppression of
urine has been preceded or attended by sopor
or coma, or by the supine posture and  partial
loss of sensibility, the inflammation of the kid-
neys probably has been consequent upon or ag-
gravated by it; the suppression being the con-
sequence of congestion, which may pass into
asthenic  inflammation ; but if this state of the
urinary function  has  preceded sopor or insen-
sibility, or is independent of this state of the
nervous  manifestations, then is  it the  conse-
quence of inflammation of the kidneys, and not
the cause.  It is extremely rare, however, for
the suppression or the non-secretion  of urine to
precede those states of disease ; more general-
ly the urine  is secreted, its retention or accumu-
lation in  its existing morbid condition being the
cause  of the affection  of the kidneys.   In  all
cases of fever, when the urine is retained  in
the bladder  for some time, or  when this viscus
becomes distended by it, the  supervention  of
nephritis should  be suspected.  Whenever, in
the course of low fevers, the urine is remarka-'
bly scanty, or of a dark-brown colour ; when it
ceases or nearly ceases to be acid, or becomes
alkaline; when  it contains mucus, or blood
globules, or albumen ; and when the  patient
complains of pain or  difficulty in voiding it, or
of pain or of tenderness on firm pressure of the
lumbar region, then disease of the kidneys may
be inferred ; and this  inference will be the more
likely to  be correct, if suppression or retention
of urine follow its alkaline character, and if so-
por and the  more malignant symptoms become
more fully pronounced than previously.
  54. After death from this consecutive disease,
or complication,  both kidneys are found con-
gested or inflamed, but one is often more af-
fected than  the other.  They  are always more
vascular, redder,  and larger than natural.  At
the surface  and in the  vascular structure, nu-
merous red points, intermingled with purulent
specks, are  sometimes observed ; and the sub-
stance of the organ is of a deeper or darker hue
than usual, and softened in parts, or torn with
greater facility.
  55. b.  Consecutive nephritis  often proceeds
from  the absorption of purulent, or  sanious,  or
other morbid matters into the circulation.  When
these matters pass into the blood, and more
especially when  they are imbibed by the veins,
they contaminate  this fluid,  and the kidneys,
being the  most active organs in  eliminating
or excreting them from the system, are espe-
cially exposed  to their  injurious  influence.
Hence asthenic  nephritis  often occurs  in the
course of  phlebitis, especially  of uterine and
traumatic phlebitis, of the more  acute forms  of
tubercular consumption, of diffusive inflammations
of the cellular substance, and of diffusive abscess-
es, and after the rapid absorption of purulent
matter from the more chronic  abscesses, espe-
cially from abscesses of the liver.  In these cases,
various  changes in the urine  have been ob-
served.   It has  been generally alkaline, often
puriform, or muco-puriform, thick, scanty, and
ultimately  suppressed;  a  morbid state of the
perspiration, adynamic fever, sopor, and coma,
with other typhoid and malignant  symptoms,
appearing towards the close  of life.  In some
cases, a large quantity of pus,  with some mu-
cus, is voided in the urine, shortly before the
affection of the  kidneys supervenes ; but as it
becomes fully developed,  so  pain in the loins,
scanty, painful, and frequent micturition, with
the other symptoms of nephritis, are observed,
and precede the  sopor and other typhoid symp-
toms, which are the consequence chiefly of the
partial or total suppression of urine caused  by
the consecutive nephritis.   On dissection the
kidneys generally are found containing, in  their
vascular and tubular structure, small  collec-
tions of pus; the  structure  immediately sur-
rounding  these  being  softened, of a dark  or
brownish  hue, or  paler, especially  in patches,
and  infiltrated  with purulent matter.   Occa-
sionally the tubular structure seems filled with
pus, and, in rarer instances, the renal veins
have  been found inflamed.
  56. d.  Nephritis is  often consequent upon  the
eruptive fevers, more particularly upon  scarlati-
na and smallpox.   Its connexion with scarlatina
is of two kinds:  1st. It may appear in the course
of this fever; and, 2d.  It may not take place
until  the  fever  has subsided, or  until the ad-
vanced progress of convalescence from it.—(a)
When it occurs in the course  of scarlatina, it
generally  assumes very  nearly the same fea-
tures as have been noticed in  connexion with
typhoid fevers (§  7), and is extremely acute, the
urine being either suppressed or very  scanty,
dark-coloured, bloody, or  abounding in blood-
globules, albuminous, and passed frequently, in
drops merely, or  in very small  quantity and
with much pain. These attacks of nephritis are
either consequent  upon a premature disappear-
ance  of the  eruption, or on an  imperfectly de-
veloped state of it; or it complicates the more
malignant  states of scarlatina, and causes  its
rapid termination in coma,  &c.—(b)  Where
nephritis  appears  during convalescence  from
scarlet fever, it  is  more frequently of that par-
ticular kind  which has  been called albuminous
nephritis,  or granular degeneration of the kid-
neys, and which I have viewed, since it was
first described by Dr. Bright, as a  form of  in 
732               KIDNEYS—Inflammation

flammation of these organs; and as such it has
also been  recently considered by  M. Rayer,
When this state of disease is discussed, then its
connexion with scarlatina will be fully noticed.
  57. (c) Asthenic nephritis also  occurs during
smallpox, particularly its confluent  and malig-
nant forms.  In these cases the urine is very
scanty, alkaline, muco-puriform, or bloody, and
sometimes nearly black;  or  it is altogether
suppressed.   When this complication  of small-
pox takes place, all the characters of the dis-
ease assume  an aggravated or more malignant
character, coma and other typhoid symptoms
supervening.   After death the kidneys are found
congested, ecchymosed, partially softened, of a
dark  hue,  and,  in  rare instances, infiltrated
with purulent matter.
  58. e. Nephritis is often  consecutive  of para-
plegia ; and the influence of this  state of palsy
in causing it  is remarkable, whether the para-
plegia proceed from  injuries or from  diseases
of the spine  or spinal chord.  Nephritis may
also be consequent upon coma, especially in low
fevers, as  above mentioned ; while  in these
maladies, it more commonly produces or aggra-
vates this and other  adynamic symptoms than
is supposed.  When nephritis appears in these
cases, it usually proceeds from retention of
urine, and  the changes  caused  by this reten-
tion ; for it rarely takes place when accumula-
tions of urine are prevented.  Probably, how-
ever, the loss of that portion of nervous power
supplied  to the urinary organs by the spinal
chord has some influence in predisposing to in-
flammation of the kidneys ; and in imparting
an asthenic character to the disease, which, in
these circumstances, is  attended  not only by
retention of  the secretion, but also by a very
alkaline, offensive, or ammoniacal state of it,
indicating the existence of disease of the blad-
der.  Indeed, the alkaline, or ammoniacal, or
offensive odour of the urine in these cases, ari-
ses from the  partial  decomposition of the mu-
cous and other animal matters in  it, while the
urine is retained in the pelvis of the kidney and
in the bladder.  In these  cases the structural
changes in the kidneys are nearly  the same as
are met with after other consecutive inflamma-
tions of these organs, as already described.
  59. /. Nephritis is often consecutive of prolong-
ed  disease seated in the urinary bladder, or in
the  prostate  gland, or urethra.  The frequent
and continued irritation of the urinary bladder
from inflammatory action of its  mucous mem-
branes or of  its mucous follicles, may occasion
congestion or inflammatory action of the kid-
neys, owing  to the intimate connexion depend-
ing  on  function, and nervous communication.
Disease of the prostate gland, when of long du-
ration, or when it interrupts the discharge of
urine, is also  apt to be followed by inflammation
of the kidneys, either with  or without  calculous
formations or gravel, these latter more frequent-
ly occurring in the gouty diathesis in connexion
with the prostatic disease.  The pressure,  also,
of stone in the bladder, by the irritation it oc-
casions in this viscus, and in the neck of the
organ and prostate, in connexion  with the in-
terruptions it produces to the free discharge of
urine, often  gives rise  to  inflammation of the
substance, as well as of the pelvis of the kid-
ney.  In some of these diseases, the morbid
action seems to extend from the bladder along
OF THE—CoN8EQUENCE9 OF.

 the ureters to the kidney, as shown by the in-
 flammatory action and  its  consequences ob-
 served in one or both these ducts.   Strictures
 of the urethra, more especially where they pro-
 duce  retention  of urine, are not infrequently
 followed by acute or chronic nephritis.  As re-
 spects all circumstances,  in which the disease
 appears consecutively of disorder or structural
 change of some  other  portion of the urinary
 passages, it should be recollected that it is oft-
 en  chronic, sub-acute,  slow, and insidious in
 its progress ; that it requires close and careful
 examination of the  physiological symptoms,
 and of the appearances and states of the urine,
 to detect  it; and that its  progress, as well as
 its accession, is often masked by the symptoms
 referred to the bladder, urethra, and perinaeum,
 where they are most severely felt, as well as
 by  those  attending  the  excretion of urine.
 When nephritis is thus superinduced, its  indi-
 cations are to  be found chiefly  in connexion
 with  the seats of primary disorder, with the
 powers of retaining the urine, with the frequen-
 cy of passing it and  the quantity passed, with
 appearances and characters, and with its par-
 tial or total suppression or retention.
  60. iii.  Of the influence of Inflammation
 of  the Substance of the Kidneys in produ-
 cing  other Maladies.—This subject was im-
 perfectly  noticed, until Dr. Bright directed at-
 tention to it in his researches in the granular
 degeneration of these  organs.  The consequen-
 ces which arise from this particular state of
 disease will be stated hereafter. I shall confine
 myself chiefly at this place to the consideration
 of those which more immediately proceed from
 the states of nephritis already brought under
 consideration.   It must be manifest that, where
 inflammation attacks those structures which
 are more especially concerned in the perform-
 ance of  the functions of the organ, the dis-
 charge of these functions must be remarkably
 disturbed.  It  is well known  that, like other
 glands, when  the kidneys  become  inflamed,
 they  experience a remarkable impairment of
 their functions.  The membranes which sur-
 round them and support them have the effect
 of  compressing  them,  especially when  their
 vessels are injected, congested,  and inflamed,
 thereby  increasing their  incapability,  arising
 from the inflammatory  state,  of performing
 their usual offices.   The deposition, also, of
 coagulable lymph, either in considerable patch-
 es, or as  an infiltration of the textures, farther
 increases the pressure on the vascular and tu-
 bular structures, and otherwise interrupts the
 eliminating action of these organs.  Whether,
 however, impairment, or interruption, or sup-
 pression  of the functions of the kidneys be thus
 or otherwise  produced, there can be no doubt
 of either the one  or the other of these being
 the consequence of developed inflammation of
 the proper structures of these organs.  Owing
 to this change—to this interruption—the fluid
 and saline matters requiring elimination from
 the blood accumulate in it, and  the vascular
 system experiences  a  state of excrementitial
 plethora, giving rise to impairment of vital en-
 ergy, to  congestions of other viscera, and to
 effusions into shut cavities  and  cellular parts.
 During the earlier stages of this vascular dis-
 order, and before the blood becomes so impure
 and  so watery as  to overpower  the tone and 
KIDNEYS—Inflammation of
the—Complications of.                  733
 reactive energy of the vessels, and  hence to
 occasion congestion and loss of function of vi-
 tal organs, a vicarious elimination of a portion
 of the injurious materials accumulated in  the
 blood takes place by means of the skin and di-
 gestive mucous surface, and in the form  of
 aqueous vapour from the surface of the bronchi
 and air cells. At last, however, if the functions
 of the inflamed kidneys  are  not restored,  the
 brain becomes  congested or oppressed, and se-
 rum is effused in the ventricles and  between the
 membranes.  Hence the sopor and coma which
 occur in the last state of unfavourable cases of
 nephritis,  and which supervene the more rap-
 idly the more abundant and  the more impure
 the blood has been previously to the occurrence
 of nephritis, as in the consecutive forms of the
 disease just considered.
   61. Even when a vicarious action is exerted
 by the skin and mucous surfaces during inflam-
 mation of the kidneys, yet these are incapable
 of evacuating several or all of the  elements or
 materials  requiring excretion from the blood,
 and of combining them into those forms which
 facilitate their  discharge.  The blood,  there-
 fore,  must become, not merely loaded with
 these materials, but farther changed, and even
 rendered morbid or noxious by the influence
 they exert upon the  hapmatozine  or  principal
 constituents of this fluid.   Hence a state of
 actual cachexia, of a most acute and malignant
 nature, particularly in respect of its  conse-
 quences, is developed, the soft solids are ulti-
 mately universally contaminated, and the body
 experiences a rapid dissolution as  soon as life
 departs.  During the progress of  these chan-
 ges in the blood, produced by the accumulation
 in it of aqueous and effcete matters, various lo-
 cal diseases  may appear as consequences  of
 this excrementitial plethora,  and contribute to
 hasten a fatal result, or concur with others in
 producing it;  or these consecutive  maladies
 may subside, if they  be not  severe, upon  the
 removal of the inflammation, and restoration of
 the functions of the kidneys.  Thus, diseases
 of the digestive  organs, particularly of the liver,
 asthenic inflammation of the  lungs, of the brain,
 of the endocardium, and of the veins or arteries,
 and dropsical effusions, may appear as results
 of the action of the impure and morbid blood
 on these organs.  Dropsy, however, unless the
 more acute states of it and sudden effusions of
 serum,  does  not appear as a consequence so
 frequently of the inflammations of the kidney
 already considered, as of the  more chronic and
 peculiar form of disease first described by Dr.
 Bright.
   62.  Various  other  important consequences
 follow nephritis, and arise rather from the inti-
 mate connexion subsisting between the kidneys
 and the parts  consecutively affected, through
 the medium of nervous association and rela-
 tions, continuity of surface, and intimate con-
 sent and connexion of function.   Many other
 diseases of the  urinary and sexual organs pro-
 ceed from  a  primary disorder  of  the kidney,
 more especially when such disorder is connect-
 ed with the formation of gravelly and calculous
 substances, and with inflammatory irritation of
the calices and pelvis of the organ ; but to these
a stricter reference will be made in the sequel.
As to the part performed by slight  or  partial
inflammatory action in the substance of the or-
gan, in giving rise to the formation  of gravel
and calculi in the kidney, it is difficult to decide.
It is not improbable that it may favour these
deposites by obstructing the free passage of the
urine along the tubuli; but there is much more
reason to infer that these deposites take place,
independently of pre-existing inflammatory ac-
tion, from the superabundance in the blood of
the elements  or materials  constituting them;
and that when inflammation does occur, it  is
rather a consequence than a cause of their
formation—that they proceed, in the first place,
from impaired power of the digestive functions,
in connexion  with an excessive supply of the
articles of food abounding in the chief elements
of which they consist, and consecutively of im-
paired action  of the kidneys, probably some-
times in connexion with partial congestions or
inflammations.
  63. iv. Complications of Nephritis.—It  is
obvious, even from what has already been ad-
vanced, that inflammations of the vascular  and
tubular structures of the kidneys will both su-
pervene in  the course of other maladies, being
thus consecutive, and give rise, when it is  pri-
mary, to various important changes in the econ-
omy, both of  a local and of a constitutional
kind.  Owing to these circumstances, nephritis
will often present itself in practice as an asso-
ciated or  complicated  malady—most frequently,
1st. With inflammation of the mucous mem-
brane lining the calices and pelves of the  kid-
neys ; 2d. With gravel or  calculi in the sub-
stance or pelvis of the organ ; 3d. With inflam-
mation of a portion, or of most of the investing
membranes ;  4th.  With disease of the ureters ;
5th. With disease of the bladder and prostate
gland ; 6th. With stone in the urinary bladder ;
7th. With stricture in the  urethra ;  and,  8th.
With any two or  more of these.  As  already
shown, the disease may be farther complicated
with one or other of the diseases, upon which
it occasionally supervenes, or which it some-
times produces  or develops.   It is obvious
that these associations of nephritis cannot re-
ceive a more particular  notice at this place.
To several of them attention will be paid here-
after ; and  others of them are fully treated of
in  the articles Urine, Urinary Bladder,  and
Urinary  Calculi.
  64. v.  Prognosis.—The  prognosis entirely
depends upon the  progress that nephritis  has
made, upon the nature of the predisposing  and
exciting causes, upon  its severity, upon  the age
of the patient, and upon the circumstances of
its being  a primary and uncomplicated malady, or
consecutive  of, or complicated with some other
disease, either of the urinary organs or of some
other viscus.  The simple states of  nephritis,
particularly when occasioned by cold and hu-
midity, or by turpentine or cantharides, gener-
ally yield to judicious treatment; but when the
disease is consequent upon other affections of
the urinary organs,  or upon operations  on  any
of these organs, or when it occurs in  aged  per-
sons, or when it is so severe as to be attended
by suppression of urine, or by incontinence of
it, the prognosis should be unfavourable, or, at
least, be  given with caution  and reservation.
The prognosis ought, also, to be  extremely
unfavourable, when the disease  occurs in the
course of low, adynamic, and exanthematous
fevers, or when it  is  productive of sopor oi 
734
KIDNEYS—Inflammation of the—Treatment.
coma, or wnen any of the more important chan-
ges, either  in the  blood  or in  other  organs,
which it has been shown occasionally to cause,
is unequivocally manifested.  The occurrence
of retention, or of suppression of urine  in aged
persons, who have been the subject of inconti-
nence of it, or of the more  chronic symptoms
of urinary disease,  or the supervention of the
acute attack, upon a slight or chronic state of
the malady,  is always most dangerous.  In
every instance, when the symptoms indicating
the accession or the presence of suppuration,
abscess, or  of any  other  unfavourable conse-
quence of nephritis, are manifested, or even
when the disease has not yielded to a judicious
treatment within the period assigned to the
acute form of the malady;  when the urine be-
comes alkaline, offensive, and purulent,  as well
as scanty, and the perspirations are urinous and
copious, the constitutional symptoms indicating
depression of the powers of life, obscuration or
oppression of the cerebral functions, and con-
tamination of the circulating fluids ; and when
a severe attack of nephritis occurs in  the ad-
vanced progress of disease of some other organ,
or of low or exanthematous fevers, then a most
unfavourable prognosis of the result  should be
given.
  65. When disease, also, of the  bladder super-
venes on a chronic affection of the kidney, ow-
ing to the morbid state of the urine ;  and more
especially if suppuration occur about the neck
of the bladder, in consequence of irritation, in-
flammation, or other lesion of the kidney, a very
dangerous state of disease is present, more par-
ticularly when it occurs in aged  persons, or in
those who have been subject previously to dis-
order of the digestive  or  urinary organs.  In
these cases, the disease of the one organ reacts
upon  the other, and thus  both are aggravated
to a most dangerous extent.
  66. vi. Treatment.—The treatment of neph-
ritis is  subordinate to  the causes,  particular
form, complication,  and state of the disease, to
the progress it has made, and to the age and con-
stitution and previous ailments of the patient.
  67. A. Treatment of primary and simple Neph-
ritis.—(a) When the disease proceeds  from a
concussion,  sudden jerk, contusion,  injury, or
wound,  early and even repeated blood-letting
ought to be then especially prescribed,  and the
patient should be restricted to an antiphlogistic
regimen ; diluents and demulcents being allowed
in small or moderate quantity.   Of these, lin-
seed tea, barley water, the mucilages, the usual
emulsions, &c, are the most appropriate.  An-
odyne or opiate fomentations or poultices  may be
placed upon  the  loins; and the patient may
have recourse to a tepid, emollient,  or  slightly
warm bath,  on the  following day.  If the pain
and other symptoms continue notwithstanding
this treatment,  or if they  be only partially  re-
moved, or if symptomatic  fever  is still  consid-
erable, more blood should  be taken away ; and
it may be taken by  cupping or by leeches, the
former being the preferable mode; but the
quantity should be prescribed without reserve,
for too copious  vascular depletion is less inju-
rious  in this disease than in most others, and
much less so than  a too  sparing recourse to
this measure.  The smallness or contraction
of the pulse should not deter from  copious blood-
letting, especially if the local and symptomatic
pains are severe, and if retching or vomiting
is frequent.   In these cases, the pulse will be-
come fuller and more developed by depletion.
  68. (b) M.  Rayer remarks,  that,  if the in-
flammation is caused by a wound of the kid-
neys, and the fever has  been  subdued, and the
pain is inconsiderable, and if the  discharge of
some pus in the urine indicate the supervention
of suppuration, blood-letting should be abstain-
ed from, and a  severe  regimen  and  regular
dressings of the wound prescribed.  If the sup-
puration is prolonged, the diet ought to be more
generous, as  a certain degree of power  is fa-
vourable to recovery ; while too great severity
of regimen may retard recovery, and is only
applicable when the injury or  wound has ex-
tended to the peritoneum, or has complicated
the nephritis  with enteritis or peritonitis.
  69. (c) When nephritis is caused by canthar-
ides, by turpentine, by iodine, or  by acrid diu-
retics, in too large doses, or too  long employed,
and the disease is slight, a moderate blood-let-
ting, demulcents, and tepid baths  soon remove
the disease.  If the symptoms, however, per-
sist, these means should be carried still farther,
according to  the circumstances  of  the  case.
Camphor has been  recommended when the dis-
ease  has  been caused by cantharides; but it
should not supersede blood-letting.   It  is an
excellent adjuvant of other means, particularly
when conjoined with oleaginous, mucilaginous,
or demulcent substances, and given in small or
moderate doses.
  70. (d) Nephritis, caused chiefly by cold and
humidity, in strong, young, and plethoric per-
sons, requires an  active recourse  to  general
and  local blood-letting,  and the antiphlogistic
and  emollient means above  advised.   If the
symptoms  are merely abated,  cupping, or a
repetition of  it, over the loins, must be prescri-
bed, and demulcents taken by  the mouth and
administered in enemata.  For nephritis from
this  cause, tepid or gently warm  baths, and
sudorifics, conjoined with emulsions and ano-
dynes, are especially  indicated.   In this, as
well as in other states of the disease, the bow-
els should be kept in an open  state;  and for
this  purpose, castor oil, or sweet oil, or both,
may be prescribed  and administered  in demul-
cent vehicles.  In  some cases, after the dis-
ease  has been even for some days  apparently
subdued, chills or  rigours return, followed by
pain in the loins,  febrile reaction, and  other
symptoms  of a recurrence  of inflammation.
When this is observed, a large  blood-letting
ought to be  prescribed, unless  the  patient be
far advanced  in life ; and, in this case, cupping
on the loins,  and the abstraction  of eight, ten,
or twelve ounces of blood may be sufficient.
When the symptoms lead to the inference that
the investing  membranes are  chiefly  affected,
then the depletions  should be copious, and cal-
omel, with antimonials, or with other  diapho-
retics, ought  to be freely prescribed.
  71. (e) Sub-acute nephritis requires a similar
treatment to  that above advised ;  but vascular
depletions need not, in  general, be  carried so
far as in the  acute form.  One large cupping
over the loins may be  sufficient; but it will
often be necessary to repeat it; and, although
this state of nephritis may not be so severe, it
may be more obstinate than that  already con-
sidered ;  and  when both kidneys  are affected, 
KIDNEYS—Inflammation of the—Treatment.
735
the treatment should be more energetic.   The
other means just mentioned are also appropri-
ate in this state of the disease ; or the diet and
regimen should not be materially different from
that directed for the acute form.  The use of
animal food, and of fermented and spirituous
liquors, ought to be especially avoided.
  72. (/) Chronic nephritis is often removed
with much more difficulty than the acute at-
tack ; for, as it often has proceeded far before
it has come under treatment, and is frequently
caused and perpetuated by calculi in the kid-
ney, the  most judicious means may produce
only temporary benefit.  It is generally render-
ed more  obstinate by the  continuance of the
habits and  modes of living usually pursued by
the patient during the treatment, notwithstand-
ing the injunctions of the physician to the con-
trary.  Generally one or two cuppings on the
loins, with  the antiphlogistic regimen, aided by
a strict avoidance of animal  food and of exci-
ting beverages, will remove the disease, or
very remarkably ameliorate it, even when cal-
culi  have produced  it; but  farther  measures
are often necessary, particularly when it pro-
ceeds from this cause.   Having, in such cases,
carried vascular depletions and other antiphlo-
gistic means as far as may seem prudent, some
permanent external derivative will be requisite,
in order to supersede the irritation still exist-
ing in the kidneys.  Issues or setons in the
loins, or  in the insides of the thighs, kept free-
ly discharging for a considerable time, and the
internal use of the preparations of the diosma,
or of the uva ursi, with  demulcents, with alka-
lies, or with acids, especially the muriatic or
nitro-muriatic,  according  to  the state of the
urine, which ought always to be carefully and
even chemically examined, are often the most
beneficial means which can then be advised,
particularly if they be aided  by a suitable diet
and regimen.
   73. If  either the sub-acute or chronic states of
the disease suddenly assume an acute or hyper-
acute form (y 14-17) — a  circumstance by no
means uncommon—the means advised for acute
nephritis (v 67-70) ought  to  be most promptly
and energetically employed.
   74. B. The treatment  of the  modified and con-
secutive nephritis (v 46, et  seq.) necessarily va-
ries with the diathesis of the patient, and  with
the disorders or maladies occasioning it.—a.
Nephritis in the gouty diathesis (y 47) is gener-
ally removed by cupping on the loins, and ab-
stracting blood,  according to  the age, strength,
and habit of body of the patient; by derivatives
applied to  the lower extremities, and by dilu-
ents and demulcents containing some one of
the alkalies or alkaline earths, and anodynes.
Magnesia or soda, with  colchicum, or  these
with cathartics or purgatives, a vegetable or
bland diet, attention to the digestive functions,
and avoidance of heating and exciting ingesta,
are also of great service.
  75. In  robust and plethoric persons, general
blood-letting  is  often  necessary at the com-
mencement of the treatment; and when the
inflammatory action  is perpetuated by the irri-
tation of calculi or of gravelly matter, local de-
pletion should be repeated, and  demulcents,
combined as above, should be assiduously em-
ployed.   When the disease passes into a chron-
ic form, the treatment recommended for chronic
nephritis (y 72) ought to be prescribed, and the
infusion of Pareira Brava, or of the diosma cre-
nata [or the uva ursi], aided by the alkaline min-
eral waters and  external  rubefacients, freely
employed.  When gravelly or crystallized sub-
stances are voided, or when their presence in
the tubuli uriniferi is  inferred, these remedies
and the means already advised should be per-
sisted in  for a considerable time.  This form
of nephritis is not readily removed when it as-
sumes a chronic form in  old, gouty subjects, or
when it has been neglected in an early stage,
or in previous  attacks.  In these cases more
especially, much  attention is requisite to diet
and regimen, and to the state of the evacua-
tions.  The biliary secretions should be promo-
ted,  and  the  bowels  kept  freely open by sto-
machic purgatives and moderate doses of the
milder preparations of colchicum.  When the
stomach is irritable and flatulent, or when nau-
sea and vomiting occurs, creasote, with  small
doses of opium, and with magnesia or some al-
kaline  preparation, in demulcent and aromatic
mixtures,  is often extremely serviceable.
  76. b. Rheumatic nephritis (y 50) has been
shown above  to be so obscure, in many cases,
as to render  it difficult to determine how fai
the kidneys are really affected.   When, how-
ever, the  symptoms particularized above  are
present, there can be little doubt of those or-
gans being acutely, or sub-acutely, or chronically
inflamed ;  and still less of the propriety of hav-
ing recourse to cupping on the loins, to demul-
cents and  diluents, to the infusion of diosma,
or of Pareira, or to the decoctions of marsh
mallows, of guaiacum, of senega, &c, with al-
kalies, with colchicum, &c. When the attack
is severe, and the patient is strong or plethoric,
general blood-letting  should precede  the  cup-
ping on the loins, and external derivatives, par-
ticularly to parts previously the seat  of rheu-
matism, ought to be applied.  The turpentine
embrocation may also be prescribed to the loins,
and morbid secretions and faecal accumulations
duly evacuated.
   77. If any  dread of the occurrence of endo-
carditis or pericarditis be reasonably entertained,
camphor may be given with mercurials and opi-
um, or the decoction of senega, or of guaiacum,
[or colchicum], may be taken with alkalies, an-
odynes, &c ,  and external derivation by means
of open blisters, issues, or setons, or by rubefa-
cients, assiduously employed.
   78. c. For  secondary or  consecutive  nephritis
(v 52), the treatment must depend chiefly upon
the states of vital power, of vascular action,
and of the circulating fluids.  In proportion as
the vital energy is depressed or sunk, and the
blood contaminated, and as the  disease  con-
sequently  assumes an asthenic  character, so
should vascular depletion, even  locally, be Te-
sorted to  with caution, or  be altogether with-
held.   In  these cases, the capillary circulation
of the kidneys is interrupted, the vessels are
congested and incapable  of reacting upon their
contents,  and the secreting function is impeded
or altogether suppressed.  In these circumstan-
ces, although local depletion, especially cupping
on the loins, may partially unload the weaken-
ed and congested vessels, yet it cannot restore
the nervous or vital power of the kidneys so as
to enable them to perform their functions.   We
often find, in the more severe of these consec- 
736                    KIDNEYS—Cachectic Inflammation- or the.
utive states of nephritis, the secretion of urine
altogether suppressed, and both organs affected,
particularly when occurring in the  course of
continued or eruptive fevers, or after the ab-
sorption of morbid secretions into the blood, or
after injuries of the spine.   When this  is the
case, but little  benefit results from cupping on
the loins or from other modes of vascular de-
pletion, unless  means be used at the same time
to rouse the action of these organs.  The choice
and  application of these means are, however,
among  the  most difficult things in practical
medicine.  Indeed, the practice, in  these cir-
cumstances, can only be experimental, endeav-
ouring,  however, to suit the remedies to the
pathological states inferred to exist at the time
of prescribing them, and to  the sensible quali-
ties of the urine.  In most  of  these cases, es-
pecially  when  the  disease  is  consecutive of
paraplegia (y 58) or coma, the urine is more or
less  alkaline, and is probably secreted in this
state, although the partial  decomposition or
change  of the  mucus secreted by the urinary
mucous  passages may farther increase it.  The
mineral acids, particularly the hydrochloric, con-
joined with hydrochloric ether, and given in ton-
ic, antiseptic, and restorative vehicles, seem to
be the most appropriate medicines to these ca-
ses.   Camphor may also be tried in conjunction
with nitre or the chlorate of potash; and em-
brocations containing this  substance  and the
spirits of turpentine may be applied to the loins ;
or, this latter may also be given internally, in
small doses, with the view of exciting the ner-
vous energy of the kidneys and the action of
the congested  vessels.  When,  however, the
patient  is plethoric  or robust, and vascular ac-
tion  and tone  are not  remarkably reduced, the
abstraction of blood from the loins by cupping
should precede the use of the above remedies,
and  should be  carried as far as the states of
vital power and of the circulation may permit.
When vascular depletion cannot be farther pre-
scribed, dry cupping on the loins may still be
had recourse to.
  79. For the form of asthenic nephritis which
sometimes occurs in the course of low fevers,
or in consequence of the absorption of morbid
secretions into the blood (y 53-57), the  reme-
dies  now recommended may be tried, particu-
larly  dry cupping,  camphor, the chlorate of
potash,  the chlorides, hydrochloric acid  and
ether,  nitre and the  spirits of nitric  ether,
stimulant and  rubefacient  embrocations  and
blisters  on the  loins, or other derivatives ; but
little dependance can be placed on  medicines
when this state of the disease is attended by a
total suppression  of the urine, as observed in
the worst cases of it, and more especially if
coma or convulsions have taken place.
II. Cachectic Nephritis.—Syn. Granular dis-
  ease of the kidneys ; Renal disease, accompa-
  nied with secretion of albuminous urine, Bright.
  Diseased state of the kidneys connected with al-
  buminous urine, J. Gregory.   Granular degen-
  eration of the  kidneys, Christison.  Albuminu-
  ria. Martin-Solon, Willis.  Morbus Brightii,
  Maladie de Bright, Auct. var.  Nephrite albu-
  mincuse, Rayer.  Nephritis cachectica,  N. so-
  ciata,  Associated Nephritis, Nephritis from con-
  stitutional vice,  Nephritis from a morbid state
  of the blood,  Inflammation  of the Malpighian
  corpuscles, Author.
  80. Defin.— Uneasiness or pain  in the loinf,
pallid or cachectic appearance of the  countenance,
disorder of the digestive functions, more frequent
calls to void urine than natural, this fluid contain-
ing albumen, and  being of less  specific gravity
than usual, owing to a diminution of its salts and
of urea, dropsy or some  visceral disease appearing
in connexion with the morbid state of the urine.
  81. Pathol. Charact.—A morbid state of the
blood, characterized chiefly by the presence of urea
and deficiency of albumen,  and of hamalosine, in
connexion  with lesion  of the circulation, minute
glandular bodies, and [altered] structure of the kid-
neys, with various organic changes in other viscera,
and generally with serous effusion into the cellular
tissue and shut cavities.
  82. A general idea may be formed from the
above definition  of the view I intend to take of
this  disease, which has attracted much  atten-
tion  since it was discovered by Dr. Bright, yet
not more  attention than  its real  importance
deserves.   Although  medical writers of  high
authority have fully investigated this malady,
still certain topics connected with  both its pa-
thology and its treatment, the particular tissue
of the kidneys primarily affected in it, require
farther  elucidation.  Indeed, the  connexions
subsisting between it and morbid states  of the
blood, and between it  and many visceral mala-
dies, still require a full exposition, and to these
topics farther notice will be directed in the se-
quel.
  83. i. Description.—Cachectic nephritis as-
sumes two forms, the Acute  and the Chronic,
the one gradually passing into the  other, al-
though  sometimes sufficiently distinct,  in re-
spect of the course of individual cases, to war-
rant this distinction,  which has been made by
both Dr. Christison and M. Rayer.  The acute
form is frequently febrile,  or attended by mark-
ed vascular reaction ;  the chronic is non-febrile,
and  although the  pulse may be accelerated, it
is usually compressible or soft, or even small
and weak.  The symptoms may be acute at the
commencement, but  pass into  those  of the
chronic in  the course of the disease ; and after
having thus assumed the chronic state, exacer-
bations of febrile states may occasionally  take
place ; but in  either  form,  especially in the
chronic, it  may  present a variety of aspects—
numerous modifications—according to the pre-
vious circumstances, disorders, or predisposi-
tion of the patient, and to the various affections
either associated with  it at its commencement,
or appearing in  its progress.
  84. A. Symptoms of Acute Cachectic Nephritis.
—This form of the disease is frequent among
children after scarlatina, especially during cer-
tain  epidemics,  and also in adults, after expo-
sure  to cold  and  humidity, and  to sudden
changes of temperature ; but is much less com-
mon than the chronic.  It often is ushered in
by shivering or chills, followed  by the usual
symptoms  of fever, particularly a  hard  pulse,
heat and dryness of the skin, and restlessness.
A dull aching, or pain, or a sense of uneasiness
or of weight, or of constriction, is always felt
in the loins, sometimes more in one side than
in the other ; but M. Rayer believes that these
feelings are never so severe as in simple neph-
ritis ; nor are they attended  by retraction of
the testes, nor by pains darting in the direction
of the ureters.   Dr. Christison, however, has 
KIDNEYS—Cachectic  Inflammation of the.                    737
 Observed, in some cases, pain extending down
 the inside of the thighs and to the genitals.  At
 the same time  with the occurrence of these
 symptoms,  the urine quickly becomes scanty,
 occasionally nearly suppressed, highly albumin-
 ous, and occasionally even bloody, or of a red-
 dish colour, resembling the  washings of fresh
 meat.   It is always acid ; and its specific gravi-
 ty is often above, seldom below, that of healthy
 urine, the proportion of urea and of the saline
 ingredient  not being  materially altered,  ac-
 cording to M. Rayer ; but such is the case only
 at the commencement of the disease.  When
 allowed to rest, the urine deposites a filament-
 ous substance, apparently of a fibrinous nature.
 The odour of the  urine is feebly urinous ;  but
 at the end  of twenty-four hours it resembles
 that of beef-soup.  When the albuminous and
 sanguinolent urine is first voided, it may be seen
 by aid of the microscope, suspending a number
 of blood-globules,  also  the globules of mucus
 and minute  lamellae of epithelium ;  all which,
 with the fibrinous  substance, forms  a sediment
 when it  is left some time at rest.   There is
 frequently distress, or even pain, in  voiding the
 urine, occasioned  by sympathetic irritation of
 the bladder and urethra, increased by the diffi-
 cult  passage, in some cases,  of the fibrinous
 substance along the urethra ; and the calls  to
 pass it are more  frequent  than usual.   The
 quantity of urine is much less than that of flu-
 ids taken. There is always more or less fever.
 The tongue  is furred or loaded, and  the bowels
 confined.  Nausea and  vomiting occur, some-
 times with  pain across  the epigastrium,  and
 cough is occasionally present.
  85.  Very  soon  after these symptoms  have
 been, developed—generally within twenty-four
 or forty-eight hours—signs of dropsical effusion
 appear, and proceed with great rapidity, affect-
 ing first  the eyelids and whole  face, or the
 limbs, and extending to the other parts of the
 body.   The  skin is hot, and does not pit, un-
 less after very firm pressure.   If blood be drawn
 at this time, it is always buffy, sometimes very
 remarkably so, and the serum  is occasionally
 milky.   At the commencement of the disease
 the serum coagulates nearly as in health, but
 in a very few days the coagulum furnished by
 the serum is much less firm, and this fluid be-
 comes  specifically  lighter.  The greater  the
 quantity of albumen in the urine, the lower is
 the specific gravity of the serum ; and as the
 albumen  becomes  less abundant in the urine,
 so the density of  the  serum  increases.   Ac-
 cording to the researches of Dr. Christison,
 urea may be detected at an  early stage of the
 disease in the blood.
  86. The terminations of the acute form of the
 malady are,  1st. In restoration to health ;  2d.
 In the chronic state; 3d. In  coma, or convul-
 sions, or  both ; 4th. In pleurisy, or  in inflam-
 mation of some  other  serous surface ; and in
 death, usually preceded by one or other of these
 more acute affections.—a. Recovery often takes
 place rapidly under judicious treatment, espe-
 cially after scarlatina or during pregnancy ; and
 is commonly indicated by profuse and general
 perspiration,  by a  copious discharge  of urine,
 by a diminution of the albumen, and increase
of the urea and salts in the urine, and by a sub-
sidence of the febrile  symptoms and of  the
aDasarcous  swellings.—b. The chronic state is
    II.                93
 generally shown by the subsidence of the febrile
 and acute symptoms, and often of the anasarca;
 the urine, however, still  continuing albumin-
 ous.—c. The occurrence of coma, or convulsions,
 or of both, is generally a fatal indication.—d.
 The appearance of pleurisy, pneumonia, or peri-
 carditis, or of any other visceral inflammation,
 or of effusions  into shut cavities, is always a
 dangerous circumstance, and even in their mild-
 er states renders recovery protracted, or even
 doubtful, especially if  the urine still continue
 albuminous.
  87.  B. Symptoms of Chronic Cachectic Nephri-
 tis.—This  form of the disease  is sometimes
 consequent upon the acute, but  it is incompa-
 rably more frequent without any febrile or ac-
 tive stage—latent and obscure in its origin ; and
 it is a  very much more common malady than
 the acute.  It generally occurs in persons of an
 original or an acquired constitutional taint, or
 in those whose vital powers have been depress-
 ed or exhausted, and their assimilative  func-
 tions and circulating fluids deteriorated by pre-
 vious  disorder  (y 141), or  by exhausting, de-
 pressing, or other  injurious  circumstances, as
 exposure to cold and humidity, insufficient or
 unwholesome nourishment,  &c.  For a long
 period, there  is no disorder sufficiently severe
 to withdraw the patient from his usual occupa-
 tions, or even to attract particular notice, un-
til gradually increasing debility, or an unhealthy
or pallid countenance, alarms him or his friends;
and then, if the medical adviser is alive to the
 nature  and frequency of the malady,  the urine
is found specifically lighter, and more  or less al-
buminous, its solid ingredients being deficient.
Not infrequently,  almost  contemporaneously
 with, or rapidly consequent upon debility, pal-
lor of countenance, or  still more manifest ca-
chexia,  some serious visceral disorder or dis-
ease is developed, and proceeds pari passu with,
or even outstrips  the renal malady and the
symptoms by which it is indicated.  Dr. Chris-
tison  remarks, that, in cases apparently the
most obscure in their origin, the urine has been
very long scanty,  or, on the other  hand, too
abundant, or  occasionally of a cherry-red col-
our from a little blood, or that it was passed
 frequently, and  with difficulty or with pain, or
that there were frequent gnawing pains in the
loins or flanks, extending at times to the thighs
or groins.  He  farther remarks, that  no symp-
 tom is so invariable, or indicates so truly the
commencement of the disease, as the patient
 being  regularly awakened once  or  oftener in
 the night by the call to pass water.
  88.  The disease may thus advance in obscu-
 rity, particularly in scrofulous persons, for
 months, or even for years, until either the state
 of the  urine  attracts attention, or some inci-
 dental cause aggravates the disease, or renders
 it more acute, or develops a partial or general
 anasarca, or some associated or secondary mal-
 ady.  It is, however, generally indicated by re-
 duction of strength, slight emaciation, by pallor
 or sallowncss of the countenance, by a dry state
 of the skin, and want of perspiration during ex-
 ercise, a frequent tendency to drowsiness, va-
 rious dyspeptic symptoms, or  a  weakness of
 digestion, and  occasionally  sickness, or  even
 vomiting in the morning or when first awaken-
 ing from sleep, slight thirst, and the other symp-
 toms  above mentioned (v  87).  The counte- 
738                    KIDNEYS—Cachectic Inflammation of tub.
nance  presents a uniform paleness, or a  pale
dinginess, which  becomes more  marked, and
attended by manifest anemia,  as the  malady
advances.  The altered state of the urine and
of the blood, the dropsical effusion, and the un-
healthy complexion, are the most invariable
and  characteristic symptoms,  and require  a
more particular notice.
  89. a.  The urine, when first passed, is gener-
ally slightly acid, but in a few cases it is neu-
tral, or even alkaline.   It is always pale in the
advanced or chronic stage, sometimes more or
less  opaque, or like whey, suspending small,
whitish flocculi.  Its  odour is  faint, and very
different  from that of the  healthy secretion ;
its specific gravity  is generally below, some-
times very considerably below, that of the urine
in health. The want of transparency is occa-
sionally owing to fatty matter  held in suspen-
sion, which may be removed by means of sul-
phuric  ether, when the urine  becomes clear.
Examined by the microscope, albuminous urine
generally exhibits numerous small, thin lamellae
of a whitish colour, often blended with mucous
matter, which is  either amorphous or in the
form of  globules.   A  vessel  containing  this
urine usually presents on its  sides or on the
surface of the fluid a number of bubbles ;  and
when air is blown through a tube into it, a mul-
titude of large bubbles are formed.  The appli-
cation of heat  forms in it an albuminous coag-
uluni, or small coagula, which are remarkable
in proportion to the quantity of albumen.   Ni-
tric and  other strong  acids, and a solution of
the bichloride of mercury, produce a similar ef-
fect.  The yellow cyanuret of potassium and
iron also coagulates albuminous urine, if it has
been previously acidulated with acetic acid.  A
sediment sometimes  forms after it has been
passed, which is  commonly lithic acid or the
lithate of ammonia, and which is redissolved at
a gentle  heat, lower than what is required for
the coagulation of albumen.  Besides contain-
ing albumen, the urine deviates from the healthy
standard in containing an unusually small quan-
tity of its solid ingredients.   This urine is also
more prone than healthy urine to decay, a deci-
dedly ammoniacal odour being occasionally soon
developed after it has been discharged.
  90. Dr. Christison  remarks, that this urine
at the boiling point sometimes forms a gelatin-
ous mass ; more frequently it becomes a soft
pulp like thin custard ; often, too, when the
quantity of albumen is less, there are distinct
flakes  in a  separable  fluid.  The earlier the
stage of the disease, the more is the urine load-
ed with these flakes, and the more does it form
of a pulpy or gelatinous mass.  Nitric acid acts
in like  manner; but it separates  the albumen
always in the form of flakes or pulp.  It is ad-
visable to use the tests both of heat and of ni-
tric acid  ; for, if the urine be ammoniacal, heat
may fail of coagulating the albumen, although
the proportion of it be considerable ; and heat
alone may occasion a flaky precipitate where
there is no albumen, owing to the superabun-
dance and consequent separation of earthy phos-
phates—a deposition which nitric acid will both
prevent and remove.   Also, nitric  acid alone
may occasion a flaky precipitate of lithic  acid,
which, however, is redissolved by an elevation
of temperature, while albumen remains insolu-
ble.  To avoid all sources  of error, the urine
 should be  tested before it decays or becomes
 ammoniacal.  In the  early  stage of chronic
 cachectic nephritis, the chief characters  of the
 urine are, a moderate  reduction of its specific
 gravity, a strong, albuminous impregnation, and
 a material diminution of the daily discharge of
 solid ingredients—of the  urea and saline sub-
 stances.
   91. As the disease proceeds, the albumen
 often is diminished in the urine, or even sud-
 denly and for a time disappears.  When  it has
 made considerable  progress,  the quantity of
 urine is often but little reduced; frequently it
 exceeds  rather than falls short of the healthy
 ratio ;  and in some  cases, the  amount has con-
 tinued for weeks as much as double or  treble
 that of health.  But the  quantity may  be di-
 minished either when  the exciting causes de-
 velop an acute state  of the disease in  the
 course of the chronic, or when coma, stupor,
 or  intercurrent  inflammations take place, or
 when the granular degeneration has reached a
 certain  or great extent.   As disorganization
 advances, the density  of the urine  sinks from
 about 1021 to 1026, which it  usually presents
 at an early stage, to 1016, 1014, or 1012; and
 when it has proceeded far, the  density is gener-
 ally as low as 1010 to 1007, even although the
 quantity  be rather under than  over the natural
 standard. The lowest density which Dr. Chris-
 tison has ever noted, where the quantity was
 not in excess, was  1004.  A low density, he
 remarks, is an essential character of the  urine
 in  the middle  and  final  stages, whether the
 quantity be great or  small;  and the density
 goes on  diminishing as the disease advances.
 When disorganization  of  the  kidneys has pro-
 ceeded very  far, the albumen very frequently,
 if not generally, disappears altogether, and may
 not reappear unless acute symptoms occur. In
 this stage the chief characters of the urine are,
 a great reduction  of its  specific gravity,  and
 an  equal reduction  of the daily discharge of
 solids—of  urea, lithic acid, and salts, frequent-
 ly associated with the presence of albumen in
 small quantity.
   [M. Raspail discovered that the genito-uri-
 nary epithelium, as well as that  of other mu-
 cous membranes, undergoes continual desqua-
 mation in the natural state, and that in certain
 diseased conditions, as that of the disease un-
 der consideration,  this physiological process
 acquires morbid activity, the scales that are
 thrown off appearing under the microscope of
 extreme delicacy,  and transparent,  except in
 occasional instances.   With  respect to  the
 presence of albumen in urine, the combination
 of the two following tests would seem  to be
 necesssary to establish it: 1st.  Coagulability
 by heat and nitric acid ; 2d. Non-precipitation
 by acetic acid.   Thus, urine containing milk or
 caseine  would  coagulate by  heat  and  nitric
 acid, although it contained no albumen; but,
 unlike albuminous urine, it would not coagulate
 on the addition of acetic acid.   Again, if albu-
 minous urine is alkaline,  it will not  ordinarily
 lose its transparence by the action of heat, un-
 less the quantity of albumen be very great, but
 it will instantly coagulate  on the addition of a
 small quantity of nitric acid.   A quantity of
 acid, however, barely  sufficient to neutralize
I the alkali present, will not always  suffice to
i render albuminous urine coagulable by  heat: 
KIDNEYS—Cachectic Inflammation of the.
739
 lire quantity of acid should be considerably in
•excess.   Where alkaline urine is rendered tur-
 bid by heat, Mr. Ress has shown that the loss
 of transparence is usually due to the precipita-
 tion of phosphates, as is proved by its complete
 restoration on the addition of nitric acid.  Dr.
 Christisov states, that where the urine is mud-
 dy, from the deposition  of lithic acid and the
 lithate of ammonia, heat will remove the tur-
 bidity, by dissolving those compounds :  as mu-
 cus causes muddiness, and will  not  disappear
 under the action of heat, it should be removed
 before the test is employed.   It should also be
 borne in mind, on the other hand, that precipi-
 tation by nitric acid alone will not prove the
 matter thrown  down to consist of albumen.
 Such precipitate may be composed of  lithic
 acid or lithate of ammonia. The matter thrown
 down by nitric  acid may consist of albumen,
 uric acid, and  urate of ammonia; but micro-
 scopic inspection (with  which every physician
 should make himself familiar) will, in such ca-
 ses, prevent error, by disclosing the lamellar,
 corrugated, and peculiar appearance of  albu-
 men, crystals of lithic acid, and an amorphous
 powder,  convertible into similar crystals by ni-
 tric acid (lithate of ammonia);  we can ascertain
 the proportions  of the three ingredients by ace-
 tic acid and ebullition.   If albuminous urine be
 red-coloured from the presence of haematosine
 and the  globules of the  blood, nitric  acid, in a
 great measure, discolours it, by precipitating all
 the foreign principles together: the microscope
 will detect the globules, either in the urine, or
 imprisoned in the flakes of albumen.
   The quantity of albumen present  in the urine
 in  this disease  varies exceedingly  in different
 cases, causing, of course, different appearances
 in  the coagulum.  In some instances, its  pres-
 ence is barely perceptible ; in others it amounts
 to  at least j^ by weight of the mass of urine.
 Where the proportion is as low as  one  part in
 a thousand, ebullition and evaporation should
 be prolonged for a considerable time.  The pre-
 cise quantity of this principle present may be
 ascertained by taking the coagulum  obtained by
 heat, washing it in alcohol, drying  and weigh-
 ing it, and  then subtracting the  amount  from
 the total weight of the  urine employed.   Dr.
 Christison has proposed the following scale,
 which would lead to obvious scientific and prac-
 tical benefits, were it adopted by medical wri-
 ters and  practitioners : " 1. Gelatinous by heat;
 2.  Very strongly coagulable—where a precipitate
 distinctly separates by heat, and yet occupies, in
 twenty-four hours,  the  whole,  or nearly the
 whole fluid ; 3.  Strongly coagulable—where the
 precipitate, in twenty-four hours, occupies half
 the volume of the fluid ; 4. Moderately coagulable
 —where  it  occupies a fourth of the  fluid ; 5.
 Slightly coagulable—where it occupies an eighth
ofthefluid; 6. Feebly coagulable—whereitoccu-
pies less than one eighth of the fluid; 7. Hazy by
heat—where the urine becomes cloudy, but does
not form visible flakes a few seconds after be-
ing boiled" (p. 44).   There are other tests for al-
bumen, such as tannin, creasote, alcohol, ferro-
cyanate of potass and acetic acid, bichloride of
mercury and alum, but they are  inferior in ac-
curacy to those already mentioned.  We would
urge upon practitioners the importance of mi-
croscopic inspection  of the urine, as it is indis-
pensable  for the recognition of the  globules of
 pus, mucus, or blood, and of the particles of
 lithic acid and lithate of ammonia,  which are
 often thrown down in union with the  coagulum.
 It is now generally  admitted by chemists that
 healthy urine contains no albumen, but that it is
 found to be present, in greater or less quantity,
 in a considerable variety of local or general de-
 rangements of the system, either owing to a
 morbid state of the blood, or to a defective ex-
 ercise of its  secretory function, or, perhaps,
 subsequent  admixture.  We find albuminous
 urine, for  example  (See  Brit, and  For. Med.
 Rev., July, 1839),  in—I.  An abnormal condition
 of the blood,  dependant on scurvy, purpura, haem-
 orrhagic eruptive fevers, and  perhaps absorp-
 tion of pus, or absorption of albuminous  or
 dropsical effusions.  II. In lesions of the genito-
 urinary apparatus, either,  1, of a functional kind,
 as idiopathic  hasmaturia,  diabetes,  secretory
 excitement of the urinary organs and passages,
 produced by articles  of food,  or  by  medicinal
 agents, and  active renal hyperaemia; or, 2, of
 an organic nature, which cause albumen to be
 formed subsequently to the act of secretion, as
 in blood thrown  out in cases  of contusions,
 wounds, calculous hyelitis, cancer of kidney,
 fungous tumours, acute cystitis, or as in tuber-
 cle, encephaloid,  strumous matter, pus; e. g.,
 in cases of prostatic abscess, in muco-pus, in ca-
 tarrhal inflammation of raucous membrane  of
 urinary passages, especially of  the bladder.
 III. There may be an accidental  admixture of
 healthy genito-urinary albuminous products, as
 in semen, prostatic secretion, catamenial fluid ;
 and, IV. The cause  may  be  doubtful, as  in
 acute  febrile  affections, hysteria, scarlatina,
 gout, chronic  diseases independent of renal
 lesion, and,  lastly, chylous  urine.  We  doubt,
 then, the correctness of assuming in  all cases
 that albuminous urine is diagnostic of Bright's
 disease of the kidney, for Rayer states ex-
 pressly that  he has found that the albumen and
 globules of the blood pass occasionally into the
 urine, in cases of scurvy, purpura, and hsemor-
 rhagic fevers,  while  the fibrin diminishes  in
 the vessels,  and the  fluid portion becomes  in-
 filtrated into the cellular tissues, or exhaled on
 the surface of the mucous membranes.  Dr.
 Blackall also relates cases of scorbutus and
 petechia;, in which the urine was coagulable.
 That albumen occurs in the urine, in the drop-
 sy succeeding  scarlatina, is known  to  every
 practitioner; whether the  kidneys labour un-
 der the organic change observed in  Bright's
 disease,  remains to  be determined,   although
 Drs. Graves,  Willis, and others have given
 us the history of several  cases  where the kid-
 neys preserved a  perfectly healthy structure.
 (Edinb. Med. and Surg. Jour., Jan., 1833 ; Lond.
 Med. Gaz., Oct. 20, 1833.)  Dr. Williams has
 also  recently  given  us the details of several
cases (Lond. Med. Gaz, Aug. 1 and 15, 1845) of
albuminaria, connected with scarlatina, with.
disease of the heart, diseased uterus,  renal
calculus, pleuro-pneumonia, hysteria, &c, in
some of which the patients entirely recovered,
 the albumen disappearing from the urine, which
proves  that there was  no  serious organi^
change.  Temporary albuminaria, Dr. W. sup-
poses, may be produced by congestion  of the
kidneys brought on by cold, intemperance, &c,
often  complicated with other  affections, and
disappearing with them,  sometimes,  however, 
740
KIDNEYS—Cachectic Inflammation or the.
leaving behind  a cacoplastic deposite, which
weakens the functions and impairs the struc-
ture of the renal organs.  Dr. W. also believes
that there are cases of albuminaria, connected
with some amount of structural disease, which
are far from proving fatal, and which are not in-
consistent with a considerable amount of health
and duration of life. — (Loc. cit.)   It has also
been proved, by the observations of M.  Solon,
that the urine in one eleventh of patients af-
fected with acute diseases may be expected to
become albuminous  at some period or other
before their  recovery, owing,  probably,  to  a
modification  of secretion, occasioned by ner-
vous  influence.  It remains,  perhaps, to  be
proved whether these cases are to be regarded
as instances of a tendency to granular deposi-
tion, arrested along with the local and  general
reaction which  it accompanies, or the result of
an  accidental functional disturbance in the re-
nal apparatus.
  It is unnecessary, however, to  enlarge on
this point.   In  the present state of our knowl-
edge, we are hardly authorized,  we think, in
inferring the existence of a special lesion of
the kidneys  from the mere presence of albumen
in the urine. All the circumstances are  to be
taken into account, which  are known  to give
rise to the presence of this proximate principle
in the renal  secretion]
   92. b. Dropsical effusion into the cellular tis-
sue, or  into  shut cavities, or into both, general-
ly takes place in the course of chronic as well
as  of acute cachectic nephritis ; but the altera-
tions of the urine described above may continue
for many months before it appears, and without
being attended  by any disturbance besides de-
bility, impaired appetite, and an unhealthy ap-
pearance of the countenance.   However, if the
patient be not  carried off by some casual dis-
ease, or by some of the attendant or contingent
maladies which so  frequently complicate ca-
chectic nephritis, he will certainly become drop-
sical, sooner or later.   Anasarca is the most
common form  of dropsy, the eyelids and face
becoming puffy in the morning, and the ankles
and feet cedematous in the evening.   When
oedema of the  lower extremities  is caused by
this malady, it  does not so readily or so entire-
ly  subside in the morning as when it is pro-
duced by disease of the heart.  M. Rayer just-
ly  remarks,  that  nephritic anasarca  is  more
sensibly and rapidly  aggravated by exposure to
cold  air than  any  other  form of  anasarca;
and I have  observed the chronic form of the
nephritic disease suddenly changed into  the
acute  by this  cause, with  a rapid increase
of the anasarca, and with  effusion into the se-
rous cavities.  Ascites not infrequently super-
venes, especially when disease of* the  heart or
liver is associated with disorganization of the
kidneys. Effusion into the pleuritic and pericar-
diac cavities sometimes also  occurs in the ad-
vanced stage of this malady.  Urea is  general-
ly detected in the effused serum, besides albu-
men and the usual saline substances.
   93. c. The blood undergoes remarkable chan-
ges in  this malady, especially in the advanced
stage, as Dr. Christison has very ably shown.
I believe that this fluid is affected at an earlier
period than is  usually considered, and  general-
ly  before any dropsical effusion takes place, if
not before the  urine  itself, or even the  kidneys,
betray disease.   This,  however,  cannot  be
readily determined ;  for the state of symptoms
does not alwavs indicate the propriety of blood-
letting, and the patient  rarely has recourse to
medical aid  at so early a period.  The ques-
tions  are, whether or no the changes in the
blood  are consequent upon, and caused by those
of the kidneys, or whether the latter  depend
upon the former, or whether both proceed either
coetaneously or successively from  some other
state  of disorder.  These must  be  adverted to
hereafter;  at present I  must note only the al-
terations which take place in the blood in con-
nexion  with this  malady.  The serum of the
blood is reduced in density, has more or less of
a milky appearance, and it  contains less  solid
matters.  The amount varies in different cases
—from 1029 or 1031, the density of health, to
1022, 1020,  or even 1019;  and  the solid con-
tents being  reduced from  100  or 102 in one
thousand, to 68, 64, or even 61.  The reduction
is considered by  Dr. Christison to affect the
albuminous equally with the saline  ingredients.
It occurs only where there is an abundant dis-
charge  of albumen with  the urine ;  but then
invariably, owing to the loss of albumen, the
serum coagulates loosely when heated.  This
physician established, as early as 1829, an im-
portant fact, which  has since been confirmed
by several writers,  namely, the presence of a
large quantity of urea in the blood.  He states
that  urea is invariably found in the serum at
all stages of the disease where the  daily dis-
charge of it by the urine is  materially diminish-
ed, that is,  to about one third of the natural
 amount.  Hence  it may be discovered in the
 early stage, if the quantity of  urine have not
 been much increased by incidental causes  be-
 yond the common average at this  period ; but
 if the urine be thus increased, it may not be de-
 tected, or traces of it merely.
   94. The  proportion of fibrin in the blood  is
 commonly increased in the early stage of the
 chronic malady, although not so greatly as in
 the acute form.  Dr. Christison considers the
 quantity of dry fibrin to vary in healthy blood
 from 25 to 52 parts  in ten thousand ;  but in the
 acute state, or stage of the disease, he has seen
 it as high as 82, and as low as 30  parts, the
 variation apparently depending upon the degree
 of general vascular reaction or  local inflamma-
 tion  which is present.  The proportion of ha-
 malosine or of colouring matter he believes not
 to be materially affected at an early stage, when
 the patient has enjoyed good health previous to
 the attack; but  such a state of health I con-
 sider rarely to exist just before  cachectic neph-
 ritis  is produced — rarely before  even the
 acute form of the disease; many of the sup-
 posed cases of this form, occurring in healthy
 persons, being actually cases of simple nephri-
 tis, which also is often attended by  a slightly
 albuminous  state of the  urine.   I have  never
 seen a case of this malady in  a  person who
 was  quite healthy just before  its commence-
 ment.  All that  is  known of the  state of the
 blood in the early stage is, that the serum is de-
 ficient  in albumen,  and that  it generally con-
 tains more or less urea; and that the propor-
 tion  of fibrin is often increased.
   95. d. As the disease advances, the blood pre-
 sents much greater changes than the above :
 1st.  It separates into a  less  bulky  clot relr 
KIDNEYS—Cachectic Inflammation of the.
741
 tftivcly to the quantity of serum, which is gen-
 erally not so lactescent as in the early  stage.
 The coagulum is also not  so frequently  buffed
 or cupped as in this stage or in the acute  state;
 but it often assumes these appearances when
 general reaction or local inflammation super-
 venes.   In  many  cases the clot  is  remark-
 ably small  and contracted,  forming scarcely a
 fourth part of the whole weight of the  blood.
 2d. The  density and solid  contents of the  se-
 rum, which were much reduced in the early
 stage,  gradually return  to  the healthy  stand-
 ard, or even exceed it at a more advanced pe-
 riod, unless when reaction occurs, and  when
 the urine becomes highly  coagulable.  In the
 most advanced stage, where there is very  lit-
 tle coagulability of the urine, the density of the
 serum may amount to 1030, and the proportion
 of the  salts and albumen  to the entire blood
 may be as  high as  970 in ten thousand, the
 healthy standard being 780 to 800 according to
 Lecanu, and 816 to  853 according  to Christi-
 son.  Where, however, reaction or inflamma-
 tion has  occurred in  this stage, both the den-
 sity of the serum and the proportion of the sol-
 ids  are greatly reduced.  3d. The urea  often
 disappears from the serum in the middle stage ;
 but it  commonly reappears in the most ad-
 vanced stage,  and is sometimes present  to-
 wards the close in larger proportion than  ever :
 this is owing chiefly to the  quantity of urea and
 its combinations passed in the urine during the
 twenty-four hours at these  different periods of
 the disease.  4th. The fibrin is usually in nat-
 ural proportion after the early stage is passed,
 and becomes abundant only when  reaction is
 produced  and when the blood is decidedly buffy.
 Dr. Christison states it to  vary from 27 to  43
 parts in 10,000 as  the malady proceeds, and
 from 56 to  85 parts  where  reaction or inflam-
 mation occurs,  the clot being thickly buffed.
 5th. During the progress of the disease, the
 colouring matter, or hainalosinc, becomes grad-
 ually but  rapidly reduced, and ultimately, if the
 patient be not carried off by some severe com-
 plicalion, it  forms  less than a  third of the
 healthy average.  In some  cases the reduction
 is partly owing to blood-letting, but it is quite
 as great where no vascular depletion  has been
 practised.  On examining  the  blood  with the
 microscope, the red globules are  observed to
 be less numerous than  in  health, and mixed
 with them are seen other globules of a whiter
 colour and of a larger size  than they.  Doctor
 Christison  observes that  there is no chronic
 disease which  so  closely approaches haemor-
 rhage  as  this in impoverishing the blood.  It
 thus appears that, in the  advanced  stage  of
 chronic cachectic nephritis, the proportion  of
 hsematosine  in  the  blood  is  invariably and
 greatly reduced ; the other morbid changes are
 variable ;  the solids of the serum are most fre-
 quently defective, but sometimes  in  excess ;
 and  often, especially if the  disease  be  very  far
 advanced, the serum also contains urea.
  (M. Simon states that he has  analyzed the
 blood in four cases  of Bright's disease with
 the following results.—(See table.)
  The  urine was albuminous in all these cases,
 and in  some  of them  the quantity of urea was
 very considerable.— (Animal Chemistry, by Dr.
J Franz  Simon.  Translated by Dr. G. E Day,
2 vols.  Sydenham Library ed., p. 322.) Dr.
Water ....
Solid constituents
Fibrin ....
Fat.....
Albumen  ......
Globulin  ......
Hiematin......
Extractive matter and salts
CH«e 1.	C..».- J.	Case::.
830	82b'	823
169	173	176
7	3	5
2	1	2
103	109	97
40	41	54
3	4	5
12	13	12
839
160
  3
  2
 63
 71
  4
 11
 Christison found, as the result in 13 cases of
 analyses of blood in Bright's disease, that the
 water varied from  808 to  837 parts in 1000,
 the average composition of healthy blood being
 775 ;  the solid constituents, from 113 to 191 (av-
 erage in healthy blood, 2243);  fibrin, from 27
 to 85 (average in health, 38);  of blood corpus-
 cles, from 56 to 133 (average of healthy blood,
 137-1); of residue of serum, from 52  to 97 (av-
 erage in health, 834).  Andral and Gavarret
 have arrived at very similar results.]
  96. The leucophlegmatic, or sallow and blood-
 less state  of the countenance, characterizing
 the progress of the  malady, is owing  to  the
 changes in the blood.  A pale, transparent,
 waxy hue is  gradually induced; or a peculiar
 dingy or brownish tint, which is most frequent-
 ly observed in persons of a dark complexion,
 although sometimes also in those who are fair,
 and readily suggests the probable existence of
 this malady when seen by the observing physi-
 cian.
  97.  Besides the above changes and  symp-
 toms, there are generally a marked diminution
 of the perspiration, and more or less dyspnoea :
 there are  sometimes also  vomiting  and diar-
 rhoea.   However profuse the latter may be, it
 rarely  causes any sensible  diminution of  the
 dropsical effusion when this has taken place.
 The dyspnoea is generally owing either to bron-
 chitis, to pulmonary oedema, or to hydrothorax,
 or to some other affection of the lungs or heart,
 which  may have  been antecedent  to, contem-
 poraneous with, or  consequent  upon the renal
 disease.
  98.  e. The duration of chronic cachectic neph-
 ritis varies from a few months to several years.
 The time  of  its commencement is always as-
 certained with great difficulty, as patients fre-
quently do not apply for advice until dropsy ap-
 pears.  [When] once the characteristic change
 takes place in the urine, some form or other of
 dropsy, generally anasarca,  may be  expected to
 occur,  with much confidence, unless some in-
 tercurrent disease carry off the patient.   When
effusion does take place, it is impossible to say
 truly how long he may survive.  In most in-
 stances, the dropsy continues until death, pre-
 senting, like the disease of  the kidneys, remis-
 sions  and exacerbations at longer or shorter
 intervals, or,  perhaps, occasional amendments
so considerable and so durable that the patient
 is enabled to attend to his affairs  without in-
 terruption for months, or even years ; and un-
 til the  disease, assuming a more active form,
 confines him  to bed, and then terminates fatal-
ly, more or less rapidly, in consequence of some
 secondary malady, as some cerebral  affection,
or pleurisy, pneumonia, pericarditis, gangrenous
erysipelas, or obstinate diarrhoea, with or with-
out vomiting  and fever.
  99.  C. Appearances of the Kidneys after Death.
—These appearances have  been very fully de-
scribed  by the authors already mentioned, and
especially  by Dr. Bright, Dr. Christison, and 
742                    KIDNEYS—Cachectic Inflammation or thz.
M. Rayer.  The last-named writer describes
six forms of organic lesion—two, more  espe-
cially, belonging to the acute, and four to the
chronic disease—presenting features more or
less  distinct or peculiar.  But these forms of
lesion may be found united in the  same case
when the disease has attacked, successively
and  at  longer  or shorter  intervals, different
portions  of the two kidneys.   In almost every
instance  both kidneys  are  affected, although
very often unequally.  In one case only have
I seen the one organ very slightly altered when
the other was very remarkably diseased.
  100.  First  Form.—The size and weight of
the kidneys are very much increased—from 4
ounces, their ordinary weight, to 8, or even to
12 ounces.  Their consistence is greater, but
they are  not indurated ; and their surface is
morbidly red, and spotted over with a number
of red points of a deeper colour than the rest
of the organ.   On dividing the kidney, the  in-
crease of bulk  is found to be owing to tume-
faction of its cortical substance, which exhib-
its numerous red spots similar to those visible
on the surface, and which,  according to  M.
B,ayer, correspond to the glands of Malpighi,
highly injected with blood.  I have found these
glands not only injected, but their central cavi-
ties  either obliterated  or filled with a  whitish
or yellowish granular matter, which I have con-
sidered  to be albuminous in  its  nature.  The
tubular structure, compressed between the  tu-
mefied prolongations of the cortical or vascular
substance and  the enlarged  or  tumid Malpi-
ghian bodies, is of a duller red, and its striae are
less  apparent than in the healthy state.  The
mucous membrane of the calices and pelvis is
sometimes injected,  and exhibits vascular  ar-
borizations on its surface.   This^c*/ stage of
the disease is  rarely  observed, as it  seldom
proves fatal until ulterior changes have occur-
red.  It  should  not be  confounded with con-
gestion  consequent upon disease of the heart
or upon other maladies, nor with simple neph-
ritis, in which latter the kidney is harder and
redder, and  almost always  presents purulent
points  disseminated  through   its  substance
($36).
  101.  Second Form.—The volume and weight
of the  kidneys are still increased ; but  their
consistence is not quite so great as in the first
form.  The  lobules are more distinct  than in
health.   The special character of this  form is
the  very remarkable commixture of anaemia
and hyperaemia, which gives a marbled appear-
ance to the surface of the  organs.  On incis-
ion, the  cortical structure is found still swol-
len, but it is now of a pale yellowish hue, spot-
ted with  red ; and there is a marked line of de-
marcation between it and the tubular structure,
the colour of which is reddish-brown.
  102. Third Form.—The kidneys are still lar-
ger  and  heavier than  in health  ; but they  do
not present any red patches or marbled  appear-
ances.   The  cortical substance, both  on the
surface and when divided, exhibits  a tolerably
uniform pale or whitish-red colour, passing into |
yellow.   In  some  cases it is still  paler, and |
closely resembles the hue of the flesh of the !
eel.  Minute  vessels, injected with blood, ap-
pear here and  there, and  more rarely small j
brownish patches or large whitish granulations,
produced by an old deposition of lymph.  The I
papillae of the  tubular structure  often present
red indurations; and the mucous membrane of
the pelvis and calices is sometimes thickened,
and here  and there injected ; but these latter
changes are also found  in simple nephritis.
   103. Fourth Form.—This form  is what  has-
been  designated by Dr. Bright  the granulated
texture of the kidneys.   The size and  weight
of these organs are still increased.  Their ex-
ternal surfaces, usually of a yellowish  colour,
are dotted, and  sometimes covered with minute
spots of a milky-white with a yellowish hue,
which are often elongated, appearing as if small
portions of milk curd bad been irregularly spread
over  them.  These granulations are generally
most numerous and distinct at the two ends of
the organ ; they are not prominent, the surfa-
ces of the kidneys being quite smooth, but are
imbedded  in the cortical  substance.   On di-
viding the kidney from its convex to its con-
cave  side, its cortical structure exhibits, as in
the second and third  forms, a pale yellow col-
our, which contrasts strongly with the red line
of the tubular substance.  The  cortical struc-
ture is swollen, and  occupies  a considerably
larger space than in health, particularly in its
prolongation  between the cones.  The milk-
white spots, or granulations of Dr. Bright, in-
stead of being rounded  and distinct from each
other, as they usually are on the outer surface
of the organ, now appear like irregular floccu-
leHt lines, which seem  to  be continuous with
the divergent striae of the tubular cones.   When
the incision has been well made in the  direc-
tion of these striae, this arrangement is very
distinctly seen, especially  at the periphery of
the kidney and  the base of the  cones, where
the granular degeneration is generally most
conspicuous.  In some cases the granulations,
although very distinct on the surface of the or-
gan, can hardly be observed in  the substance
of the cortical structure ; while in other cases
they are scattered through every portion of it,
even  to the  small prolongations which  pene-
trate  into the bases of the tubular cones.  The
granulations  become more distinct if the kidney
has been  macerated for some time  in water;
their dull white colour then stands out more ob-
viously from the surrounding cortical structure.
   101. Fifth  Form—The kidneys are  larger,
heavier, and  have their  lobules more distinctly
marked than in the  healthy state.   They  ap-
pear as if a great number of minute grains of
the semolina were sprinkled on their surfaces
under their  proper  investing  cellular mem-
brane.  These  minute  grains are Malpighiau
glands enlarged by albuminous infiltration, and
are distinct from the yellowish particles some-
times observed  in the cortical substance, which
are also small granulations of lymph, accident-
ally met with in this and in other varieties of
nephritis.   This form of lesion is much more
rare than the preceding ; but, like them, are
generally attended, during life, by dropsy.
  105. Sixth Form.—This corresponds with the
third  variety described by Dt. Bright.  The
kidneys are sometimes larger, but often small-
er than in the  healthy stale.  They are hard,
and more or less irregular and tuberculated.
Few, or perhaps none at all, of the milky spots
or granulations  are observed on their surfaces;
but a  certain  number is  always found when an
incision is made into  the  cortical structure. 
KIDNEYS—Cachectic Inflammation of the.
743
 The surfaces of the organs are indurated, cor-
 rugated, and mammillated ; but, although stud-
 ded over with minute  asperities, they  do  not
 exhibit the  genuine  granulations  of Bright
 In  some cases, however, the anatomical char-
 acters of this form of the disease are so close-
 ly alike to those observed after simple chronic
 nephritis {§ 22), that  it  would be scarcely pos-
 sible to point out the distinction between them
 if the  phenomena  present during the  life of
 the patient were not taken  into the account.
 In  this advanced stage of the disease  the in-
 vesting membranes are almost always thick-
 ened, at least in several points, and strongly
 adherent.
   106. The other changes of structure some-
 times  observed  in  connexion with the above
 forms of lesion are neither very remarkable nor
 necessarily connected with them.  They may
 occur in any of the varieties  of nephritis.   Al-
 terations of the  ureters, urinary bladder, pros-
 tate, and urethra, are merely coincidences, and
 are sometimes observed.   But extensive chan-
 ges of the lungs,  heart, stomach,  intestines,
 liver, serous membranes,  &c, are very often
 found  in addition to those existing in the kid-
 neys, and are either primary, or consecutive
 upon the renal malady, and in either case more
 or  less intimately connected with it.  To this
 subject, however, more particular attention will
 be directed hereafter.  Dropsical effusion most
 commonly exists either  in the cellular tissue or
 in the shut cavities, and much more rarely in
 the ventricles of the brain and in the spinal
 canal.   The quantity of fluid effused is gener-
 ally large.  Sometimes  the cellular tissue con-
 tains a gelatinous fluid  instead of serum.
   107. The  above  lesions, with the exception
 of  those found in the first and fifth stages or
 forms  of the disease, are  nearly  such  as  are
 described  by M. Raver.  Besides these, how-
 ever, there are various  other alterations of the
 kidneys and  urinary passages, which are occa-
 sionally seen in connexion with them. Of these,
 the most important and intimately connected
 with the disease seem to be congestion or fibrin-
 ous concretions  in the emulgent  veins, and
 signs of inflammation or of its consequences
 in these veins;  but  these have not been  ob-
 served either frequently or with requisite pre-
 cision.  The granular deposites and other chan-
 ges described in the second and other forms of
 lesions  above enumerated, are  chiefly  conse-
 quences of those described in the first form of
 the changes  in the Malpighian bodies,  and in
 the cortical  structure generally, which, owing
 to the deposites of albuminous-like matter in
 them, present different appearances, according
 to the amount of such  deposites,  and  of  the
 alterations of surrounding tissues occasioned
 by  them.   These  alterations have  frequently
 reached their farthest limits before death oc-
 curs, and before  they come under observation.
  108. I have already  stated (t) 100) that  the
 granular deposites first  noticed  by Dr. Bright
 in connexion with dropsy, and described  by him
 by  the name of " granular degeneration of the.
 kidneys," appear to originate  in the glandular
 bodies  of  Malpighi.  Since  the time  of this
 anatomist, and more particularly by Ferrein,
 Bertin, Schumlanski, Eysenhardt, and Map-
 pes, the  Malpighian glandules or  bodies have
been viewed  as the structure more immediately
concerned in the secretion of urine.   As such
they have been described by Meckel, Cloquet,
and others, who observe that these bodies, glan-
dules,  or granulations, appear to consist of
rounded corpuscles, visible to the unaided eye.
in the form  of  very small points, which are
connected with the minute and ultimate rami-
fications  of  the  blood-vessels.  Under the mi-
croscope, these bodies appear not only to con-
sist of a reticulum of these vessels, but also to
give origin to minute white, tortuous canals,
the conduits of Ferrein, which canals form a
considerable  portion of the cortical structure,
and  convey the  urine from the corpuscles to
the tubuli.   Meckel denominates these canals
■' the excretory canals of the Malpighian  cor-
puscles."  (T. iii, p. 557.)
  109. From what has been stated above (§ 100),
I infer that inflammation of the Malpighian cor-
puscles takes place in cachectic nephritis ;  that
an albuminous deposite forms in them, giving
rise lo a granular appearance  ; and that, as the
changes  of  these  bodies  and of the cortical
structure advance, the other tissues are thereby
altered more or  less, until at last the tissues
compressed  by them become  condensed or at-
rophied, and the  substance of the organ farther
altered in consequence.   These changes in the
kidneys, which are nearly the  same in both,
especially the earliest changes, as the inflam-
matory state of the Malpighian corpuscles, and
the commencement  of granular deposites in
them, are excited  by previous changes in the
blood, as contended for hereafter ($ 141, et seq.);
and the associated maladies arise chiefly from
the same cause, and from farther alterations in
it, owing to the  morbid state of this very im-
portant emunctory.
  [Dr. George Johnson recently read a paper
before the Royal  Medical and Chirurgical Society
of London (Nov.  11, 1845;  Lond. Lancet,  Jan.,
1846, p.  84),  in  which he  maintained that
" Bright's disease" consisted  in  a diseased
state of the secretory or epithelium cells which
line the urinary tubules ; that these cells natu-
rally contain a minute quantity of oil, in the shape
of globules, which, in this disease,  is much in-
creased ;  in short, that  there is a fatty degen-
eration of the kidney, analogous to the  fatty
degeneration of  the liver, described  in recent
pathological works.  Dr. J. supposes that  this
accumulation of  fat in the secretory cells is the
result of constitutional causes, that  it neces-
sarily leads to the engorgement and  dilatation
of the tubules which they line, and that one or
more convoluted tubes, thus  gorged with fat,
and  projecting either  on the surface of the
gland, or on  the surface of a section, consti-
tutes one of the so-called "granulations of
Bright."  The frequent connexion of albumin-
ous  and  bloody  urine  with Bright's disease,
and the atrophy of the kidney, are attributed by
Dr. J. to the mechanical operation of the above-
described fatty accumulation ; it being a sec-
ondary phenomenon, and dependant on the  pre-
vious morbid changes.  In short, Dr. J  main-
tains that this deposite is the  cause, and not the
result of  the congestion of the kidney, which
finally leads to the presence of albumen in the
urine.
  Dr. Quain, on  the other  hand, states (Lond.
Lancet, Feb., 1846, p. 139) that, in more thau
60 instances in which he has examined the kid- 
744
KIDNEYS—Cachectic Inflammation of  th«.
neys in this disease, the fatty condition was in
only one case  sufficient  to  attract attention ;
that there  are  other deposites besides that of
oil, as that  called cacoplaslic (badly organizable)
by Dr. Williams, such as we find  in other or-
gans and tissues which have been  the seat of
unhealthy inflammation or degraded nutrition
This matter, Dr. Q. states, has  been generally
observed to assume, 1. The form of nucleated
cells, varying in size and shape, and also in the
number and character of the nucleoli;  2. As
simple granular matter, nucleated cells being
fewer in number ; 3.  A distinct filamentous or
fibrous character.  The deposites in the kidney,
according to Drs. Quain and Williams, assume
the following characters: 1.  The simple enlarged
mottled kidney,  the surface of which, on remo-
ving the capsule, is generally smooth.  In this
the deposite consists of simple nucleated cells,
more or less mixed with granular matter.  This
form is analogous to the hypertrophied mottled
liver.  2. The truly granular or atrophied kidney,
the surface of which  is rough,  irregular, and
generally of a  pale-red colour.   In this form,
the filamentous tissue, contractile in its nature,
as  such  formations always are, exceeds the
quantity  of the  cellular  or granular matter.
This latter sometimes extends to the convolu-
ted extremities of the tubes.  The contractile
tissue surrounding the tubes and bodies can  be
readily supposed to give  rise to the rough  or
granular formation.   This form resembles the
hob-nailed  or  gin-liver.  3.  The large, flabby,
fatly-looking kidney.  In this the quantity of fat
exceeds the amount of the other matters pres-
ent.  The  fat is present in the substance, and
probably in the tubes themselves. This resem-
bles the fatty degeneration of the liver.  Minor
modifications of these forms are produced  by
the relative proportions present.  There is  no
reason to  suppose that one condition  is the
necessary  antecedent  of  another, but that the
character assumed in the first instance may be
permanent.  (See Williams's  Led.,  in Lond.
Medical Gazette, 1845 ; et Princ. of Medicine.
Quain, in Lond. Lancet, Feb., 1846.  Johnson,
in Ibid., Jan., 1846.]
   110.  ii.  Diagnosis.—A. The acute form  of
cachectic or albuminous nephritis is readily
recognised  by  the  coexistence  of  an  albumin-
ous, and often a sanguinolent state of the urine,
with the rapid  development  of anasarca, and
occasionally of serous effusion into some inter-
nal cavity.   In a few cases,  no* dropsy takes
place ; but then the state of the urine, in  con-
nexion with febrile irritation and derangement
  * [In a most remarkable case of cachetic nephritis, occur-
ring iu New-York several  years  ago, says Dr. Francis,
the patient, a male subject, aged about 48 years, had long
laboured under pneumonic oppression and serous effusion
of the lower extremities ; his countenance, towards the lat-
ter period of his sufferings,  became extremely leucophleg-
matic, and numerous grumous-coloured spots manifested
themselves on different parts of the surface of his trunk.
His urine was scanty, sometimes gelatinous, and often of an
albuminous character.  The occasional changes in the col-
our of the urine gave reason to apprehend disorder of the
kidneys of an inflammatory nature, inasmuch as his suffer-
ings in the lumbar region were not unlike a paroxysm of
gout, to which disease  he had been a sufferer.  On exam-
ination after death, which was sudden anl unexpected, both
kidneys were found to be enlarged, the left much more than
the right. Traces of their lobular structure were suffi-
ciently apparent; their colour was  of a pale or yellowish
aspect;  their texture  soft  and flabby: their weight ap-
proached  full sixteen ounces.  In many respecis it deserves
to be classed under the first  division of M. Rayer J
of the general health, will sufficiently indicate
the nature of the disease.  It may, however, be
mistaken for simple hematuria; but, in this lat-
ter, pure blood  passes, mixed with the  urine,
and fibrinous concretions or filaments, or even
small clots  of  blood are voided ;  while these
circumstances do not occur in cachectic nephri-
tis.  In haematuria,  moreover, one or both re-
gions of the kidneys are more pained, and more
tender on pressure than in this disease.  The
urine also is  rarely passed  without  pain,  or
having the same appearance at different hours
of the day—-circumstances rarely existing in
this form of nephritis.  In simple nephritis, and
in some cases of the eruptive fevers, the urine
contains albumen in  a  slight degree  and for a
brief period, but there is generally also  a due
proportion of urea, and the urates, and other
saline matters, and hence the urine is not spe-
cifically lighter.
   111.  B.  The  Diagnosis of chronic cachectic
nephritis is  more uncertain than that of the
acute.  When  in a  patient  who experiences
only trifling, if,  indeed, any pain in  the loins,
the urine is found of a low specific gravity, and
contains albumen with only a small proportion
of urea and the urates, the existence of chronic
cachectic or albuminous  nephritis is  almost
certain, especially if  he be free from disease of
the heart.  And, even when there is disease of
the heart, the chances of mistake are small;
for, if the congestion of the kidneys consequent
upon disease of the heart give rise to the pres-
ence of albumen or of blood globules in the
urine,  the quantity  is small, and only occa-
sionally observed ; and the specific gravity of
the urine, and the proportion of urea and urates,
are not materially affected.  The dropsical ef-
fusion, also, caused by disease of the heart usu-
ally commences  in the lower extremities and
extends upward, whereas that  arising from
disease of the kidneys is often first  perceived
in the face.
   112. M. Raver remarks, that when, after  a
few  days'  indisposition, a  patient is  affected
with  serious cerebral  symptoms, or  with re-
peated attacks of vomiting, without dropsy, and
when, at the same time, the urine is strongly
charged with albumen, and is of a low specific
gravity, and if we cannot detect any disease of
the heart, or of  the bladder or urethra, the ex-
istence of chronic albuminous nephritis may be
regarded as more probable than that of a pri-
mary cerebral  affection.   And if it  be ascer-
tained that the  patient has  been exposed  to
wet and cold, or addicted to the abuse of spir-
ituous liquors, or affected with  dropsy some
months before,  the  presence of renal disease
may be asserted with still greater confidence.
The milky or whey-like appearance of the se-
rum of the  blood is  no proof of the existence
of the disease under consideration, for it has
been seen very frequently by Hewson, Trail,
Babington, myself, and others, in various oth-
er diseases besides  this;  and  urea  has been
found  in the blood after simple  nephritis, and
in atrophy of the kidneys, when the urine was
not albuminous.
   113.  iii. Complications and Relations  of
Cachectic  Nephritis  to  other States  of
Disease.—I have already stated that cachectic
nephritis rarely occurs without some previous
disorder, or even actual disease, and that such 
KIDNEYS—Cachectic Inflammation of the".                   745
disorder is generally characterized by impaired
organic nervous energy, by imperfect assimila-
tion, and by the consequently morbid state of
the blood.   I have, moreover, contended (v 141,
et seq.) that the inflammatory condition of the
kidneys in the acute  form, and  the  lesions of
these organs in the chronic, are consequences
of these antecedent  morbid conditions ;  and
that several of the affections, which  I now pro-
ceed to notice, in  relation to cachectic nephri-
tis, often exist in a slight degree, either pre-
viously to, or coetaneously with, the develop-
ment of this malady ;  while others, or even the
same affections in different cases, do not ap-
pear, or at least are not manifested, until con-
secutively upon the renal disease.   From this
it will  be evident that I view cachectic nephri-
tis as  a consecutive or secondary malady, and
that the  various  affections  with  which  it is
more or less  intimately connected  are either
pre-existent to it, or coexistent with it, or con-
sequent upon it; that they are all, in many in-
stances, progressive manifestations of success-
ive  changes in the economy,  affecting more
especially the circulating, or the assimilating,
or the excreting organs, according to their sev-
eral  predispositions to disorder, or  to inflam-
matory action, or  to  structural  change,  or to
the  influence  of incidental  causes and exter-
nal  agents; while in other cases, certain  of
them may occur as coincident effects of path-
ological causes—of pre-existing disorder, espe-
cially of that  already specified.   It  should  be
recollected  that the  associated affections  or
complications are rarely single ; that disease
of several viscera, besides the dropsical effu-
sion, generally appears in connexion with the
renal malady even in the same  case ; but this
will  be seen more fully in the sequel.
   114. A. Relations of Cachectic Nephritis to Dis-
orders  of the Digestive Organs.—a. The mouth
and  pharynx are rarely affected in  connexion
with this disease unless consecutively upon it,
when aphthae, and even ulceration of the pha-
rynx, may occur at an advanced stage.  It  has
been observed that mercurials more  readily  af-
fect  the mouth and salivary apparatus in  the
course of chronic cachectic  nephritis than in
most diseases.—b. The stomach is more or less
disordered either  previous  to or  at  an  early
stage of this malady.   At this early  period the
disorder of the stomach consists chiefly of the
more severe symptoms of dyspepsia; but nau-
sea and vomiting are frequently complained  of,
and  generally  occur early  in the  morning, or
when fasting, especially in  persons addicted to
intemperance.  In these cases, stimulants and
food relieve the symptoms, and often compara-
tively little loss of appetite is  felt during  the
day   In the acute states of the renal disease,
the disorder of the stomach is more or less se-
vere ; while in the chronic form this disorder
varies—is sometimes slight, at other times se-
vere, or consists chiefly of a sense  of load or
weight at the stomach, with eructations, acid-
ity, and other symptoms of indigestion.  These
disorders are  generally functional;  but struc-
tural changes of the stomach are sometimes
coincident with the advanced progress of the
renal disease,  especially inflammatory states
and  softening of the villous coat, ulceration,
with or without perforation of the coats of the
organ, and fungous or encephaloid tumours.  In
     II.               94
these cases, particularly  where ulceration  or
perforation has occurred, thickening or indura-
tion of the  margins of the ulcerated part, and
adhesions of the adjoining viscera, may have
taken place.
   115. c. The intestines are more or less affect-
ed  in many cases  of this malady,  and most
frequently in the form of diarrhea.  Both Dr.
Christison  and M. Rayer  have  noticed the
frequency of this complication, it having oc-
curred in more than one half of their cases, but
Dr. Bright  and Dr. Prout have  observed it
less frequently.   It is observed chiefly in the
chronic disease, and is sometimes  preceded  or
attended by colicky pains in the abdomen, and
occasionally  by  vomiting ; but, in  this latter
case, there is often also pericarditis complica-
ting the malady.  The  diarrhoea is generally
consequent upon the renal disease, and it some-
times  assumes  a  dysenteric  character; the
stools containing blood,  and more rarely a floc-
culent whitish matter.  However abundant  or
watery the discharges, they have no influence
in diminishing the attendant dropsy, which may
even  increase  during the diarrhoea.   After
death, the intestines do not always present le-
sions co-ordinate with the amount of disorder
during life.   In  many cases, little  or no  red-
ness of the  mucous surface is observed.   In
others,  redness  of  this  surface, with enlarge-
ment of the  follicles,  with or without ulcera-
tions, and often with anaemia of other parts, is
remarked.   Frequently,  although the diarrhoea
has been great  and obstinate during life, the
mucous membrane, and, indeed, the intestinal
canal, have been anaemic throughout. Ulcera-
tions are most common near  the termination
of the ileum, and in the large  intestines.   In
the former situation they  are generally conflu-
ent ; in the latter, disseminated and  small.
   116. d Peritonitis in  rare instances occurs
consecutively upon cachectic nephritis.   Cases
of this complication  are recorded by Dr. Bright,
Dr. Gregory, Dr. Christison, M. Rayer, and
others.  In  some instances  the peritonitis  is
granular or tubercular;  in others it is attended
by considerable effusion  of a sero-puriform flu-
id.  The peritonitis may  be consequent upon
enteritis, with or without ulceration (see arti-
cle Intestines) ; or it may arise without the
intestinal disease having been  manifest.  It is
generally caused by the influence of cold and
humidity during the  existence of the renal drop-
sy, and is often not  the only affection complica-
ting this latter ;  both pleuritis and pericarditis,
either singly or conjoined, being also present.
In these cases, the symptoms of peritonitis are
more or less manifest,  generally with vomit-
ing, diarrhoea, &c. ;  but as frequently they are
by no means decisive.
  Il7. e. Lesions of the liver are often found  in
connexion  with  cachectic nephritis;  but,  in
many cases, the lesion  is slight.  Dr. Bright
found the liver quite sound in 40 cases out  of
100 ;  the change was  slight in 35, and serious
in 18 cases.   M. Rayer slates that this organ
was more or less altered in about a third of the
cases which he examined after death, in some
throughout its whole extent, in others only  in
parts.   It was enlarged in a small  proportion
of instances (one sixth), and chiefly in those
cases where the heart was also diseased.  Oc-
casionally some portion of its peritoneal  sur- 
74G
KIDNEYS—Cachectic  Inflammation of the"
face was adherent to adjoining parts.  It was
softer than natural in a  few instances, but  it
was much oftener harder,  or even indurated
and diminished in bulk.   In this latter case its
surface was irregular, of a deeper colour than
usual.  When divided, its substsnce was found
tuberculated,  presenting  the lesion  which has
been denominated cirrhosis, or the  tubercular
liver of  drunkards.   This particular  lesion
seems to be  more frequently  associated with
granular  kidney than  any other alteration of
the liver.  In some cases the liver is enlarged,
pale, and fat;  a portion of its structure leaving
an oily stain  in paper.   In  a few instances, it
contains large whitish tubercular masses.  The
bile is generally more or  less changed from the
healthy state.   It is probable that the advanced
stages of these lesions are consequences of the
renal malady  ;  but it is  at least equally  proba-
ble that their early stages, or the  functional
disorders preceding them, exist antecedently to
the development of this malady. The nephrit-
ic disease and the attendant dropsy  are not in-
frequently farther associated with affections of
the lungs, or  of the heart, or of the  alimentary
canal, or with chronic peritonitis.   The com-
plication with hepatic disease is often rendered
manifest by the usual symptoms of  chronic af-
fections of the liver, and  attended by vomiting,
diarrhoea, and ascites.
   118. /. The  Spleen  and Pancreas are some-
times diseased in cachectic nephritis.  In all
the cases in  which the  liver  is affected, the
spleen is also more or less  altered, most fre-
quently enlarged, and  occasionally  its sub-
stance is loaded with grayish granulations anal-
ogous to those found in the  liver (Rayer).
The structure of this organ  is sometimes soft-
ened, occasionally firm or indurated.   The pan-
creas has been found diseased only in  a few
instances, and in a slight degree.  The disease
has in a few instances appeared in  the course
of pregnancy, and M. Rayer details some cases
thus associated.
   119.  As  far as I have been able  to observe
the phenomena of the early stage of cachectic
nephritis, and to learn  the  history  of the pa-
tient's previous ailments, there has  been more
or less  manifest  disorder of the digestive or-
gans, generally of a functional kind, but prob-
ably advancing to structural  change in some
cases, as the disease made progress.  The in-
fluence of such disorder  upon  the state  of the
blood, and upon the processes of secretion and
excretion, is sufficiently evident.  In  all these
cases, and  before  dropsical effusion or vascu-
lar reaction had taken place, depression of the
organic  nervous energy, and consequent im-
pairment of the functions of digestion, sangui-
faction,  and  assimilation, were more or  less
remarkable.  The vascular excitement, which
sometimes appears at an  early period  of the
disease, is the consequence, as I have already
shown, of the morbid state of the  blood, and
of its influence upon the ganglial and vascular
systems.
   120. B.  Relations of  Cachectic Nephritis  to
Diseases of the Respiratory Organs.—a. Inflam-
mation of the throat, extending to the pharynx
and larynx, occurring in the course of scarlati-
na, sometimes is continued, with more or less
severity, during the progress of the  renal drop-
sy following Uiis  fever;  and when  the  larynx
becomes affected, the disease of this part may
be so remarkably severe as to be speedily fa-
tal.  This form of complication, however, la
not so frequent as inflammation and ulceration
of the larvnx, trachea, and even of the larger
bronchi, which so frequently occur in the course
of phthisis, the pulmonary malady  giving rise
not only to the affection of the respiratory pas-
sages, but also to renal disease and its conse-
quent anasarca. In two cases, in which there
existed  a venereal taint, the progress of which
I closely watched, and where it was difficult to
decide whether the  laryngeal or the pulmonary
disease  was the primary one, renal dropsy ap-
peared at early periods of their progress, ad-
vanced  remarkably  far, and accelerated the fa-
tal issue.
   121. b.  Bronchitis is one of the most frequent
affections consequent upon  renal disease   M.
Rayer states, that  he has observed it in seven
eighths  of the chronic form  of this  malady.
The bronchitis that occurs is rarely acute; it
is almost always chronic; and while  the res-
piration is very slightly affected in  some cases,
it is much accelerated,  and very  difficult  in
others,  particularly at an  advanced period  of
this malady.  The matter expectorated is chief-
ly mucus, occasionally thick and yellowish, in
some instances glairy,  and  in  others  very
abundant.  The bronchitis generally aggravates
the disease, and is  sometimes the more imme-
diate cause  of death.  It  frequently  occurs
without any manifest cause ;  is rapidly propa-
gated throughout the bronchi;  is  little influ-
enced by treatment  or ameliorated by deple-
tions ; and often passes into oppletion of the
minute  ramifications and air cells,  and exten-
sive oedema of the lungs.   Its more acute form
is sometimes followed by lobular pneumonia.
On dissection, the  mucous membrane of the
bronchi is found red throughout.
   122.  c. Pneumonia sometimes occurs as a sec-
ondary complication in the advanced stage of ca-
chectic  nephritis, and is more or less extensive
and severe.  The inflammation attacks some-
times several lobes,  sometimes only the whole or
part of a lobe, and occasionally it affects many
lobules of the lungs.  In this latter case, the in-
flamed  points are disseminated and isolated in
the substance of the organ, some of them being
in the state of red  hepatization, others of gray
hepatization, and closely resembling the lobular
form of pneumonia, which  occurs after morbid
poisons, and sometimes after surgical opera-
tions.  One or both  lungs may he  affected, more
frequently both. The symptoms and signs of ihis
pneumonia are usually masked by the general
cachexia, by the dropsical effusion, by affections
of the heart, and by other pulmonary lesions.
Even the stethoscopic signs are ascertained with
great difficulty, or are altogether  absent.  The
expectoration also  is seldom characteristic of
the disease,  being  more  frequently catarrhal
or  bronchitic, than  of the  kind  distinctive of
pneumonia.  Hence the inflammation is either
latent, or not  detected during life.  In some
cases, however, the sputa and the stethoscopic
signs evince  the   existence of  the   disease.
This complication is most dangerous, owing to
the state of the constitution, and to the ineffi-
cacy or even injurious effects of blood-letting,
and of many other  means of treatment.  It is
often associated with pleuritis, or with  bronchi- 
KIDNEYS—Cachectic Inflammation  of the.
747
Us, or even with both, when it occurs consecu-
tively upon renal disease.
  123. d.  Plcuritis is rare as a secondary dis-
ease, in its simple form, in  connexion with ca-
chectic pleuritis ; but associated with pneumo-
nia, or with pulmonary tubercles, and with se-
rous effusion in the pleuritic cavities, or with
pericarditis, it is by no means unfrequent.   It
is generally latent or overlooked, or masked by
dyspnoea or by  bronchitis.   It  is  sometimes
chronic, and occasionally acute and manifest.
In some of the more chronic, masked, or latent
cases, the disease assumes much of the  char-
acter of hydrothorax, owing to the  amount of
fluid effused, and the slight grade of inflamma-
tory  action.
  124  e.  QHdema of the lungs, with  or without
bronchitis or bronchorrhcea, is the next frequent
secondary affection to bronchitis which occurs
in the course  of albuminous nephritis.   Dr.
Bright and M. Rayer found this lesion in  about
one  third of the fatal  cases.   Emphysema of
the lungs occasionally occurs, and pulmonary
apoplexy more rarely, in the progress of the re-
nal malady.
  125. /.  Tubercular consumption is very fre-
quently connected with cachectic nephritis, but
the connexion is most commonly of a different
kind from that usually observed in the  other
pulmonary affections with which this malady
often becomes  complicated in its course;  the
renal disease is almost always consequent upon
the tubercular malady.  M. Rayer believes that,
in rare instances, the latter may be secondary
of the former; but, although I have seen very
many cases, since 1828, of renal dropsy super-
vening in the course of phthisis, I have  never
met  with one in which this order was reversed.
The renal malady may appear during any peri-
od of the tubercular disease, and in every form
of it;  in the most acute and  febrile, and  in the
most chronic and apyretic.  Generally the urine
becomes more or less albuminous  before  any
signs of anasarca appear.  In a few cases the
urine has been albuminous, and less dense than
natural, in the  advanced state of phthisis,  and
the  kidneys  have been  found granular after
death, and yet anasarca had not occurred. This
may have arisen from  the continuance of the
colliquative  perspirations, as  these often  cease
upon the occurrence of the anasarca.   Diar-
rhoea frequently continues during the renal  dis-
ease, without diminishing the dropsical effusion.
Bronchitis, pneumonia, pluritis, laryngitis, pneu-
mothorax, pleuritic effusion, or oedema of the
lungs, or even two or more of these, may  far-
ther complicate the tubercular malady and its
consecutive renal disease.
  126. C. Relations  of  Cachectic  Nephritis to
Diseases  of the  Vascular  System.—a. Diseases
of the heart are  often associated with cachectic
nephritis, but the connexion between  them is
not altogether evident.   In some cases the car-
diac, in others  the renal disease seems  to be
primary.   The  frequency of this complication,
also, is not fully ascertained.   M. Rayer states,
that  it occurred in  one fifth  only of his cases,
while Dr. Bright  found it in sixty-five cases
out of a  hundred.   The cardiac affection may
appear, in some instances, as the  primary, in
others as  the consecutive, and in others as an
accidental malady;  and yet both it and the re-
nal disease may only be the more or less remote
effects of previous changes  in the states of
organic nervous power, and of the circulating
fluids,  either of which may precede the  other
in the order of succession or sensible manifest-
ation, in different cases, or in different circum-
stances.  This view of the subject,  which is
equally applicable to some other complications
of this malady, has been unaccountably  over-
looked by those who, in most respects,  have
written well on the disease,  and contributed
greatly to its history and elucidation.  The oc-
currence of this complication has great  influ-
ence upon the production and increase of the
dropsy generally consequent  upon the  renal
malady, and usually  causes the anasarca to
commence in the lower extremities.  Dr. Bright
and Dr. Christison think that the cardiac dis-
ease is most frequently secondary, while M.
Rayer believes that the kidneys are  oftenest
consecutively effected ;  and I consider that in-
terrupted  circulation  through the  heart and
lungs  favours  remarkably  the occurrence of
the chronic states of this  malady. That  the
urine is often albuminous in persons affected
with disease of the heart, when there  is no se-
rious affection of the kidneys, cannot be denied;
but if,  along with this character, it is  of a pale
citrine colour, strongly coagulable, and  of a
low specific gravity, these are strong proofs of
the presence of structural  disease  of the kid-
neys.
  127. b. The  pericardium often  contains a
small quantity of limpid serum,  from four to
five ounces, in fatal cases of cachectic nephri-
tis ;  but rarely so much as to constitute true
pericarditis.   Lesions of the pericardium may
be either antecedent to, or  consequent  upon
those  of the kidneys.   The relative  dates of
these  lesions may be often inferred  from the
history of the case, in connexion with  their ap-
pearances upon dissection.   There can  be no
doubt  that, when the heart or its valves are
diseased, the pericardium becomes more  liable
to inflammation, or to be the seat of effusion ;
and that this liability, more especially to inflam-
matory action, is much  increased by  the  renal
disease and the morbid  state  of the blood.
Hence old lesions of the pericardium,  or recent
changes in it, or even  both, will occasionally be
found after renal dropsy, although they may be
detected with difficulty during life, whether they
be associated with other cardiac lesions or not.
The remarks I offered above ($ 126), respecting
the  complication with  cardiac disease,  apply
here ;  the pericardiac lesion maybe either pri-
mary or secondary in appearance, and yet both
it and  the renal malady may be only  the con-
secutive effects of anterior disorder, some ex-
citing  or concurring cause, as cold and humidi-
ty, developing these two diseases as effects of
this disorder, which may not have  been  mani-
fested, especially in these  organs, if  such ex-
citing or determining cause had not been  in op-
eration.
   128. c.  Endocarditis is also sometimes asso-
ciated with  cachectic nephritis,  and  is  most
probably consequent upon the morbid state of
the  blood in the advanced stage of the  latter
malady.  It  may be present either simply or
complicated  with  pericarditis or  other lesions
of the heart.   M. Rayer thinks it  not always
possible to  say which of the two affections is
primary or secondary. .  He believes them, in a 
748
KIDNEYS—Cachectic
Inflammation of the.
very few cases, to be almost coetaneous;  but,
in a much greater  number, he  considers the
endocarditis to have preceded the renal malady.
I think that the  order of morbid procession  is
different from this in most instances.
  129. d. Various lesions of the heart, of its valves,
and of its orifices are found in  connexion with
albuminous nephritis ; and these morbid states
may be  farther associated with alterations of
the serous surfaces of the organ, or with  dis-
ease in  some  other important viscus, as the
lungs, the bronchi, &c.  Among these, lesions,
hypertrophy, dilatation, &c., of some one of the
chambers, dilatation of the orifices, insufficiency
of the valves of the heart, &c, are not uncom-
mon ; but it is unnecessary to specify  the va-
rious  combinations  of disease which present
themselves in this class of cases, as they vary
much in different instances.  These lesions fa-
vour the supervention of the renal malady by
causing congestion of the kidneys.
  130. e.  The blood-vessels sometimes present
alterations of structure in cachectic nephritis,
consisting chiefly of atheromatous and ossific
deposites, with or without dilatations, and vari-
cose states of the veins ; more rarely of aneu-
rysmal dilatations, and of the consequences of
inflammation.   Dr. Bright and M. Rayer have
found evidence of pre-existent inflammation of
the renal  veins; and  have remarked that the
arterial ramifications through the granular kid-
ney were  not so easily penetrated by an injec-
tion as those of a sound kidney.
  131. iv. Relations  of Cachectic Nephritis  to
Cerebral Affections.—Cerebral affections some-
times occur in the course of the renal malady,
and chiefly in its far advanced stage, and in its
more acute form.  These affections consist  of
comatose,  apoplectic, or convulsive seizures,
and of more or less sudden  death, with insen-
sibility.   In many of these cases there is little
or no appreciable lesion of the brain ; but more
frequently there  is effusion of serum within the
ventricles and under the  arachnoid.  All these
affections are consequences of the renal mala-
dy, or, rather, of that change of the blood which
is connected with and augmented by the renal
disease.   In a few instances, lethargy or coma
precedes death for a considerable period, from
which the patient may be partially roused, but
in which  he immediately afterward falls, the
comatose state becoming gradually more  pro-
found, and passing into apoplexy, with sterto-
rous breathing, or into convulsions, or into a
mixed state of apoplexy and convulsions.   The
serum within the ventricles or under the arach-
noid,  in these cases, has been  found by Dr.
Barlow  to contain urea.   Extravasation of
blood in various  situations within the cranium,
as in the substance  of the brain, in the ventri-
cles, or  between  the membranes, or true  apo-
plexy, in the course of cachectic nephritis, has
been observed by Dr.  Bright,  Dr. Christison,
and M. Rayer, but this, probably, was only an
accidental complication: it is of  rare occur-
rence.
  132. D. Relations  of  Cachectic  Nephritis  to
Diseases of the Skin and Cellular Tissue.—Chron-
ic eruptions on the skin, indolent and gangrenous
sores and ulcers of the extremities, erythema, and
erysipelas, are  someiimes associated with the
renal malady.   When  they appear  during the
distension occasioned by  the dropsical effusion,
both their  occurrence  and the unfavourable
form they are apt to assume chiefly arise from
this circumstance.  But in earlier  periods of
the disease they proceed, in a great measure,
from the existing cachectic state of the consti-
tution and the  change in the  blood, disposing
any injury or irritation of the skin to pass into
inflammation,  which,, owing  to these states,
often  assumes  an asthenic or  spreading  char-
acter.  This form of complication is not infre-
quently farther  complicated with disease of one •
or more of the  abdominal and thoracic viscera.
   133. E. Relations  of Cachectic Nephritis  to
Eruptive and other Fevers.—The appearance of
this disease,  in connexion with these fevers,
has been almost confined to scarlatina.  A case,
however, has been published by Dr. Gregory,
in which it was consequent upon measles in a
scrofulous  girl.  The  occurrence  of  dropsy,
with scanty,  bloody, or coagulable  urine, sub-
sequently to  scarlatina, especially to the less
severe forms of that disease, and in some epi-
demics more frequently than in others, has long
engaged the attention of medical writers.  Cal-
vo, Borsieri,  Storck,  Plenciz,  Rosenstein,
Wells, Blackall, and Reil, have noticed the
state  of the urine, and the peculiar character
of the dropsy, after scarlet fever, but have not
connected  the  disease with inflammation or
other lesion of the kidneys ; and, until very re-
cently, the dependance of this  form of dropsy
chiefly upon an inflammatory state of the kid-
neys  was not  ascertained or even suspected.
Dr. Fischer,  in a Memoir on  the  Treatment
of Scarlatina,  published  in  Hcfeland's  and
Ozann's Journal (Feb., 1824, st.  53), remarks
that the kidneys are often severely affected in
the latter stages of scarlatina ;  that they are in
a state of congestion, which is readily convert-
ed into inflammation by diuretics, and especial-
ly by those which are  stimulating and  acid.
He adds, that he long considered the vomiting,
which frequently attends the accession of drop-
sy consecutively upon scarlet fever, to be caus-
ed by disease of the brain ; but farther observa-
tion and careful dissections proved to him that
it  was symptomatic  of disease  of the kidneys.
He subsequently endeavoured to ascertain the
symptoms which marked this affection of the
kidneys at its  commencement, and he found
them  in the urine, which became more scanty,
of a  deeper colour, sometimes tinged  with
blood, or even containing pure blood, when the
vomiting appeared.  Mr. Hamilton details a
case in  his account of an epidemic scarlatina,
&c. (Ed. Med. and Surg. Journ., vol. xxxix., p.
145), in  which the same appearances as are de-
scribed under the first form of lesion (v 100) of
the kidneys were found  in a patient who  died
from this consecutive disease.  Respecting this
connexion of renal dropsy with scarlatina, M.
Rayer remarks:
   134. 1st. That in certain  cases of scarlet
fever, particularly during the period of desqua-
mation, the urine is  more or less loaded with
albumen,  without dropsy  occurring ; at the
same time, the kidneys are  congested with
blood, or present  lesions corresponding with
those belonging to the first form, which is com-
monly produced by cold and humidity, or by
the abuse of spirituous liquors.  2d. That the
dropsy sometimes observed after scarlatina, in
its course, and as respects its exciting or de- 
KIDNEYS—Cachectic Inflammation of the.
749
termining cause  (cold and  humidity);  in  its
general characters, and the alteration of the
urine  attending it;  in its abdominal, thoracic,
and cerebral complications; in the structural
lesions observed after it; and  as to its nature
and treatment, differs in no respect from the
acute and chronic albuminous nephritis produ-
ced by other causes, and appearing under other
circumstances. These inferences are fully sup-
ported by my own experience, and by the evi-
dence recorded by Bright, Wood, Stark, Ali-
son, Graves, Seymour, Guersent, Rayer, and
others.
  135. When  cachectic  nephritis takes place
after scarlatina, it commences  about the  close
of the third or beginning of the fourth week
from  the appearance of the  eruption.  The
patient, although  he may have previously  re-
covered,  becomes uneasy  and somewhat  fe-
verish.   His sleep is disturbed, his  appetite is
impaired, and  sometimes nausea and vomiting
are present.   A few days afterward,  a puffiness
is noticed about the eyelids, gradually extend-
ing to the face and neck, and thence to the ex-
tremities and trunk.  The countenance,  at the
same time, becomes pale and cachectic.  Some-
times the oedema appears suddenly, and almost
simultaneously, over the whole surface of the
body.   The  urine is commonly much diminish-
ed in quantity, and voided frequently and with
difficulty. It is of a deep reddish  br >wn, and
often  contains a portion  of blood mixed with it.
Generally, a flocculent whitish matter may be
seen  suspended in it, resembling  unclarified
whey, or, when there is any admixture of blood
in the urine, like the water in which raw meat
has been washed.   Its specific gravity is more
or less below the healthy standard.  The  ac-
tion of the heart is frequently strong or tumult-
uous ; the skin is  hot, and the  breathing is
quickened and oppressed.  In  some cases the
head, in  others the  chest, and in others the  ab-
domen, is the chief seat of suffering.   Such
usually is the acute form of the disease  as  oc-
curring consecutively upon scarlatina;  but it
has occasionally appeared more suddenly, par-
ticularly when the  patient  has been exposed,
at or soon after the period of desquamation, to
cold and humidity, and it has then, in a few  ca-
ses, terminated fatally in forty-eight hours after
its appearance, from the supervention of coma,
or convulsions, or  asphyxia.   In  the chronic
state consequent upon scarlatina, there is com-
monly little  or no fever, and the action  of the
heart is  much less exerted.  The  symptoms
are less severe, and more gradual in their  ap-
pearance and progress.  The  urine is  deeply
coloured, but always albuminous, and of lower
density than natural.
  136. In the acute form of the disease conse-
quent upon  scarlatina, vomiting, dilatation of
the pupils,  slowness and  irregularity of  the
pulse,  stupor, coma, paralysis,  convulsions,
cce, sometimes appear, and indicate a most
dangerous affection of the brain, often with se-
rous effusion within the ventricles or under  the
arachnoid.   Pulmonary  complications are very
common in  the acute cachectic nephritis  fol-
lowing scarlatina.  These are  either inflamma-
tion of the bronchi, or of the  lungs, or  of  the
pleura ; or serous effusion in the cavities of the
pleura or in the pericardium, or oedema of  the
lungs, these effusions being consequent upon
an inflammatory or congested state of these
parts, the vessels, owing to the cachectic con-
dition of the constitution,  and to the states of
vital power and of the blood, being  incapable
of throwing out coagulable lymph, but allowing
a liberal discharge of serum.   These inflamma-
tory complications were frequently observed in
the epidemic scarlatina which occurred in Flor-
ence in  1717 ;  and Borsieri remarks, that the
Florentine  physicians  " mortuorum  cadavera
secuerint, inveneruntque  pulmones,  pleuram,
intercostales  musculos, diaphragma, renes, et
intestina plus minusque inflammatione correp-
ta."   Cachectic inflammation of the kidneys
may occur  after scarlatina, the urine being al-
buminous, a'nd yet no anasarca may take place.
Generally, in these cases, there is either a very
scanty secretion or an entire suppression of
urine, and the  patient  is more or less sudden-
ly carried off by internal congestion, or inflam-
mation, or  serous  effusion, stupor, coma,  pa-
ralysis,  convulsions, or asphyxia ushering in
dissolution.  The occurrence of this form of
nephritis after other fevers, as typhoid, remit-
tent, and intermittent fevers, has not hitherto
been observed.
  137. F. Relations of Cachectic Nephritis to
Scrofula.—Most of the instances of this disease
that I have observed have  been in children and
adults of the scrofulous diathesis; and the ex-
perience of  Bright,  Gregory, Christison,
Hamilton,  and Rayer  is  to the same effect.
Strumous children who are insufficiently cloth-
ed and fed, and exposed to cold and humidity,
are liable to be affected with this malady ;  and
some of them possessed of this constitution be-
come the subjects of this form of nephritis with-
out being exposed to these exciting causes  ;
and, indeed, all the patients  who are attacked
with it,  independently of these causes or of in-
temperance, more especially those  who  are
young, present more or less decided evidence
of a  scrofulous taint, which acts,  as  shown
hereafter (§ 148, 152), both  as a predisposing
and as  an  exciting cause.  In many of these
cases, evidence of anterior scrofulous disease
is manifest, while in others scrofulous abscess-
es or diseases of the bones coexist with chron-
ic cachectic nephritis.
  138. G.  The connexion of this malady with the
syphilitic taint has been pointed out by M. Ray-
er ;  and it may be doubted whether or no  this
connexion  is  owing to a syphilitic cachexia or
to the means which had been employed to cure
it, as a liberal or excessive use of mercury.
Wells  and Blackall ascribed the  appearance
of dropsy with coagulable  urine, in  such cases,
to this  particular cause.   In two  cases, both
professional, but not medical men, this form of
nephritis occurred during an advanced stage
of their maladies.   They  both had had severe
secondary syphilitic symptoms, for which mer-
cury had been employed,  and soon afterward
tubercular  consumption manifested itself.  Du-
ring the treatment of this latter, the usual signs
of cachectic nephritis  appeared, and hastened
death much sooner that it probably might oth-
erwise  have taken place.  A similar instance
is recorded by M. Rayer.
  139. H.  The connexion  of cachectic nephritis
with rheumatism has been  insisted upon by Dr.
Christison, who  remarks that, in  every  in-
stance  of obstinate chronic rheumatism that 
750
KIDNEYS—Cachectic Inflammation of the.
comes under his  care, he examines the state
of the urine as to its coagulability and density.
The rheumatic affection  which is sometimes
thus connected is commonly of the neuralgic
kind,  and precedes,  rather than  attends, the
dropsical affection.   This complication occurs
chiefly in those who have been habitually ex-
posed to cold and humidity.   The connexion
of this form of nephritis with gout is compara-
tively rare.
  [Dr. Williams, of London, has recently treat-
ed of this affection (The Med. Times, Jan., Feb.,
1845,  p. 375, &o.) in so able a manner that we
think  some of his views well  worth presenting
to the reader.  Dr. W. does  not regard albu-
minaria as purely inflammatory, but  places  it
under the head of congestive diseases of the
kidney, affecting the cortical structure.  It oc-
curs in two forms, acute and chronic ;  and that
it is the result of congestion simply, Dr. W.
thinks is demonstrated by the fact that, in ca-
ses  of obstructive diseases of  the heart, attend-
ed with great congestion in the venous circu-
lation, the urine becomes albuminous for a time,
and the same occurs whenever any febrile af-
fection supervenes on this congestive state of
the  vessels, the albumen disappearing from the
urine as this affection is removed or diminished.
Hence we often find albuminous urine in con-
gestive fevers, and in the paroxysms of fever,
and  especially  in scarlatina, in  which there
would seem to be a tendency to disease in the
kidney itself.  Hence it is that Bright's dis-
ease is so often caused by exposure to wet and
cold, in persons whose kidneys have been pre-
viously excited by  intoxicating  liquors,  ckc.
Here there is a predisposition to congestion of
these organs, and the influence of cold, acting
on the whole surface, drives  the blood inward,
and the congestion that ensues interferes with
the secreting powers of the kidney, and the se-
rum of the blood passes through unchanged,
but often coloured by blood, and highly charged
with  albumen.   After noticing the symptoms
usually characterizing the acute stage of the
disease, as  pain  and tenderness in the loins,
feverishness, and dry state of the skin, thirst,
accelerated pulse, nausea, vomiting, and vari-
ous nervous symptoms, as delirium or stupor,
anasarca, rheumatic  pains about  the joints,
with  effusions  under the capsules containing
some of the constituents of the urine, he pro-
ceeds to state that fluxes also occur from the
mucous membranes : humid  bronchitis is  fre-
quently present, with diarrhoea, and a variety
of symptoms which arise  from the retention of
urea in the blood, thus poisoning the system,
and producing a noxious effect on all the func-
tions.  These secondary effects, caused by the
retention of urea  and the other constituents in
the  blood, differ according to the predisposition
of the individual; in some we  observe ner-
vous derangement, nausea, vomiting, diarrhoea,
and flux from the mucous surfaces ;  in others,
affections  of the serous  membranes, dropsy,
and low inflammations, &c.   Owing to a dete-
rioration of the red globules, and diminution
of the albumen and fibrin, the  blood becomes
preternaturally thin, hence causing a  disposi-
tion to effusion into the several tissues.   The
prevention of the  proper excretory function of
the  kidney thus impairs the healthy condition
of the blood, and all the other sequelae and com-
plications are owing to this cause.   Hence nu-
trition is impaired—that function by which the
growth  of the textures is supplied ;  but  if it
goes on, the nutritive  material, from the  loss
of colouring matter in the  blood, is of a low or
degraded character, and hence any new depos-
ite that  takes place presents a less organizable
property than in the natural condition, consti-
tuting what Dr. Williams calls the cacoplastic
exudation.  To this cause we trace, in granu-
lar degeneration of the kidneys, the deposition
of tubercle  in the lung ; functional and organic
derangements of the liver; atheromatous de-
posites  in the coals of the blood-vessels,  ren-
dering them brittle, and liable to rupture, and
often leading  to apoplexy ;  hypertrophy  and
dilatation of the  heart are also occasioned by
the same imperfect constitution of the blood,
besides  a multitude of other changes, as chron-
ic diarrhoea,  terminating  in ulceration of the
intestines;  chronic dyspepsia, leading to ulcer-
ation of the  stomach ; and, in short, all the
chronic  diseases of the system.  All these are
referred by Dr. W. to a primary diseased state
of the kidney, leading  to a retention of excre-
mentitious matters in the system,  which, from
their poisonous  effects, sometimes  occasion
coma, stupor, and sudden death.   Scrofula,
or the tuberculous diathesis,  Dr. W. thinks, is
one  of  the causes  of granular degeneration,
inasmuch as  it leads to a degradation of the
textures of the whole system.  Intemperance,
bad diet, and low living are also frequent caus-
es of this affection.  Its connexion with gout
and  rheumatism, and  chronic diseases of the
heart, is too obvious to dwell upon.  Conges-
tion of the heart from functional disease of the
organ will, sooner or later, terminate  in struc-
tural disease.  Owing to the impaired secretion
of the kidneys consequent on such congestion,
superfluous or morbid matters are retained in
the  system, and  are liable to be  deposited in
the different organs. In chronic albuminaria, as
remarked by our author,  the kidneys become
contracted and atrophied, owing to a wasting
of the  texture, as in cirrhosis of the liver.
This is occasioned probably  by the deposition
of the granular matter  around the vessels, thus
compressing  their structure ;  and as  the  ves-
sels  are pressed  upon, the blood is unable to
pass through them ; the nutritive supply is thus
cut off,  and there is a wasting away of the tis-
sue,  causing a reduction in the  bulk of the or-
gan  in  proportion  as  the disease advances.
Owing to the same cause, the quantity of albu-
men and urea in the urine is diminished,  and
the watery portion increased ; there is no room
for the solid parts of the urine to pass  through,
and the  watery portion alone  is excreted.]
  140. iv. Nature of Cachectic or Albumin-
ous  Nephritis.-■—From what I  have already
stated with reference  to  the causes  and  the
associations, or complications of this  malady,
views as to its nature,  and more especially the
one entertained by the author, may be readily
understood.   Hitherto  it  has  not  been suffi-
ciently considered as a merely secondary  dis-
ease, all the phenomena in any way connected
with  it  being considered rather as signs  and
symptoms of its pre-existence, in some one or
other of the forms of lesion  described above
(y 100, et seq.), than as concomitant changes,
many of which depend more  upon antecedent 
KIDNEYS—Cachectic Inflammation of the.
751
disorder than upon the associated or otherwise
related  affection of the kidneys.  The ques-
tions, therefore, are : 1st. In what does this pri-
mary disorder  consist ?   2d. In what manner
does the renal malady arise consecutively upon
it 1 and, 3d. Wherefore is this consecutive dis-
ease so very generally associated with others,
in some part of its course 1  What has already
been  advanced  will render it  unnecessary to
enter upon lengthened  details in  answering
these questions.
   141. 1st.  The  several  circumstances con-
nected with the origin of the malady—the pre-
disposing and the concurring and exciting caus-
es ; the existence and the character of antece-
dent disorder affecting either the  general con-
stitution or the  functions of some vital organ—
all combine in evincing that the earlier morbid
states are impaired  organic  nervous power,
and, consequently, insufficient sanguification
and assimilation, with disordered secreting and
excreting functions.   It  will  necessarily fol-
low, even from  an early stage, or from a slight
grade  of these  morbid  conditions, that the
blood will be more or less affected, and that a
change in the blood will, according to the na-
ture of such change, affect also other organs.
   142. 2d. It is difficult to state with  any de-
gree of precision  what are  the  changes which
impaired organic  nervous power,  and  conse-
quently weak digestive and assimilative func-
tions, will produce in the blood  at early stages
of their existence ; but, in more prolonged pe-
riods of their  influence, the results are  fre-
quently remarkable to the senses, although not
so precisely determined by chemical or physi-
cal analysis.  It is probable, from the  results
of observation  and of analysis  as partially em-
ployed, and from analogy, that  the chyle is not
fully elaborated in the first instance, and sub-
sequently changed into healthy blood ; that the
serum contains more oily or fatty matter than
natural, the result of insufficient assimilation ;
and that the several constituents of  the blood,
in relation to each, other and to the  system in
which they circulate, are held together by a
weaker vital affinity.   During this state of the
organic nervous power and of  the circulating
fluids, the excretory  functions  necessarily be-
come impaired; and, although  those substan-
ces which are the ultimate results  of assimila-
tion  may not be abundantly produced, certain
of them, as urea, may be present in  excess in
the blood, owing to insufficient excretion, es-
pecially by the  skin and kidneys.   The result-
ing morbid condition of the blood will thus be-
come an exciting cause of vascular disease of
the kidneys progressively advancing to organic
change ; and, once these important eliminating
organs  are diseased, the  blood  will  become
more and more altered, and sanguification the
more impeded  or  altogether arrested.  In all
cases, also,  both kidneys will be affected ;  for
as in other diseases, where the causes are con-
stitutional, consisting of cachectic states, or of
changes in the  blood, double organs, or similar-
ly constituted tissues, will  experience similar,
or even identical changes.
  143. 3d. The  chief reasons  for the appear-
ance of cachectic  nephritis in connexion with
other maladies are apparent in the very condi-
tion or circumstances of the constitution, and of
the health of persons in which it occurs.  There
is not only the pre-existing impairment of the di-
gestive and assimilating powers just insisted
upon, but there are also, in many cases, other
antecedent maladies, which are always attend-
ed by weakness of these functions, as phthisis,
scrofula, scarlet fever, &c, and which readily
give rise, especially in certain states  of predis-
position, to the renal malady as a secondary or
more remote effect.  In these cases, the associa-
ted or related disease is primary, and favours
the production of that state of  the blood which
affects the circulation, and ultimately  the struc-
ture of the kidneys.  Other complications are
either associated results of the previous disor-
der—are equally with the renal malady effects
of the previous changes in the  states of organ-
ic  nervous energy, and of the  blood—or they
are consequences of the disease of the kidneys,
through  the  medium of the blood,  a  morbid
state of this fluid being much increased by the
affection of these organs ;  and being such as
readily inflames or irritates parts which, from
predisposition, former disease,  or the influence
of concurring causes, or prevailing influences,
become more liable to those consecutive affec-
tions.
  144. The  dropsy  so generally attending this
malady arises from more than one of the path-
ological states  constituting it.  In the  acute,
or early state  of the  disease, and especially
when it is consequent upon scarlatina, the an-
asarca is chiefly owing to the  weakened vital
affinity subsisting between the  constituents of
the blood, and to the weakened tone of the ex-
treme capillaries.   Probably something is also
owing to the suppressed functions of  the skin :
exhalation from the external surface  of the in
teguments being interrupted,  it becomes in-
creased into the areolar tissue.  The action ol
the kidneys  is also impaired  in most of the
acute states  of the disease ; the watery parts
of the blood become excessive ; excrementitial
plethora is thus produced, and effusion takes
place from  the  overloaded vessels.  In  the
chronic and far  advanced states of the disease,
the dropsy is owing chiefly to the change in
the blood itself;  to its thin and impoverished
condition, and to impairment of the vital affin-
ity  between its several  constituents, and be-
tween it and the blood-vessels.   That the drop-
sy is not owing to  excess  of serum, is shown
by  its coexistence  with  a free discharge of
urine, and with diarrhoea, and with an anaemic
state of the vascular system,  in many instan-
ces.  It may, however, be increased by the sup-
pressed perspiratory functions  of the  skin.*
  145. v. Prognosis.—The very  serious  and
dangerous  nature of this disease  may be  in-
ferred from what has already been stated  re-
specting it.—A. In the acute state, death some-

  *  [N. Corrigan makes two distinct varieties of this dis-
ease (Lond. Med. Times, April 5, 1845), corresponding to
the  acute a»d chronic states of Copland and Williams.
In the first, he says that " the kidney  becomes larger than
natural, of a mottled yellow colour, which gradually spreads
over the whole  gland, and the tubuli  uriniferi extend far
towards the cortical part of the kidney.  In the other va-
riety, the kidney becomes smaller than  in health, the tubuli
uriniferi traverse a much greater space through the kidney
than in the former, running, in this variety, almost to the
capsular covering ; its surface becomes studded with mi-
nute tuberosities, which project above the capsule, as if nu-
merous grains of small shot were irregularly distributed
through, and sunken into, the cortical portion of the kidney ;
the two varieties corresponding, in fact, to hypertrophy and
cyrrhosis of the liver.] 
752
KIDNEYS—Cachectic  Inflammation of thk.
?imes takes place suddenly, owing to the rapid
development of disease  in the brain, lungs, or
pericardium.   Hence the propriety  of attend-
ing to the states of these organs as long as the
urine continues to be albuminous or sanguino-
lent.  This form of the disease is less danger-
ous when it occurs after scarlatina, or during
the early stage of pregnancy, than in other cir-
cumstances.   The nature of the chief causes
should always be considered before  a prog-
nosis be given in  any case ; for when the mal-
ady  proceeds  chiefly  from intemperance, the
chance of associated visceral disease, although
it may not be very manifest, and the danger,
are always increased.  The prolonged influence
of cold humidity, and  of low or damp residen-
ces, generally occasions a more dangerous mal-
ady  than the  temporary  operations  of these
causes.
  146. B. In the  chronic form, the prognosis is
still  more unfavourable than in the acute : a
fatal issue may be more remote, but it is more
certain ultimately.  As long as the  urine  is
coagulable, and of diminished density, the  pa-
tient is in a most  precarious state, from the
tendency  in these  circumstances to  dropsy,
pleuritis, pericarditis, cerebral  affections,  and
to various other maladies, which assume the
most dangerous  forms when  associated with
renal disease.   Any marked diminution of the
quantity  of urine, when  it is of morbid  corn-
position, should  always be viewed with great
suspicion,  as  often preceding  the maladies
now mentioned.   A still more remarkable dim-
inution of the quantity of urine, or  its entire
suppression, is generally a precursor of a cere-
bral  attack, and  of a fatal issue.   The more
manifest, also, the cachectic  state of the con-
stitution, and  the more important the affection
complicating the renal  malady, the more  un-
favourable does the prognosis  necessarily be-
come, and still more so when these two cir-
cumstances are conjoined in  the same case.
   147. An increase of the quantity  of urine,
relatively to the amount of fluid taken, coinci--
dently with a diminution  of the dropsy and of
the albumen in the urine, is generally a favour-
able omen ; but, unfortunately, it is not rare to
see this change arrested suddenly in the course
of a few days, and followed by an increase of
all the  symptoms.  A  return  of  the specific
gravity of the urine to the natural state, owing
to an increase of the urea and salts  naturally
existing  in it,  coincidently with a marked dim-
inution of the albumen, is a very favourable
circumstance; but it is very rarely  observed
in the chronic form of the disease.  The dimin-
ished density, on the other hand, of the urine,
is an unfavourable circumstance, more partic-
ularly if the quantity voided  be not augment-
ed.  Upon  the  whole,  the prognosis in  this
form of the disease  should  depend upon  the
number  and nature of the primary concomi-
tant or consecutive affections complicating it,
rather than upon its duration and history.   Of
these affections, some  are acute, as cerebral
attacks,  pneumonia,  pericarditis,   &e,  and
speedily fatal; others are chronic, as scrofula,
tubercular consumption, organic lesions of the
stomach, or of the liver, or  of the heart,  the
syphilitic cachexia, &c, and place  the patient
in equal, although not in so immediate danger.
   148. vi. Remote Causes.—A. The predispo-
sing causes of cachectic nephritis are whatever
depresses vital power, and tends lo render the
system  cachectic.  The  scrofulous diathesis
and a syphilitic taint, the former especially, fa-
vour the operation of the more direct or exci-
ting causes.  This  disease  rarely attacks in-
fants, or very aged persons ;  but it  is frequent
in children, in the acute form, chiefly as a se-
quela of  scarlatina, and occasionally in the
chronic form in  children of the scrofulous di-
athesis, both primarily and consecutively upon
scarlatina, and  upon febrile or other disor-
ders.   It is most prevalent in cold and humid
countries, and in places where spirituous liquors
are most indulged in.  It occurs more frequent-
ly in males than in females, probably in conse-
quence of the former being more exposed to its
exciting causes  ; and it is most prevalent be-
tween the ages  of twenty and fifty.  My own
observation fully confirms the following state-
ment of Dr. Christison. In the greater pro-
portion of cases,  he observes, in  almost all
those of a chronic nature, as well as in  a few
of the acute, the disease appears to be formed
gradually, without any obvious exciting cause,
under the influence of some  depraved state of
the constitution.  And  even in  many of the
acute cases, arising apparently in decided ex-
posure to cold, the malady has silently origina-
ted in some constitutional cause at an earlier
period, recent exposure having merely super-
added some acute secondary affection, or given
an acute  character to  pre-existing essential
symptoms.  It is clear, too, from the character
of the disease in the generality of instances, as
well  as  from  the very  peculiar nature of the
morbid deposition in all, that there must al-
ways coexist  some constitutional infirmity, or
otherwise some essential predisposing cause.
This circumstance, however, does not exclude
from the disease the constitutions of the robust
and athletic.  Dr. Christison has several times
witnessed it in persons of robust habit and pow-
erful frame; and M. Solon makes the  same
remark  as to his experience.  But a robust
frame is not incompatible with infirmity of con-
stitution in respect of morbid predisposition, as
is familiarly exemplified by phthisis.
   149.  In  this country, that  state of constitu-
tion which results from habits of intemperance
is the most influential in predisposing to the
disease.  Dr.  Christison remarks, that  from
three fourths to four fifths of the cases he has
met with  in Edinburgh  have been in  persons
who were habitual drunkards ;  or who, without
deserving this appellation, are in the constant
practice of using ardent spirits several  times in
the course of the day,  and of occasionally in-
dulging to intoxication.   In these persons, this
habit is both  a predisposing and an exciting
cause, no other remote cause concurring to
develop the morbid conditions constituting the
disease.  In most  of the cases that thus ori-
ginate, we find  both tubercular liver and gran-
ulated kidneys,  and the resemblance between
both  kinds of lesion  is  very close.  In many,
however, of the  cases which  appear thus to ori-
ginate, it will be found  upon a strict examina-
tion—upon inquiring into their previous  states
of health, their hereditary predispositions, their
apparent diathesis, and the evidences of either
external  or internal  pre-existent affections—
that  they present more or less   conclusive 
                        KIDNEYS—Cachectic

 proofs of the scrofulous constitution ; habits of
 intemperance, and various other concurring or
 exciting causes, chiefly aiding this condition in
 originating the disease.  The frequency of its
 occurrence in  persons who have  had enlarged
 or inflamed glands, or have presented other evi-
 dence of scrofulous or tubercular affections in
 early life, and in persons labouring under tuber-
 cular consumption, is an additional proof of the
 truth of this inference.  Among  this class of
 causes, intemperance in sexual  indulgence and
 manustupration may be added.*
   150.  Previous disease of the digestive,  as-
 similating, and circulating organs of the stom-
 ach, liver, lungs, and heart—tubercular forma-
 tions, and continued and eruptive fevers, more
 especially scarlatina—favour more or less  the
 occurrence of this malady.  In many instances
 scarlet fever both predisposes to  and more di-
 rectly occasions it;  no other causes but this
 being apparently concerned in producing it.
   151. B. Exciting Causes.—a. Exposure to cold
 and humidity, or to either singly, and whatever
 has the effect of suddenly checking perspiration,
 as drinking cold fluids when the skin is  perspi-
 ring, are the most frequent causes of the acute
 state of the disease;  which most frequently
 occurs in persons who are most exposed, by
 occupation, to those causes and to vicissitudes
 of temperature, or who live in  cold and damp
 cellars or localities.  These causes also often
 co-operate with others, not only in originating
 the  malady, but also in producing relapses or
 exacerbations.  They frequently,  even  in their
 slighter grades, are more or less  influential in
 developing  the  disease  after  scarlatina, espe-
 cially during or soon after the  period of desqua-
 mation.
   152. b. The chronic form of  the disease is
 generally occasioned either by intemperance or
 by the  prolonged influence of cold, humidity,
 and low,  damp residences, or by both  classes
 of causes.   M. Rayer  considers cold and damp
 the most frequent cause of the disease in France.
 Poor, innutritious, or unwholesome food, phys-
 ical misery and destitution, are  also influential
 in producing it.  The inordinate or liberal use
 of mercury was considered by Dr. Wells and
 Dr.  Blackall to be occasionally productive of
 albuminous urine ; but Dr. Rayer has met with
 no proof of this effect of mercury.  He states
 that pregnancy seems to give rise to an albu-
 minous  state of the  urine.  I have seen two
 instances of this change in the  urine in preg-
 nant females, but had no opportunity of ascer-
 taining the results in these cases.   The pre-ex-
 istingdiseases which seem to be most influential
 in exciting, as well as in predisposing to cachec-
 tic nephritis, are scrofula, scarlatina, disorder
 of the functions of digestion and  assimilation,
 diseases of the lungs, of the heart, and of the
 liver, and the syphilitic taint.  It appears in the
 advanced  course of tubercular consumption in
 a very large proportion of cases, and is  always
 the consecutive affection, as  remarked by M.
 Solon and Dr. Christison ; but  this connexion
 of the disease is more fully insisted upon above
 (_v_125)._______________

  * [Alcoholic liquors, we believe, are by far the most fre-
quent cause of this disease in the United  States; indeed,
among the many cases we have seen in hospital, dispensary,
and private practice, in adults, we recollect none in which
stimulant drinks have not been freely used.]
    II.               95
 Inflammation of the.                    753

   153. vii. Treatment.—The treatment of this
 disease should depend  much upon the form it
 assumes, upon its stage  or duration, upon the
 causes which have  induced it, and  upon the
 complications it presents.—A.  In the acute form
 and early stage of the  disease, the treatment
 should be decidedly antiphlogistic, but yet with
 strict reference to the predisposing and exciting
 causes. — a. Blood-letting, general or local,  is
 always necessary, especially at the commence-
 ment of the disease; and it should be carried
 to an amount which the  circumstances of the
 patient and the degree of febrile action will sug-
 gest.  In the majority of cases, cupping on the
 loins is the  most appropriate method of vascu-
 lar depletion ; but,  in the most acute states,
 and in  more  robust persons, a general blood-
 letting should be premised ; and, in these, cup-
 ping on the loins may be even repeated in some
 instances. In children, after scarlatina, cupping
 should be the chief or only mode of depletion.
   154.  When the anasarca is great, venesection
 should be practised with caution,  as respects
 this operation itself; for, although there is a
 necessity for blood-letting,  there  is a great
 tendency to inflammation of the vein, if the in-
 cision be  imperfectly closed, or exposed to the
 air.   It is chiefly in the febrile, acute, and early
 stage of  the  disease, that  vascular depletion
 can be employed with advantage, and especially
 when the disease is  caused by exposure to cold
 and humidity.   When acute or sub-acute symp-
 toms appear in the course of the chronic form
 of the malady, even local depletions should be
 practised with caution ; the previous and pres-
 ent states of the disease,  the  complications,
 and the constitutional and vascular conditions
 being the only  guides  by which the  practice
 ought to be directed.  In most cases, cupping
 is a preferable mode of depletion to the appli-
 cation of leeches,  inasmuch as the quantity
 and  state of the blood drawn are  more accu-
 rately ascertained by the former, and erysipelas
 is less likely to follow it than the latter.
   155. b.  In the acute  and early stage of the
 malady, the warm or vapour  bath may he em-
 ployed, and  be aided by warm bed-clothes,  so
 as  to promote  the cutaneous transpiration.
 Diaphoretics may also be prescribed ;  and their
 operation may  be assisted  by warm diluents,
 demulcents,  &c, containing small quantities
 of nitre, or  the spirits of nitric ether.  If the
 patient  leave  his bed, especially if the season
 be cold, the clothing should be warm,  and  he
 ought to wear flannel from  head to foot, and
 avoid currents of cold air and stimulant bever-
 ages.
   156. c.  Purgatives are always requisite, and
 the  more so when the  dropsical  effusion is
 great.   They ought to be exhibited  at the com-
 mencement of the treatment, and instantly after
 the first blood-letting.  The selection of purga-
 tives should be guided by the complications, by
 the form and amount of the dropsy, and by the
 state of the urine.   The compound jalap pow-
 der,  elaterium,  gamboge, the more  common
 purgative pills (see Appendix), the saline aperi-
 ents, &e, may be prescribed  according to cir-
 cumstances, and to  the states of the stomach
 and bowels.   When vomiting, or much irrita-
 bility  of stomach is present,  blood-letting,  as
just advised, will often allay this symptom, and
prepare for the exhibition of purgatives, which 
754                    KIDNEVS—Cachectic Inflammation of tub.
may be conjoined with colchicum ;  but if this
symptom continue, creasote or the hydrocyanic
acid will generally allay it.  Dr. Prout remarks
that, when  the  more  active  symptoms  have
subsided, the purgatives may be associated with
diuretics ; or the diuretics may be given alone,
as the case may indicate.   Of diuretics, the
nitrate, tartrate,  or  super-tartrate  of potash,
conjoined with nitre and the spiritus aetheris
nitrici, are among the best, and may constitute
a part, at least, of the prescription.   Blisters
are doubtful remedies ; though, if not kept ap-
plied too long, they may be sometimes useful.
But strong  mustard poultices,  or  other irri-
tants producing  speedy and  decided effects,
are  preferable.  When diarrhea accompanies
this state or stage of the disease, warm baths,
small doses of opium, or of  Dover's  powder,
and leeches applied to the perinaeum or anus,
are the most beneficial remedies.
   157. When the urine has assumed its usual
quantity and properties, we may conclude that
the acute state has subsided;  though the urine
will be found to contain more or less serum for
a considerable time subsequent  to  the attack,
particularly after meals.   In  the latter stages,
purgatives must be given with caution ; but di-
uretics are  occasionally required to the last;
and warm baths are often of service, particu-
larly when they are used by the bedside  of the
patient, and shortly before the hour of repose.
If, after a week or two, the quantity of albumen
in  the urine again become  increased, and if
other signs of a  recrudescence of the renal dis-
ease be present, cupping on the loins should be
repeated, and this may be followed  by the ap-
plication of external  irritants, and these  by
emollient  cataplasms  in the same  situation.
During the  acute stage of the disease, the diet
and regimen should be antiphlogistic. M. Rayer
states that he has found a milk diet, continued
for some days after the subsidence of the acute
symptoms, of great service.
   158. B.  Treatment of  the  Chronic  Form.—
While the  treatment  of the acute disease is
simple, that of the chronic is difficult and com-
plex ;  and while it is often  efficacious  in the
former, it is generally ineffectual in the  latter.
In the majority of cases, all that we can hope
to effect is, to arrest or suspend the morbid ac-
tion ;  a complete cure is  hardly  within our
reach.   The  treatment, nevertheless, should
embrace the various considerations suggested
by the states  of  the urine and kidneys, by the
attendant  dropsy, by  the constitution of the
patient, and by  the  antecedent disorder and
present complications.
   159. a. Whenever there is reason to suspect
the existence of active  congestion of the kid-
neys, either from a feverish state of the system
or from local  uneasiness, cupping on the loins
may be resorted  to; but we should be careful
not to employ too large depletions, more espe-
cially when the renal malady has been prolonged
and is far advanced, or structural  lesion very
serious.  Great mischief will be done by low-
ering the powers of life in these circumstances,
and the local change will be increased  rather
than diminished by the depletion.   Unless at a
very early  stage of the chronic  malady, the
morbid state of the blood, and even its deficien-
cy, forbid the abstraction of it unless in small
 or moderate quantity, when  the supervention
of acute or sub-acute symptoms, or of inflam-
matory attacks of other organs, as of the pleu-
ra or lungs,  demands a recourse to this meas-
ure ; for the  occurrence of these attacks during
the course of the renal disease is the conse-
quence of the attendant state of the blood chief-
ly, and not of the lesion of the kidneys per sc—a
state of the blood which generally contra-indi-
cates vascular depletion,  although the nature
of the complication may seem to require it.  The
circumstances which more especially should
suggest great caution in prescribing even local
depletion are, debility and a manifest cachectic
appearance consequent upon previous ill health,
or a chronic continuance  of the renal disease
The coexistence  of chronic incurable maladies,
as tubercular phthisis, lesions of the heart and
valves,  particularly insufficiency of the valves,
organic changes in the stomach, altogether con-
tra-indicates  a recourse  to general  or  local
blood-letting.
   160.  b. In the  chronic as well as in the acute
form  of the  malady, warm or vapour  baths,
flannel  clothing  next the skin, and the avoid-
ance of cold, humidity, spirituous liquors, and
other exciting causes, are requisite.   M. Ray-
er states that he has found setons, issues, and
other exutories in the loins very advantageous;
and that from four to twelve drops of  the tinc-
ture of eantharides, given for a dose  in some
emulsion, have also been of service.  I have
given equal quantities of  this tincture with the
tincture of   the  sesqui-chloride of iron, with
marked benefit, in a few instances.  Ioduretted
and mercurial ointments  have been prescribed
to the loins  without any service ; and the bal-
sams have been  taken internally with little or
no advantage.
   161.  c. In the more advanced states of the
disease,  the  preparations of  iron,  judiciously
 chosen, and combined with other medicines, arc
 often more or less beneficial.  I have seen more
 advantage derived from  them  than from any
 other class of medicines.   Tho circumstances
 of particular  cases  can  alone suggest those
 preparations which should be selected.  When
 the dropsical effusion indicates a  recourse to
 hydrogogue cathartics or  to  diuretics,  some
 preparation of iron should be added, particular-
 ly when  debility or  cachexia  is very manifest.
   162.  d. Of all diuretics, M. Rayer prefers a
decoction of the wild horseradish.   It may be
 made a vehicle for other medicines.   He agrees,
however, with Dr. Bright in having little con-
fidence  in the most  of diuretic remedies, and
thinks that  Dr. Christison has overrated their
value.   In this disease, many substances disor-
der the stomach, thereby farther impair diges-
tion and assimilation, and accelerate  its unfa-
 vourable progress.  Many diaphoretics, partic-
ularly when given in full doses, have this effect,
as Dover's and James's powders.  The decoc-
tion or tincture of guaiacum is the best of this
class of medicines,  especially when the skin is
cool as well as dry.  Diaphoretics, diuretics,
 and purgatives or aperients, when clearly indi-
 cated,  should be selected and  conjoined with
 strict reference  to the states of the  digestive
 organs, of the vital powers, and  of the circu-
 lating fluids, as  shown in preceding  sections.
 It  is chiefly owing to a neglect of such refer-
 ence that an injudicious  recourse to punctures
 of the skin has been had  in this disease, in or- 
KIDNEYS—Cachectic Inflammation of the.                   755
der to allow the escape of  the effused fluid.
The states of the system just alluded to favour
the occurrence of inflammation and consequent
gangrene of the  punctured parts.  Dr. Prout
advises a recourse to a seton or issue in the
region of the kidneys, and to the infusion of
diosma with sarsaparilla.  As a  diaphoretic he
prefers the citrate of ammonia, and, as the dis-
ease proceeds, the pareira brava, or the uva ursi,
combined with other medicines, according to
the circumstances of  the case.
   163. C.  The  treatment of the complications of
cachectic nephritis is always difficult and often
hopeless.  When they assume an acute form,
they must be promptly met, and  subdued or ar-
rested within twenty-four hours from their ap-
pearance.  If they are of a  chronic kind, we
can expect only to palliate the more urgent
symptoms.  Of the diseases which are associated
with the  renal malady, it will  be necessary to
notice the treatment only of a few;  for the
means which are appropriate to the rest are
either so manifest, or depend so entirely upon
the circumstances of individual cases, that the
physician will readily perceive them, and apply
them accordingly.
   164. a. In relation  to diseases of the digest-
ive organs (y 114), the treatment of cachectic
nephritis requires the utmost  attention to diet
and regimen.  The food should consist of arti-
cles which are the most readily assimilated, es-
pecially of the lighter kinds of animal food, and
of  milk  boiled  with farinaceous substances.
The bitter tonics, sarsaparilla with liquor po-
tassae, or lime-water, or with Brandish's alka-
line solution, and other restoratives, are espe-
cially  necessary when the dyspeptic affection
is attended by acidity and flatulence.  In these
as well as in other circumstances, the prepara-
tions of  iron,  but  especially the Mist. Ferri
Composita,  are also beneficial,  and should be
taken  for a considerable  time.   When irrita-
bility of  stomach or  vomiting is present, crea-
sote, with or without  opium, is a valuable med-
icine.   When  the bowels  are  also  irritable,
opium or morphia may be combined with crea-
sote with advantage; but, in  other cases, the
latter may be given with bitters  and aroinatics.
Hydrocyanic acid may also be prescribed in sim-
ilar combinations.    If diarrhea  be present,
opium, cretaceous mixtures or powders, lime-
water, and aroinatics, are requisite.   In either
of these  affections, also,  embrocations or fo-
mentations may be applied over the epigastrium
and abdomen, consisting chiefly of rubefacient
and discutient  substances,  as the turpentine
embrocation, &c.  In the more obstinate cases
of diarrhoea, the sulphate of zinc or of copper,
or the nitrate of silver, or the acetate of  lead,
may be given with opium,  &c.   If peritonitis
supervene,  vascular  depletion   ought to  be
promptly prescribed; but with the knowledge
that in most states of the disease, and in the
more  advanced stages especially, the loss of
blood  is not attended by much advantage.  This
is particularly the case if the dropsical effusion
is considerable,  and leucophlegmasia or ca-
chexia manifest.  The peritonitis, in these cir-
cumstances, is  most successfully combated by
fomentations with warm turpentine applied over
the abdomen, and by opium with camphor ta-
ken internally.   Lesions of the  liver or spleen,
even  when recognised, are  hardly influenced
by medicine, when  associated with this  mala-
dy.  The exact nature of the hepatic lesion
frequently cannot be  ascertained  during life;
and, if correctly inferred, the most appropriate
treatment is neither  manifest nor generally
beneficial.   In these,  as well as in other unfa-
vourable complications, the  chief indication is
to support the powers of life  by  attention  to
diet, by residing in  a  dry and warm air, by ta-
king gentle  restoratives with alteratives, and
by attending to the  alvine excretions.
  165. b.  The associations of this  disease with
affections of the  respiratory passages and lungs
require  the most cautious use of the remedies
usually  prescribed for either the former or the
latter;  and  those which are most serviceable
for the  one are most injurious for the other.
—a. Bronchitis is generally extended  to both
lungs; and,  although it  may  be  slight  for a
time, it may be suddenly aggravated so as
speedily to terminate  life.   In most cases, the
treatment advised for  the more asthenic states
of Bronchitis (§ 81, et seq.) should be  prescri-
bed.—/?. Pneumonia, also, when it  occurs, gen-
erally affects both lungs, and is often of the kind
usually denominated asthenic or nervous.  Un-
less in the earlier stages of the nephritic disease,
and in the more robust subjects, vascular deple-
tions are seldom beneficial in these complica-
tions.  A free use of tartar emetic,  aided by ex-
ternal derivation, is much more deserving  of
confidence, especially in pneumonia, than deple-
tions ; but all means often fail in these cases.
—y. The same-remarks are applicable to pleu-
ritis, when it appears  in the course of this mal-
ady.  The disposition to effusion requires the
prompt use of suitable  means ; but these means
are not the  same as  are generally found ser-
viceable in the early stages of common pleuri-
sy.  Blood-letting  and mercury must  be spa-
ringly, cautiously,  or not  at all  prescribed;
while the repeated application of  blisters,  of
the turpentine fomentation, &c, and a recourse
to the hydriodate of potash internally, with oth-
er means suggested by circumstances, are most
to be depended upon.—(J.  When the nephritic
malady  arises in the course of phthisis (t) 125),
the latter is generally accelerated in its prog-
ress, whatever treatment may be adopted.  As
diarrhoea still continues to be more or less dis-
tressing, astringents,  absorbents,  and opiates
are requisite, especially the sulphate of iron or
of copper, with opium  and creasote.  The con-
secutive anasarca is  commonly attended by a
subsidence  of the  colliquative perspirations,
and is sometimes diminished by a  frequent re-
course to the vapour  bath;  but the benefit  is
never permanent. Indeed, no plan of treatment
is found of lasting service in this complication.
I have employed the  Mistura Ferri Composita,
or  other preparations of iron,  conjoined with
other medicines suited to the circumstances of
the case, in this complicated state of disease ;
and although, in some instances,  benefit was
manifestly derived  from them for  a time, an
unfavourable issue  ultimately occurred.
   166.  The  associations  of cachectic  nephritis
with diseases of the heart and vascular system
($ 126)  are  no less hopeless than  those with
maladies of the lungs.  The lesions of  both the
kidneys and the heart are reciprocally aggrava-
ted by association with each other.   Even when
recognised during early periods of the compli- 
756                    KIDNEYS—Cachectic Inflammation cf the.
cation, treatment has little influence in arrest-
ing or in impeding the progress of either.   The
means most influential in producing the  latter
effect are those which promote digestion, as-
similation, and free excretion.   To support the
powers of life, and at the same time to procure
the discharge, by the several emunctories, of
assimilated, effcete, and injurious matters, are
the chief intentions  by  which the treatment
can be directed.   These  being recognised and
guiding our practice, the choice of means should
altogether depend upon the features of individ-
ual cases.
   167. d.  The association of this disease with
cerebral affections (y 131) is  chiefly  contingent
upon  the  acute  state of the  former, and  are
then owing to imperfect assimilation and  ex-
cretion, and to consequent  excrementitious
plethora ;  congestion or  serous effusion  being
thereby much more frequently produced than
organic lesion  of the brain  itself.  In  those
more  acute states of this complication, cupping
over the mastoid processes, or on the nape of
the neck, blisters in these  situations,  active
purging, stimulating embrocations on the loins,
and the other means advised for the acute form
of this malady, (y 153) are to be chiefly resorted
to. When cerebral affections occur in the ad-
vanced course of the chronic state of cachectic
nephritis, they depend almost entirely upon ex-
hausted vital power, in connexion with vascu-
lar inanition ; coma or lethargy being the most
frequent forerunners of dissolution.
   163. e.  Cachectic  nephritis  consequent upon
scarlet fever (y 133)  is  the  most  favourable
form of this malady ;  and when it assumes the
acute  state, the treatment should not materially
differ from that advised  above (y 167).   Gen-
eral or local blood-letting, purgatives, vapour
or  warm  baths,  diaphoretics, diuretics, and
warm demulcents, the warmth of bed, warm
flannel clothing, and  removal to  a warm, dry
air, are the chief means of cure.   If the dis-
ease be unattended by fever, if it become chron-
ic, and the powers of life sink, stimulants and
restoratives,  particularly the  tincture of  the
sesqui-chloride of iron, with the tincture of can-
iharides,  warm,  medicated  baths,  embroca-
tions, blisters, &c.,over  the loins, are then re-
quired.  If complications appear  in this state
<>f the disease, they must be treated conform-
ably with the principles already insisted upon ;
but this subject is more  fully  discussed in the
article on  Scarlet Fever.
   169. /.  The treatment of the other associations
of cachectic nephritis mentioned above hardly
requires farther remark.   When the disease is
very obviously complicated with  scrofula, and
particularly with  scrofulous  abscesses  or ul-
cerations, the Mistura Ferri Composita, liquor
potassae, with small doses of the  iodide of po-
tassium,  sarsaparilla, the iodide of iron, &c,
and other restorative remedies,  with  change
of air, or change to a dry and warm atmosphere,
and attention to the digestive, assimilating, and
excreting  functions, are most  deserving of at-
tention.  The frequent occurrence of the dis-
ease in the scrofulous diathesis indicates  the
propriety of having recourse to the same means
as have been found most beneficial in scrofu-
lous affections.  The appearance of cachectic
nephritis during secondary syphilis  (y 138), or
consequent upon  it, although  occasionally ob-
served, has not been satisfactorily elucidated ;
inasmuch as it is not proved whether or not
the renal disease is a consequence of syphilis,
or of the inordinate use of mercury in the treat-
ment of it.   The two cases alluded  to above
(v 138) occurred in scrofulous  constitutions ;
mercury was largely employed ;  the secondary
symptoms became aggravated, phthisis super-
vened, and in this state they came under my
care.  Hydriodate of potash with  sarsaparilla
was then prescribed, and, during the  use of it,
and in an advanced state of the pulmonary dis-
ease, albuminous urine and anasarca appeared.
These cases prove  only the tendency of this
disease to appear whenever a state of general
cachexia is produced by causes  depressing vi-
tal power, and impairing the assimilating pro-
cesses so as to overturn the healthy crasis or
constitution  of the blood.   I have never met
with an instance of this disease connected with
'rheumatism, unless where the treatment has
been of a lowering kind ;  and in this complica-
tion  the preparations of iron, quinine, and cam-
phor  have  been  generally prescribed  with
greater benefit than any  other  medicines.   I
have generally preferred the following, or sim-
ilar combinations:
  No. 283. R Ferri sulphatis,- Quiniie  sulphatis, SB 3).;
Camphors rasie, jss.; Extract. Aloe's purif., 3j.; Extr. Hu-
muli (vel Extr. Hyoscyami), 3ij. ; Mucilag. Acaciie, q. s.
M.  Contunde bene et divide in Pilulas xxxvj. quarum ca-
piat duas vel tres, bis terve quotidie.
  [The treatment of acute albuminaria, accord-
ing to Williams (loc. cit.), consists of four in-
dications.  The  first indication  is, to remove
the congestion ;  the second, to restore the se-
creting  function of  the kidney; the third,  to
counteract  the effects of the diseased state of
the blood ;  and the fourth and last, to treat the
various symptoms of disease that may arise
out of this disordered condition of the blood.
The  first indication will be effected by the  rem-
edies for congestion, especially  blood-letting
and cupping at the loins.  This remedy should
be employed freely, in proportion to the strength
of the patient and the fulness of the blood-ves-
sels. This is to be aided by derivatives. Hydra-
gogue purgatives tend to diminish the amount
of blood in the  system, and to drive out its
watery parts.  One of the best of these is cream
of tartar, or combined with jalap, but in its gen-
eral  effect it is better alone ; or half  an ounce
of it may be combined with half a  grain of ela-
terium, unless the latter prove too nauseating.
The  indication of derivation may be powerfully
aided by sudorifics, by warm or vapour baths,
and by the hot air bath.  Where  the circulation
is excited, antimony, with Dover's powder, for
the purpose of increasing the cutaneous secre-
tion, will prove useful after active congestion
has been relieved.   Diuretics will be proper:
among the best  of these are the  tinctures of
digitalis and cantharides, super-tartrate of po-
tass  in  small  doses, combined with opium, or
hyoscyamus, to  obviate  any irritating effects
they might  otherwise produce.   In the early
stage of congestion,  there is no doubt that diu-
retics are liable to do much harm, from a ten-
dency to excite  inflammation in the kidneys;
cupping over the loins, combined  with strong
counter-irritation, as recommended by our au-
thor, are highly useful, and they  should be con-
tinued until the urine loses its albuminous de-
position, when they  may  be  withdrawn.   We 
KIDNEYS—Inflammation of Pelvis, &c, of the.
757
are, as yet, but little acquainted with the best
means of counteracting the effects of diseased
blood, though there can be but little doubt that
hydragogue cathartics do this by expelling urea.
It has been ingeniously suggested whether mat-
ters containing oxygen in excess will have any
influence in this  respect.  The Indian hemp
(Apocynum  cannabinum), which  is a  powerful
hydragogue cathartic  and diuretic,  has been
tried, with considerable advantage, in the New-
York hospital, in these cases, in the form of
decoction and extract.  We have known such
positive  benefits result from its use  in  the
treatment of this disease, that we think it well
worthy of farther trials.  The greatest disad-
vantage  attending it is the extreme uncertain-
ty of its effects; but these, we  think, may be
partially obviated by greater care in gathering
and preserving  it.   A  portion of its activity
depends  on a volatile  oil, which escapes by
drying  and long exposure to  the  air.  The
troublesome symptoms  attending  the  acute
form of  this affection are to be combated in
the usual  manner—vomiting by effervescing
potions, or mustard to  the epigastrium; diar-
rhoea, by astringents, as the  sulphates of zinc
and copper or acetate  of lead ; bronchitis by
blisters,  opium, &e. ; dropsical accumulations
by hydragogue purgatives and diuretics.   Per-
haps, however, there is no  class of  remedies
more decidedly useful in the treatment of this
affection, and all its complications, than diaph-
oretics.  The patient  is  to be kept  warm  in
bed, and a gentle diaphoresis kept up for a con-
siderable time  by external warmth and  mild
diluents, and under this course we often find  a
decided  improvement  both in the quality and
quantity of the urine, independent  of other
means.  Dr. Osborne even assures us that, in
treating of this disease, he found that " when-
ever general perspiration came on, either spon-
taneously, or in consequence of medicine, the
cases always terminated  favourably."  In ad-
dition to the diaphoretic remedies already men-
tioned, we may name the acetate of ammonia,
carbonate of ammonia, with camphorated mix-
ture, and the ammoniated  tincture of guaiacum.
We are inclined to  believe,  with Corrigan,
that when the disease has arrived at that stage
which this writer terms cirrhosis of the kidney,
it is nearly, if not  altogether, incurable.   Dr.
Williams recommends  in this form cupping at
the loins, and hydragogue purgatives, repeated
from time to time, according as the strength
of the patient will bear, together with external
counter-irritants, warm, vapour, and hot air
baths, warm clothing, &c.  Croton oil, or the
Emp. tart, ant., forms the best mode of exciting
counter-irritation.   In addition to the diuretics
already mentioned, we think the  iodide of po-
tassium one of the best.   Tonics we regard as
indispensable, for,  by improving  the general
health, we increase the tonicity  of the relaxed
vessels of the kidney.  The  best of this class
of remedies are quinine, nitric acid, combined
with cascarilla, pareira brava, diosma,  or  uva
ursi, iodide of potassium, sarsaparilla, and espe-
cially the persesquinitrate of iron.  The bowels
are to be kept free, and all aggravating causes
avoided,  such as cold,  considerable  exertion,
irregularities of diet, use of stimulating drinks,
mental depression,  &o.   Mercury is  regarded
by many as a hazardous remedy in every form
 of this disease.  Dr. Bell, however, of Phila-
 delphia (Bell and Stokes' Pract., vol. i., p. 599),
 states that, " as a purgative either alone, and
 followed  by castor oil, or rhubarb  and magne-
 sia, or combined with jalap or rhubarb, it is en-
 titled to  a  preference over most of the class.
I In, the first  mode, it is particularly useful where
I diarrhoea is present, a complication contra-indi-
 cating  resinous or  irritating  purgatives.  In
 smaller  doses, as of one or two grains, or an
 equivalent  proportion of  blue  mass, I know
 of no medicine, next to antimony, which  acts
 generally so well on the skin, by rendering it
 6oft  and  moist, certainly none which acts so
 kindly on an inflamed or irritated kidney   One
 of the peculiar advantages of these mercurial
 preparations is their ready  and tranquillizing
 operation on  inflamed  secretory  glands  and
 surfaces.   My own  experience makes me as
l confident of the propriety of administering cal-
| omel or blue mass after veneesection, for an ex-
 cited kidney, whose secretory function is impe-
| ded, as I would be of its use in a similar condi-
 tion  of the liver."   Where bronchitis is asso-
 ciated with granular  disease of the kidney, Dr.
 Bell also  states, that he knows  no adequate
 substitute for the calomel.  So far as we have
 observed, our experience in the use of this ar-
 ticle coincides with that of Dr. Bell. It should,
 however, be recollected that salivation is easi-
j ly induced  in this  disease, and, when brought
 on, produces highly injurious effects]
   170.  III.  Inflammation of the  Pelvis  and
j Calices  of the  Kidney.—Synon.  Pyelitis
 (from nve?.oc, pelvis).—Pyelite, Rayer.—Pyeli-
 tis, Prout.
   171.  Inflammation of the mucous membrane
 lining the pelvis and calices of the kidneys  is
 distinct  from the species of nephritis already
 described, not only in its seat, but also in its
 symptoms  and consequences.  It  sometimes
 assumes an acute form, but more frequently a
 sub-acute or chronic state.  It may affect the pel-
 vis and calices of only one kidney or of both;
 and  it may be limited to a portion only of their
 surface, or  extended to several calices.
    172. i. Symptoms.—Pyelitis assumes  varied
 states, according to its grade  of  activity, its
 causes, and other circumstances. It sometimes
 attends or  supervenes upon catarrhus vesice, or
 inflammation of the mucous surface of the blad-
 der ; and it sometimes even follows gonorrhea,
 especially when suddenly checked by astringent
 injections, and retentions of urine from strictures
 or other causes.  But it occurs in its most def-
 inite and best marked form when it proceeds
 from the  irritation of sabulous or calculous mat-
 ters  in the  excretory portion of the kidneys, or
 is connected with the oxalic acid diathesis.   It
 is occasionally, also, connected  with  certain
 cutaneous affections  remotely allied to syphilis.
    173. A.  When pyelitis supervenes upon ca-
 tarrhus vesice,  or  upon gonorrhea, the  symp-
 toms are usually uneasiness, or more  or less
 pain and  sense of heat in the loins, attended by
 low  febrile  action, sympathetic irritation of the
 testicles, and sometimes by nausea, particular-
 ly when  the secretion of mucus or muco-puri-
 form matter is unusually large.   If the inflam-
 mation of  the mucous surface  of the  bladder
 still  continue, the  symptoms referable to this
 viscus predominate, and often mask those more
 immediately connected with  the kidneys.  In 
758
KIDNEYS—Inflammation of Pelvis, &c, or thb.
all cases the symptoms should be examined in
connexion with the states of the urine.
  174. B. When pyelitis  arises from the irri-
tation of calculous or sabulous  substances in the
excretory portion of the kidneys, the symptoms
vary with the  constitution and  age of the pa-
tient, and with the nature, and form, and situa-
tion of those substances.   When a calculus or
calculi are situated so as not to obstruct the
passage of urine from the organ, the inflamma-
tion  is frequently slight and limited in extent
But when it is large, and  is situated at the out-
let of the pelvis, or at or in the commencement
of the ureter, so as to obstruct more or less, or
entirely to close this opening, the parts above
the  obstruction  generally  become  inflamed
throughout, and distended by urine, mixed with
mucus,  and often with  puriform  matter and
blood.  In  these cases, the kidney is greatly
increased in  bulk, and the local and  general
symptoms aggravated.
  175. Pyelitis from calculi may be slight, and
not exceed a state of irritation  not amounting
to that grade  of inflammation developing gen-
eral febrile reaction.   In  such cases, the grav-
elly matters pass from the calices into the pel-
vis, and  thence, by the ureters, into the  blad-
der, occasioning only more or less pain in their
transit.   But when the calculi, from their size,
sharpness, or roughness, irritate greatly these
parts, or cannot readily  pass along them,  in-
flammatory action, with  more  or  less severe
symptoms, is produced.
  176. a. In the more acute cases, a sharp, severe,
or lancinating pain is felt in  the region of ei-
ther kidney, descending thence, in the course
of the ureter, to the bladder, attended by chills
or rigours more or less marked.  The urine is
scanty,  voided by drops,  with a sense of heat,
sometimes with gravelly matter and a small
quantity of blood.  The   pulse,  at first small
and  oppressed, becomes  developed and  more
frequent, and febrile action supervenes,  espe-
cially after nausea and vomiting have occurred.
If the calculus or gravel is not voided in the
course of the following two or  three days, the
symptoms continue ; and if it does not entirely
shut up the passage to the bladder, and if only
one  kidney is  thus affected, the urine always
contains some  mucus and blood.  On cooling,
the mucus appears in the urine in the form of
flocculi, which  afterward  fall to the bottom of
the vessel, and the blood  globules, when  pres-
ent,  form a slight layer on the  surface of the
sediment.  All these  symptoms may quickly
cease when the calculus has passed into the
bladder, and the urine becomes natural.
  177. b. When calculi remain in the calices or
pelvis for a considerable time, the inflamma-
tion  becomes chronic, and the pain ceases to be
acute.  The patient complains chiefly of unea-
siness or of weight in the region of either kid-
ney ; but  pain,  sometimes obtuse,  at  other
times sharp,  occurs upon a sudden effort, or
unusual movement of the trunk, or when riding
either in a carriage or on horseback, and  the
pain generally extends to the bladder and  the
course of the ureters, and to  the testes and
limb  corresponding with the affected organ
Numbness as well as pain of the limb is often
also felt.  Decubitis on the abdomen, or on the
side  opposite  the affected organ, where one
only  is  affected, straining at stool, coughing,
 sneezing, a deep inspiration, the warmth of bed,
 dec, generally augment the pain ; which, how-
 ever, may  be  slight,  although  several calculi
 are contained in the pelvis and calices.  These
 pains, thus varying in severity and character-
 being occasionally  slight,  sometimes colicky
 and severe—frequently are independent of any
 febrile action ; but they are usually attended by
 retraction  of  the testes, and  by  a reddish,
 scanty, and mucous  state of the urine, which
 is slightly coagulable by heat.   Sometimes the
 urine is sanguinolent ; at other times it is per-
 fectly transparent, particularly  after diluents
 and demulcents have been freely used.  These
 different  states of the urine may be observed
 in  the  same person  in the course of twenty-
 four hours.  Upon cooling, uric acid, or the
 salts, are deposited with the blood and mucus,
 these latter forming the surface of the sedi-
 ment.
   178.  When the gravel consists of uric acid,
 as is most frequently  the case, the urine is acid,
 and the sediment  contains rhomboidal crystals
 of a yellowish-red colour.   When  it consists
 of the phosphates,  the urine is alkaline and tur-
 bid at  the  time of emission.   Dr.  Prout ob-
 serves, that when the concretion is lithic acid,
 the quantity of mucus in the nrine, though con-
 siderable, is not so striking and characteristic
 as it sometimes is when it consists of the oxa-
| late of lime.  This arises partly, perhaps, from
 the diminished quantity of mucus secreted, and
 partly from the quantity of lithate of ammonia
 and other matters usually  present, which in-
 volve and conceal it.  Where  the  calculus is
 oxalate of lime, the mucus is sometimes void-
| ed in large, transparent,  greenish  gelatinous
 masses of  considerable tenacity, which occa-
 sionally, in passing down the ureter, excite all
 the acute symptoms.   When the renal concre-
 tion consists of phosphate of lime, the symp-
 toms are much the same, and the mucus often
 contains  the earthy matter intermixed with it
 in  considerable quantity.
   179.  c. At  a more  advanced stage of chronic
 pyelitis from calculous concretions, irregular
 chills or rigours occur, especially towards night,
 or after a meal, and various morbid sensations
 are felt in the loins—as of pulsation, of tension,
 of numbness,  and even of cold—which often
 extend down  the corresponding thigh.  The
 urine  is sometimes sanguinolent, but  oftener
 turbid  and whitish,  allowing a puriform  and
 white, or slightly  greenish-white, sediment to
 fall, consisting  chiefly  of pus and urinal salts.
 The discharge  of blood in the urine  is occa-
 sionally the first  remarkable symptom, espe-
 cially when the pelves of both kidneys contain
 calculi.   Subsequently the urine becomes tur-
 bid and puriform,  and passes frequently and in
 small quantity, with  or without sabulous mat-
 ter in it.   In the course of the disease, the pa-
 tient experiences exacerbations, characterized by
 more acute symptoms, by vomiting, and fever.
   180.  The urine is usually bloody or purulent
 every time that it is  voided, unless one kidney
 only is affected,  and the secretion from the
 diseased  one is partially or entirely interrupted.
 Great variations, however, both in the frequen-
 cy of the calls to pass the urine, and in the
 physical and chemical  characters of it, are ob-
 servable.   When  purulent  urine coming from
 the inflamed pelvis of a kidney is retained only 
KIDNEYS—Pyelitis—Diag nosis.                         759
partially in  its cavity, it is mixed  in variable
proportions  with the urine from the other kid-
ney, which may  be  then  perfectly  healthy.
Hence the urine may, in the course of the same
day, be different in appearance at different times
—it may be charged with pus or blood, or with
both, at one hour,  and be  clear and healthy at
another hour.   The urine, therefore, should be
frequently inspected.  In some cases, M. Ray-
er states, the  suspension for a time of the  un-
healthy urine is accompanied with an aggrava-
tion of the  renal distress, and with a febrile
state of the system, probably in consequence
of the  ureter  of the affected organ becoming
obstructed, and the urine  therefore accumula-
ting in its pelvis.   The symptoms usually sub-
side when the  urine exhibits a purulent admix-
ture.   When  this  fluid is  at all purulent, it is
found also albuminous ; the amount, however,
of the coagulum produced  by heat or nitric acid
is by no means proportionate  to the quantity
of purulent matter in it.
   181.  d. When chronic pyelitis has existed for
a long  time, and the excretion of urine along
the ureter is  much obstructed  either by  the
presence of a  calculus in it or in the pelvis, or
by any other cause, a swelling may sometimes
be  distinctly  felt  in  the  lumbar  region,  the
swelling occasionally evincing an obscure fluc-
tuation, and appearing irregular or lobular on
examination.  This tumour is  formed by  the
accumulation of puriform  matter in the cavity
of the  pelvis and calices  of the kidney; and,
when very  large, is felt in the corresponding
flank, where it may extend from the margins
of the.  ribs  to the iliac fossa.  M. Rayer has
seen tumours formed by purulent matter dis-
tending the pelves and calices of the  kidneys
weighing as much  as  from ten to fifty  pounds.
Owing to the development of such tumours, the
lumbar region is more or less swollen, enlarged,
and deformed  on the affected side.  On percus-
sion, the swelling  emits a dull sound  behind,
and generally  also  anteriorly, unless the colon,
distended by air, pass before it.  When, how-
ever, the tumour is large,  the colon is general-
ly pushed aside by it.   The right kidney, when
thus distended, sometimes  adheres to the mar-
gin of the liver, and thus seems, on percussion
and palpation, to form one structure with this
organ,  and is  often mistaken for a  tumour, or
for enlargement of it.  Tumour thus formed of
the left kidney is  not so readily  mistaken  for
enlargement of the spleen, unless the examina-
tion is  very superficial.  When the tumour is
very large, it generally seems knotted or lobu-
lated, and fluctuation may be  perceived in it.
Pain is rarely acute in this state, although it
may be produced by pressure or succussion of
the trunk.
  182.  e. In  a few instances, the mucous mem-
brane of the pelvis and calices of  the kidney
surrounding the calculus  becomes  thickened,
indurated, so as to secrete little or no purulent
matter, and these parts form,  with the atro-
phied substance of the kidney, a sac. or shell,
more or less closely surrounding the calculus
If the  opposite kidney is  healthy, this change
may not be even suspected during life, the pa-
tient experiencing  no pain, and the urine con-
taining no pus ; but if disease, calculus, or ob-
struction affect the sound organ, suppression
of urine and death soon  take place.   In  the
 less severe and chronic cases of the disease,
 suppression of urine and death may also occur,
 especially when both  organs are seriously af-
 fected, or when calculi obstruct both the pelvic
 outlets or ureters.
   183. These several  stales of pyelitis may be
 denominated nearly as  M. Rayer has named
 them : 1st. Pyelitis, characterized by sharp pain,
 or nephritic  colic,  and  suppressed or scanty
 urine (y 176, a);  2d. Pyelitis  with mucous
 urine and occasional  pain (y 177, b); 3d. Pye-
 litis with purulent urine, and without renal tu-
 mours (y  179, c); 4th. Pyelitis  with purulent
 urine and with  renal tumour  (y 181, d); and,
 5th.  Atrophy of the  kidney, the urine being
 generally clear (182, e).
   184. ii.  Diagnosis.—Pyelitis may be mista-
i ken  for several  other diseases ; for a  mucous
 or purulent state of the urine attends inflamma-
 tion of the bladder or urethra ;  and lumbar pain
 exists in rheumatism, nephralgia, &c.  Tumour
 of the lumbar region also proceeds from dis-
 eases connected with  the kidney.—A.—a. Pain
 in acute simple nephritis is sometimes as severe
 as in pyelitis, but seldom as severe or as sharp
 as in pyelitis caused by calculi.   In this latter,
 the pain occurs  in paroxysms, or presents ex-
 acerbations, and is  more disposed to shoot in
j the direction of the  ureter, and to be attended
 by retraction  of  the testes of the correspond-
 ing side.  The existence of mucus or purulent
 matter in the urine will also assist the diagno-
 sis.—b.  True nephralgia may  be  confounded
 with calculous pyelitis ; but generally the pain
 of the latter is  more acute and cutting, or la-
 cerating than in the  former, and is obviously
 connected with gravel, calculi, and other chan-
 ges  of the urine, above described ; while the
 former very rarely occurs, unless in connexion
 with hysteria or with irritation of the uterus.
 —c.  In lumbago the pain commonly affects both
 sides alike and  at  the same time, instead of
 being felt  chiefly or altogether in one side, as
 in pyelitis; is more continued,  and does not
 extend, in the course of the ureter, to the blad-
 der ; and it is exasperated by the  movements
 of the  trunk.  Lumbago  is generally without
 fever, and often preceded by rheumatic pains
 in other parts.—d. Hydatids in the kidneys are
 seldom  attended by much pain, unless  they
 pass into the pelvis  of the  organ, and occasion
 inflammation there or in the calices, where the
 pains, although less  acute,  and the other symp-
 toms are nearly the same  as in calculous pye-
 litis.  The passage  of hydatids  with purulent
 urine will generally indicate their source in the
 kidneys when pain is  referred to the renal re-
 gion, but  not with certainty,  for  they may
 come from cysts connected with the bladder,
 but this is a very rare occurrence.—e. In some
 rare cases of suppression of urine the pain in the
 region of the  kidneys  has been severe, and the
 patient has been carried off by cerebral affec-
 tion  ; and yet all the structures of the kidneys
 have been found free from marks of inflamma-
 tion.  In some  cases, very large calculi may
 lodge in the pelvis without causing either much
 inflammation or  much pain. Occasionally, also.
 the pain has  been felt in  the situation of the
 opposite kidney to  that which contained the
 calculus, or  in  some part still  more remote
 from the irritated organ.  Instances where very
 large calculi were formed  in the kidneys with- 
760
KIDNEYS—Pyelitis—Diagnosis.
 out having produced any marked symptoms, or
 even much  disorganization, are  recorded by
 Baglivi,  Houlier,  Henrie, Boralli, Pozzi,
 Morgagni, De Haen, Van Swieten, Howship,
 and others.
   185. /.  Caries of the vertebra  is generally at-
 tended  by a  dull pain, but it cannot be mista-
 ken  for pyelitis, unless paraplegia, with reten-
 tion  of urine, and changes in  this fluid, take
 place, and then pyelitis  may  actually super-
 vene.   The state of the vertebral column, and
 abscess appearing in some one  of its usual sit-
 uations, will  generally show the nature of the
 disease.—g.  Psoitis is accompanied with pain,
 which is  continued  and often  severe, extend-
 ing from  the lumbar region to the pubis  and
 top of the thigh, the trunk being bent forward,
 and  to the affected side.   Motion of the thigh
 is extremely painful, and oedema of  the  limb
 often occurs.  If suppuration  take place, the
 abscess increases the oedema, but its  situation
 is lower,  and more anteriorly than that of the
 puriform  collection in the pelvis of the kidney
 consequent upon pyelitis.   If the abscess open
 into  the bladder, the diagnosis will be more dif-
 ficult, as  in a case recorded by Mr. Howship.
 —h.  Aneurism of the abdominal  aorta gives rise
 to pain, very much resembling  nephritic colic,
 or the renal  pain attending calculi in  the kid-
 ney.  The pulsation of the tumour, the evidence
 furnished  by  auscultation, and the state of the
 urine, will,  however,  indicate  the   disease.
 When tumour is inconsiderable or absent, the
 nature of the lesion is obscure, particularly in
 its early stages.—i. Inflammation  of a portion
 of the colon  in the vicinity of  the kidney  can
 hardly be  mistaken for pyelitis,  for the state of
 the bowels, and the appearance of the urine,
 will prevent them from being confounded with
 one another.—k. Hysterical pains in the region
 of the kidneys are characterized by abundant,
 pale, and  transparent urine, and by other indi-
 cations of hysteria (see the article).   Hysterical
 patients are,  however, liable to  disorder of the
 excretion of urine, but not to those  character-
 istics  of this  fluid attending inflammations of
 the kidneys; and  they are prone to   attempt
 various  deceptions connected  with the  per-
 formance  of this function.
  186. B. The excretion  of mucus and muco-
puriform or purulent matter in  the urine may
 take  place in other  diseases besides  pyelitis,
 and especially from acute  or chronic inflamma-
 tion of the  bladder, which may simulate  disease
 of the kidneys; this latter  also,  in its  turn,
 often simulating disease of the bladder.  In all
 cases, it is most difficult to determine, by the
 appearance of the urine only, whether  the kid-
ney or the bladder is inflamed ; in some cases
both  are  affected, although not equally.  In
 most  instances, the urine  is glairy and viscid
in cystitis, and there is pain or uneasiness in
the bladder, but there is no pain or swelling in
 the loins,  nor any of the sympathetic  feelings
depending upon pyelitis.  The  urine is gener-
ally less puriform and opaque than in this latter
disease, the dysuria attending which being usu-
 ally connected with the presence of pus.  How-
 ever, if  the puriform urine of pyelitis  be alka-
 line,  it will become both glairy and viscid ;  and
 the secretion  from the inflamed surface of the
 bladder  is not always glairy. The absence of
 pain  in the region of the bladder, while severe
 or sharp pain is  felt in  either lumbar  region,
 will also assist the diagnosis.
   187. C. The tumours consequent upon chron-
 ic pyelitis, with occlusion of the outlet of the
 pelvis or ureter, may be  confounded with oth-
 ers, and it is sometimes of importance to form
 a correct diagnosis between them.—a. M. Ray-
 er remarks,  that a collection of urine in  the
I pelvis of the kidney, owing to obstruction  of
I the ureter (hydronephrosis), causes a tumour or
I enlargement of the lumbar region, very closely
I resembling that  produced by an accumulation
 of pus in the same situation ; that both are lob-
 ulated, dull on percussion, and evince fluctua-
I tion ;  but that the latter is the seat of occasion-
 al pain,  or becomes painful on pressure, and is
 attended by fever—phenomena which seldom
 accompany the collection of urine merely.  Be-
 sides, when the passage from the kidney is not
 entirely obstructed in pyelitis, the urine is some-
 what puriform and opaque.—b. An abscess seat-
 ed in  the cellular tissue  in the vicinity of the
 kidney may be mistaken for purulent collection
 in the pelvis of this organ ; but in the former,
 fluctuation is more superficial and manifest than
 in the latter, and  there is generally oedema of
 the sub-cutaneous cellular tissue in  the lumbar
 region, an oedema never met with in the latter.
 Cases, however, may occur of an abscess form-
 ing externally to the kidney in connexion with
 an accumulation of purulent urine in the pelvis
 and calices ; but these  are rare,  and occur
 chiefly when  a fistulous opening is  formed be-
 tween the pelvis and the  adjoining cellular tis-
 sue.   Ulceration,  caused  by calculi penetrating
 the pelvis,  may give  rise to abscesses, which
 may open either externally or into  the  colon,
 or even into some  other viscus ; and one or
 more renal calculi may be voided in  these situ-
 ations, either subsequently to  or  along with
 the discharge of pus.   The origin of these fis-
 tulae is shown by the urinous odour  of the dis-
 charge and by the presence of uric acid, or of
 the urinous salts, or of calculi: still, these signs
 may be  wanting for a time, although one  or
 other of them may recur from time to time.
   188. c. Stercoraceous abscess may form in the
 vicinity of the kidney, owing to perforation by
 ulceration of a part  of the colon.  If such ab-
 scess  point externally, the diagnosis will  be
 easy ;  for the escape  of faecal matters and of
 intestinal gases will show its nature.  Abscess
 consequent upon caries of the vertebra and ab-
 scess arising from psoitis  may be distinguished
 by the history of  the  case, by the antecedent
 symptoms, especially as regards the state of the
 vertebrae and  the movements of the  thigh, and
 by the other phenomena  already alluded to (v
 185), particularly those connected with the ex-
 cretion and state of the urine.
   189. d. Tumours, or swellings  in the region
 of the kidney, may proceed from other diseases
 than the above, and render the diagnosis of
 distention of the pelvis and calices of this or-
 gan by puriform matter more or less difficult.
 These diseases are cysts in or near the kidney,
 containing hydatids; simple, or serous, or uri-
 nous cysts of large size ; tumours developed in
 the supra-renal capsules ;  aneurisms  of the ab-
 dominal  aorta; enlargements of the spleen; tu-
 mours  or cysts connected with the right lobe of
 the liver; enlargement of an ovary;  accumula-
 tions of fecal matters in the cecum or colon; and 
KIDNEYS—Pyelitis—Complications, etc
761
txtra-vlcrinc pregnancy.   Of all these it is un-
necessary to take particular notice.  The rec-
ollection that these may severally closely re-
semble, in  their situation and  local signs, the
consequences of  chronic pyelitis  now  under
consideration, and the attention to the existing
phenomena which the recollection  will excite,
cannot fail of guiding the practitioner to a right
conclusion.   The  history of the case, the sym-
pathetic pains, the states of the stomach and
bowels, and,  above all,  the  appearance of the
urine and the circumstances attending the ex-
cretion of it, will  receive from  him the fullest
consideration, and serve to point out the seat
of disease.
   190. iii.  Prognosis.—Pyelitis in its first or
more acute form (y 176), arising from urinary
concretions, is generally not attended by dan-
ger when one kidney only is affected ; but the
second, and more especially the third and fourth
states of the chronic disease, are  always of
more or  less serious moment, even when one
kidney is implicated : if both organs are diseas-
ed, the prognosis  is still more  unfavourable;
for the contingencies of ulceration of the pel-
vis of the kidneys, of atrophy of their structure,
of suppression of urine and its consequences,
and various other results of less frequent oc-
currence, are to be expected in a large propor-
tion of such cases.  Anticipations should be
still more unfavourable if a puriform collection
in the pelvis of the organ arise from obstruc-
tion at its outlet, and thus form a tumour in the
loins, unless  it opens externally : in this latter
case, it often terminates favourably.   The com-
plications of  chronic pyelitis  with other lesions
of the kidney or of the urinary organs, or with
other maladies (v  192, et seq.), render the prog-
nosis extremely unfavourable.
   191. In cases of tumour or abscess of the kid-
ney consequent upon the  obstruction of a cal-
culus, as described above (y 187), suppuration
and ulceration may proceed, as already men-
tioned ; and if the swelling point in the loins,
the calculus or calculi may escape in this situ-
ation, by the spontaneous or artificial opening
of the abscess, and the patient recover.   Pro-
ceeding upon the  results  of such cases, soim
physicians  have recommended  either that an
incision should be made into this tumour at a
proper period of  its progress,  or that caustic
should be used in opening it.   Each of these
modes of procedure may be  resorted to, and be
successful in  cases to which they are severally
appropriate.  It is most probable that, in the
successful cases of these operations on record,
the calculi had passed by ulceration  from the
pelvis of the kidney into the cellular tissue ex-
terior to it, and that they had been extracted
from an extra-renal abscess formed by it.
  192. iv.  Complications.—A. Inflammation
of the pelvis and  calices  of the kidney occurs
more  frequently in connexion with inflamma-
tion of the vascular and tubular structures than
in a simple or uncomplicated state ; or, in oth-
er words, pyelo-nephritis is more common than
either simple nephritis or simple pyelitis. — a.
When pyelitis is the primary affection, nephritis
often  supervenes ; and, as  a consequence of
the former, or of pyelo-nephritis, atrophy of the
cortical and tubular structure is the most fre-
quent.  Ulceration and perforation of the pelvis
of the kidney is less common than atrophy of
    II.                 96
  the organ ; but when  it takes place, abscess
  external to  the kidney generally forms, with or
  without the escape of the calculus that caused
  it.  Although one kidney is affected, still func-
  tional disorder may,  at the same  time, be ex-
  tended by sympathy  to the other.  Calculous
  pyelitis of both kidneys is not rare.  M. Rayer
  refers to several instances of the double mala-
  dy.   In  the more prolonged cases of chronic
  pyelitis of one organ, .the other either remains
,  healthy or  is  hypcrtrophied  consequently upon
  increased function.
    193.  b. Pyelitis  is  often attended by hemor-
  rhage from the kidney, particularly when caus-
  ed by calculi; and the haemorrhage may prove
  critical of pre-existing pyelo-nephritis, the in-
  flammation  of the substance of the organ being
  abated or altogether removed by the discharge.
  This  association has  been aptly named, by M.
  Rayer, hemorrhagic  pyelitis and  hemorrhagic
  pyelo-nephritis, and is certainly not of  unfre-
  quent occurrence in connexion, especially, with
  calculi in the kidney, although the  sanguineous
  state  of the urine  constitutes  apparently  the
i  chief, but actually the least important part of
  the malady.
   194. c. Pyelitis, in  any of its states, may be
  associated with disease of the prostate gland,
  or of  the bladder, or of the urethra, or of all of
  them, and these affections may  be farther com-
  plicated with stone in the bladder.   In the  ma-
  jority of such cases,  the ureter or ureters  are
  also affected, being either dilated or constricted,
  or both dilated and constricted, in different or
  alternate parts.  Sometimes the coats of the
  ureters are  thickened ; and occasionally a com-
  plete  obliteration of the canal  of one of them
|  is found in  some points, which are  either oc-
  cluded by a whitish, firm, albuminous deposite,
  or are reduced to a fibrous  chord.  Mr.  Coul-
  son very ably remarks, that when  a urinary
  vesical calculus has been formed for years,  and
  has brought on severe  symptoms,  and espe-
  cially when  attended by stricture of the urethra
  or enlarged  prostate gland, the  kidneys, though
  before healthy, become involved ;  the  severe
  dysury causes enlargement of the  ureters from
  distention of the retained urine, and  inflamma-
  tion extends along them, even to the kidneys
  themselves.   The pelvic cavities become alter-
'.  ed in shape and enlarged, the  infundibula  ex-
  tended or unfolded, and the internal membrane
  of all  the cavities thus acted upon,  from repeat-
  ed  attacks  of inflammation, is  thickened,  and
  furnishes a catarrhal secretion.   The  paren-
  chymatous substance of the kidney is more or
  less absorbed, the mammary projections are ob-
i  literated, spurious hydatids occupy the cortical
I  part, and all the serious evils,  ulceration, con-
|  tiguous abscess, or gangrene, are  met with as
  sequelae of vesical calculus.
   195.  When  pyelitis  is associated with inflam-
  mation  or other diseases of the bladder or pros-
  tate gland, the severity of the symptoms in these
  organs may render obscure or altogether mask
  the affection of the kidneys ; and this is  the
  more  likely  to be the case, inasmuch  as pyelitis
  is commonly the consecutive or superinduced
  malady: and it  may  even continue after  the
  disease of the bladder has been removed.   It
  is a more rare occurrence for pyelitis to propa-
l  gate itself along the  ureter, so as to occasion
I  true cystitis,  and it is met with chiefly when sab- 
762                     KIDNEYS—Pyelitis—Complications, etc.
ulous or gravelly matters, occasioning pyelitis,
pass into the bladder, and inflame it or the ure-
thra, or when  purulent matter from the pelvis
of the kidney produces the same effect, which,
however, seldom arises unless this matter is
retained for some time in the bladder, or under-
goes some degree of decomposition, or  occa-
sions an ammoniacal state of the urine, or un-
less the urine  is more or less alkaline when it
passes into this viscus.  It should be recollect-
ed that, when great irritation is produced by
calculi in  the kidneys,  severe  symptomatic
pains are sometimes  felt  in the  bladder,  with-
out any actual disease existing in it;  but it is
much more common  to  find very  serious le-
sions in the kidneys,  although no pains in the
loins  had been complained of,  disease of the
bladder, or  calculus there, being the only  appa-
rent malady.  Thus it has happened that able
surgeons, before undertaking the operation of
lithotomy or of lithotrity, have examined atten-
tively the  regions  of  the  kidneys, without de-
tecting any signs of disease of these  organs;
and yet, after  the operation has  been perform-
ed,  a violent rigour or shiver has taken place,
followed by fever and  death ; and, upon dissec-
tion, not only  have calculi and pus  been found
in the pelvis of the kidney, but also the sub-
stance of the  organ has  been more or less in-
flamed or otherwise altered.  These latent states
of pyelitis occur not only in connexion with ves-
ical calculi, but also with other maladies of the
bladder and prostate gland ;  and they are  latent
merely from want of due attention to, or due
knowledge of, the states of the urine attending
the renal disease, this fluid generally contain-
ing purulent matter,  or  pus globules, readily
miscible  with it, and very distinct from  the
glairy mucous sediment accompanying chronic
cystitis—the urine in pyelitis being puriform,
that of cystitis being mucous and glairy : when,
therefore, the  one disease is complicated with
the other, there is commonly a mixture of pu-
riform matter with a mucous or a glairy sub-
stance ; and  the  one predominates over the
other, according as the one disease  is more se-
vere than the other.  Some modifications, how-
ever, of the urine in these diseases and in their
complications, arise from the saline constitu-
ents or deposites,  which  often change the ap-
pearances of those morbid secretions, an alka-
line state rendering purulent urine more glairy
than its acid or neutral conditions.  Moreover,
it should be recollected  that, in  very chronic
and  prolonged cases  of cystitis, the  urine is
often more or less purulent, or  contains  pus
globules mixed with mucus.
  196. Whenever  disease of the bladder  or of
the excretory  urinary canals is attended by re-
tention of urine, there is a great risk of the super-
vention, not only of pyelitis, but also of nephri-
tis, as a consequence  of and in connexion with
pyelitis — either this  latter simply, or pyelo-
nephritis, occurring as a result of the  disease
of the excretory urinary apparatus ;  and  the
malady, thus superinduced in the kidneys, may
be acute  or sub-acute in  the one  organ, and
chronic in the other.
  197. d. Calculous pyelitis, in any of its forms,
may be associated with  pregnancy; for,  when
there are calculi in the kidneys, they are  more
likely to give rise to inflammatory irritation at
this  period than at any other;  unless, indeed,
soon after delivery, when calculous pyelitis oc-
casionally takes place.
  198. e.  Pyelitis  is sometimes  complicated
with other diseases;  but it is  unnecessary to
describe fully the phenomena attending it when
thus associated.   A  bare enumeration of the
maladies with which  it is most frequently con-
nected will serve  to direct attention  to  the
subject, and will suggest to the physician when
such  complications may exist  or supervene.
Pyelitis may occur after injuries or diseases
of the spine;  and may  be farther associated
with lesions of the bladder and prostate gland.
In all such cases,  especially when interruption
of the excretion of urine takes place, cerebral
affections of a most dangerous  kind are apt to
appear.   Disorders of  the digestive  organs,
gout, diseases of the  vascular system, and fe-
vers, are not unfrequently connected with pye-
litis ; indeed, there is scarcely a malady which
may not be  complicated  with it, particularly in
persons far advanced in life.
  199. B. Pyelo-nephritis, or inflammation of
the pelvis,  calices, and substance of the kidneys, is
the most important of the above complications,
and occurs oftener than either nephritis or pye-
litis simply.—a. In pyelo-nephritis, the  inflam-
mation generally commences in the pelvis and
calices, and rarely  in the substance of the organ.
Hence it  generally proceeds from  the same
causes as are productive of pyelitis, as the irri-
tation of calculi, interruptions to the excretion
of urine, and inflammation propagated from the
urethra,  bladder,  or  ureters, &c.   It  is more
prevalent  in males than in females, and in per-
sons advanced in  age than in  the young.  In
these  respects, however,  it agrees  with  the
other  forms and   complications  of nephritis,
deaths from this   disease,  according  to Mr.
Farr's letter to the  registrar-general (Third
Annual Report  of Births, Deaths, &c), being in
the proportion  of  21 20 males to 7 60 females,
or nearly 3 to  1» in the  years 1838 and 1839;
and from diseases of  the urinary organs gener-
ally being 1275 in  the former to 259 in the  lat-
ter, or 12 750 to 2 590,  or about 6 to 1, in  the
same years.
  200. b.  Pyelonephritis may be either acute
or chronic ; it may be limited to one kidney, or
extended  to both ;  and it may  be  more or less
acute  and severe  in one  organ  than  in  the
other : it may,  moreover, present the following
states, according  to  its  causes and prominent
characters: it maybe, 1st. Simple inflammation
of the pelvis, calices, and proper structures of
the organ ; 2d. Inflammation of these parts in
connexion with gravelly or calculous substan-
ces ; 3d.  Inflammation accompanied with haem-
orrhage, or haematuria ; and, 4th. Inflammation
with a disposition  either to albuminous exuda-
tions or to gangrene,  according to  the state of
constitution of the individual and  intensity of
the disease.   Of these,  the last  is the most
uncommon.
  201. c.  In these forms  of pyelo-nephritis,
mucus and pus globules may be detected in  the
urine ; but they will not  be observed in simple
nephritis,  or when the inflammation does  not
extend to the calices and pelvis of the kidney.
When pyelo-nephritis follows  lesions  of  the
urethra, prostate,  or bladder, it commonly  ex-
tends to both organs, but both  do  not  present
the same extent  and grade of inflammation. 
                        KIDNEYS—Pyelitis-

When it proceeds from injury, or when the dis-
ease commences in the  cortical and tubular
structure (a comparatively rare circumstance),
and extends to the calices and pelvis, or when
it is caused by calculi, then only one kidney is
generally affected.
  202.  C.  Peri-nephritis, or inflammation ex-
tending  to the fibrous, cellular, and adipose tissues
surrounding the kidney, rarely  occurs, unless af-
ter injuries or wounds  implicating this  organ
and those tissues, and when  calculous pyelitis
is followed by ulceration and  perforation  of the
pelvis of the kidney, and by renal fistula.   It is
chiefly in these circumstances that peri-nephri-
tis is usually met with, and it  is then associated
either with nephritis, or with  pyelitis, or pyelo-
nephritis.
  203. a.  It rarely appears  in a primary and
simple form, and as rarely can be detected  as
such during life, or until it passes into abscess,
when it assumes  nearly the form of abscess
consequent on pyelitis with perforation of the
pelvis of the kidney (y 187).   Instances,  how-
ever, have been recorded of primary inflamma-
tion of the cellulo-adipose substance surrounding
the kidney after injuries, and the impression of
cold ; but it is more common as  a consequence
of the passage of purulent matter into the cir-
culation, of severe fever or erysipelas, of ulcer-
ative  perforation of the colon ; and in  these
circumstances  it has been found chiefly upon
examination after death.  Peri-nephritis  more
frequently follows caries or fracture of the ver-
tebrae, and in these, as well as in other circum-
stances of its occurrence, generally gives rise
to abscess of greater or less extent.   When
this takes place, fulness or swelling of the loin
of the  affected side,  with obscure fluctuation
and oedema of the sub-cutaneous cellular tissue
over  the  part, is usually present.   When ab-
scesses form in this situation, they may involve
the kidneys, pelves, and ureters, more or less,
and  they may extend to and open  in  imme-
diately adjoining viscera, or  parts considerably
remote.
   204.  b. When peri-nephritis is simple,  or has
not involved the kidney, pelvis, or ureter, and
is independent of disease of these parts, it is
generally obscure. The urine does not present
the characters marking  the presence of nephri-
tis or  pyelo-nephritis;  but there is much ten-
derness of the loin and symptomatic fever, soon
followed by oedema and swelling.   As soon as
purulent matter forms,  it increases, and  accu-
mulates between  the peritoneum and lumbar
muscles ; and it may thence  extend to the iliac
fossa or crural arch ; or  it may open into the
peritoneal  cavity, or into the colon or rectum ;
or it may make its way in other directions, as
in the lumbar region, or at  or near  the  angle
formed by the spine and posterior  part  of the
crest of the ilium, on either  side of the lumbo-
sacral or lumbo-iliac ligaments.  When the ab-
scess is opened early in these situations, par-
ticularly the latter, recovery may take place ;
but this result will depend chiefly on the  nature
of the  original  disease,  or of its causes and
associations.   These abscesses have usually
been denominated lumbar or psoas abscesses, and
are more fully noticed in the  article Abscess.
  205. c. Gangrene is a much rarer termination
of peri-nephritis than  suppuration.   In a re-
markable case of the  primary and simple form
-Complications, etc                      763

of this malady—the  inflammation apparently
commencing in  the cellulo-adipdse tissue sur-
rounding both kidneys — recorded by Dr. Tur-
ner (Med. Trans, of Coll. Phys., Vol. iv., p. 226),
the disease followed exposure to a current of
cold air after being overheated  by prolonged
exercise on horseback.   Severe pains  were
felt in the loins, and  the symptoms were alto-
gether  violent and obscure.  The urine was
natural in quantity, and there were no unusual
calls to pass it.  Death  speedily ensued.  On
examination,  the cellulo-adipose tissue  sur-
rounding  both kidneys  was found quite  gan-
grenous :  the capsules  of  both  organs were
inflamed ;  but the substance  of the kidneys
was only slightly inflamed.
  206.  d.  Peri-nephritis may, therefore, arise
from inflammation extending  from the  kidney
to the surrounding cellulo-adipose tissue ; but
this rarely occurs, unless the pelvis of the kid-
ney is  perforated by ulceration, especially in
calculous pyelitis, as shown above (y 187);  and
when such perforation occurs, a renal fistula is
often formed  in consequence  of it. If  peri-
nephritis arise independently of disease of the
kidney, it may be either primary and simple, or
it may be consecutive of other maladies, espe-
cially of lesions  of the parts in the vicinity, and
of constitutional disease, as alluded to above,
and more fully in the article Abscess.
  207.  D.  Renal Fistula.—Renal fistula may
follow wounds implicating the kidneys, or their
pelves or ureters ; but they are more frequently
the consequences of inflammation of the pelves
and calices, which become  distended by  puri-
form matter, owing to obstructions  to its pas-
sage to the bladder;  and these obstructions are
commonly caused by the impaction of one or
more calculi in the pelves or ureters. The ac-
cumulated matter may find  its way, by  ulcera-
tion and distention, into the surrounding cellu-
lar tissue, and thence open either in the  lumbar
region, or near the crural arch, or in the colon
or  duodenum,  or in  the  peritoneal cavity, or
even in the corresponding pleural cavity or
lung.   These  fistula? commonly extend  from
the pelvis and calices into the cellular  tissue
upon which the posterior aspect  of the kidney
rests.   In these cases, an extra-renal abscess,
more or less extensive, forms, and proceeds in
one or other of the directions just named.  The
most frequent and most favourable situations
in which  it points are  the  lumbar region  and
near the  crural arch.   In the other situations
where  a fistulous communication has  been
formed with  the kidneys, examinations after
death disclose the nature of the  lesion, and, in
some cases, prove the accuracy of the diagnosis
which had been formed from the swelling in the
region of the kidneys, and from the nature of the
matters voided during the life of the patient.
   208.  v. Treatment of Pyelitis.—A. In the
early and acute state of pyelitis, the chief inten-
tion should  be to diminish local vascular action,
and to alleviate the  more  urgent symptoms.
Local blood-letting, by cupping over the loins, or
the application of leeches to the perineum and
around the  anus ; the warm bath, or the semi-
cupium ; mucilaginous and emollient beverages;
opium, or other anodynes, with demulcents, &c ,
are the chief means by which this indication
may be fulfilled.  When pain is very acute, and
is attended by  suppression of urine, frequent 
764
KIDNEYS—Pyelitis—Treatment of.
vomiting, or spasmodic attacks, cupping on the
loins should ba decidedly employed and repeat-
ed, and  be followed by the warm  bath:  pills,
containing camphor, opium, or belladonna, may
be  taken :  frictions or embrocations  with any
of the liniments prescribed in the Appendix, to
which opium or the extract of belladonna has
been added, may be applied to the  loins or ab-
domen,  and  emollient  and laxative  enemata
with henbane may be administered.  The  prep-
arations of ether, or the spirits of nitric ether,
with the compound tincture of camphor, the
alkaline  carbonates, and anodynes, may like-
wise be prescribed, in mucilaginous mixtures,
and in some cases with  one or other of the
preparations of colchicum.  The more violent
symptoms generally subside in  a  few hours,
owing either to the change in the position of the
calculus, to which they are  generally  owing, or
to its passage into the bladder.  In some cases,
the  calculus or calculi, or gravelly matter, is
passed with  the  urine, and relief is  obtained.
In  these more severe  attacks or  paroxysms,
and after the above means have been  employed
without  relief, dry cupping on the perineum, or
over the course  of  the  ureter, may  be tried.
When a calculus is  obstructing,  and  irritating
one of the ureters, as indicated by the seat
of  pain, and by the sympathetic phenomena, I
have found this means sometimes successful.
Purgatives, especially calomel, or calomel with
opium, followed in a few hours by castor oil, or
any suitable  purgative draught, or by  emollient
and laxative enemata, are generally of service.
Emetics, and standing  with the feet on cold
stones,  sometimes advised  in these circum-
stances, have  appeared  more injurious  than
beneficial;  but ipecacuanha or emetic tartar,
conjoined with opium, and given so as to  occa-
sion more or less nausea for some considerable
time, has occasionally been of service.  When
the acute symptoms indicating the  presence of
a calculus in the pelvis of the kidney, or in the
ureter, have subsided, and the patient has not
voided it, the urine still continuing to be charged
with mucus,  a catheter  or sound should  be
passed into the bladder, in order to  ascertain
whether it is in this viscus or not, so that it
may be  removed by such medical or surgical
means as may be deemed most appropriate.
  209. B. The second indication is to remove
chronic inflammatory action in the kidney, and
to counteract the disposition to  form calculi,
or gradually to dissolve them by physical means
suited to the morbid disposition, and to the
presumed nature of the urinary deposites.—a. j
This indication is more especially appropriate |
to the  chronic, or second and third states of the
disease (v 177-9).  The  morbid  condition  of
the  urine, in  most of these  cases, is owing to
the  states of digestion  and  assimilation,  in
connexion  with excess  in  the  quantity, and
with inattention to the quality and congruity of
the  food.  The  chronic inflammatory action
existing  in the kidneys is also thereby perpet-
uated,  and in its turn  assists in determining '
the  seat  and form of the urinary deposite.  In
these states  of disorder, a restricted diet,  or a j
diet suited to the states of constitutional pow-
er, and to  the  amount  of exercise habitually i
taken ; attention to the digestive, assimilative, |
and excreting functions ; regulated  exercise in |
the  open air; occasionally small cuppings on j
I the loins, or a seton or issue in this situation,
 or a  recourse to terebinthinate embrocations
 applied on the lumbar region, and various rem-
 edies taken internally,  may be prescribed.
I   210.  In this state of disease alkalies and the
 alkaline carbonates, in  various forms of combi-
j nation, have been employed.  But they are not
I suited to all cases, nor is a persistence in the
 use of them without inconvenience, or even de-
 void  of risk.  Even in those cases for which
 they  are most appropriate—where uric acid de-
 posites are observed—they may so impair  the
j digestive functions as to increase the evil they
i are employed to  remedy.  In every case, the
 selection of internal remedies should be direct-
 ed by the chemical state of the urine, and par-
 ticularly by its acidity and alkalescence.
I   211.  b. When the urinary deposite indicates
 the presence  of  the lithic acid, calculi in  the
| kidney—the most frequent form of concretion,
 especially in gouty and plethoric persons—cup-
 ping  freely on the loins, calomel with colchi-
| cum  or henbane, and  brisk purgatives;  alka-
i line  and gently diuretic substances in  mucila-
 ginous  mixtures ; a farinaceous or milk diet,
 simple  diluents,  and  regular  exercise in  the
I open air, are the most  beneficial means.
   212.  c. When we infer, from the  nervous and
 the hypochondriacal state of the  patient, and
| from characters  of the urine, that the affection
 of the kidneys is  connected with the oxalate of
 lime concretion, depletions and evacuations are
 not so requisite as in the foregoing circumstan-
 ces.  The means which are most serviceable
 for removing this form of concretion are diu-
 retic purgatives,  or diuretics only ;  and  more
 especially the dilute nitro-muriatic acid, with
I either  the nitrous ether, or the hydrochloric
I ether.   In addition to these, sedatives, as hen-
| bane, the compound tincture of camphor, the
 warm bath, regulated diet, consisting of animal
 food  and the purest farinaceous articles, atten-
 tion  to the digestive and excreting  functions,
 and exercise in the open air, are generally ben-
 eficial.
   213. d. When the affection of the kidneys is
 connected with  the  cystic oxide or phosphatic
 concretions, as caused by the cachectic, debili-
 tated, or exhausted state of the constitution,
 and by  the alkalescent condition of the urine
 and the composition of its deposites, a course
 of sarsaparilla ;  warm rubefacient or terebin-
 thinate embrocations and  fomentations on the
 loins, or setons or issues in this situation  ; de-
 mulcents and sedatives, and the  remedies just
 mentioned (y 212), may then be employed.
   214. e. During the descent of these or of oth-
 er  calculi, the means already advised  (y 208,
 et seq.), warm fomentations, warm diluents,
 and sedatives ; emollient enemata ; nauseating
 doses of ipecacuanha, or of antimony ; the va-
 rious  kinds of soap, with opium, belladonna, or
 henbane ;  the  infusion of diosma, with medi-
 cines appropriate  to the nature of  the urinary
 concretion ; and citrate of ammonia or nitre in
 demulcents,  may  be prescribed  according to
 circumstances.
  215. /. When the chronic states  of pyelitis are
 characterized by a puriform state of the urine,
 the infusion of diosma, or the infusion, decoc-
 tion, or extract of uva ursi, of pareira, [or of py-
 rola umbellala], may be  prescribed, and be con-
joined with anodynes when pain is  complained 
KIDNEYS—Organic Lesions of the.                       765
of.   If, in connexion with  this state, the uric
acid gravel be formed, or if the urine he acid,
and  if the patient manifest a gouty diathesis,
the  alkalies  or  alkaline earths may be also
given, or ammonia and camphor may be com-
bined with these, and with narcotics ;  or, still
more advantageously, with colchicum. The bal-
samic and terebinthinate remedies have been rec-
ommended in cases of chronic pyelitis with pu-
riform urine, and  are often very serviceable ;
and they may be exhibited  in the combinations
just mentioned, or consolidated to a pilular con-
sistency by means of magnesia, when the urine
is acid ; but  their effects  should be carefully
watched.  As soon as the urine becomes at all
alkalescent, or even neutral, the nitric or hydro-
chloric acid, or the nitro-hydrochloric acid, con-
joined with the ethers above mentioned (v 212),
and with tonic restorative  or alterative  reme-
dies,  should  be  employed.   Dr. Prout justly
remarks, that when the affection of the kidney
seems to be of a scrofulous character, the same
general principles of treatment as have been
developed with  respect to the  nature of the
renal concretion should be kept in view ; but
the tonic and restorative plan usually adopted
in that form of cachexia should also be applied,
as far as circumstances will permit.  For these
cases, warm  sea-bathing is often  particularly
advantageous.
  216. g. The diet should be easy of digestion,
and   free  from  all stimulating condiments.
When a plethoric state of the  abdominal vis-
cera, or the gouty or lithic acid diathesis pre-
vails, a milk or farinaceous diet is often  bene-
ficial.   Hard waters are generally prejudicial,
and  increase the pain  in the loins ; yet  many
of the milder effervescing alkaline and chalyb-
eate  mineral waters, as the Seltzer, Pyrmont,
Ems, &c, are often of service, when judicious-
ly taken.
  217.  C. In that state of  the disease charac-
terized by accumulation of puriform matter in
the pelvis and calices, so as to occasion swelling
or tumour in the loins, the treatment is generally
difficult, and  the question of operation, recom-
mended and performed by the older as well as
by modern surgeons, may in some cases be
entertained.  As long, however, as a more or
less  copious  discharge of puriform matter oc-
casionally takes place  in the urine, and if the
tumour be partially diminished from time to
time, or does not increase, while signs  of in-
flammation of the adjoining viscera, or  great
tenderness of the tumour and surrounding parts
on pressure,  or  hectic fever, or diarrhoea, are
not observed, perfect repose, a regulated diet,
a recourse to small local depletions as soon as
exacerbations of  inflammatory action  occur,
warm baths, fomentations, and the use of such
medicines as have been already recommended
to be  taken  internally, according to the pre-
vailing diathesis  and presumed nature of the
obstruction or calculous  concretion, are the
means chiefly to be relied upon with the object
of repressing exacerbations  of inflammatory
excitement, and  of ultimately removing the in-
terruption to the  passage  of  the accumulated
matter.
  218. When, however, the renal tumour forms
in a person of previously good constitution, and
is painful, notwithstanding vascular depletion,
mucilaginous drinks, and warm baths;  if there
be much symptomatic fever, with nocturnal ex-
acerbations;  if the stomach and  bowels are
irritable ;  if the tumour becomes more painful
on exercise;  and if suppression of urine takes
place, or  if inflammation extend to adjoining
viscera, the propriety of having recourse to the
operation of nephrotomy becomes more mani-
fest ;  and still more so if fluctuation in the tu-
mour  is more superficial and extended, showing
a large accumulation of pus to have formed in
the cellular tissue between the kidney and lum-
bar muscles.   The great depth of the abscess,
and the slowness  with which  it makes its  way
to the external surface, as well as the risk of
its opening internally, or changing its direction
when left long to itself, are  arguments in fa-
vour of an early recourse to the operation.  It
should also be recollected that those collections,
particularly when they involve, by perforation
of the pelvis of the kidney, or otherwise, the
cellular tissue on which the organ  rests, are
generally fatal if they open internally, or other-
wise than in the more favourable external situ-
ations, or when not aided by art.  The circum-
stances of the  case, and  the progress of the
tumour, will determine the surgeon whether or
not the operation should be performed by incis-
ion only, or  by incision and puncture, or by
cauterization and  incision.  M. Rayer, who is
favourable to the  performance of the operation
under the circumstances  now alluded to, as-
signs  the following states as  not admitting of
having recourse to it, and surely no one could
contemplate it in such cases: 1st. When  it is
supposed, from the symptoms and  history of
the case, that both kidneys  are affected, and
probably contain calculi, and while extra-renal
abscess is not yet  formed—an  abscess the
opening  of  which  should  not  be  deferred;
2d. While  the puriform matter continues  to
pass off with the  urine ;  while the renal swell-
ing is but slight, and  there appears to be no
risk of the immediate  perforation of the pelvis
of the kidney; and while the kidney of the
opposite side continues to discharge its duties,
or performs  an increased  function ; 3d.  While
serious  or dangerous  lesion exists in the blad-
der or prostate gland, or in one or more of the
other viscera.
  219. IV. Of various organic Lesions of the
Kidneys.—i.  Of Hemorrhage in or from the  Kid-
neys.—Hemorrhage, generally to a small amount,
often  accompanies inflammations and active con-
gestions of the kidney, especially the acute form
of cachectic nephritis, and pyelitis when caused
by renal concretions.  In these cases, the blood
is mixed with the urine, in the form of blood
globules, sometimes with mucus, and occasion-
ally with both mucus  and pus globules.  Renal
hemorrhage may take place :  1st, from the ex-
ternal surface of the  kidney ;  2d, into some
part of  its substance ;  and, 3d, from  the interi-
or of  the calices and pelvis.
  220. A. Hemorrhage very rarely takes place
from the external  surface of the renal capsules,
unless after wounds and other injuries.  Blood
sometimes is effused between the  surface of
the organ and its fibrous capsule, most frequent-
ly owing to injury, and, in rarer instances, to
great congestion  of the organ, either conse-
quent upon inflammation of the emulgent veins,
or upon interrupted  circulation  through the
right side of the heart. 
766
KIDNEYS—Organic Lesions of the.
  221. B. Hemorrhage into the substance of the
kidney occurs in the  form of petechie or ecchy-
moses, as in  malignant and adynamic  fevers,
scurvy, and purpura  haemorrhagica;  or of lar-
ger deposites or collections, as in cerebral apo-
plexy—the renal apoplexy of  French patholo-
gists—so as to  form  considerable clots.  These
latter are rare,  and when the  patient lives for
some time  after their occurrence,  the coagula
are found to have undergone similar changes to
those manifested by them in other viscera.
  222. C. When blood exudes from the surface
of the calices and pelvis, it may either accumu-
late there and in the ureter, or it may pass off
more or  less intimately mixed with  the urine.
The haemorrhage may proceed  from injury, con-
tusion, succussions of the trunk on horseback,
or in a carriage, or  on descending  stairs ;  or
from inflammation, congestion, or other diseas-
es attended by  obstructed return  of blood  by
the renal veins;  or from  calculous  pyelitis.
When the haemorrhage in this situation occurs
suddenly, and in considerable quantity, the blood
may  coagulate  either in the pelvis or in the
ureter, and thus occasion  more or less obstruc-
tion to the passage of urine from the kidney lo
the bladder; but such is not frequently  the
case, for the blood commonly passes along with
the urine, presenting appearances varying with
its quantity, with the state of constitution and
of disease, with the nature of  the  secretions
accompanying  it, and with the duration of  its
retention in the bladder.
   223. Ha?morrhage from the calices and pel-
ves of the kidneys  may be :  1st.  Symptomatic
of diseases of  these organs;  especially of re-
nal calculi, of cancer and fungous haematodes,
and of those just enumerated  (y 220-222); 2d.
Constitutional or essential, or  dependant upon
diseases characterized by depression of vital
power, by weakened vital cohesion of the soft
solids, and by a morbid state of the blood, as in
malignant or adynamic continued and eruptive
fevers, in purpura haemorrhagica, scurvy, &c.;
3d. Supplemental, or caused by suppression of
accustomed or of periodic discharges, and be-
come recurrent or periodic, as when  it  follows
suppression of the haemorrhoidal discharge, of
the catamenia,  of epistaxis, &c ; and, 4th. En-
demic, which is rarely observed ; but M. Rayer
mentions it among the endemics of the Isle de
France.  In  the second of those  varieties  of
haemorrhage from the kidneys, the blood is al-
ways very intimately mixed  in the urine, is
never coagulated, and generally imparts a dark
colour to the fluid.   In  the others, it  may be
connected  with fibrinous shreds in  the urine,
or  with  coagula,  generally very  small.  The
quantity of blood varies from the slightest
tinge to a very copious admixture, or large
proportion of it, in the fluid voided.   The blood
may flow from  only one,  or from both kidneys:
it generally is  exuded from both in  the 2d, or
the constitutional form of the  above  varieties.
   224. Persons subject to, or suffering renal
haemorrhage, generally complain of pain, or of
a sense  of weight in one or both loins, gener-
ally increased  upon firm pressure;  but these
feelings  may be wanting in  the  essential  or
constitutional form of the disease. Occasionally
the pain is acute, or is colicky,  particularly
when it  proceeds from calculi in the kidney, or
from fibrinous  clots obstructing the pelvis or
1 ureter.  When it arises  from vital depression
 and the state of the blood, the haemorrhage may
 be so great as to  occasion general anaemia, a
 result rarely occurring in other circumstances.
   225.  ii.  Congestion, or hyperemia of the  kid-
 neys, is sometimes found after death from  dis-
 eases, when this state was scarcely expected
j to be seen.  It is most frequently found in con-
 nexion with diseases of the heart, particular-
 ly those attended by interrupted circulation
 through the right side of this organ ; and when
 the return of blood by the renal veins is impe-
 ded by any lesion, either of them or of related
 parts.   Sometimes  the  engorgement  is  so
 great, that the blood gushes out when an incis-
 ion is made in the kidneys.   It may affect  one
 or both kidneys, always both when the  cause
 is constitutional, or when it depends on disease
 of the heart, and in diabetes.  When the con-
 gestion is considerable, the kidneys present a
 chocolate colour, and are large or swollen.
   226. iii.  Anemia of the kidneys, also, is occa-
 sionally observed  after death from diseases in
 which  this state of these organs could hardly
 be anticipated.  It is observed chiefly in per-
 sons who have died  of chronic maladies, as
 phthisis, cancer, chlorosis, uterine haemorrha-
 ges, and the advanced stages of granular de-
 generation of the kidneys, or chronic cachectic
 nephritis, in connexion with  dropsy and scanty
 urine.   In some cases, the kidney is so pale as
 to contain scarcely a drop of blood ; and  this
 state  may extend to  all the  organ, or may af-
 fect only, or chiefly, the  cortical or the tubular
 structure.   In  other  instances,  the kidney is
 pale in patches, or natural  or red in others,
 generally in the cortical substance.  Occasion-
 ally it presents a yellow colour, which is either
 uniform  or spotted  with  red or white;  the
 whole  structure of the organ being remarkably
 diminished in vascularity. When they are thus
 bloodless, they are sometimes, also, soft  and
 flaccid, but they are occasionally, a\so, firm, and
 even indurated, and, moreover, atrophied.  They
 are, however,  more commonly  granulated, as
 about  to be noticed,  and as described above
 (y 103).  The functional derangements conse-
 quent upon this state are chiefly a serous, mor
 bid, or defective state of the urine; dropsical
 effusions ;  and a diseased or poor condition of
 the blood, or deficiency of its red globules.
   227. iv.  The Nuti i'ion of the Kidneys is some-
 times much altered.—a.  Occasionally they are
 much larger than natural, without any lesion
 of structure.  This simple hypertrophy is often
 limited to one  organ, particularly when  the
 other is wanting, or is much smaller, or when
 it is destroyed by disease.  Hypertrophy of one
 kidney has been observed where two renal ar-
 teries  have been  transmitted to it ; and also
 where  it received, besides its ordinary supply
 of nerves from the semilunar ganglion and less-
 er splanchnic, several branches from the sec-
 ond lumbar  ganglion (Lauth).  Hypertrophy of
 both kidneys is often observed in cases of diabe-
 tes.  They  are  enlarged, or  rather distended,
 by  the augmented vascularity or congestion,
 and the granular deposites of the  early stages
 of cachectic nephritis, than, strictly speaking,
 hyportrophied.
   228. b.  Atrophy  of the kidneys may be conse-
 quent  upon anaemia or granular deposites, or
 both, or it may be independent of both.   It lias 
KIDNEYS—Organic Lesions of the.
767
 been observed in connexion with smallness of
 the renal artery, with compression of the organ
 by large tumours in the vicinity or attached to
 the uterus, with calculi stopping up the pelvis
 or ureter, and  with cancerous disease of re-
 mote parts.   In rare  instances, no cause by
 which it could be explained has been detected.
 Atrophy may  be either general or partial, in re-
 spect of the anatomical constituents of the or-
 gan    General atrophy may affect one  or  both
 kidneys ; it is characterized merely by the dim-
 inution of volume, without any change of struc-
 ture.  It is sometimes found on dissection of
 cases in which  no marked disturbance of the
 urinary  functions  was observed during life.
 Partial atrophy of  the structure of the kidneys
 is found chiefly in the advanced  stages of chron-
 ic cachectic nephritis (y 87), when the enlarged
 Malpighian bodies, and the granular deposites
 in them, have pressed upon and  atrophied the
 vascular and tubular structures, especially the
 former.   Partial atrophy occurs more rarely
 without  granular deposites, and, in  this case,
 the cortical or vascular tissue  is chiefly alter-
 ed, the bases of the tubular cones almost  rest-
 ing on the fibrous coat of the kidneys, or being
 separated from it only by a delicate layer of the
 vascular substance.  In some instances, there
 are  evident depressions  between the  cones,
 arising from the loss of the vascular structure.
   229. c.  Softening and induration of the kid-
 neys sometimes occur.  The former is often
 accompanied with  increased vascularity or con-
 gestion.   This association may be considered
 as conclusive  evidence of inflammation, partic-
 ularly when any of the consequent changes de-
 scribed above  (y 38, etscq.), as  being met  with
 in proper nephritis, are also observed ; and is
 occasionally seen attending calculi in the kid-
 neys, and various chronic  alterations  of the
 structure of the bladder,  as thickening of its
 coats, and brownish coloration  of its  mucous
 membrane, enlargement of and  puriform secre-
 tion  from its  follicles, (fee.   But softening of
 the kidneys may exist, also, independently of
 increased vascularity, the  substance of the or-
 gan being remarkably pale, or of a peculiar gray
 tint.   M.  Andral  has observed this  change
 where  there had not been any  sign of disease
 of the urinary passages.
  230.  d. Induration, like softening of the kid-
 ney,  is attended either by increased vascularity
 or by diminished vascularity and  blanching of its
 structure.  The former state is  generally ac-
 companied with some degree  of hypertrophy
 of the  organ.   When  the induration is of the
 pale  kind, it is rarely attended by enlargement,
 but commonly by  general or partial atrophy.
 M. Andral remarks,  that the  pale  induration
 presents  two grades :  in the first, the kidney is
 firmer  than usual, but it  retains its  natural
 structure; in  the second,  a more advanced
stage of the first,  its  tissue is  so condensed,
hard, and white, as nearly to  resemble carti-
lage.  This second grade of induration is some-
times partial,  or confined to two or three of
the tubular cones.
  231.  v. Morbid secretions and formations  in
the substance  of  the  kidney are, 1st.  Serum,
contained in small  simple cysts,  with  serous pa-
rietes,  which  adhere but slightly to the sur-
rounding tissue, is frequently met with in the
cortical structure, and less frequently in the
tubular.  The serum is generally limpid and
colourless, occasionally  slightly  yellowish  or
gelatinous.  These cysts are frequently numer-
ous, generally small, particularly in the tubular
structure, but they are sometimes large in the
cortical substance.   They are more rarely met
with in the cellular tissue surrounding the renal
vessels ; but they occasionally acquire  a very
large size  in this situation, and cause  propor-
tionate wasting  of the parenchyma of the or-
gan.  When the cysts are thus developed, their
cavities  are sometimes divided into  several
compartments by transverse septa.   Serous
cysts are found in the kidneys after death from
various diseases.  They are observed after the
several  forms of nephritis.   I have seen them
frequently  in cases where death was caused by
the more chronic diseases of the heart.
  232. 2d.  Fatty matter is sometimes found in
the cortical substance of the kidney.   M. An-
dral  has observed it, particularly when  this
substance  was  pale or yellow,  to  evidently
grease the  scalpel.   It is connected, he thinks,
with a special predisposition in  the individual
to the secretion of fatty matter.   The existence
of oil in  the blood in considerable quantity, in
some cases, particularly when  digestion  and
assimilation are  impaired, renders  it  by  no
means singular that the secreting structure of
organs circulating so much  blood through them
as the kidneys should become imbued with this
substance.
  233. 3d.  Purulent matter is often found in the
kidneys.  Abscesses sometimes form: occasion-
ally they are very small, and  the surrounding
structure is scarcely  altered ;  more rarely they
are extremely large, the whole organ being
converted into a purulent sac, which is  gener-
ally divided into compartments.  This sac may
even surpass the size of the kidney so much as
to produce a tumour distinguishable through
the abdominal parietes.  The bulk of this pu-
rulent sac  is seldom less than that of the  kid-
ney, unless it be  bound down by adhesions pro-
ceeding from inflammation of the adjoining por-
tions of the peritoneum, or  be  surrounded by a
collection of pus  in the cellular structure.  The
septa dividing the compartments of the sac oft-
en  consist  of a hard,  lardaceous  substance.
The matter thus formed in the kidney may pass
off by the ureter, or it may find its way in  va-
rious directions,  as explained above (y 207).
  234. In some instances the purulent  matter,
instead of existing in the form of a distinct  ab-
scess, is  infiltrated through the substance of
the kidney, giving rise to a number of whitish
specks,  from which  it may be squeezed.   M.
Andral thinks these whitish specks have been
mistaken for and described  as tubercles.  This
infiltration   generally co-exists with purulent
formations in other organs, particularly in the
veins: I have met with this purulent  infiltra-
tion of the kidney in a  fatal case of puerperal
metritis, in which pus had  formed in the sinu-
ses of the uterus.  M. Andral has observed it
after abscess in the right iliac fossa, and a sim-
ilar case is recorded by M.  Gillette.   (Journ.
Hebdom., t. xi., p. 75.)
  235. 4th. Granular deposites, and their origin,
have been  described above. They exist in the
vascular or cortical  structure, and  sometimes
are found,  also, in this structure, where it  ex-
tends between the tubular cones.   They  are 
768                       KIDNEYS—Organic Lesions of the.
small, whitish bodies of various sizes, some-
what  firm, and of a rounded form.  In some
cases they are few, in others they are very nu-
merous  and crowded together,  filling and dis-
tending  the  cortical structure, and even occu-
pying the intervals between the cones of the
tubular structure.  In some instances they pro-
ject beyond the surface of the  organ, and are
distinguishable through  its fibrous  coat.  In
others they occupy chiefly the more deep-seat-
ed parts of the cortical structure.
  236. 5th.  The deposition of ossific matter has
been very rarely observed  in the kidneys, and
then chiefly or only in the fibrous capsules of
the organs, and in the arteries of aged persons.
Cases are recorded  by  the older  writers in
which portions of the substance of the kidney
are said to have been  ossified ; but they are not
detailed with any degree of precision, and can-
not be relied on.   The external cysts of hyda-
tids are sometimes partially ossified.
  237. 6th.  Gelatinous matter has also been ob-
served in the kidney by MM. Andral and Ray-
er.  This substance  resembled a strong jelly
of a pale colour, or a solution of starch, into
which the whole cortical structure of the organ
was transformed.  A case occurred to me some
years since in a mulatto boy, where this  sub-
stance existed in one of the kidneys.
  238.  7th.  Melanosis of the kidneys is very
rarely met with, and never affecting this organ
alone.  In the cases where the kidneys were
affected by this malady, recorded by Cars well,
Fawdington,  Petit, Rayer, and Chomel, sev-
eral other  viscera  were  similarly diseased.
(See art. Melanosis.)
  239.  8th. Encephaloid matter  has  been found
in the kidney, either in small masses, occasion-
ing no alteration of the size or form of the or-
gan, or  in considerable tumours, or in the form
of fungus hematodes, and greatly increasing its
bulk.  Sometimes the kidney is wholly trans-
formed  into this substance, and  forms a very
large tumour, which may even be felt external-
ly.   It  has  been met with more frequently in
young persons than in adults and those advan-
ced in  life.  This  matter  may either form in
the kidney, without appearing in any other or-
gan, or  it may coexist with similar productions
in other parts.  M. Andral states, that it some-
times seems deposited in the substance of the
organ, and  at other times lodged in its  small
vessels.  It seldom is indicated during life, un-
less when,  in connexion with  this disease in
other parts, a tumour is detected in the region
of  the  kidney, and a considerable quantity of
blood is passed in  the urine : its existence may
be  then suspected.   Other forms of cancerous
or  malignant  disease  are very  rarely found in
the kidney, and then chiefly consecutively of
its existence in some other part.
   240.  9th. Tubercles are not often found in the
kidneys, and when they are met  with in these
organs  they always exist, also, in  some other
viscus,  and  do not differ from those of the lungs.
They may  be recognised  by their dull,  white
aspect, commonly with a slight grayish yellow
tint, by their friability, and by their amorphous
appearance under the microscope.  They are
either distinct or confluent.  They sometimes
soften,  and the softened matter  finds  its way
into the pelvis of  the organ, leaving renal cav-
erns or fistulae. In some cases only a few tu-
bercular germs are observed;  in  others, and
when the  degeneration is far advanced, it ex-
tends to both the cortical and tubular structures,
to the calices  and pelvis, and  even to the ex-
ternal membranes and ureters.   They are often
disseminated through the organ in the form of
small grains  the  size of millet seeds.  When
confluent or grouped, they appear as masses of
considerable size, but when the mass is divided
it is sure to be composed of a number of small-
er tubercles.   In  some cases, they consist of
small compact masses;  being  the largest tu-
bercles, which are most disposed to soften, and
to occasion farther disorganization.  The tissue
surrounding them may be either sound, or paler
than usual, or more vascular.  When they soft-
en, the tissue around them is generally injected.
In most  cases, the organ is not materially in-
creased in bulk by them;  in a few it is  very
considerably augmented.  When they form in
or beneath the mucous membrane of the calices
and  pelvis, they  are  either distinct,  rounded,
and the size  of the head of a pin, or they are
grouped.  In the former case, they render the
surface rugous ; in the latter, they produce ele-
vated patches, of variable form and extent.
   241. In sixteen cases of tubercles of the kid-
neys, M.  Rayer  found them  16 times in the
cortical structure, 15 times in  the tubular, 13
times in  the  mucous membrane of the calices,
pelvis, and ureters, and  twice in the capsules
of the organ.  He has seen this lesion twice in
new-born infants, and considers it rare in  aged
persons.   Of 16  cases, both kidneys  were af-
fected in 6 ; and of the 10 cases of affection of
a single organ, the left was 7 times the seat of
the disease.
   242. The symptoms of this change are seldom
such as  to indicate  its existence. It is  only
when  the  tubercles  soften  and open into the
pelvis of the organ  that the existence of the
disease may be suspected, and then chiefly from
the appearance of the matters contained in the
urine.  The tubercular matter passing with the
urine into the bladder generally excites inflam-
matory action in the  mucous  surface of this
viscus, and the patient's sufferings are usually
referred  to it, and the original seat of disease
thereby masked.
   243. 10th.  Hydatis,  or   acephalocystis  (the
Acephalocystis socialis vel prolifera), are rarely
found in the kidneys of men.  They are gener-
ally  numerous or multiplied, and contained in
a mother cyst, which frequently acquires a large
size, forming a tumour which may often be felt
externally.   They present  the same appear-
ance in this  organ as described in the article
Hydatids.  The  hydatidic cyst is developed in
the substance of the organ, and, as it acquires
a large size, it generally forms adhesions to the
parietes of the calices or pelvis, and opens into
the  renal  cavity by one  or  more openings,
through which the smaller of the hydatids, and
the debris of the  larger, with the serum which
they contained, escape with the  urine.   The
expulsion of the hydatids commonly occasions
pain in the region of the kidney, and sometimes
retention of urine or diminution of it, owing to
obstruction of the pelvis or ureter by one or
more of them.   These retentions, occasional,
or repeated, or more or less continued, may ul-
timately cause dilatation of the ureters and of
the  pelvis, and various  changes in the struc- 
KIDNEYS—Organic Lesions of the.
769
tures of the organ.  The symptoms of hydatids
in the kidneys are very equivocal.  They fre-
quently occasion but little disturbance until the
mother cyst acquires a large size.   It is chiefly
by their presence, or by their debris in the urine,
that we can form a correct opinion as to their
existence.  In one case I thus recognised them ;
but the patient passed from my observation.
  244. llth.  Worms are very rarely found in
the kidneys.  The Strongylus gigas, the Dacty-
lius  aculcatus, and the Spiroptera hominis, are
the  only worms found  in this  viscus.  Their
exact situation has not been fully determined.
[t is probable that they exist only in the pelvis
of the organ, although  they have been described
in general terms as found in the kidneys. M.
Rayer has adduced many of the cases of this
description on record,  and, among others, those
published by Messrs. Lawrence, Burnett, and
Curling, and to which reference is made in the
Bibliography to this article.
  [Dr. Gross describes a case of abscess of the
kidney  in a gentleman 40  years of age, who
had  long suffered under symptoms of chronic
nephritis.   On inspection, the left  kidney was
found reduced to  a mere  membranous shell,
containing  three pints  of a thin,  chocolate-
looking  fluid.    All the other viscera  were
healthy, excepting the  stomach, which exhibited
marks of former inflammation.—(Path.  Anat.,
p. 697.)  Dr. G. also describes a case of scirrus
of the kidney, occurring in a child 2£ years old
The body was excessively emaciated, the ab-
domen hard and distended, and the right lum-
bar region unusually prominent.  All the intes-
tines were  firmly agglutinated together, and
the mesenteric ganglions, of a white rose colour
and  gristly hardness,  presented one agglomer-
ated mass of disease.  Individually, they varied
in size between  a cherry and an orange.  The
entire  mass  nearly equalled a cocoanut, and
embraced loops of intestine,  the  aorta, vena
cava, and choleducf. duct.  There  were a few
tumours on the anterior margin  of the  liver,
similar to those of the kidney, and the mucous
membrane  of the colon exhibited patches of in-
flammation, with here and there a small ulcer.
—(Ibid., p. 700 )
  Encephaloid of the kidney has been observed
by Dr. Weems, of Washington city (Am. Jour.
Med. Sci., vol. xvi.), in a female 35 years of age,
although there was no symptom present during
life that could have caused a suspicion  of the
existence of renal disorder.  The left kidney
was found increased to the weight of 7 pounds,
completely disorganized, and converted  into a
soft, bloody, cerebral mass, in which it was im-
possible to  discern anything of  the  normal
structure.   The  disease had existed for about
four years, and  been treated for an enlarged
spleen.
  Tubercles in the kidney have also been ob-
served by Prof. Gross (Path. Anat., 2d edition,
p. 702),  in the right kidney of a young man 27
years of age, who died of psoas abscess.  There
were upward of 500 in the cortical substance,
of all sizes  between that of a mustard seed and
a cherry stone.  In some parts they were ag-
glomerated, in others  isolated.  They were of
a white, opaque appearance, semi-cartilaginous
in their consistence,  and  evidently organized,
since, in cutting through them, the existence of
vessels  could  be distinctly traced, the  blood
    II.               97
standing upon  the  incised surface in  minute
dots.  Externally the organ had a dark, mottled
aspect, and in its interior were two tubercular
excavations ; one, situated in the superior ex-
tremity  of the gland, was scarcely larger than
a hazelnut; the other, which occupied the lower
half of the viscus, was about the size of a tur-
key's egg, and filled with  thin,  ropy, whitish
pus, destitute of smell.  The abscess was lined
throughout with  a  thick layer of lymph, and
intersecting it in different directions were four
rounded cords, the  remains, probably, of the
tubular  texture, which resembled a good deal
the fleshy columns  of the  heart, or the bands
which we  often see in tubercular excavations
of the lungs.  The  kidney was very little en-
larged,  and some tubercular matter was also
found in the excretory  passages, the cavity of
the ureter having been nearly obliterated by it.
In this  case  there  were no tubercles  in the
lungs ; the heart and brain were healthy ; but
strumous  matter was  abundantly contained in
the lymphatic ganglions of  the pelvis, and the
seminal vesicles  were  completely distended
with it.—(Loc. cit.)
  Serous cysts, though rare  in the kidney of the
human  subject, are yet  very common in the
hog, and have often been noticed by Prof. Gross
(loc. cit.).  Dr. G. also describes a cyst contain-
ing the  right kidney, with two gallons of pure
pus, in the body of a man 26 years of age. The
sac was exceedingly vascular, and about the
thickness  of the  human  skin ; it was  formed
mainly at the expense of the ureter, which was
entirely closed,  and  was studded internally  by
a number  of bony  deposites, some  of which
were very firm  and  as large as a thumb-nail.
The renal  tissue was completely absorbed, and,
in place of the  papillae, were  seven  digital
pouches, isolated, and large enough to admit a
finger.  " In a few instances," says Dr. G.,  "I
have seen the kidney transformed into a sub-
stance resembling fibro-cartilage.  In one of the
cases to which I refer, the organ  was less than
one  third  of the  natural volume, remarkably
white,  dense, fibrous, and creaked sensibly
under the scalpel on  being cut.  The  fibrous
capsule  was inseparably adherent to the outer
surface  of the kidney, the  ureter  and  funnel-
shaped processes were obliterated, and scarcely
a trace remained of the tubular structure. The
renal vessels, both artery and vein, were much
diminished in size, and many of the  larger
branches,  with pearly  all the smaller ones, had
disappeared.
  This  transformation  sometimes  recurs  in
small patches, which  are generally of a light-
bluish tint, and distinctly fibrous  in their tex-
ture.  The kidney  has been found ossified in
several  instances  in this country ; in some, the
earthy matter has been mostly confined to the
uriniferous tubes ;  for an  example of which,
see Gross's Path. Anat., 2d ed., p.  706.  See,
also, Dunglison's Practice  of Medicine,  2d ed.,
vol. ii.,  for a very lucid account of renal and
urinary  affections.  The reader,  also, will  do
well to consult  the " Clinical Lectures" of Dr.
Graves, who denies that the albuminous state
of the urine in dropsies, always, or even gen-
erally, depends on structural change in the kid-
neys, but who supposes that this condition often
depends on mere functional  derangement of the
secreting organ.] 
770
KIDNEYS—Structural Lesions of the.
  245. V. Morbid Changes in the Calices and
Pelvis, and  in  the Ureters.—The  mucous
membrane, or, rather, the submucous tissue of
these parts, is often simply congested without
any other lesion ; and this has sometimes been
the only alteration discoverable when the pa-
tient has been passing bloody urine, with pain
in the region of the kidneys  and course of the
ureters.  In  some cases, minute ecchymosis
may be observed, in addition to congestion of
these parts.  This membrane sometimes ap-
pears thickened, either in parts or throughout
its whole extent, producing temporary, or even
permanent  obliteration of the ureters.   Vege-
tations from this membrane of a red, soft, fun-
gous appearance, with a broad base, and vary-
ing from the size of a pea to that of a small
walnut, have also been found in the pelvis of
the kidney.   M. Louis met with  a case of great
thickening of the walls of the calices, pelvis, and
ureters, with increased capacity, the kidneys
themselves being reduced to  half their ordina-
ry dimensions.  The mucous membrane in this
situation, as in other parts, often secretes pus,
and  more frequently  without being  ulcerated
than when this lesion has taken  place.  M. An-
dral has seen it covered by a false membrane re-
sembling that of croup. The submucous tissue
of the pelvis and ureters has been, as noticed
above (y 240), filled with a layer of tuberculous
matter ; but in such cases this matter has ex-
isted also in the substance  of  the kidneys as
well as in the lungs.
  246. Dilatation of the calices,  pelvis, and ure-
ters, sometimes  to a  remarkable extent, fre-
quently takes place when any obstacle exists to
the free passage of the urine into the bladder.
The ureters are  often greatly dilated in various
chronic  affections of  the uterus, particularly
when  tumours form  in  the  uterus and  press
upon the bladder, diminishing its cavity, or ob-
structing the outlets  of  the ureters.   When
the obstacle  to the  passage  of  the urine along
the ureter is situated near the kidney, the por-
tion of this duct below it frequently contracts,
and becomes even obliterated.   Ulceration and
perforation of the pelvis or  ureter  sometimes
occur, occasioning extra-renal abscess and uri-
nary fistula,  as shown above (y 187).
   247. VI. Alterations  of the Blood-vessels
of  the,Kidneys.—A. The  renal arteries have
been  found  variously diseased, in  rare  cases
only.  Aneurism of  the emulgent  artery has
been recorded in only two or three cases—by
D.  Nebelli (Ephem. Nat. Curios., cent, ix., ob.
59, p. 142), L.  Rouppe (Aro!;a Acta Phys. Med.,
t. iv., p. 67,  1770), and M. Dourlin (Journ. de
 Chirurg. et de Med., t. vii., ann. xii., p. 252).  I
saw a preparation  at the Medical Society of
London, many years  ago, which appeared to
indicate a small  aneurism of the emulgent ar-
tery.  Cartilaginous  and  ossific deposites  have
been  found  in the  renal arteries of very old
persons.
   248. B.  Inflammation  of  the  emulgent veins
sometimes occurs, generally in connexion with
some form or other of nephritis.  In most of
these cases the canal of  the vein has been
 nearly filled with fibrinous or albuminous con-
 cretions. M. Rayer observes that he has seen,
 in  several cases of albuminous nephritis—the
 cachectic  nephritis  of the  author—the renal
 veins filled with fibrinous concretions, and the
coats of the vessel thickened.  Not only maty
inflammation of the renal veins be connected
with nephritis or structural lesions of the kid-
neys, but it may be connected, in other cases,
with inflammation of the vena cava, or of the
ovarian vein.   I have seen  several  cases in
which inflammation of the emulgent vein ac-
companied inflammation of the uterine and ova-
rian  veins in the puerperal state.   Similar in-
stances have been observed by Dr. R. Lee, M.
Duges, and others.
  249. VII. Affections of the Nerves of the
Kidneys have been noticed by writers, but le-
sions of the structure of these nerves have not
been observed, nor, indeed, can such lesions,
although existing to some extent, readily admit
of detection.   Painful affections,  referred  to
the nerves of the  kidney under  the  term of
Nephralgia, are generally owing to the irrita-
tion  of calculi, either in the  kidneys  or about
to pass from the pelvis into the ureter ;  and is
only a different name for what has been called
nephritic colic, caused by renal calculi.  Nephral-
gia may attend calculous pyelitis, as noticed
above (y 184), or may be merely that  grade or
state of irritation which occasions a manifesta-
tion  of morbid sensation in the renal nerves,
without inducing or being attended by inflam-
mation—the sensible expression  of  irritation
produced by a mechanical cause.   Nephralgia
is sometimes complained of in nervous or hys-
terical females, and is  manifestly owing  in
them to irritation or excitement of the nerves
of the uterus and ovaria, propagated thence to
the  nerves of the kidneys, in consequence of
the intimate connexion of the sexual and renal
nerves (see Art. Irritation).    That the sensi-
bility of the renal  nerves should  be morbidly
excited in  many cases of hysteria is not sur-
prising, when  we  consider the exaltation  of
function—the copious secretion of urine—which
generally attends uterine excitement and hys-
teria.
   250. The treatment of nephralgia will entirely
depend upon its pathological  relations.   If it
proceeds from calculous irritation,  much  of
what  has  been advised  for pyelitis depending
upon this cause, and combining these with nar-
cotic and external derivatives and rubefacients
—with the diosma, camphor, henbane, opiates,
alkalies, fomentations, warm  baths, &c.—may
be prescribed.   If  the nephralgia  be hysterical,
or be  connected  with uterine irritation, the
treatment  advised for the other affections of
this nature (see Hysterical Affections, y 22)
will generally remove it, and attention to the
means there recommended, with  the view of
restoring nervous tone (v 84), will prevent the
recurrence of this affection.
   251. VIII. Absence of the Kidneys has been
 noticed by several pathologists.   The  entire
 absence of both kidneys has been observed in the
 foetus by Odhelius, Buttner, Everhard,  Gili-
 bert, Heuermann, Mayer, and others.   Bec-
 lard remarks, that the kidneys are often want-
 ing  in acephalous foetuses, but that one or both
 exist when the whole or greater part of the
 spinal chord is present.   Absence  of one kidney
 has been met with  on several occasions.   Gen-
 erally the  existing kidney is much larger than
 usual, and sometimes double its ordinary weight;
 and it may be either placed naturally, or some-
 what too high or too low.  In two cases of this 
KIDNEYS—Bibliography  and References.
771
description which occurred to M. Andral, one
presented  the supra-renal capsule of the side
on which  the kidney  was  altogether wanting
fully developed,  proving that the existence of
the former does  not depend upon that of the
latter.   The  other  case  was  important,  inas-
much as the single kidney was in a state of dis-
ease, being studded  with whitish granulations.
The patient was  dropsical, evidently from this
state of the kidneys, the  other internal viscera
being sound.   Sometimes when one kidney  is
supposed  to be wanting,  the other, instead of
being in its natural situation, is placed in  front
of the vertebrae.   M. Andral states, that in ev-
ery case of this  description  which he had ex-
amined, the kidney was only apparently single,
being composed of the two united, and confound-
ed together at the  median line.   There  may,
apparently, be but one  kidney, from the cir-
cumstance of the other  being situated in the
hypogastrium beside the bladder.   Andral met
with a case of this description.
   252. IX. The situation of the kidneys may
be unnatural,  or  uncommon.   In a few instan-
ces they have been found united and placid, in
the form  of a horseshoe, across the spinal col-
umn.  Numerous references to cases  of this
description  have  been adduced by Ploucquet
and Raver.  One or both kidneys may be placed
much lower than usual, and, in very rare instan-
ces, they may occupy  the pelvis, or  its brim ;
but only one of these organs has been found so
low as to  occupy the pelvis.   Cases of this un-
natural position of one kidney have been refer-
red to by the writers just named.  Where this
occurs in the female,  the uterus is generally
more or less  displaced by the kidney; and, if
the female thus  circumstanced becomes preg-
nant,  serious consequences may  accrue.   In-
stances  of this kind  have been recorded by M.
Boinet (Arch. Gen. de Med., t. vii., 1835, p. 348),
Dr. Hohl  (Bullet, de M. Furrusac, t. xvii., p. 3),
and Dr.  Heusinger  (Ibid., t.  xv., p. 131).
   253.  One or both  kidneys—one especially—
may be displaced  by the pressure of an enlarged
viscus, or by a tumour, abscess, or other cause.
The displacement may be even so great as to
constitute a hernia of the organ, as in the cases
recorded by Haller, Monro, and Portal.  One
or both kidneys may also be more or less move-
able, owing to the  state of the tissues surround-
ing  and  connecting  with them, and to structu-
ral lesions of their substance, especially calculi
and abscesses.    Generally,  however,  lesions
of the organ  itself are but little concerned in
giving rise to  its mobility,  either in a vertical or
horizontal direction, although insisted upon by
Riolan.  Instances of this lesion have been no-
ticed by Velpeau, Gerdy, and Rayer, and sever-
al of them are detailed by the last-named writer.
   254. The symptoms in these cases consisted
chiefly of pains  in the abdomen or loins and
corresponding thigh ;  of hypochondriacal and
colicky affections;  of weakness  or neuralgic
pains of the limb, and sometimes of oedema of
the  thigh, or  a moveable tumour  detected in
the abdomen.   Most of the instances on record
occurred in females, and the right kidney was
almost exclusively   thus affected.   They ap-
peared to  arise from enlargement of the liver,
distention of the caecum,  frequent pregnancies,
muscular efforts, &c, and, in some of them, pe-
culiar dispositions of the  peritoneum and of the
 blood-vessels of the organ were remarked.   M.
 Rayer alludes  to  two  physicians whose right
 kidneys were thus moveable.
   255. In cases of this  description, the patient
 should wear a suitable belt or support, as being
 the  principal means of preventing as well as of
 removing the pains and  other symptoms caused
 by this lesion.   In some instances, the cold or
 tepid  douche on the  loins, and  the horizontal
 position, may be advantageously recommended.

  Bibliog. and Refer.—Aristoteles, De  Genr. Animal.,
 lib. iv., c. 4. — Celsus, Lib. iv., c. 10. —  Galenus, De Ren.
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Anat. Pract. Rat., cent, i., obs. 45.—L. Beverovicius, De
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 Batav.,  1638.—Tyson, Philos. Trans., No.  142.—G. Rolfinck,
De Calcul. in Corpore Humana, prcecipue Renibus et Vesica,
is Generat. Signis, Remedico, 4to.  Genae,  1663.—/. Boscius,
De Lapidibus  qui nascuntur in Corpore Humano praecipue
Renibus ac Vesica,  et  ipsorum  Curatione, 4to.  Ingolst.,
 1680.—Berber, Dissertation sur les Ulceres  des Reins et de
la Vessie, 12mo.  Dijon, 1685—G. E. Stahl, De Nova Path-
olog. Calculi Renum, 4to.   Halls, 1698.— W, Rutty, Treat.
of the Urinary Passages, with the principal Distempers thut
affect them, particularly Stone of the Kidneys and Bladder,
4to.  Lond., 1726. — Baglivi,  Opera Pract. Med., lib. i., p.
 118. — S. Olivier, Traite des  Maladies des Reins et de la
 Vessie,  &c, 8vo. Rouen, 1731.—/. Douglas, in Med. Es-
 says and  Observat., &c, vol.  i., p.  231.  — Stoerck, Annus
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 Wittemb., 1720.—C. T. Trew, in Ephemerides Acad. Natu-
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 the Kidneys, Bladder, &c, 8vo. Lond., 1775.—Petit, Traite
des Malad. Chirurg., iii., p.  8.—/. Clarke, in Duncan's Med.
 Commentaries, <fec, vol. vi., p. 204.— W. Keir, in Medical
 Communications, <fcc, vol.  i.,  p.  127.—H. Fearon, in Ibid.,
p. 416.—Bonet, Sepulchret., lib. iii., sect. 21, obs. 8 ; sect.
22, obs. 4, 23; lib.  iv., sect,  i., 38.  — Douglas, in Philos.
Trans.,  No. 325.—Roederer, Observ. ex Cadaveribus Infan-
tum Morbosis.  Goet., 1758.—Morgagni,  Epist., xl., art. 12,
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 Comment.  Goetting., t. viii., No. 8 ; et Element. Physiol.,
t. vii., p. 242.—Monro, Observ. on Crural Hernia, <fcc.—/.
A. Murray, Comment, de Arbuto Uva-ursi, p. 164.  Goet.,
 1765.—Bang, in Acta Regf.  Soc. Med. Haun., vol. i., p. 301  ;
 vol. iv., p. 171. — Wichmann, Ideen zur Diagnostick, b. iii.,
p.  6. — Sandifort, Exercit.  Acad., lib. ii., c. 11; et Anat.
 Pathol., lib. in., p. 96; et Museum Anatom., lib. i., p. 251.
 —Zeviani, in Memorie  di Verona, t. v.,  p.  391.—De Ha< n,
 Ratio Medendi, p. ix., c. 1;  et  OpuscuJ. Inedit., p. i., No. 20.
 —Wiseman, Chirurg. Treatises,  &c, vol. ii.—M. Stall, Rat.
 Medendi, p. vii., p. 360.—Halle, in Hist, de la Soc. Roy. de
 Med., ad. 1781-82.— Walter, in Nouv. Memoires de l'Acade-
 mie a Berlin, 1790-91,  p.  106;  Anat. Museum, vol. i., p.
 165. — A. M.  Cava,  De  Renum  Calculo, ejusdemque cum
 aliis Morbis similitudine, 8vo.   Ticini, 1790.—W. Falconer,
 Of the  Efficacy of Aqua Mephitica Alkalina in Calculous
 Disorders, 8vo.  Lond., 1799,  3d ed.—Dupont, in Journ. de
 Med., torn, xxxii., p. 135.— T. A. Walter,  Einige Krank-
 heiten der Nieren, <fcc, 4to.  Berlin, 1800.—Carter, in Med.
 Facts and Observat., vol. vi.,  art. 3. — R. Willan, in Ibid.,
 vol. iii.,p. 1;  Ibid., vol.  vii., p. 285.— Pole, in Mem. of Med.
 Soc. of  Lond., vol. ii.. No.  39.—S. Lowdell, in Ibid., vol. i.,
 p. 319. — Erratt, in Ibid.,  vol. v., art. 6. —P. Copland, in
 Ibid., vol. v., p. 71 ;  vol. vi., p. 601.—/. P. Frank, De Cur.
 Horn. Morbis, lib. ii., p. 294 ;  et lib. vi., par. i., p. 283 ; et
 Acta Institut. Clinic. Vilnensis, ann. iii., p. 83. — Caldani,
 Memorie di Fisica della Societa Italiana a Modcna, torn, n.,
 p. 2.—Hohnstock, Die Magen und Nieren-Entziindung, &c,
 8vo.  Sonders.,  1808. — Horn, Archiv. fiir Pr. Mtdicm., b.
 vi., p. 337.—  Vblker, in Ibid.,  July,  1812, p. 133, 138. —M.
 Baillie, Series of Engravings, &c, fasc. vi., 4, 5, 6, S.— G.
 Blane,  Trans, of Society  for Improv. Med. and Chirurg. 
772
LACTATION—Slighter Disorders or.
Knnwlcdie, vol. ii.—Conradi, in Amemanm Magazin, b. i.,
p. 17t>.—Portal, Ccnrs tl'Anat. Med., torn, v., p. 378; et p.
390.—Rudolphi, Bemrrkungen, Ac, th. ii., p. 190.—Frank,
Interpret. Clinic, i., p. 242,261. — Pearson,  in Med. Ob-
servat. and  Inquiries, vol. vii.—Schmidtmann, in Hufeland,
Journ. der Pr. Arzneyk., b. vii., St. 4, p. 44. — Chopart,
Traite de Malad. des Voies Urmaires, Ac, edit. Felix Pas-
cal, 2 tomes, 8vo.   Paris, 1830.—/. Wilson, Lectures on  the
Struct, and Physiol, of the Urinary Organs, and on the Na-
ture and Treatment of their Diseases. 8vo.  Lond., 1821.—
/. Howship, Pract. Treat, on some of the most important
Complaints that affect the Secretion and Excretion of Urine,
8vo.  Lond., 1823—.A. Marcet, in Trans, of Med. and Chi-
rurg. Society of London, vol. x., p. 147.—H. Earle,i\\ Ibid.,
vol. xi., p. 211.— V. De Lafosse, in Nouv. Biblioth. Medi-
cale, torn, viii., p. 43.—K. Caspari, Der Stein der  Nieren,
Ac, 8vo.  Leipsic, 1823. — Julia, in Archives G£ner. de
Medecine, torn, ii., p. 577; torn,  xviii., p. 124. — Dance, in
Ibid., torn, xxix., p. 149.—Boisseau, Nosographie Organique,
Ac, torn, iii., p. 350.—P. Copland, in Edin. Med. and Surg.
Journ., vol.  vii., p. 38. — Abercrombie, Ibid., vol.  xvii., p.
210.— W. Howison, in Ibid., vol. xviii., p. 557.—R. Robin-
son, in Ibid., vol. xix., p. 33.—/. C. Gregory, in Ibid., vol.
xxxvi., p. 315 ; et vol. xxxvii., p.  54.—Craigie, in Ibid., vol.
xli., p. 120.—J. Fosbrooke, Pract.  Observat. on the Pathalog.
Relat. between the Kidneys and other Organs, 8vo.  Chelt.,
1825. — Hevin, in  Mfcm.de l'Academie Roy. de Chirurg.,
torn, iii., p. 262.—F. Smith, in Lond. Med. Gazette, vol. vii.,
p. 138.—Graves, in Ibid., vol. vii., p. 585.—B. C. Brodie, in
Ibid., vol. viii., passim. — R. Bright, Reports of Medical
Cases, illustrating the Symptoms and Cure of Disease, Ac,
p. 1, et seq., 4to.   Lond., 1827; and  in Guy's Hospital Re-
ports, vol. i., p. 380; and Johnson's Med. Chirurg. Rev.,
July, 1836, p. 193. — /. Lawder, Trans, of Med. and Phys.
Soc. of Calcutta, vol. vii., p. 473.—Gluge, in Brit, and For.
Med. Rev., April, 1838, p. 556.—R. Christison, On  Granu-
lar Degeneration  of  the Kidneys, 8vo, ed. 1838.— W. Eng-
land, Observat. on the Functional Diseases of the Kidneys,
Ac, 8vo.  Lond., 1930. — Graves, in Dubl. Journ. of Med.
Sciences, No. xvi.—B. C. Brodie, Lectures on the Diseases
of the Urinary Organs, 8vo.  Lond.,  1832.— Carter, Cyclop.
of Pract. Med., vol. iii., p. 6, 161.—/. G. Crose, A Treatise
on the Formation,  Constituents, and Extraction of the Uri-
nary Calculus, Ac, 4to, plates.  Lond., 1835. — R.  Willis,
Urinary Diseases and their Treatment, 8vo.  Lond., 1838.
— W. Coulson, On Diseases of the  Bladder and Prostate
Gland, Ac,  8vo.   Lond., 1840.— W. Prout, On the  Nature
and Treatment of Stomach and Urinary Diseases, Ac, 8vo.
Lond., 1840, passim.—Martin Solon, De I'Aibuminurie on
Hvdropisie causee par Maladie des Reins, Ac, 8vo.  Paris,
163S.—P. Rayer, Traite des Maladies del Reins, et des  Al-
terations de la Secretion Urinaire, Ac, 3 tomes, 8vo. Paris,
1838-1841.  (See, also, References and Bibliography to ar-
ticles on Urine and Urinary Bladder.)
  [Am. Bibliog. awd Refer.—/. /. Berzelius, The Kid-
neys and Urine, translated from the German by M. H. Boye
and F. Learning, M.D.  Phil., 1843, 8vo, p. 179.-/. F. Si-
mon, Animal Chemistry, with reference to the Physiology
and Pathology of Man ; translated and edited bv George E,
Day, A.M., Ac, 2 vols.  Lond. and  Phil., 1845-6.— W. P.
Alison. Outlines  of Pathology and  Practice of Medicine.
Phil., 1844, 8vo, p. 424. — G. J. Guthrie, On the Anatomy
and Diseases of the Urinary and Sexual Organs, Ac.  Phil.,
1845, 8vo, p. 150.—T. Watson, Lectures on the Principles
and Practice of Physic. Phil., 2d  ed., 1645, 8vo. — /. D.
Heaton, in Lond. Med. Gazette, March, 1844.—/. Aldridge,
in Dub. Jour, of Med.  Science, Jan., 1844, p. 444,  479. —
George  Johnson,  in  Lond. Lancet, Jan., 1845, p. 84, Am.
edition.—E. G. Shearman, in Lond. Lancet, Aug., 1845, p.
126, Am. edition.—Richard Quain, in Lond. Lancet, Feb.,
1646, p. 139, Am. edition. — C. J. B. Williams, Principles
of Medicine, and Lectures, in Lond. Med. Times, Jan., Feb.,
and March, 1845.—/. Corrigan, in Lond. Med. Times, March,
1845. — Golding Bird, Urinary Deposites,  their Diagnosis,
Pathology, and Therapeutical Indications.  Phil., 1M5. 8vo,
p. iil.—Muller, Physiology ; translated by Baly, 1814—S.
D. Gross, Elements of Pathological Anatomy. Phil., 2d ed.,
1815. — G. O. Rees, Analysis of  Blood and Urine, Ac, 2d
ed., 8vo.—/. A. Swett, Notice of Rayer on the Kidneys, in
New-York Journ.  of Med., vol. iv., p. 168; and New-York
Jour. Med. and Collat. Sciences,  vol. iii., p. 9.— W. C. Rob-
erts, Cases of Renal Disease in Children, Ac, in New-
York Jour, of Med., vol. iii., p. 44.—A. Grissolle, An Essay
on Phlegmonous Tumours of the Iliac Fossal; transl. by C.
L. Mitchell, M.D., in New-York Jour, of Med., vol. ii., p.
390.—Barlow, in Provincial Med. Jour., July, 1842.—Good-
sir, in Lond. and Edin. Monthly Jour. Med. Sci., May, 1842.
—C. Haller, in Arch. Gen. de Med., Dec, 1842. — Graves,
Clinical Lectures.   Dub., 1843; and in Lond. Med. Gaz.,
Oct., 1838. — T. C. Adam, Diseased Kidney, with Albumi-
nous Urine,  in Am. Jour. Med. Sci., vol. xx., p. 331.—/. M.
Nye, in Bost. Med. and Surg. Jour., vol. xxix., p. 514.—/.
Watson, in New-York Jour. Med.— Wm. H. Luce, in Post.
Med. and Surg. Jour., vol. xxii.,  p. 21.—/ D. Mansfield, in
Bost. Med. and Surg. Jour., vol.  xxvii., p. 9.—R. Burriage,
in Bost. Med. and Surg. Jour., vol. xxvii., p. 29.—/. Hinckley,
in Bost  Med. and  Sure- Jour., vol. xxv , p. 275.--C«M
Pierce, in B..»t. M«d. and Surg. Jour., vol. v., p. IM-—J »■
Brown, in Bost. Mad. and  Surg. Jour., vol. ».. ]•■ 155.—K.
Dungtison, Pract. of Med., 2d ed.  Phil , M5, 2 vols.]
LACTATION. — Lactatus,  Lactatio.  Yalovxia.
   Lactation,  allaitement,  Fr.   Smgung, Germ.
   Allatamento, Ital. (Suckling).
     Classif.—General  Pathology.—Special
       Pathology.—III.  Class, I. Okdek (Au-
       thor).
   1.  Defipt.—The function  of secreting and ex-
creting milk.
   2.  It is justly observed by Dr. Locock, that
lactation in the  human female,  when naturally
conducted,  cannot be  called a disease ;  but
even under the most favourable aspect there
are  often  circumstances which  require atten-
tion and regulation, for the purposes both of al-
leviating  pain   and  of  preventing  mischief.
There  are also  frequent interruptions to this
usually healthy process, and so many important
questions  connected with it, at various periods,
that it  becomes necessary to notice them, al-
though briefly.
   3. The intimate sympathy between the mam-
mae  and the uterus is evident even in the un-
impregnated state.   This is observed  in con-
nexion with menstruation, and in  some dis-
eases of the womb.  In  pregnancy the  altera-
tion  in  the breasts  is well marked,  and  the
quantity of milky serum  secreted is sometimes
very great, particularly  towards the close  of
utero-gestation.   Many women, however, have
no appearance of milk before delivery, and yet
have an abundance afterward.
   4.  I. Slighter Disorders  or Lactation.—
a. After parturition, the infant is usually applied
to the breast, as soon as the  exhaustion more
immediately consequent upon this process is
partially removed, or generally  within the first
twenty-four  hours, in order to  draw  out and
form the nipple,  before the breasts become hard
or distended, and to encourage the flow of milk.
There is seldom any quantity of milk secreted,
with first children, before the  third  day;  but
about that day or one or two later, the breasts
become swollen and hard,  and  often  hot and
painful; the pulse  is accelerated ; and slight
chills, febrile commotion,  thirst, disturbed sleep,
and  occasionally slight disturbance of  the sen-
sorium, supervene.   This constitutional excite-
ment attending the establishment of the func-
tion of lactation continues until the milk is at
its height, as it is termed : the breasts are then
extremely  hard, knotted, loaded,  and  tender.
The swelling may extend to the clavicles and
axilla, the  glands in this latter  situation being
also enlarged ; but a small quantity of milk will
ooze out  from  the  nipples, especially  if  the
breasts  be fomented or  gently  pressed.   The
act of suckling the infant is attended by great
pain in the breast; but it is followed by relief,
and as the milk flows, the hardness and swell-
ing are  diminished.   After  some hours, if the
milk be freely drawn off, the sensations become
more comfortable, and the process of lactation
is duly established.
   5.  b. The above state of local  and  general
disturbance ushering in this process may vary
in grade from that described ;  but, when it is
at all considerable, means should be used to al-
leviate it.   As  soon as  the febrile symptoms
begin, a cooling  saline purgative should be giv-
en, and repeated in twelve or twenty-four hours. 
LACTATION—Disorders of.
773
according to circumstances.  In order to allay
thirst, and to prevent  the distention  of the
breasts,  which copious  draughts would occa-
sion,  cooling saline  diaphoretics,  or efferves-
cing draughts, ought to  be  prescribed.  When
the infant cannot draw out the nipple of a hard
or distended  breast, or obtain the thick milk
distending the ducts, an older  child may  be
applied, or a grown person should do this, or
have  recourse to artificial  means, such as the
breast-pump, &c   Natural  or artificial suction,
fomenting  the breasts with hot water,  warm
poultices, &c, generally relieve the local dis-
order, and  promote a free discharge of milk*
  6. c. The milk first drawn contains a consid-
erable quantity of  what has been  called colos-
trum, and has a purgative quality, thus serving
to evacuate  the meconium which loads the
large  intestines.   When, therefore, the  infant
does  not get the  first draught of the breast,
from  being suckled by a wet nurse, or from be-
ing brought  up by hand,  a gentle purgative
should be given to it; as diarrhoea or convul-
sions may  arise from the retained  meconium.
In other circumstances, the exhibition of a pur-
gative may be superfluous ; for, as Dr. R. Lee
has shown, a quantity of highly nutritious albu-
men is found in the small intestines above the
situation of the excrementitial meconium, ser-
ving for  the sustenance  of the infant until lac-
tation is fully established.   A purgative, there-
fore,  given before  this  process is fully  com-
menced will carry off this substance.
  7. d. The milk varies  much in its properties,
and even in  its sensible qualities  and appear-
ance,  during the usual period of lactation, ac-
cording to the diet, modes of living, state  of
mind, and bodily health  of the nurse.  At first
the milk is thick, yellowish, and abounds with
cream; but, after a  few days, it  assumes the
usual  appearance,  and  becomes thin,  bluish,
and sweet.   The taste and qualities of the milk
are altered by several articles of diet, by reple-
tion, hot and close  rooms, by medicines, and
moral emotions, particularly those of a violent
kind,  and the infant is more or less affected by
the alteration.  The milk may be so disordered
as to have a saline, a bitter, or an otherwise
unpleasant taste, the  infant relinquishing the
breast instantly upon tasting it.   So remarka-
ble an influence may medicines have upon the
milk,  and through it upon the child, that a pur-
gative taken by the nurse  may affect the for-
mer without materially affecting the latter.  Al-
kalies, mercury, various alteratives, and  saline
substances often act  in a  similar  way.  The
colour of milk may be changed somewhat, ow-
ing to an  admixture of a  little blood with  it
from the exterior or interior of the nipple.   It
is not infrequently  altered by biliary disorders
of the nurse.  Dr. Locock has  seen four in-
  * [In some cases, there is retention of the milk from vi-
cious conformation of the nipple, such as its absence and its
congenital or accidental imperiforation. Sometimes the milk-
ducts are obstructed from  flattening or induration of the
nipple, or from turgescence of the mammse; and in some
cases the obstruction coincides with depression of the  nip-
ples, which  may often be  remedied. Dr. Pratt, of  this
city, has invented a very ingenious artificial nipple, con-
sisting of a  small metallic shield, with n valve or opening,
and a moveable cap of gum elastic, which is an  excellent
substitute for the natural organ. We have known it applied
with instantaneous relief and success in cases of excoriated
or retracted nipple, and hence we recommend it in all cases
of this kind']
stances where it was of a golden yellow hue,
and where, upon standing, a thick layer of bit-
ter cream, as yellow as pure bile, floated on its
surface.   In neither of these  cases was the
nurse jaundiced ; but, a very copious flow of
bile being procured from the intestines by mer-
curial purges, the yellowness gradually disap-
peared ;  the child, till then, having been much
griped and affected with diarrhoea.  Yet in no
cases where the wet  nurses have been jaun-
diced has  Dr. Locock seen the milk yellow;
and it is not uncommon for them to become thus
disordered, owing to a sudden transition from
a scanty diet  to a full and luxurious mode of
living.   Milk may disorder  the  infant from
merely  being too rich.   The remedy in  this
case is to purge the nurse, to cause her to take
active exercise, and to abridge her diet.*
  8.  e. The properties of the milk are altered
more or less  by menstruation and pregnancy.
Menstruation generally impairs both the quality
and the duration of the milk.  The infant often
brings up the  milk, becomes fretful and disor-
dered in the bowels, the stools being watery,
frequent, or of  a spinach colour.  When this
form of disorder occurs, menstruation in the
nurse should be suspected.  The pregnancy of
the nurse  may not only cause  the milk to be
scanty, watery, &c, but may also variously dis-
order the infant.  It is supposed by many that
suckling will prevent  impregnation ;  and, ow-
ing to this notion, lactation is often  continued
for much too long a  period, as  respects  the
health both of the infant and of  the nurse ;  but
women  very frequently do become  pregnant
when suckling, while some do not.  Mr. Rob-
erton found that, in 160 cases,  81 had become
pregnant once or oftener during this process.
Dr. Locock is decidedly of opinion that those
women who menstruate  during lactation will
more readily conceive than those who do not;
and  he  has also remarked, as  Dr.  Hamilton
has done, that both these occurrences are more
common with first children : hence women un-
der these circumstances are not, ceteris paribus,
as eligible  as others for wet-nurses.
  9.  II. Milk Fever.—a.  This disorder is  a
morbidly aggravated form of the local and gen-
eral  excitement attending the commencement
of lactation, and noticed above (y 4).   The feb-
rile symptoms are  much more  severe than in
it, and  are ushered in by chills  or  a marked
rigour.   There are severe pains and throbbing
in the head, flushed  face, intolerance of light
and  sound; excessive thirst,  a hot and dry
skin ; a  rapid,  full, or hard pulse,  furred or
loaded tongue, costive bowels, scanty or high-
coloured urine, and sometimes a diminution of
the lochia.
   10. These attacks are commonly caused by a
stimulating diet, a heated or close apartment;
by over-exertion, disturbance, or mental agita-

  * £Colombat gives the following test by which to judge
of the qualities of human milk.  To discover whether the
consistence of the milk is loo thin or too thick, place a drop
on one of the nails; if it adheres to it at first, and then
spreads, without running, it is in the natural condition ; in
the contrary case, it is not sufficiently consistent; while it
is too thick if the drop adheres to the nail without spread-
ing.  In fleshy, fat women, the milk is generally thick ; in
nervous females it is thin,  not very nutritious, and subject
to slight alterations after the slightest vexation.  Spintuous
liquors, instead of increasing, as many suppose, diminish
the quantity of milk secreted.—(Colombat de L'Isere;
transl. by Meigs.  Phil., 1845.)] 
774                           LACTATION—Disorders or.
tion, and exciting beverages.  They were fre-
quent occurrences when brandy caudle, large j
tires, imperfect ventilation,  and  loads of bed-
clothes  were  generally  adopted ;  and were ]
often followed by inflammatory fevers, phren-
itis, &c.
  11.  b. The treatment of this disorder is very
manifest:  cooling  saline purgatives, cooling
diaphoretics, due ventilation, and a moderate
temperature of the apartment;  the encoura-
ging of a copious flow of milk, and the avoid-
ing of mental emotions and  excitement  of the
senses, are the most influential means of cure ;
and generally produce a remission of the symp-
toms in the course of a  few hours, and a co-
pious  perspiration.   If,  however, injudicious
means be  employed, and  either the milk or the
lochia, or  both, be suppressed, very dangerous
disease will supervene, and  copious depletions
will be requisite, with other  remedies appropri-
ate to the nature of the consequent  mischief.
  12.  III. Excessive  Secretion of Milk.—a.
The secretion of milk may be excessive in re-
ality, or only apparently.  The former  exists
when the quantity secreted and excreted is in-
ordinate, the breasts being  distended, painful,
and knotted, although the discharge  from them
is free, or even very copious; the latter ob-
tains chiefly where there is  deficient power  of
retaining the milk, a constant discharge taking
place  in the intervals between suckling.    In
most, however, of such cases, the quantity se-
creted is really augmented.   In connexion with
this excessive secretion, there is generally more
or less constitutional disorder;  for, as  in the
first  instance, if the breasts be much swollen
and painful, a species of chronic milk fever may
attend this excessive function ; and  ultimately,
in such cases, as well as  in those characterized
by deficient powers of retaining the milk, the
frame of the nurse is exhausted by the inor-
dinate discharge, and by the diversion of the
nourishment from  herself.   In  such circum-
stances, similar disorders to those observed in
females who have suckled too long, or in those
who are  constitutionally,   or from previous
health, incapable of suckling at all, soon mani-
fest themselves, and the nurse  sinks  into  a
state of marasmus, or of hectic or  of chronic
debility, or becomes consumptive, or complains
of dragging pains and weakness  in the back  or
loins, &c, or presents the state  occasioned  by
prolonged lactation about to be noticed.
   13. b. The treatment in these states of disor-
dered lactation should depend much upon the
form which it assumes, and the effects it has
produced  on the general health.  In the first
form (y  12), or when the secretion is very ex-
cessive, the breasts being  swollen, hard, and
tender, and the health not materially impaired,
cooling  diaphoretics, saline  aperients, refriger-
ants, low  or moderate diet, and avoiding sex-
ual indulgence, are the most  appropriate means.
In the second form (y 12), or when there is  an
insufficient power of retention, it has been pro-
posed to have recourse to topical astringents,
as lotions of alum, zinc, &c. ;  but these  are
apt entirely to suppress  the secretion of milk.
Others, again, have advised the internal use of
astringent tonics and  the mineral  acids ;  but
these remedies frequently disorder  the  bowels
of the infant.   The preparations of steel, or of
cinchona, or other vegetable tonics, the show-
er bath, or cold salt-water bathing, and a cooi
state  of the breasts, are the most beneficial
remedies.
   14.  IV. Undue Lactation.—Lactation may
be undue or improper as respects, 1st.  The
state  of the nurse's constitution and existing
state  of health ;  and, 2d.  The lengthened con-
tinuance of it.  Females of a nervous, suscep-
tible temperament, and weakened constitution ;
those who are predisposed to pulmonary con-
sumption, to puerperal mania,  or to insanity in
any form ; and those who have  been chlorotic
and very hysterical  before marriage, frequently
are incapable of suckling for any considerable
time,  without exhibiting indications of its inju-
rious  effects upon their constitutions, and even
upon  the infant also.  These effects are usual-
ly the same as those which follow a too pro-
tracted period of lactation.
   15.  a. The duration of suckling should have
strict reference to the health of the nurse and
the state of the  infant.   Many begin, and con-
tinue  to suckle for some  time, with great suc-
cess ; but, owing to disturbed rest, insufficient
food,  and too frequent or too prolonged appli-
cations of the infant  to the breast, the health
of both nurse and  infant ultimately  suffers.
Where lactation  is judiciously regulated, and
the health of the nurse is not impaired thereby,
while strength and nourishment  are preserved
by a suitable quantity of food and drink, and
the rest is not prevented by too frequent ap-
plications to the  breast, the period may be pro-
tracted  without  injury to either  the nurse or
infant.  But if the nurse menstruates, or be-
comes pregnant, the period should be termina-
ted forthwith ; such provision being made for
the nourishment of the infant as its age, state
of health, and its progress in the process of
teething will warrant.
   16. b. The symptoms of undue  lactation are
such  as naturally result from a protracted dis-
charge or drain, beyond the assimilating pow-
ers and strength of the  nurse.  When the in-
fant is at the breast, or  a short time after its
application,  she  feels a  sense of dragging  in
the back  or loins, and of sinking at the ster-
num and pit of the stomach, with a feeling of
emptiness,  which continues for  some  time.
After these  have been felt for a time, the appe-
tite fails gradually; general lassitude  is com-
plained of; the pulse becomes quick and feeble;
alternate  chills and flushes of heat come on,
and the  spirits sink,  or  are irritable or weak.
Subsequently, emaciation, costiveness,  head-
ache, weakness of sight, loss of memory, thirst,
dry tongue  at night, and night perspirations
supervene ;  and in  some cases pulmonary con-
sumption, in others symptoms closely simula-
ting consumption, or  a chlorotic or anaemic ap-
pearance of the  surface, leucorrhoea, neuralgic
pains in  various situations, or pleurodynia, and
not infrequently that form of puerperal mania
which I have described (see Insanity, v 534)
as occasionally  following undue lactation, are
thus caused.
   17. c. The treatment should consist of the im-
mediate removal of the cause of the disorder.
The infant should be weaned, and those disor-
ders, if they have not made too great a prog-
ress, or  gone on to  organic  lesion, will gen-
erally disappear  before  appropriate remedies
But unless  lactation  be  terminated, such rem- 
LACTATION—Disorders of.
775
©dies will often fail of being serviceable.  This
having been done, or being in progress, vege-
table tonics, the compound steel mixture, or
the  acetate or other preparations of iron, cold
or sea bathing, the shower bath, change of air,
and  light, nourishing food, in conjunction with
such other means as the form of disorder thus
caused will suggest, will generally restore  the
patient to health.
   18. V. Suppression of the Milk.—The milk
may be suppressed, or suddenly disappear from
the  breasts, at  any period of  lactation,  but
more readily very  soon after delivery.   The
suppression may be total, or only partial;  and
it may be primary, or consecutive.—a.  It may be
considered as primary when milk does not ap-
pear at all  in the breasts after delivery,  and
consecutive when  a  total or partial suppression
follows the establishment of the process of lac-
tation.  The  non-appearance  of milk in  the
breasts is generally owing to some fault in the
organization, or in the nervous energy of these
glands ; to want of constitutional power, or of
necessary nourishment; to excessive dischar-
ges, whether hemorrhagic, lochial, or leucor-
rhoeal; to  the occurrence of  acute or inflam-
matory  diseases; to the  pre-existence of or-
ganic maladies ; to mental distress and anxie-
ty ;  to cold applications and astringents to the
breast, and to various circumstances peculiar to
individual cases.   Frequently, instead of a to-
tal suppression, or non-appearance of milk in
the  breasts, there is merely an insufficient se-
cretion,  the quantity being much below that
which is requisite to the health and growth of
the infant.
   19. b. The consecutive suppression of milk is
generally owing to fear,  sudden terror or fright,
anxiety of mind, unpleasant news suddenly or
unexpectedly communicated,  grief, all the de-
pressing passions and emotions, startling  noi-
ses, disappointment, vexation, anger, &c.  It
may be occasioned also by severe attacks of
disease, or  by any of the  causes enumerated
above (v 18).  While the suppression of  the
lacteal secretion  may proceed from the devel-
opment  of inflammatory or other acute  dis-
eases, these latter may also arise from the sup-
pression of milk caused by mental emotion, or
by other occurrences.   In the former case, it
may be considered that the  inflammation or
sanguineous afflux, constituting these  diseases,
creates  a diversion of the vital current from
that quarter where it is necessary for the con-
tinuance of the lacteal secretion : in the latter
case, either the passage of the milk from  the
breast into the mass of blood, or the accumu-
lation in it of the constituents requisite to the
formation of this fluid, creates such  a state of
vascular plethora, or affects the blood in such
a manner as readily to kindle  inflammation, or
cause congestion, effusion of serum, or  other
changes in organs  disposed to  such  maladies
either by original conformation  or by an  ac-
quired predisposition.  Dr. Locock states—and
even more remarkable  facts of  a similar kind
have, been recorded by numerous writers of
high character—that he  has  observed, when
bleeding has been had  recourse to in inflam-
matory diseases,  with sudden suppression of
milk, that the serum of the blood, when sep-
arated  by rest,  has been white, opaque,  and
bearing nearly all the characters of milk,  ex-
cepting the formation of cream on its surface.
It  may also be observed,  that when the milk
has been driven back by  active purgatives, a
large quantity of milk-like  fluid may be seen in
the motions.  However, a milky state of the
serum of the blood often attends the puerperal
states, independently of  any suppression of
milk; and I have seen,  in  several cases, some
years ago, in Queen  Charlotte's Lying-in Hos-
pital, the serum effused in the peritoneal cav-
ity, in fatal cases of complicated puerperal fe-
ver, present a milk-like  appearance, with clots
like the curds of milk;  and yet the secretion
of milk was not suppressed during the disease.
The same appearances have also been observed
in  cases where a suppression of the milk had
occurred.
  20.  In rare instances, when the milk is sup-
pressed, a vicarious discharge of it, or of a fluid
very closely resembling it,  takes place from va-
rious situations : this has been termed a trans-
lation of the milk, and in many of such instan-
ces the general health has not  materially suf-
fered.  The situations where this vicarious dis-
charge has occurred are, the mucous surface of
the intestines ;  of the womb  or vagina, in the
form of leucorrhcea ;  the fauces and throat, the
kidneys, &c.
  21. c. The treatment, in cases of the non-ap-
pearance or of the suppression of the milk, must
depend upon the causes producing it, the extent.
to  which it has been carried, and upon the effects
it has occasioned.  When  it is desirable to re-
store the secretion, the infant should be kept
to  the breast, or the  breasts ought to  be regu-
larly drawn;  and if the suppression be partial,
or owing to  insufficient nourishment, the re-
moval of this cause will generally be sufficient
to  restore the secretion.  Some females  have
an insufficient  and watery or thin supply of
milk, owing to the use  of too  much  fluid, as
weak tea, &c, and to a poor, vegetable, or wa-
tery diet, and living in low, damp situations
and dwellings.   A due  supply of light animal
food, of richer beverages,  and living in a dry,
pure air, will restore to these the healthy se-
cretion of milk.  If inflammatory or other dis-
eases have resulted  from  the non-appearance
or suppression of the milk, the treatment will
necessarily depend upon the nature and char-
acter of such disease, keeping, however, in rec-
ollection  this particular circumstance connect-
ed with their production.
  22.  There are two facts connected with the
non-appearance  or  suppression of the  milk
which should not be  overlooked.  Some wom-
en dissemble, and wish to  make it appear that
they have no milk, or an insufficiency of milk,
in  order that they may avoid suckling.  A few
of these  may have a fear of its  effects  upon
their own health ; but much more  frequently
they dissemble, with a  view of avoiding the
trouble and confinement connected  with suck-
ling, and of preserving the form of their breasts.
Hired nurses, on the other hand, often pretend
that  their milk is abundant and healthy when
it is neither the one nor the other, or even when
it is nearly gone.   When the milk is gone, and
when, in most instances, it cannot be restored,
it will be found  that the breasts do not swell
nor become firm after a considerable time from
the last period at which  the infant was applied
to  them.  The infant seems hungry, even upon 
776
LARYNX AND TRACHEA—Nervous Affections or.
quitting the  breast, and  is constantly seeking
to be applied, but quits the nipple, after having
taken it for a very  short time, with impatience
and with distressing cries.  It passes very little
urine, it sleeps little, and is rapidly emaciated.
  23. VI. The termination of the period of j
lactation becomes necessary when the infant |
is sufficiently old to be fed by many of the usu- !
al articles of diet, when it is from eight or nine
to fifteen  months old, and when it  has four or
six teeth, or more.  But there are other cir-
cumstances  which  indicate  the  propriety of
terminating the period of lactation before  it be
prolonged to the term now named, and to which
attention  is more especially directed above (y
16).   When  these  exist, or when the child is
dead, the secretion of milk should be gradually
suppressed.  A sudden suppression of this func-
tion  might endanger the occurrence of phreni-
tis, of fever, or of internal inflammations.  The
safest means of accomplishing this end are, the
exhibition of saline purgatives, and  of refriger-
ants, a low and cooling diet, and a sparing use
of fluids.   If the breasts  become hard or pain-
ful, a small quantity of milk may be drawn off
and  stimulating liniments  may  be applied to
them.   They should also be rubbed  gently with
warm oil.  After a few days but little inconve-
nience will be felt,  and in a few more the milk
will  have entirely disappeared.
  24. In weaning an infant, however, the grad-
ual withdrawal of it from the breast, and the
partial feeding it, for  some time previously to
complete  weaning,  generally  favours  the  dis-
persion or suppression of the milk, and prevents
much disorder or inconvenience being felt  from
the cessation of this function.  Still, the  bow-
els ought to be kept very freely open, and pur-
gatives should be given from  time  to time, or
according to circumstances, otherwise  loss of
health, depression of spirits, disorder of the di-
gestive organs, or some specific  disease, to
which a predisposition may exist,  may super-
vene.   (See,  also, connected with this subject, the
article Mamma.)

  Bibliog. and Refer.-Sainte-Marthe, Maniere de non-
rir les Enfans a Mamelle, 8vo.  Paris, 1698.—J. Colbatch,
Of the Art of Nursing, 8vo.  Lond., 1733.—A. I.evret, Lettre
sur I'Allaitement des Enfans, 8vo. Paris, 1771.—H. Smith,
Letters to Married Women on Nursing. 8vo.   Lond., 1774.
—F. Baldini, II Metodo di  allatare i Bambini, 8vo.  Nap.,
1784.—R. De Lepinoy, Avis aux Meres qui veulent allaiter
leurs  Enfans, 8vo.  Paris, 1785.—B. Lara, An Essay on the
injurious  Custom of Mothers not suckling their Children, I
8vo.  Lond., 1792.— G. A. Chevalier-Demolle, Consider.
M6d.  sur les Avantages de I'Allaitement Stranger pour les
Enfans des grands Villes, 8vo.  Paris, 1803. — L. J. Boer,
Ueber die Saiigung Neugebohrner Kinder, 8vo. Wien.,
1808.—Dawborn. The Rights of Infants ; a Letter on Nurs-
ing, 8vo.  Lond., 1805. — F. Von Leuthner, Abhandlung
ueber  die Vernachlassigte  Saiigung bey  Muttern., 8vo.
Num ,1810. — Gardien, Diet, des Sc. Med., t. i. — Desor-
meaux, Diet, de  M&lecine, t. ii., p. 2; et t. xii.—Lachaise,
Revue Medicale, t. iii., p. 472,1825.—Duges, Diet, de Med.
Prat., t. ii.— W. C. Dendy, Book of the Nursery, 8vo. Lond.,
1833.—T. Bull, Hints to Mothers during Pregnancy, &c,
12mo.  Lond., ll-3'J. — Locock, Cyclop, of Pract. Med., vol.
iii., p. 9— A. Combe, A Treatise on the Physiological and
Moral Management of Infancy, p. 187, 12mo.  Edin., 1840.
  IAm. Bibliog. and Refer.— W. P. Dewees, On Females,
and on Diseases of Children.—Colombat de L'Isere, transla-
ted by Dr. Meigs.  Phil., 8vo, 1845.—Green, in New-York
Journ. Med. and Coll. Sci., vol. v. —J. Eberle, A Treatise
on the Diseases and Phys. Education of Children,  1 vol.,
Svo.— T. Bull, Hints to Mothers during the Period of Preg-
nancy and in the Lying-in-room, 18mo.—G. Ackerley, On
the Management of Children in Sickness and in Health,
1 vol., 12mo. — C. M. Billard,  On Diseases of Children;
translated by Stewart.  New-York, 1  vol., 8vo.]

LARYNX AND TRACHEA.—Synon. Aapvy?,
  Larynx.   Luftrdhrenkopf, Germ.   Larynx, Fr.
  Laringe, Ital-—Trachea. Die Lnftrohre, Germ.
  Trachte, Fr.  Trachea, Ital.   Windpipe.
  1. I comprise under  this  head those  affec-
tions which more especially interest the func-
tions and organization of the larynx, epiglottis,
and trachea.   Those disorders  which are sym-
pathetic, nervous, or functional are first consider-
ed,  and those diseases which are inflammatory,
and  are  consequent upon inflammation, are next
discussed.  The physiology and  connexions of
this part of the  respiratory apparatus should be
constantly kept  in view when we  discuss the
causes, symptoms,  nature, and treatment of
its  diseases.  The circumstances of its being
the portal through which  air passes into and
out of the lungs, and the chief part of the organ
of voice or of human sounds, during the pas-
sage of this fluid from the lungs, the exquisite
sensibility with  which it is endowed rendering
it capable  of preventing injurious  matters of
every grade of fluidity or consistency from en-
tering into  an organ which more immediately
than any other interests the life of the individ-
ual  ; its intimate connexion with the parts con-
cerned in the process of deglutition, and the
protection it receives from the epiglottis, can-
not fail of suggesting  important considerations
respecting  the  relations,  conseqnences,  and
treatment of its disorders.
  2. I. Nervous, Functional, or Sympathetic
Affections of the Larynx.—As the exact ex-
tent of function  of the larynx has not been fully
undferstood  until recently, so the  nature  and
connexions of the disorders of this organ have
been  very imperfectly known, and several of
these disorders  have been confounded with one
another, or been referred to pathological con-
ditions from which they are altogether distinct
and  alien.  Several of the sympathetic affec-
tions of the larynx hardly differ from each oth-
er in their phenomena, particularly as regards
the disorder of the function of respiration, and
yet they proceed from very different, or even
opposite pathological states; and some of these
states do  not admit of recognition daring life.
Others, again, may be distinguished from one
another, as respects both their individual char-
acters and their morbid relations.   It becomes,
therefore, a work of  interest, but of no small
labour, to  point out  those distinctions  which
actually exist between some, as well as the re-
lations that subsist between others of these af-
fections; and the difficulty of doing this is much
increased by the circumstance of the  same
names having been applied by several writers
to very  different morbid conditions ; and, in
some instances, from one name having been
made to comprise more  than  one distinct form
of disorder.  This confusion has arisen from
writers having described these disorders partly
from the recollection of a few ill-observed phe-
nomena,  and partly  from imperfect  descrip-
tions contained in books.   Thus, the affection
which was  correctly denominated  " Spasmodic
Croup" by Wichmann, Michaei.is, and Double,
and the " Acute Asthma of Infants" by Simpson
and Millar, and which I have described as a
species of croup characterized by predominance
of spasmodic or nervous symptoms, in connex-
ion with signs of inflammatory or catarrhal irri-
tation in the respiratory passages, has been con-
founded with the stridulous respiration with la- 
LARYNX AND TRACHEA—Nervous Affections of.               777
 ryngic suffocation, which arises from a variety
 of pathological states, which is entirely uncon-
 nected with any affection of the respiratory pas-
 sages, and which is very distinct from true spas-
 modic croup, which is always attended by signs
 of inflammatory, bronchial, or catarrhal  irrita-
 tion, as shown in the article  Croup (y 14, et
 seq.).  Again, to the affection which is charac-
 terized by stridulous  respiration with laryngic
 suffocation, and which is  aptly enough termed
 " Laryngismus stridulus," Dr. Good applies, with
 practical ignorance of the disorder, the descrip-
 tion truly belonging to the spasmodic croup of
 Wichmann, &c, or the acute asthma of infants
 of Millar ; thinking that this affection is iden-
 tical with that noticed by Clarke,  Cheyne,
 Ley, Marsh, and  others.   These  distinct dis-
 orders have been confounded together by other
 writers also, and more recently by Dr. Joy.  I
 proceed to consider  stridulous inspiration, or
 stridulous laryngic suffocation of children.   The
 affection most nearly resembling it. in this class
 of patients, is that to which I have now  refer-
 red, and which  I have  described as a species
 of croup with predominance of spasmodic or ner-
 vous symptoms (see art. Croup, $  14, et  seq);
 both these distinct affections having come fre-
 quently under my care, especially during the
 fifteen years that I was  physician to the In-
 firmary for Children, both in that institution
 and in private practice.
 i. Stridulous Laryngic Suffocation in  Chil-
   dren.—Synon.  Spasm of the Larnyx; Spasm
   of the Glottis, Marsh.  Laryngismus stridulus.
   Good.   Crowing Disease of Infants ; Cerebral
   Croup;  Spasme de la  Glotte et du  Thorax,
   Gardien.  Psuedo-Croup nerveux, Guersent. I
   Asthma thymicum, Kopp and Frank.
     Classif.—II.  Class ; III. Order (Author
       in Preface).
   3. Defin.—Crowing inspiration, with a sense
 of suffocation in the larynx, and a tumid and pur-
 ple countenance,  commencing suddenly and after
 irregular intervals; the attacks being of very short
 duration, ceasing also suddenly, and not attended
 by cough, or other sign of irritation seated in the
 larynx itself.
  4. A. Symptoms.—The  earliest  accounts of
 this disease,  distinct from the  affections  with
 which it was and still is confounded, have been
 furnished by Drs. John Clarke, Monro, Golis,
 and  Cheyne, who have described  it nearly in I
 the  following terms :  The child  is suddenly
 seized with a spasmodic inspiration, consisting
 of distinct attempts to fill the lungs, attended
 by a shrill  noise ;  the eyes are staring, and the j
 child is evidently in great distress, and seems
 threatened with  suffocation.   The face  and I
 extremities, if the paroxysm continues  many
 seconds, become purple; the head is thrown
 back, and the spine bent: at length  a strong
 inspiration takes place, a fit of crying generally
 succeeds, and  the patient falls  asleep.   The
 paroxysm may occur often in the course of the
 day; but it is .most apt to take place on first
 awaking, or on exposure to causes of irritation,
 or when vexed, about to cry, or startled by
 any cause.
  5.  This affection may continue  to recur for
 some months,  if neglected,  until at last the
extremities are also affected by spasm, or con-
vulsions become general.   When it appears
upon  waking  from or  during  sleep, or UDon
    II.               98
I rudely waking the child, there are a state of
 alarm and agitation, a struggle for breath, with
 crowing or shrill inspiration, which cease after
 the "lapse of a few seconds.  The attack may
 return after  various  intervals:  at  the  com-
 mencement the child often  continues many
 days, or even some weeks, exempt from them ;
 but, if the morbid state on which  they depend
 be not removed, they generally return  more
 frequently, and  at  any period in the day or
 night, and  are brought on  by the  most trivial
 circumstances, especially by surprise, fright, or
 any mental irritation  or excitement.   At last
 the child may be carried off by an attack, and
 with the usual signs of asphyxia.
   6.  In some cases, this affection of the glottis
 goes on, unassociated with spasm of any other
 part  beyond the attempts to inspire, which are
 generally powerful and convulsive.  But in se-
 vere or neglected cases, and, in some instances,
 from the very commencement, the muscles of
 the arms and legs are affected ; the thumbs are
 drawn firmly in upon  the palms of the hands;
 the toes  are  bent  downward, and the wrists
 and ankle-joints are inclined  inward, forming
 what has been named " carpo-pedal contractions."
 The  progress of the  disease is not uniform :
 occasionally the attacks become less severe,
 less frequent, and less complicated, and again
 resume their former  frequency  and severity.
 They may be fatal in  the simple  laryngeal
 forms ; or they may not prove so until they are
 attended  by the carpo-pedal  contractions, or
 pass  into  more general convulsions.   I  may,
 however, mention, that not only is the laryngeal
 affection  sometimes simple, and  unattended by
 the carpo-pedal contractions, but these contrac-
 tions may be the only form of spasm, and may
 entirely disappear with the morbid condition of
 which they are sympathetic, without the larynx
 being affected ;  in  rare  instances even, they
 may precede the affection of the  glottis, and be
 associated with it.   When convulsions or gen-
 eral  spasms  supervene,  they are often very
 severe and tetanic.
   7.  This affection  of the larynx, either in its
 simple state, or when associated with the car-
 po-pedal  contractions, or with  more general
 spasm  or  convulsion, rarely presents itself
 without more or less  evidence of disorder of
 the general health, in  connexion with more es-
 pecial derangement of either  the digestive or-
 gans, or of the cerebral circulation or functions,
 or with dentition.   In some  cases,  however,
 where the affection is connected with irritation
 near the base of the brain, the  constitutional
 disorder may not be very manifest at first, the
 sleep being sound, the appetite  good, and the
 countenance lively.   But if  the state of the
 patient, while sleeping  and waking, be  very
 closely observed; if the evacuations, the state
 of the abdomen, and of the gums, the position
 in bed, the temper,  the expression of the coun-
 tenance, and the state of the  brows upon ex-
 posure to light, &c, be attentively examined,
 evidence of disorder will  be found in either the
 brain,  or  in  the digestive organs, or in the
 gums,  or even in all of them  in many cases,
 but most generally  in the brain  and digestive
 organs, sometimes  in both ;  and very rarely,
 and  then  merely accidentally, will  there  be
 found  any affection  of  the  respiratory pas-
 sages,  such as catarrhal, or bronchial, or tra- 
778              LARYNX AND TRACHEA—Nervous Affections of.
cheal irritation.   Although the early state of
the affection may be connected with, or sym-
pathetic of,  the  irritation of teething merely,
or of disorder of the alimentary canal,  still it
may become, after its continuance, or in its
more advanced states, very manifestly associ-
ated with disease within the cranium, such
disease being more  evident  as this affection
proceeds.
  8. B. The diagnosis of this affection has been
well stated  by  Wichmann and Schmalz, and
still better by Mr. Ryland.   It can be con-
founded only with the spasmodic form of croup,
with which,  as I have stated, it has been, even
recently, confounded by  some writers of pre-
tension.   It differs  from spasmodic forms of
croup, in its being excited by the  passions of
the mind, and causes of  momentary irritation,
and by the irritation of distant  but related
parts; it occurs chiefly in those who are dis-
posed to convulsive affections ; its attacks are
intermittent, distant, and irregular, and are re-
lieved chiefly by means which impress the ner-
vous system; it has no precursory signs, but
attacks suddenly and unexpectedly ; there is
neither fever, cough, nor pain ; catarrhal symp-
toms form no essential part of it,-and  it pre-
sents, after  death, no traces of irritation in the
respiratory  passages ; while  spasmodic croup
depends upon cold,  damp air, and  sudden at-
mospheric vicissitudes ;  and the fits of difficult
breathing in it are  attended  by cough, the
symptoms gradually subsiding, or being more
quickly relieved by the accession of vomiting ;
it presents remission in the day, with exacer-
bations in the evening and night, and generally
terminates  with a  glairy expectoration, &c.
(See Croup, v 14.)
   9.  C.  Causes.—The more  remote causes are
not very manifest.   Infants and young children
are most disposed to it.   Dr. Hamilton con-
siders it peculiar to the  period of cutting the
deciduous teeth.   Dr. Clarke  thinks  that it
seldom occurs after the third year.   Mr.  North
says that the earlier symptoms generally ap-
pear between the third and seventh month, and
that the disease seldom occurs after the ap-
pearance of the  teeth.  I have rarely met with
it after the  third or fourth year.  The numer-
ous instances I  have seen, and I have  had as
many  as  three  cases under treatment  at the
same time,  have been generally  between the
third month and third year of age.   It  may
doubtless occur  at a more advanced age; but
most of the cases which have been said to have
occurred  from  four or five  to ten or twelve
years of age, have been cases of the more spas-
modic forms of croup.
   10. Children who are hereditarily predisposed
to cerebral affections ; who are of a scrofulous
diathesis; and who are insufficiently nourished,
or live in a  close  or unwholesome air ;  those
brought up by hand, or who are delicate  during
the early months  of existence, or  are  reared
with difficulty—whose sutures are long  in clo-
sing, and  whose digestion and assimilating pro-
cesses are weak and readily disordered, are the
most prone  to this affection.
   11. The  pathological  states of which  it is
most frequently sympathetic, or by which it is
generally caused,  are, functional disorders  of
the digestive organs, especially the alimentary
canal and liver; difficult or delayed dentition,
generally with signs of irritation, tumefaction,
or inflammation of the gums, or with the ap-
pearance of several teeth  at  the same time ;
inflammatory states  of the membranes of the
brain, changes in them or in the cerebral struc-
ture, or irritation about or near the base of the
brain, or effusion into the ventricles ;  tubercu-
lar formations in the membranes, or within the
cranium ;  enlargements  of the glands, or of
the thymic gland ; and scrofulous enlargement
or other disease of the  cervical glands, or of
the glands at the root of  the lungs, whereby
the recurrent or other laryngeal nerves are ir-
ritated or pressed  upon.
  12. D.  The nature of  the disease has lately
been  the subject of much  discussion.  It has
not been very recently disputed that the larynx
itself is entirely free from lesion ; that is ad-
mitted.  The questions are : is this an affection
depending upon inflammatory irritation, or ir-
ritation of any kind, at the roots or origins of
the laryngeal nerves, or communicated to or
existing in any portion of them, whereby the
muscles which constrict  or close the glottis are
unduly contracted?  is it spasm of these mus-
cles from direct or indirect irritation and sym-
pathy 1 or is  it owing  to  pressure upon  the
nerves which actuate the muscles which open
the  glottis,  thereby paralyzing  them?   The
crowing or shrill  inspiration, with the strug-
gles to inspire, dread of suffocation, &c, are
unquestionably owing to a more or less com-
plete closure of the glottis; but that the closure
results from spasm of the constrictors, or that
it proceeds from paralysis of the dilators of the
larynx, are the points requiring to  be proved.
The disease maybe the result of either morbil
condition—either  may be considered as suffi-
cient to cause it;  and we may even admit that
the one condition may produce it in  some in-
stances, and the other in different cases.  The
former of these views, or the opinion that the
affection proceeds from irritation at the origin
of  the nerves,  or in the  nerves themselves,
which supply the muscles constricting the glot-
tis, or from irritation in  distant but related
parts acting sympathetically upon these nerves,
was the one very generally entertained, until
Dr. Ley proposed  the opposite or latter view.
  13. There  can be no doubt of the digestive
organs or of the gums sometimes evincing dis-
order in connexion with the first appearance of
the laryngeal affection, and without  any sign
of disorder within the cranium ; and there can
be no doubt of the chief and primary indications
of disorder having manifested themselves occa-
sionally in the head ; and it is equally evident,
that whatever lesion, either during life or after
death, observed in the brain, has often been
superinduced by, or has been  the consequence
of previous disorder, or of the  repeated attacks
of  laryngeal suffocation and the consequent
congestion of  the brain.  I have  even seen
cases  in which the brain appeared either pri-
marily or  very early affected in connexion with
the stridulous respiration, and yet, after every
disorder referrible to the brain had been quite
removed,  both  the suffocating inspiration and
the  carpo-pedal  contractions  continued, al-
though in milder grades,  and recurred until the
digestive functions and secretions were brought
to a healthy state, and the child had had the
advantage of change to a pure and healthy air. 
LARYNX AND TRACHEA
Views as to the nature of this affection should
not be based upon the history of a few cases,
but upon that of many, and upon post-mortem
examinations.  Some cases have appeared to
proceed from  dentition  only, others from dis-
orders of the digestive organs merely, and oth-
ers from disease of the brain ;  and yet, upon
examination  after death, those  cases which
have manifested even the least amount of cere-
bral disorder during  life have  presented  great
congestion and vascular injection of the  brain
and its membranes, particularly about its base
and  near the medulla  oblongata, sometimes
with effusion of  serum, in rare instances even
of blood  between the membranes and in the
ventricles, especially the fourth  ventricle.  In
many of such cases there can be no doubt of the
lesion within the brain being the consequence
of attacks of this affection, and  more particu-
larly of the paroxysm which  terminated the
life of the patient.  One argument in favour of
the opinion that the lesions observed within the
cranium are the  consequences rather than the
causes of this affection is, that the same state
of parts in this situation is generally found un-
connected with any obstruction to respiration.
In such cases, however, it is difficult to deter-
mine whether or  no lesions apparently the same
are actually so ;  and it should be kept in mind
that, owing to the physical conditions of the
parts  enclosed by the cranium and spine, con-
gestion or effusion will produce not only press-
ure in its immediate vicinity, but also counter-
pressure in the most remote parts of those en-
closed in them.
   14. While Mr. Ryland and Mr. North be-
lieve that the dependance of this  affection upon
disease within the cranium is not proved, and
while Dr. Marsh seems to think that it may
proceed from  inflammation of or at the origin
of the pneumogastric  nerve, Dr. Ley imputes
it to paralysis of the muscles which open the
glottis, in consequence  of the pressure of en-
larged glands upon  the recurrent  nerves in
some part of their course.  The glands, to the
enlargement of which he ascribes the crowing
inspiration, are those at the roots of the lungs,
both before and  behind the bifurcation  of the
trachea, with  others which lie upon the arch
of the aorta, and not unfrequently between the
carotids and the  deep-seated chain of cervical
glands,  or glandule  concatenate. That  these
glands are often  enlarged in infants and young
children, particularly those of a scrofulous con-
stitution,  cannot be denied ;  and that,  when
thus enlarged, they may occasionally press in-
juriously upon the recurrent nerves and pro-
duce this affection, may be the case ;  but that
it always proceeds from this cause is not in ac-
cordance with my experience ; for I have seen
cases in which no evidence of enlarged glands
was furnished either during life or after death;
and, besides, the affection will often altogether
cease, after having been  present for a day or
two,  upon having recourse  to  means which
could either but  little affect the  state  of these
glands, or not affect them in so short  a time.
The recent experiments, however, of Dr. Reid
(Ed. Med.  and Surg. Journ.,  vol. xlix.) have
shown that the superior laryngeal nerve is al-
most entirely a sensory nerve, and that the re-
current  is almost exclusively motor, supplying
both constrictor  and dilator muscles ; and that
L—Nervous Affections of.                779

 severe dyspnoea, amounting to suffocation, may
 arise from irritation and  compression of the in-
 ferior laryngeal nerves,  or  the  trunks  of the
 pneumo-gastrics;  for when  both, or even one
 recurrent nerve was irritated,  the arytenoid
 cartilages were approximated, so  as in some
 cases to shut completely the superior aperture
 of the glottis.  When the recurrents are cut
 and  compressed, the arytenoid  cartilages are
 no  longer separated during  inspiration, and
 their movements  are so completely passive
 that they are carried inward by the current of
 entering air, which they consequently impede,
 while they are separated again by the expira-
 tory blast.
   15. My own observations of this  disease lead
 me to infer: 1st. That it may proceed from di-
 rect or reflected irritation merely—the primary
 source and seat of such irritation  being either
 in the gums  or in the alimentary canal, or about
 the base of the brain or medulla oblongata ; 2d.
 That the frequent result of attacks of this affec-
 tion is to develop  whatever disorder may pri-
 marily exist within the  cranium, and to occa-
 sion inflammation, or congestion, or effusion in
 this situation ;  3d. That irritation commencing
 in either of the three quarters just assigned
 may be sometimes propagated to the recurrent
 nerves,  and expressed  through them in  the
 muscles of  the larynx ; 4th. That the  carpo-
 pedal contractions or more general convulsions
 are frequent complications or associations of
 this affection, are often merely contingent, and,
 although they  may proceed  from  the  same
 source, may nevertheless arise from different
 sources  of irritation; 5th.  That when the la-
 ryngeal  affection  is thus associated, there is
 greater reason to  believe that the parts about
 the base or centre of the brain are more espe-
 cially  implicated;  6th.  That,  even  in  those
 cases where enlarged glands exist  and press
 injuriously upon the recurrent or other nerves,
 it is quite as likely that they irritate as that
 they paralyze these nerves;  7th. That the ef-
 fects observed to follow an enlarged thymus
 gland, about to be  noticed, although illustrating
 the influence of enlarged glands in producing
 this affection, do not prove  that the influence
 is more that of pressure than that  of irritation
 of the laryngeal nerves ; 8th. That enlargement
 of either the thymus, or the bronchial glands,
 or  the  glandulae  concatenates, may act inju-
 riously by pressing on the  veins,  and thereby
 preventing the return of blood from the head ;
 congestion, effusion, and pressure of parts with-
 in the cranium resulting therefrom, and giving
 rise to the affection of the larynx,  by either ir-
 ritating or paralyzing the laryngeal nerves.
   16. E. Closure of the Larynx by enlarged Thy-
 mus  Gland.—Thymic Asthma of  Kopp.—Mr.
 Hood, of Kilmarnock, first directed attention to
 enlargement of the thymus gland, and its in-
 fluence  in  producing morbid closure  of the
 glottis, with suffocation, and pressure of the
 veins returning the blood from the  brain. This
 memoir, although  little attended to at the time
 of its publication, is one of the most important
 that has appeared  in recent times, and contains
 the particulars of  nine cases in which the ap-
 pearances were observed after death, with sev-
 eral important pathological inferences.   (See
 Edinb. Journ. of Med. Science for Jan., 1827, p.
 39.)  More recently  (1830)  the subject was 
780
LARYNX AND TRACHEA—Nervous  Affections of.
 treated of  by Kopp,  Hirsch, and  Dr. Mont-
 gomery; still, Mr. Hood's memoir is the most
 full and circumstantial which has hitherto ap-
 peared on the subject.  A few cases of the dis-
 ease have been seen by me since my attention
 was directed to it by this writer;  and three of
 them  were examined  after death, the  appear-
 ances being altogether the  same as those de-
 scribed in Mr. Hood's  paper.  The  enlarge-
 ment of this gland is apparently of a scrofulous
 nature, as  it is sometimes connected with
 scrofulous enlargement  of  other  glands.  It
 may, however, be the result of simple  hyper-
 trophy and  inordinate  distention of  its  sub-
 stance by vascular congestion,  favoured by
 constitutional peculiarity and over-feeding. In
 some  cases the gland is denser, redder, and
 more fleshy than natural.  Occasionally it ex-
 udes a milky fluid when divided ;  and,  accord-
 ing to Mr. Hood, a cream-coloured or puriform
 fluid.   In  two cases this writer found abscess
 and ulceration of this gland.  In other instan-
 ces it  has contained  tubercular  matter, or a
 substance resembling  cheese.  When  the en-
 largement has induced a congested state of the
 brain, probably with some degree of serous ef-
 fusion within the cranium, owing  to its press-
 ure on the  veins in  the top of the chest, it
 may be expected that surprise, sudden  excite-
 ment to cry, or bodily efforts will bring on at-
 tacks of this affection by aggravating the mor-
 bid conditions upon which it depends.
   17.  a. Mr. Hood has noticed the following
 varieties of this affection.  The first modifica-
 tion consists of an enlargement  of the gland
 without any obvious cause, and when the child
 apparently continues  to  enjoy  perfect  health.
 Most frequently slight  injury or sudden  sur-
 prise is assigned as the  cause of inducing an
 effort  to cry, without  the child being able to
 raise  the  voice,  during  which the face be-
 comes  livid, respiration is suspended,  and
 strong convulsive struggles seem about to ter-
 minate its existence.   If now the child be able
 to make an inspiration, the functions are soon
 restored, and in  a short  time  it  recovers its
 wonted health and spirits.  An attack  of this
 kind is attended by the utmost danger ;  yet, by
 adopting means for promoting health, the child
 may never have a return of the complaint.  In
 the second  form the  child still retains its usual
 plumpness, but the flesh is soft  and flabby, and
 the countenance somewhat pale, and, on crying,
 quickly becomes  pale  and livid.   On awaken-
 ing out of sleep, or beginning to cry, the infant
 seems incapable  of making an inspiration, the
 face becomes livid, and there is an appearance
 of alarming  convulsions ; but generally these
 symptoms  suddenly cease on taking the  child
 up.  The  same kind of fits may be brought on
 by  feeding, dressing, crying, &c, or by what-
 ever excites or irritates it. At first the attacks
 are seldom, but they  become frequent as the
 disease makes progress.   Yet, it  occasionally
 happens that  the  child improves  in  every re-
 spect for weeks or months, and yet it suddenly
 expires in an  attack.   In all such cases the
veins of the meninges  are  found after  death
loaded with blood, with more or less serous ef-
fusion  between the membranes and in the ven-
tricles.  The veins of the neck and top of the
chest are much  distended by the  pressure of
the enlarged gland, and  the  heart is  void of
 blood or coagulum.   In a third class of cases
 which  Mr. Hood has noticed, the  voice is  al-
 tered just before and after  the  fit, and has a
 croupy sound, which is not heard  during the
 height of the attack, for then respiration is  al-
 together suspended.  He considers the com-
 plaint to be much modified by derangement of
 the stomach, or  by intestinal irritation, or  by
 difficult or painful dentition.
   18. It is very difficult to distinguish these ca-
 ses from those arising from other causes,  as
 noticed  above  (v 13-15) ; and  it  is  probable
 that many of those attacks which have been re-
 ferred to this disease within  the cranium, or to
 dentition, disorder of the alimentary canal, and
 to  scrofulous  glands irritating the recurrent
 nerves,  have been instances  of the disease
 caused by enlargement of the thymus  gland.
 The  symptoms, particularly  as  respects the
 stridulous inspiration, the threatened suffoca-
 tion, and the occasions and  recurrence  of the
 attacks, are very nearly the same ;  and I know
 that most of the cases which I have seen since
 the publication of Mr. Hood's paper would have
 been considered cases  of laryngeal affection
 from the more remote causes of irritation, if
 that  paper  had not appeared ; which paper I
 believe to have  originated the views of Ley,
 Kopp, and others.   Still, all cases of laryngeal
 suffocation,  appearing spontaneously  in chil-
 dren, do  not proceed from enlargement  either
 of this  gland or of  any other, for undoubtedly
 some cases arise from the causes noticed above
 (v 13, et seq.); and, in these, the glands  of the
 neck and top of the chest are either unaffected
 or  not materially affected.   Indeed, it  is not
 yet fully shown whether or not  the symptoms
 are caused  more by the  pressure  of the en-
 larged glands upon the veins, and the conse-
 quent congestion, pressure, or counter-press-
 ure of the parts at  the origin of the laryngeal
 nerves,  than by  the direct  effects of  these
 glands  upon  the  nerves  in  their  course.   If
 they proceed from the former condition, they
 are the consequences of the superinduced state
 of parts at the base  ol the brain, and they may
 appear whenever the same state of parts arise
 either primarily, or from other causes.*

   * [According to Haugsted, Sir Astley Cooper,
 Meckel, Cloquet, Mui.ler, and  Horner, the  weight
 of the thymus gland at birth averages about 240 grains,  or
 half an ounce.  Meckel states that it often weighs 300
 grains  in a large foetus,  born  at the full period.  The re-
 viewer of Haugsted's paper, in the Medico-Chirurgical
 Review, for April, 1834, gives the weight of the gland  at
 birth between 2 and 3 drachms, or varying from 120 to 180
 grains.  Meckel remarks, that it increases in size till the
 end of the first, and sometimes to the end of the second year,
 in the same proportion as in the full-grown foetus.  If this
 be true, allowing its normal weight at birth to be 200 grs.,
 and  the commencement  of its growth at the third foetal
 month, its weight at the end of the first year would be 536
grains ; or 648 grains, if it weighed 240 grains at birth,
gaining in the former 28, and in the latter  34 grains per
 month.  This  is evidently, however, an over-estimate
Hewson describes the gland as continuing to grow to the
end of the first year after birth ; while from the first to the
third year it is neither  perceptibly increased nor dimin-
ished ; but from the third to the eighth or tenth year it de-
creases in size,  and gradually wastes away to the tenth  or
twelfth year, when, he remarks, it is effaced, having only
ligamentous remains that degenerate into a kind of reticular
substance.   The same writer  states that  he  never saw a
case where the thymus gland existed at the time of puber-
ty.  Cloquet,  Meckel, Muller, and others, give nearly
the same account of its growth and disappearance.   In op-
position, however, to this, we  have the authority of Dr.
Krause (Muller's Archives, Heft 1, 1837), who states
that he has found the thymus in almost all individuals be-
tween 20 and 30 years of age, and very often larger than 
LARYNX AND TRACHEA—Nervous  Affections of.                  781
   15. b. The diagnosis of enlarged, thymus gland
is a matter  of importance, but of difficulty.   It
may, however, be  inferred to exist when the
infant  is gross,  pale, flabby,  and scrofulous ;

  The semiology of this affection has been fully described
by our author, and we have seen that it has been attributed
by Kopp, Hirsch, and Montgomery exclusively to en-
largement of the  thymus; by  Ley to hypertrophy of the
cervical glands; by Marshall  Hall to irritation of the
excito-motory system, through the fifth  pair of nerves in
teething, the  pneumogastric in  indigestion,  or the  spinal
nerves in constipation ; by Cheyne and Clarke to cere-
bral congestion.
  We have published a case of laryngismus stridulus, pro-
duced by enlarged cervical glands pressing upon the  recur-
rent branch of the par vagum.  A brief history of the case
is as follows ;  The patient, a boy of five years  of age, had
been subject to a convulsive, paroxysmal cough for nearly
two years, with the exception of  which his health was ap-
parently good. In July, 1841, he had the measles, after
which his cough was more frequent and troublesome than
before.  For  several months he  had  been in the habit of
starting up, frightened in his sleep, and screaming out, and
latterly this had increased upon him.  In January, 1842, he
became more unwell, was restless and  feverish at  night;
the skin became hotter than natural, and the pulse frequent,
respiration hurried and laborious ;  and these symptoms in-
creased, in spite of medical treatment, together  with the
cough, which, at  times, seemed to  threaten  suffocation.
These  symptoms  contiuued about the  same for a  week,
when the respiration became so difficult that  he had to be
kept in a perpendicular position all the time.  The moment
he lay down, a fit of coughing and choking succeeded, which
would  last for several minutes.  The same occurred when
there was any smoke or dust in the room.  At  length, fre-
quent fits of spasm of the glottis came on, attended with the
peculiar crowing  inspiration, together with the other dis-
tressing symptoms accompanying this affection, as described
by Mr. Copland.   These paroxysms  would last about half
an hour, during which the patient seemed in  momentary
danger of suffocation.  The last paroxysm continued about
three hours,  during which the  patient  died asphyxiated.
Autopsic examination revealed the following appearances :
On each side of the larynx, opposite the lower portion of the
thyroid cartilage, there was found  an  enlarged cervical
gland, dense  and  hard, of the size of a chestnut, pressing
directly upon the  recurrent branch of the par vagum.  The
mucous membrane lining the larynx was considerably con-
gested, and the portion which covers the sides of the glottis
was softened and  relaxed to that  degree that, during inspi-
ration, it undoubtedly impeded the passage of air into the
trachea.  The blood was  universally fluid, and of a dark
colour; the brain and lungs much congested, as in asphyxia.
—(Loc. cit.)
  From somewhat extensive  observation, we are satisfied
that the disease in question may be caused by gastric or
cerebral irritation, central or reflex, as by teething, as main-
tained by Marshall Hall, and by  irritation, also,  of en-
larged cervical glands.  It remains to be proved that it is
ever caused  by enlargement of the thymus.  It  is,  more-
over, to be borne in mind that irritation, wherever set up in
children, is apt to be reflected upon the glottis and respira-
tory organs, and hypertrophy of  the thymus, from its ana-
tomical relations,  must necessarily result from lesions of the
circulatory and respiratory organs.
  In a monograph  on the thymus gland  (Am. Jour. Med.
Sci., N. S., vol. iii., p. 135, 154),  we have also attempted to
show the extreme improbability of this affection being caus-
ed by enlargement of this structure, to which we  would
refer the reader.   M. BtLLARD,  whose autopsic  examina-
tions of children  have  been perhaps  more numerous than
those of any other writer, remarks : " The thymus gland is
susceptible of being affected with  certain diseases, during
the short space of its transient existence.  I  have  never
been able to  observe any peculiar symptoms belonging to
these affections ;  but,  on  opening the bodies of  children,
I have seen it, in two instances, much tumefied, very red,
and extremely friable.  I considered it as the result of in-
flammation, which, perhaps, might lead  to its suppuration
or disorganization."  The  French  pathologists, generally,
question the existence of any such disease as thymic asthma;
and Trosseau, in a recent paper (Jour.de Mtd.), considers
the cases described under this name, as well as many of
those called laryngismus stridulus, as  illustrations of partial
convulsions  of an epileptic character.   " Sometimes the
diaphragm and the inspiratory muscles of the abdomen and
of the chest alone act, and then, for one, two, or three min
utes, a peculiar laryngeal blowing sound is heard, as if there
existed  an obstacle to the entrance and to the  exit  of the
air.  If the proper muscles of the larynx are, at  the same
time, convulsed, as their motions do not coincide, the disor-
dered condition of the respiration appears alarming, although
it is only really  so when this  state is much prolonged.
Such is the real  explanation of  those states of disordered
respiration which  have  been called thymic  asthma, or
laryngismus  stridulus.  A want of harmony between the
in young children ; and that he has seen it of considerable
size between the ages of 30 and 50, and has  met with the
brownish red remains of it later in life.  In the following
cases of suicide, he found  the gland  weighing thus : Case
1st. Age, 25 ; male ;  weight, 292 grains ;  length, 34 lines ;
sp. grav., T0352.   2d  Age, 25; male ; weight of thymus,
380 grains ;  length, 42 lines ; breadth, 32 lines.  3d. Age,
20 ; weight, 356 grains.  4th. Age, 28 ; weight, 69  grains.
Dr. W. C. Roberts, of New York, has lately published the
weight of six thymus glands in new-born children,  weigh-
ing  from  80 to 360 grains.
  Now, from the situation of this gland, it has very naturally
been supposed that its morbid  enlargement must offer con-
siderable impediment to the function of respiration, not only
from its pressure upon the trachea, but also upon the lungs,
the great vessels, and the phrenic, pneumogastric, and recur-
rent nerves.  In confirmation of this opinion, reference has
been made to a remark of Sir Astley Cooper, that, as the
thymus is situated in  the thoracic opening, in its enlarged
state it soon reaches the sternum and first rib, by which  it
is bound, and therefore its increase is towards the trachea,
which becomes enveloped by it, and its function interrupted
in consequence of its compression.  But it is to be remarked
that Sir Astley was speaking of cases where the structure
of the gland had  become dense, or the seat of scirrous, tu-
bercular, or calculous degeneration.   He nowhere hints at
the possibility of its occasioning serious symptoms, or  any
impediment to  respiration, when in its  natural soft  and
pulpy state, although  in  a condition of hypertrophy. Con-
sidering  the spongy  and highly distensible nature  of  this
gland, and the cartilaginous, elastic structure of the trachea,
with the exception of its  posterior segment,  against which
we  have no reason to believe the thymus ever presses, we
should not believe, a priori, that the degree of hypertrophy
recorded by the different writers on the subject could pos-
sibly occasion the symptoms attributed  to this cause.   An-
other circumstance which renders such compression  ex-
tremely improbable, is the fact that,  when congested from
any cause,  it presses  up through the superior aperture of
the thorax (for in its natural state its lower portion only lies
behind the sternum), and is seen forming a protuberance in
the neck, covered merely by  the integuments and a thin
layer of muscular substance.  Besides, wt have seen that
it is composed of a mass of cells,  surrounding a reservoir,
and therefore little calculated in a normal state of its struc-
ture, even  when enlarged to a considerable extent, to exert
any great degree of compression upon the surrounding parts.
We shall, moreover,  see that the anatomical  position of the
gland does not aliow  it to produce much pressure upon the
air passages, the  cornua being, in those cases where it was
greatly  hypertrophied, too short to reach the larynx, and
the lateral  lobes rarely pressing upon the trachea.
  Dr. Roberts  has  also published six cases of death  in
young children from  supposed enlargement of the  thymus
gland, in which the symptoms  differed from those of thymic
asthma, or laryngismus stridulus, and seemed to establish,
says Dr. R., " the existence of a  new disease," character-
ized chiefly by " extraordinarily rapid respiration, and ex-
tensive and forcible pulsation of the  heart and great ves-
sels."  (See Am. Jour. Med. Sciences, Aug., 1837, and Oct.,
1841.  N. Y. Jour, of Med. and Surg., Jan., 1840.  .V. Y.
Med.  Gazette, July  21,  1841, &c )   In the cases whose
history is given by this pathologist, the age and weight of
the gland were as follows : 1st. Age,  29 hours ;  weight,
402 grains.  2d. Age, 8 months ; weight, 330 grains.  3d.
Age, 8 months ;  weight, 484 grains.   4th. Age, 19 months ;
weight, 175 grains.  5th. Age, 2 years 8  months; weight,
257 grains.  In the N. Y. Med. Gaz., vol. i., Dr. Hoffman
relates a case of sudden death in a child ten months  old,
which he attributed to an enlarged thymus, which weighed
330 grains.  In the same  journal, a  case is given  by Dr.
Hamilton, of  Rochester, where the gland  was found to
weigh 480 grains, or ?j., in a child 9 months old, which died
after a sudden attack of illness.  Dr. Swett, of New-York,
has published two cases of a similar character (N. Y. Med.
and Surg. Jour., vol.  ii.).  In one  instance, the gland  was
6 inches in length, and  probably weighed about fj. in a
child 16  months old.   Dr. A. N. Gunn, of N. Y., has  also
published the history  of the case of a child about 5  months
old, which was suffocated  by being overlain by its mother,
in which the thymus gland was found 5}  inches in  length,
by 31; in breadth, and weighed 865 grains, or nearly  two
ounces, the  heaviest  gland at that age  on record.  Dr. G
considered the enlargement as congenital, and remarks, that
" from birth to the time of its death, it had enjoyed uninter-
rupted health, and had  never exhibited any symptoms of
derangement of the organs of respiration  or  circulation, or
of disease of any kind ; affording to my mind the most satis-
factory evidence that  this gland may be enlarged to  a much
greater extent than has heretofore been  supposed, without
in any way impairing  the functions of the heart or  lungs."
—(Loc. cit.) 
782
LARYNX AND TRACHEA—Nervous Affections of.
when the attacks are severe, suffocative, and
unattended  by any marked evidence of head-
affection, or of disorder of the alimentary canal;
when there is distention  of  the veins in  the
neck;  when the lower part  of the neck, be-
tween  the inferior  attachments  of the sterno-
mastoid muscles, appears  full or tumid ;  when
the top of the sternum seems elevated or push-
ed out, and when there is dulness on percussion
under xthe sternum, particularly  its  upper por-
tion, and on each side of it.  Fulness of the
veins about the  head and neck, without any
obvious cause, or an unusual increase of that
fulness when the head is somewhat low, should
excite  a suspicion  of the  existence  of this le-
sion.   This form of the disease is most com-
mon in children  from a few weeks  old to the
age of two or three years;  but it  not  infre-
quently appears in  those of four or  five years
of age, and it may even occur in grown-up or
aged persons.
  20. F. The prognosis of stridulous affections of
the larynx should be stated with much reserva-
tion and caution.  A child that has once had
an attack should be considered in a precarious
state as long as it evinces any sign of disorder,
or until the  period of first  dentition has passed.
The risk increases  with the  severity and fre-
quency of the fits, and when they are associa-
ted with the  carpo-pedal  contractions or gen-
eral convulsions.  If the affection proceed from
enlargement of the thymus or other glands, the
danger is also greater than when it seems to
depend upon dentition or disorder of the digest-
ive organs only.  If it appear in the  course of
disease within the cranium, particularly of me-
ningitis and hydrocephalus, it is generally fatal,
although I recently attended a case of this kind
which recovered.  The most favourable circum-
stances are, a sound constitution, the attacks
being slight and rare ; the absence of affection
of the brain, and of scrofulous disease of the
thymus or other glands ; and the ability to have
change of air, especially to the seaside.
  21.  G. Treatment.—The  intentions with
which  the treatment of stridulous laryngeal  af-
fections should be conducted are, 1st. To avoid
the occasions or exciting causes of the parox-
spasmodic motions of the diaphragm, and of the muscles
which move the arytenoid cartilages, is sufficient to produce
the laryngeal sibilus, the orthopnoea. In the regular act of
inspiration, the superior part of the larynx opens  at the
same time that the diaphragm  descends, and produces a
vacuum in the chest.  If the contraction of the diaphragm
takes place too rapidly, and if, at the same time, there is
spasm of the larynx, as in hooping-cough, the inspiration
becomes nearly impossible, and is accompanied by a violent
sibilus.  In the case which we are examining, however, it
is not necessary to call to our assistance a want of harmony
between the movements of the diaphragm and those  of the
muscles of the larynx ; it is sufficient to suppose that the
will or the instinct no ionger presides, for a moment, over
the movements of the aryt*uoidean cartilages ; the muscles
which move them, no longer obeying any nervous impulsion,
are for the time in the condition of those of animals in whom
the recurrent laryngeal nerve has been divided.
  " The above details explain how it is that thymic asthma,
so frequent in the eyes of some observers, is never found by
others.  The former attribute to an increase in size  of the
thymus, accompanied by paroxistic arridents, what the lat-
ter consider to be merely one of the forms of convulsions in
children. The thymus, like the supra-renal capsules, is an
organ of transition, destined to become atrophied after the
birth  of the human foetus, and less than any other organ
likely to be hypcrtrophied.  During the six years that M.
Trousseau has been at the head of important wards for
very young children, he has not once met with the thymus
gland sufficiently enlarged to give rise to {he slightest acci-
dent."]
ysms;  2d.  To remove  the morbid  conditions
on which they depend ;  and, 3d. To endeavour
to prevent the paroxysm from being followed
by dangerous or  fatal results.—a. The proprie-
ty of avoiding the occasions and causes by which
a return of  the fit is produced is so  obvious as
to require only the most cursory notice.  Ev-
ery source  of excitement  and irritation, both
moral and physical, should be guarded against;
and  efforts  of all kinds, especially straining at
stool, ought to be avoided.   Sudden surprises,
and  disturbances from sleep, excitement of the
temper and passions, as well as all muscular
efforts, should be shunned; and all  the secre-
tions and excretions ought to be freely promo-
ted,  without exhausting the powers  of" life.
  22. b. The  removal of the  morbid conditions on
which the paroxysms depend is obviously the
most important indication.   This should be at-
tempted only after  a careful  examination of
symptoms, especially those connected with the
head and scalp,  with the gums, and with the
stomach and  bowels.   Sources of irritation in
the  chest, particularly in the top of it, and in
the neck, should be  carefully inquired after.—
a. The frequent connexion  of stridulous affec-
tions of the larynx with dentition ought  always
to suggest an instant examination of the state
of the gums ; and if fulness, redness, dryness,
or heat of them be present, or any other indi-
cation of irritation, and especially if the saliva-
ry flux, which usually attends dentition, be sup-
pressed or scanty, a free division of the gums
in the situation of the advancing teeth, and a
recourse to sialogogues of a mild kind, should
not be delayed.
  23. j3. If signs of disease within the cranium
either have  preceded  or accompany the laryn-
geal affection, the treatment must be directed
with a strict regard to the nature and intensity
of such disease.   The accession of carpo-pedal
contractions, of general convulsions, or of stra-
bismus, does not prove the  existence of inflam-
matory action of the  brain, for the paroxysms
of laryngeal suffocation, by interrupting the re-
turn of blood from the  brain, may have occa-
sioned congestion, irregular circulation, or even
serous  effusion  within the  cranium, so as to
give rise to  these symptoms.  However, in-
flammation  may exist, and be accompanied with
those and with other phenomena, especially in
its   advanced stages.   Of  themselves, these
symptoms indicate the  necessity of relieving
the oppressed brain  and restoring the healthy
balance of the circulation in this quarter;  but
these ends  cannot be attained by trusting to
bleeding only, or even chiefly, whereby  the
powers of life are often too far reduced with-
out removing the morbid state of circulation in
the brain.   Bleeding, however,  is generally re-
quired, but it  must be resorted to according to
the state of vascular fulness and power, and be
aided by purgatives, alteratives, diuretics, cold
affusion  on, or frequent cold sponging of the
head, and derivatives, according to the features
of individual cases.
  24. y. If the stomach and bowels are disorder-
ed, stomachic purgatives, conjoined  with alter-
atives,  and  given so  as to act regularly and
moderately, are required.  Flatulence and acid-
ity, which commonly are present in these cases,
should be removed by prescribing alkalies or ab-
sorbents in conjunction with aperients and ton- 
LARYNX AND TRACHEA—N
ics.   Small doses of calomel, or the hydrargy-
rum cum creta,  may be given  with calcined
magnesia, or with the dried sub-carbonate of
soda  and rhubarb or jalap ; and a mild tonic
infusion may be prescribed, with a little of the
sesqui-carbonate of ammonia, and of some car-
minative spirit.   But chief reliance should be
placed on  change of air, on exercise out of
doors, on cold sponging the head and general
surface,  and on cold salt-water bathing, when
the patient can  bear the  shock of the bath,
which should be cautiously and gradually tried
  25. 6.  The presence of eruptions on the scalp,
or of enlargements of the glands of the  neck,
should lead  to examination of the state of the
lower  part of the neck and of the top of the
chest,  particularly  in  scrofulous,   cachectic,
gross,  and unhealthy-looking children ; and al-
though in these disease may also exist, either
in the digestive organs, or within the cranium,
or in both these quarters, still, enlargement or
scrofulous  changes of  the more deep-seated
glands, interrupting the  return  of  blood from
the head, and irritating the recurrent nerves,
may be a chief or a concurrent cause of the
laryngeal affection.   In such cases, as well as
in those  where  the thymic  gland is  apparently
enlarged, strict attention to the state of  the
secretions  and excretions, the  exhibition of
mild and tonic aperients and alteratives,  small
doses of the iodide of. potassium, with liquor
potassae, and sarsaparilla, change of air, espe-
cially to  the seaside,  an appropriate diet, and
warm clothing, are the means chiefly deserving
notice.   An ointment with iodide of potassium
may be employed externally, but the judicious
use and combination of this substance as an
internal  medicine render it the most deserving
of confidence in these cases.  The preparations
of quinine and of iron, especially the iodide of
iron,  and the compound steel  mixture with
liquor potassae, are also of service, especially
in cachectic, flabby, and pallid children ; but as
respects patients  affected with any  form of la-
ryngeal affection  in large towns, no means are
so effectual as change to a pure, temperate, and
dry air, especially in  scrofulous constitutions,
and  without such change  all other remedies
may fail.
  26. c.  The removal  of the attack seldom be-
comes the office of the physician ; for the fit is
usually short, and if it were not so, death would
generally very soon result. The child should
be held up, and somewhat forward ; and if res-
piration  does not instantly follow,  cold water
may be  sprinkled over  the face, or it may be
affused over the head, while the lower part of
the body is  plunged in warm water.  If these
measures fail, the shoulders and back may be
slapped with the open hand or with a wet nap-
kin, and stimulating salts may be held near the
nostrils ; but these are then rarely of avail.  In
those cases  of laryngeal affection where the in-
spiration is  made partially, and with a crowing
and stridulous noise, and is not altogether pre-
vented, and consequently where there is time
to exhibit an emetic, one should be given forth-
with,  conjoined with  a little camphor; and  a
warm bath, or the semicupium, may  likewise be
resorted to.  I have seen, however, the emetic
fail to act in these cases, although it was given
in a sufficiently large dose, owing  to the op-
pression of the brain by the interruption to trie
ervous Affections of.                    783

return of blood from it; but, upon resorting to
the affusion of cold water upon the head, the
emetic effect was produced.
  27. If none of the measures just proposed is
attended with success, recourse to the opera-
tion of tracheotomy has been suggested  by Mr.
Porter and Mr. Ryland.   It certainly, howev-
er, is  not justifiable, as the former of these wri-
ters has stated, as long as respiration is carried
on even  with the greatest difficulty ; for in al-
most every case in which the rima glottidis re-
mains so far open as to allow of a partial trans-
mission of air, the affection is  not very severe,
and the  child will struggle through it.   " But
if," he remarks, •' the child is to all appearance
dead, and if the practitioner is  called to him
within any reasonable time, he  should then,
with the least possible delay, endeavour to in-
flate the  lungs and restore animation by what-
ever means appear to be the speediest,  and of
these, perhaps the most preferable will  be tra-
cheotomy."   Dr. Marsh  states, that Dr. John-
son had  seen a child, in a state of asphyxia
caused by this disease, recovered from appa-
rent death by the instantaneous  application of
artificial  respiration.
  28.  ii.  Suffocative Laryngeal  Affection
in Adults.— Croup-like  Respiration in Adults.
—Spasm of the Glottis in Adults.—This affec-
tion, as it occurs in grown-up persons, proceeds
from three principal sources : 1st. Tumours of
any kind pressing upon or irritating the laryn-
geal nerves, or pressing  upon the  veins ; 2d.
Inflammation or irritation of adjoining parts, as
of the pharynx, epiglottis, oesophagus, &c.; and,
3d.  Sympathy  with the state of more remote
parts, as in cases of hysteria and of irritation
of the sexual organs, or spinal nerves.
  29.  A. Tumours of various  kinds, small ab-
scesses, and scrofulous deposites in, or enlarge-
ment  of glands, may form in the immediate vi-
cinity of the larynx and trachea, or  between
them  and the oesophagus, and occasion  fits of
suffocation or stridulous  or croup-like respira-
tion.  Morgagni,  Rush, and  others have re-
corded instances of this kind, and I have ob-
served them.   Bronchocele, aneurisms of the
arch of the aorta, or of the arteria innominata,
and enlarged or scrofulous glands at the top of
the chest, sometimes produce a similar effect.
  30.  a.  Bronchocele, particularly in  nervous
and hysterical  females, is very  frequently at-
tended by attacks of stridulous or croupy respi-
ration, or fits of suffocation,  especially upon
mental emotion or physical efforts ; and this is
the more especially the case about the periods
of menstruation, or  when any irregularity of
this discharge exists, as often observed in bron-
chocele affecting persons of this sex.—b. Scrof-
ulous  and suppurating glands, particularly those
which are much enlarged, or contain purulent
or scrofulous matters, in  the vicinity of the tra-
chea  or  larynx, act in the adult in a similar
manner to that mentioned in cases of children
(§ 14, el  seqq.).  In a case on which I was re-
cently consulted, a cluster of glands at the root
of the lungs were remarkably large and  infil-
trated with tubercular matter, so as to form  a
very  consistent tumour, producing not  only
more or less dyspnoea, owing to its pressure on
the trachea, but also fits of suffocation, in one
of which the patient  expired.  This case close-
ly simulated one of aneurism of the arch of the 
784
LARYNX  AND TRACHEA—Nervous Affections of.
aorta, owing to the size of the tumour and to
the pulsation of the aorta being communicated
to it.   I have likewise seen the laryngeal affec-
tion caused by a fungoid tumour—a true fun-
gus hematodcs—attached to the posterior aspect j
of the top of the sternum.—c.  Of the influence
of aneurismal tumours in producing attacks of
this affection no proof need be offered, as such
instances are of frequent occurrence, and  in-
stances of them have been published by Law-
rence, Fletcher, and others.
   31.  B. Inflammation of adjoining parts, as of
the pharynx, or of the oesophagus at its upper
part, sometimes  is attended by spasm of the
glottis, particularly in nervous persons and hys-
terical females.  In these, even  the irritation
of the pharynx or of the epiglottis, caused by
the ascent of acrid eructations in the course of
indigestion, or of the globus hystericus, or of
flatulence in connexion with hysteria,  some-
times produce similar attacks.  The irritation
occasioned by an elongated uvula, either upon
the epiglottis or upon the rima  glottidis, has
had the same effect in  some  cases.   (See
Throat, Diseases of.)
   32.  C.  The irritation of the sexual organs, or
of the spinal nerves,  is  occasionally connected
with  this affection, which then assumes the
form of irregular hysteria, and in such circum-
stances an attack is often produced by cold, or
slight  inflammatory  action in the  respiratory
passages, which, from  its severity and recur-
rence, may be mistaken for acute or chronic
laryngitis, if the various nervous and hysterical
symptoms attending it be overlooked.   In cases
of this kind, an  attack may be  brought on by
violent mental emotions, especially if the di-
gestive or respiratory organs be in an irritable
state at the time ;  but it seldom occurs unless
the uterine functions be also disturbed, as indi-
cated by either a disordered state of the cata-
menia or by leucorrhcea (see art. Hysteria, $
31, 37).   It should, however, be always kept in
recollection, that cases in which there is some
degree of inflammatory action and much spasm
are often met with in females, particularly those
liable  to hysteria.  I have seen several cases
of this description, which required a treatment
 appropriate to their mixed nature.  Severe at-
tacks of spasm of the glottis are very apt to oc-
cur in the course of hooping-cough or bronchitis,
when  either of these occurs in nervous or hys-
terical females, and will readily be aggravated
by a too lowering treatment.
   33.  D. Treatment.—It is obvious  that  the
treatment of these affections should depend en-
tirely  upon the pathological conditions produ-
cing them.—a. When proceeding from tumours
of any kind, or from  small abscesses, or scrof-
ulous enlargements of glands, the iodide of po-
tassium, and liquor potassae, taken with sarsa-
parilla, are the most efficient means which can
be resorted to ; and are especially useful when
 the affection is caused by bronchocele    If hys-
 terical symptoms be present, the iodide of iron
may be employed, or the foregoing medicines
may be given  with any of the preparations of
 valerian or of camphor.  It is obvious that the
 dependance of this affection on aneurism, or on
 malignant tumours, almost precludes any hope
 of cure, and admits only of temporary allevia-
 tion.
   34.  b. Where  inflammatory irritation of the
pharynx, or upper part of the oesophagus, is at-
tended with spasm of the  glottis, means must
be employed to remove the inflammation, and
these will generally, also, prevent  the  occur-
rence of the spasm.  After such depletions as
the nature of the case may require, much ben-
efit will result from the use of a linctus contain-
ing, in a lubricating and an emollient vehicle,
a small quantity of the nitrate of potash, or of
the  hydrochlorate of ammonia, with  a little
vinum ipecacuanhae, and any narcotic or seda-
tive tincture  or extract;  and,  if the  spasms
continue, a  rubefacient embrocation may be
applied around the neck and throat.  The fol-
lowing  have been often prescribed by me with
almost  instant relief, the  embrocation  being
applied around the throat on flannel, until much
heat and redness of the skin are produced.

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chloratis, 3ss.); Mucilag. Acacis ; Sirupi Tolutani, aa 3jss. ;
Vini Ipecacuanhs, Jjss.; Tinct. Hyoscyami, Jij.;  Cetacei,
vel Pulv- Tragacanth., q. s.: ut secundum artem fiat Linctus
a quo pauxillum, urgente dyspnoea, lambat sger.
  No. 285.  R Linimenti  Camphors  Comp.; Linimenti
Terebinthins, 5a 3jss.; Olei Olivs, Jiij.; Olei Limonis, et
Olei Cajuputi, aa  jj.  M. Fiat Embrocatio, more dicto
utenda.
   35. c. The Hysterical or nervous form of
spasm of the glottis is almost instantly reliev-
ed by having recourse to the above linctus and
embrocation.   If these fail, which is  rarely the
case, camphor may be given with  a narcotic,
with the extract of belladonna, of  opium, of
henbane, &c, or with a full dose of Dover's
powder.  The  preparations of valerian with
ammonia are also of use.   When the affection
of the  glottis  is connected with inflammatory
irritation, either in the bronchi or  about the
pharynx, perseverance in  the  linctus^and em-
 brocation, varied according to  circumstances,
 will generally  remove both the  one and the
 other.   The disorder of the uterine functions,
 or the  morbid conditions  connected more im-
 mediately  with the hysterical affection, will
 next require attention, particularly with a view
 of preventing a return of it.   (See  Hysteria,
 Treatment of.)
j iii.  Atonic and Paralytic States of the La-
   rynx.—Svnon.  AQuvta, Aphonia  (from the
   privative a, and 6uv^, voice, sound).  Loquela
   abolita,  Defectus  loquele, Dysphonia,  Auct.
   var.   Raucedo paralytica, Darwin.  Sprachlo-
   sigkeit, Stummheit, Germ.  Aphonie, Fr Afo-
   nia, Ital.
     Classif.—IV. Class, III. Order (Author).
   36.  Defin. A partial or complete loss of voice
 and- speech, owing to an atonic or paralytic state
 of the nerves of the larynx.
   37.  This affection is generally symptomatic,
 but it is occasionally primary or idiopathic, as
 when it is caused by an exertion of the voice
 much beyond  the power or tone of the parts:
 it is, however, then rarely or never complete.
 The term aphonia has often been employed sy-
 nonymously  with mutitas or  dumbness, with
! which  loss of voice, or aphonia, has  thus been
 confounded.   But in dumbness, or mutitas, the
 voice exists ;  it only cannot, owing to the abo-
I lition of the sense of hearing, be modulated into
' articulate or certain sounds.   In aphonia, the
 voice is either partially or  totally lost, the pow-
 er of articulating  existing when the voice is
i partially retained.   In rare instances, however,
( the partial loss of voice is attended by a loss 
                  LARYNX  AND TRACHE.

of the power of articulation, and, in this case,
the powers of deglutition are also more or less
lost.  Aphonia, in various grades,  may arise
from a great variety of circumstances, and of
morbid conditions, which may  be  arranged un-
der the three following heads :  1st.  Functional
ox nervous loss of voice;  2d. Catarrhal aphonia ;
3d. Loss of voice from inflammations of the la-
rynx  and  their consequences; 4th.  Aphonia
from  tumours of various kinds in or near the
larynx; and, 5th. Aphonia from disease, or inju-
ries, at the origin, in the course of, and affecting
the laryngeal nerves, so as to paralyze them.
   38. A.  Functional or nervous  loss of voice  may
be said to be a  more or less complete abolition
of nervous power in the muscles of the larynx,
independent of  inflammation, or of organic dis-
ease of adjoining or of related  parts.   The pri-
mary state of this form of aphonia is generally
caused  by debility, and excessive efforts of
voice, or  inordinate  exertion  of the vocal or-
gans.  It may likewise result from overwhelm-
ing emotions of the mind, from sudden moral
or physical shocks, from chills caused by sud-
den exposure to cold, or by drinking cold water,
and from masticating narcotic plants in mistake.
More frequently, however, it is merely one of
the very numerous modes in  which hysteria in
its inregular form manifests itself, and is  then
generally  connected with irregular, difficult, or
suppressed  menstruation, with  uterine irrita-
tion, &c.   (See Hysteria, v 37.)  In these cir-
cumstances, the paralyzed state of the muscles
of the larynx may be attributed to an irregular
distribution of nervous energy, connected either
with  exhaustion or with derivation to distant
parts.  This form of aphonia may be of very
short or very protracted duration.  It may re-
cur frequently, or only at distant periods.  It
may  also be only partial, or  altogether com-
plete, and among  the most  difficult affections
to remove.
   39, B. Catarrhal aphonia is of frequent occur-
rence, particularly in females.  It is probably
connected with congestion of the mucous mem-
brane of the larynx and epiglottis, and impaired
action of the laryngeal muscles.  In its more
complete  and prolonged states, it is also partly
owing to nervous or hysterical disorder, catarrh
exciting and aggravating the  functional affec-
tion.   Catarrhal aphonia is usually accompa-
nied with relaxation of the uvula, and catarrh-
al congestion of the posterior nares  and pha-
rynx, with an atonic condition of the adjoining
parts, which is  extended to the larynx.
   40. C. Inflammation, its consequences, and oth-
er organic changes, as tumours, &c , seated in
or near the larynx, occasion, as shown in oth-
er places, more or less complete aphonia. In
the purely  inflammatory  states,  the injection,
thickening, tumefaction from effusion of serum
in the connecting cellular tissue, and the im-
paired as well as embarrassed action of the
muscles, always attending inflammation of their
surrounding and connecting tissues, sufficient-
ly account  for the  hoarseness  of voice  and
aphonia which  accompany them.  When  oede-
ma of the larynx, or when ulceration, or any
other of the consequences of common or of spe-
cific inflammations exists, so  as to injure or to
destroy, more or less, the mechanism by which
voice is produced, then no farther agency is re-
quisite to account for the phenomenon.  The
    II.               99
\.—Nervous Affections of.               785

 same  organic  lesions, which  I have  shown
 above (28, et seq.) to be occasionally causes of
 spasm  of the larynx, may also,  particularly
 when they mechanically impede the motions of
 this part, or when they paralyze its nerves, pro-
 duce aphonia.   Tumours of any kind, or ab-
 scesses, will have this effect, when situated so
 as to act in either way.
   41. D. Lesions within the cranium, when they
 disorganize, press upon, or otherwise implicate
 the origins of" the laryngeal nerves,  or similarly
 affect them in their course, will cause complete
 aphonia, generally also with loss of the power
 of articulating, and  sometimes also of degluti-
 tion.  In these cases, congestion,  effusion, or
 other changes of an organic or of a scrofulous
 kind have taken place at the base of the brain,
 near or in the medulla oblongata;  or counter-
 pressure, caused by effusion of blood or of lymph,
 or by scrofulous or other tumours in the vicin-
 ity, or even lesions  of the dura mater or bones
 of the base of the cranium, may have produced
 this effect.  Aphonia from these changes either
 attends, follows, or even precedes apoplectic,
 paralytic, or epileptic  seizures, and may gener-
 ally be considered a very unfavourable circum-
 stance, as patients thus affected rarely continue
 long exempt from a  fatal seizure.
   42.  In some cases  of this kind,  inarticulate
 sounds  may be uttered, the power of modula-
 ting the voice and of articulating being lost.  I
 was called upon, some years ago, to visit in con-
 sultation a gentleman who several months pre-
 viously  had lost the power of articulating any
 sound, however simple.  The movements of
 the tongue were nearly abolished, and the pow-
 er of deglutition, unless substances were con-
 veyed over the  root  of the tongue, was lost.
 These were the only  paralytic  symptoms, and
 he was, in every other respect, in good health,
 and  without  any  sign of  cerebral  disease.
 Treatment having proved  inefficacious, my at-
 tendance, after a time, altogether ceased ; but
 I learned that he died suddenly some months
 afterward.  Somewhat similar cases of palsy,
 affecting only the muscles  of  the larynx, pha-
 rynx, and tongue, have been  observed by me
 in children ; but they have generally been prece-
 ded by some acute cerebral affection, or by con-
 vulsions.   In every case death has taken place
 suddenly, and, in those cases where inspection
 afterward was allowed, organic lesions were
 found about the medulla oblongata, or  at the
 base of the brain, and consisted either of those
 alluded to above (v 41), or of softening of the
 cerebral structure.
   43. E. Treatment.—The plan of cure should
 entirely depend upon the evidence furnished as
 to the existence of  either of the morbid states
 to which  aphonia has now  been referred.—a.
 If the loss of voice  result only from relaxation
 or atony of the vocal chords, owing either to de-
 bility or to over-exertion, gargles containing
 capsicum, a warm rubefacient embrocation around
 ; the throat, and  tonic decoctions or  infusions,
 with mineral acids,  or other tonics, will gener-
 I ally be of service.   If it be connected with hys-
 teria, the same means as now advised, and the
 preparations of valerian,  camphor,  ammonia,
 iron, &c, may severally be employed, accord-
 ing to the state of the uterine functions and
 I constitution of the patient.   In the more obsti-
 I nate of the nervous  and hysterical cases of 
786
LARYNX AND TRACHEA—Nervous  Affections of.
aphonia, electricity  has been  advised; and  in
these I have found the pyrethrum, or other stim-
ulating substances, used perseveringly, as sialo-
gogues, of great benefit.  Occasionally an active
emetic, consisting of ipecacuanha, decoction of
senega,  and some  preparations of squills, has
proved of service,  particularly when  followed
by a  stomachic purgative, and the tonic and
stimulant remedies just mentioned.
  44. b. When aphonia  is catarrhal, the emetic,
and subsequently a stomachic purgative, diaph-
oretics,  stimulating gargles, and embrocations,
applied  to the throat or around  the neck, are
generally of service.  If it proceed from inflam-
mation, oedema, or ulceration of the larynx;
from destruction of the cartilages, or from oth-
er consequences of inflammatory action, or of
syphilis,  the means advised for these lesions
when treating of the several forms of laryngitis
are then required.*
  45. c. If aphonia  arise from scrofulous glands,
tumours, or  other lesions, paralyzing the laryn-
geal  nerves,  or mechanically obstructing the
motions of the larynx, the internal use of iodine,
of the iodide of potassium, with liquor potassas,
or Brandish's alkaline  solution and sarsaparil-
la, may be tried, and aided by such other means
as the peculiarities of the case will suggest.
  46. d. When aphonia proceeds from  disease
witkin or near the base of the cranium; when it
appears to usher an attack of apoplexy or palsy,
or attends upon, or follows an apoplectic or ep-
ilectic seizure ; when it seems to depend upon
vascular congestion, effusion, or some organic
lesion, the treatment must be remarkably va-
ried, according to the nature and state of the
disease of which it is a symptom.  If it precede
and seem to threaten an acute attack, vascular
depletions, purgatives,  and derivatives  are in-
dicated.  If it follows such an attack, the above
alteratives,  permanent  derivatives, and drains,
&c,  particularly setons,  issues, or open blis-
ters, are requisite.
II.  Inflammation  of the Larynx.—Syn.  Lar-
  yngitis,   Swediaur.    Cynanche   Laryngea,
  Cullen, &c.  Angina interna, Angina canina,
  Zacutus Lusitanus.  Angina trachealis adul-
  torum, Pinel. Caurna  Laryngitis, Young. Lar-
  yngite, Angine laryngee, Fr.  Entziindung des
  Luftrohrenkopfs,  Germ.  Laryngita, Inflam-
  mazion di laringe, Ital.
     Classif.—1.  Class, 2. Order (Cullen).  1.
       Class,  2. Order  (Good).   III.  Class, I.
      Order (Author in Preface).
  47. Defin.—Pain, soreness,  constriction, and
tenderness in the region  of the larynx;  epiglottis
swollen  and erect;  breathing shrill  and suffoca-
ting ; voice hoarse, sharp, and lastly suppressed;
short, painful, and convulsive  cough; great anxi-

  * {In the New- York Jour. Med. and Collateral Sciences,
vol. iv., p. 348, may be found a report by Dr. J. E. Taylor, of
New-York, of twelve cases of aphonia, treated by cauterizing
the larynx with the nitrate of silver (40 grs. to fj.), after the
manner recommended by Trousseau and Belloc, by means
of a sponge attached to the end of a piece of whalebon», bent
to an angle of about 80 degrees.  This was  passed directly
into the larynx, saturated with the solution, by bringing for-
ward and depressing the tongue by means of a curved, broad
spatula. In thTee instances, three applications weie sufficient
to effect a cure ; two were materially benefited : three cases
of laryngeal phthisis were only partially relieved. Dr. Hor-
ace Green, of New-York, has also reported several cases
of cures of this affection, by the employment of the same
mechanical means. We have known several chronic cases
cured by the repeated application of galvano-magnetism to
the larynx.]
ety and restlessness,  with  fever  and occasional
spasms of the glottis.
  48. This disease was first  noticed with pre-
cision by the second Monro, Home, and Cheyne,
and  subsequently by Farre,  Bailley, Blane,
and others.   The varieties which it presents in
practice have been particularized by Cheyne,
Cruveilhier, Bretonneau, Bayi.e, Trousseau,
Belloc, Ryland, and others; but we are still
without a correct arrangement of these varie-
ties, in relation  either to each other or to the
complications in  which they are very often pre-
sented to our observation.  Before I describe
the varieties of laryngitis, I shall state the ar-
rangement of them which I shall  adopt.
  49. 1st. Catarrhal  or Slight Laryngitis,
which  often  attends common colds and  sore
throats, and  is characterized chiefly by cough
and  hoarseness of the voice.   It generally sub-
sides in the course  of a  few days, and often
without the  aid of medicine ; but, in faulty or
cachectic constitutions, or in  the highly inflam-
matory diathesis, it may pass into some one or
other of the following varieties.
   50. 2d. Acute Laryngitis may appear  as
other inflammations, either primarily or consec-
utively,  and  present certain  forms depending
upon diathesis, previous disorder, and epidem-
ic influence.   It  may be sthenic,  as when it oc-
curs in a previously healthy  constitution ;  or
asthenic, when it affects weak or cachectic hab-
its, or appears in connexion with some other
malady.—A. Sthenic acute laryngitis may be,
a. Primary  and  simple; commencing in, and
limited  chiefly to the larynx and epiglottis, and
attended  by acute inflammatory fever.—b. It
may be consecutive, and complicated with inflam-
mation of the fauces, tonsils, and pharynx ;  or
of the trachea and larger bronchi, &c, as in
sporadic  and epidemic croup  (Diphtherile); al-
buminous exudations forming on the inflamed
surface, and the  attendant fever  being of an in-
flammatory or sub-inflammatory character.—B.
Asthenic  acute laryngitis  may be,  a. Primary
and simple, with  the  effusion  of  serum, or of a
sero-puriform matter in the sub-mucous tissue
of the larynx and  epiglottis,  the attendant fe-
ver  being more or less  adynamic or malignant,
and the  constitutional powers  impaired.—b.
Secondary and complicated, as when it occurs
consecutively upon scarlatina, smallpox, erysip-
elas, or malignant sore throat, low fevers, &c.
   51. 3d.  Chronic Laryngitis, which may be
either primary or consecutive of the acute, or of
disease of related parts.—a. Simple chronic lar-
yngitis,  limited chiefly to  the larynx and epi-
glottis.—b. Complicated chronic laryngitis, asso-
ciated with disease of the  lungs, generally of a
tubercular or scrofulous nature, or with chronic
bronchitis.—c.  Specific  or syphilitic laryngitis,
attended by secondary  syphilitic symptoms, or
with the  venereal  cachexia.   These are the
several  forms of simple and complicated la-
ryngitis, which will be found  arranged at the
head of the next  page.
  52. i. Description.—A. Catarrhal Laryn-
gitis is generally slight, and often attends ca-
tarrh, particularly when the catarrhal irritation
extends from the fauces to the  pharynx.   It
may be  viewed merely as  an  extension of the
affection of the mucous surface  of the throat,
thence to  the larynx, and frequently also to the
trachea and bronchi on the one hand, and along 
LARYNX  AND TRACHEA—Inflammation of—Sthenic              787
• These forms or varieties of Laryngitis may be arranged as follows :
I. Catarrhal Laryngitis I ecnera"y associated with catarrhal sore throat, catarrhal irritation of the respiratory
                      ' (   passages, &c
                                  ft Primary and Simple.
                         Sthenic.  1 &mpUcated  j with tracheitis and bronchitis,
                                  I    r     ' I with tonsillitis, pharyngitis, &c.
                                  ( Primary and Simple.
                         Asthenic, i Comlicated  I with eruptive and continued fevers,
                                  *    r     ' ( with erysipelas, sore throat, ace.
                       t Simple and Primary.
                       1 Complicated, with disease of the lungs, &c
                       ' Syphilitic.
IL Acute Laryngitis.
III. Chronic Laryngitis.
 the  oesophagus on the other.   It is character-
 ized by  the  usual catarrhal  symptoms,  by
 hoarseness or partial loss of voice, and cough,
 which is at first dry, but is attended by slight
 or more copious expectoration as the complaint
 proceeds.  There is either little or no  attend-
 ant  fever, or fever of a slight remittent form.
 This variety may pass  into  the acute, but it
 much more frequently is followed  by the sim-
 ple or complicated states of chronic laryngitis.
 It more commonly, however, disappears spon-
 taneously, or after treatment.
   53. B. Acute  Laryngitis is a most danger-
 ous  disease in all its forms ; but  more espe-
 cially in the asthenic complicated form.  The
 particular character or state  which it may  as-
 sume depends upon the habit of body, tempera-
 ment, and previous health of the patient; upon
 the  existing epidemic influence, and upon the
 nature of the disease on which it is consequent,
 or with which it is associated.  It is a formi-
 dable malady, as respects the suddenness of the
 attack, the alarming and distressing nature of
 the symptoms, the rapidity of its progress, and
 the frequency of its fatal issue.  Its occurrence
 in the course of other diseases, and the fact of
 its being the cause, in many  instances, of the
 great danger and fatality of these, render it a
 subject of great interest.   Viewing it in  all
 its relations, it may be divided (y 50) into the
 sthenic, or truly inflammatory, or as it affects a
 person in previous health, and the asthenic, as
 when it appears in the cachectic or in the course
 of other maladies.
   54. a. Sthenic acute laryngitis may appear in
 various circumstances ;  it may be—a. primary
 and  simple throughout;  or, /?. consecutive and
 complicated.   It is of importance that it should
 be considered  in each of these forms, and with
 due  relation to the other affections by which it
 may be preceded, associated, or followed ; and
 this  will become the more evident when the
 more complicated states of the disease come
 under consideration ; for several  maladies  in
 which laryngitis  often  forms a most danger-
 ous part have been frequently described with-
 out any reference to it, although the extension
 of disease to the larynx, in either a  sthenic or
 an asthenic form, has constituted the chief  in-
 terest and risk to the patient attending them.
   55. a. Simple acute laryngitis occurring pri-
 marily, or in a constitution capable of manifest-
 ing the sthenic or true  inflammatory state of
 vascular action,  frequently appears with some
 degree of sore throat, difficulty of swallowing,
 chills or slight rigours, followed by symptomat-
 ic inflammatory  fever.  Soon after the  com-
 mencement of the attack a dull  pain or soreness
 is felt in  the  upper  and interior part  of the
 throat, with a sense  of constriction, and ten-
 derness  when  the  larynx is  pressed-  The
 voice is harsh, hoarse, or sharp, and there is a
slight, frequent, short cough,  without  expec-
toration.  The fauces are  generally red or  in-
 flamed, and when the tongue is pressed down-
 ward and forward the epiglottis  may be seen
 erect, swollen, and red.  At  this stage of the
 disease  the attendant  fever is  strictly inflam-
 matory, the pulse being full, quick, and strong ;
 the skin  hot  and dry, the face flushed,  the
 tongue white and sometimes tumid, and thirst
 urgent.
   56. At a more advanced stage, and as the tu-
 mefaction of the inflamed parts diminishes the
 aperture of the glottis, the voice becomes small,
 piping, whispering, and ultimately suppressed ;
 the breathing difficult, inspiration being sibilous,
 shrill, prolonged, and laborious; the  larynx is
 drawn downward with great force on each at-
 tempt to inflate the lungs.  The cough is strid-
 ulous, convulsive, or strangulating, and attend-
 ed by scanty, viscid,  and transparent expecto-
 ration, and by attacks of spasm  of the  glottis
 threatening suffocation, which are occasionally
 induced  by difficulty  of swallowing,  owing to
 the imperfect closure of the glottis by the swol-
 len and inefficient state of the epiglottis.  The
 eyes almost start from their sockets ;  the coun-
 tenance becomes pallid and anxious ;  the pulse
 feebler, quicker, and less uniform, and the sur-
 face of the body cooler.  The constitutional
 phenomena now indicate imperfect aerification
 of the blood in the lungs, the lips assuming a
 more leaden or livid hue,  and the  tongue a
 darker colour.   More or less  fulness  or swell-
 ing may be observed in some  cases around the
 larynx and in the  course of the trachea.  The
 patient  is now apprehensive, restless,  sleep-
 less, and desirous of embracing any means of
 relief, feeling  that he is on the  point of suffo-
 cation.
   57. In the last stage, respiration can hardly
 be performed ;  the voice is  gone ; the pulse is
 weak, small, and intermitting ; the lips are liv-
 id, the face pale and leaden, and the surface
 cold or clammy.  The patient sits upright with
 open  mouth and  outstretched neck, grasping
 objects  around him to  assist  the  laboured  in-
 spirations.  In this stage, he sometimes dozes,
 but soon starts  up  in the utmost agitation,
 gasping for breath, with convulsive struggles.
 Low delirium, drowsiness, sopor, or coma now
 sometimes  appear;  the pulse becomes more
 and more  feeble,  and the  patient sinks in a
 state  of gradual asphyxia, if he be not carried
 off in one of the spasmodic  attacks of suffoca-
 tion attending the cough, or following attempts
 at  swallowing in  the advanced  stage  of  the
 malady.
   58. The  course of the disease generally pre-
 sents the three stages indicated above, when it
 is not interrupted by treatment.  These stages
 may be viewed as the first, early, or inflamma-
 tory stage ;  the second, or developed stage ; and
 the third stage, or period of exhaustion and as-
phyxia.   The duration of this form of laryngitis
 varies from eight or twelve hours (Armstrong
 and Cheyne) to several days.  The more usual 
788             LARYNX AND TRACHEA—Inflammation of—Sthenic.
duration, however, is from two to five days. It
very rarely is longer  than a few days, unless
the disease pass into  the chronic form.  The
more completely acute laryngitis is limited to
the larynx, the shorter, in general, is its dura-
tion.  Cases  are recorded by Ri'sh, Tacheron,
Porter, and others,  in  which the  inflamma-
tory appearances were  found limited  to the
larynx, and a fatal issue ensued within twenty-
four hours from the commencement of the at-
tack.
  59. /?. Consecutive or complicated sthenic laryn-
gitis is characterized  chiefly by  the extension
of the inflammation from the fauces, tonsils,
and pharynx, on the one hand, to the larynx ;
and more rarely from the trachea upward to
the larynx on the other, as in sporadic cases of
croup.  In all  such cases,  the  inflammatory
action is chiefly superficial, and is attended by
an exudation of albuminous lymph on the in-
flamed surface.  When the disease commences
in the tonsils and fauces, and extends to the res-
piratory passages, it has been termed " Diphthe-
rite," from dtfyOepa, pellis, exuvium, or " Angine
Couenneuse,"  by M. Bretonneau,  who wrote on
this subject, and confounded this form of an-
gina—the "Angina  Membranacea" of the older
writers—both with Cynanche Maligna and with
Sporadic Croup; and in this he  has been fol-
lowed by several of his contemporaries.  One
part of this mistake has arisen from inattention
to the characters of the  attendant  fever, and
to the superficial manner in which the local af-
fection has been viewed.   Attention to the fol-
lowing facts will more fully explain the source
of this  very  egregious  mistake : a mistake
fraught with  danger as regards the  appropria-
tion of the means of cure.
  60. Inflammations of the throat  frequently
occur, both as sporadic and as  epidemic diseas-
es ; they may be simple,  or they may be the
chief complication and source of danger in erup-
tive  fevers.   In many instances, and particu-
larly when they are epidemic, they are accom-
panied with an exudation of lymph  on  the in-
flamed surface ; and whether the inflammation
commences in the tonsils and soft palate, or in
the pharynx,  or whether  it assumes a  sthenic
or an asthenic character, owing  to the  nature
of the constitutional disease of  which it is a
part,  and the circumstances connected  with
the patient, it is more or less prone  to extend
itself through the various passages leading from
the pharynx; and  when  the larynx and epi-
glottis thus become affected, the disease  then
assumes a different and a much  more danger-
ous character, death sometimes taking place in
a few hours.   In all cases, when the  inflamma-
tion extends from the  fauces, tonsils, and pha-
rynx to  the respiratory passages, the local ap-
pearances and the  character of the  attendant
fever indicate the nature  and tendency of the
malady.  In some epidemics, and in a few spo-
radic cases, both the local appearances and the
constitutional  affection indicate  an  acute and
sthenic disease, an  albuminous exudation, or a
firm  and  continuous  coating  of albuminous
lymph, forming on  the inflamed surface, and
the attendant fever being inflammatory or sub-
inflammatory.
  61.  In other epidemics, and even  in  a few
sporadic cases, but more  commonly when the
affection of the throat accompanies the  ady-
I namic or putro-adynamic or malignant forms of
 eruptive fever, the inflamed parts present a dark
 red, approaching to a brown or livid line, and the
 exudations, instead of being pellicular, firm, te-
 nacious, and whitish, or yellowish white, as in
 the sthenic form, and adhering firmly to the sur-
 face, are soft, broken into crusts of an ash col-
 our, become darker after their formation, and
 are much more easily detached. In these latter
 cases the vital powers are  depressed, and the
 circulating fluids deteriorated ; hence their as-
 thenic form and rapidly fatal  tendency, as ob-
 served  in the more  adynamic and  malignant
 states of scarlatina,  smallpox, measles, or in
 certain epidemics, and in rare sporadic cases.
 (See y 68.)
   62. These forms of angina, which are thus
 distinct  from each other, whether  appearing
 primarily or  as  a complication of exanthema-
 tons  or  of other diseases—whether limited to
 the throat only or extending to the respiratory
 passages—have been  confounded together  by
 several  pathologists.   All of them may occur
 in  adults as well as  in children, although the
 latter are most predisposed to them, and es-
 pecially those of a delicate, scrofulous, and in-
 flammatory constitution.   When  the inflam-
 mation  extends  to  the larynx, many of the
 symptoms of croup are present; and hence M.
 Louis described consecutive or complicated laryn-
 gitis  as croup occurring in  adults ; and M.
 Bretonneau gave  it the name  of" Diphthe-
 rite," because of the albuminous exudation at-
 tending  it, and without reference to the other
 local characters,  and the  form or state of the
 attending fever :  matters  of the utmost impor-
 tance in describing the nature and treatment of
 anginous affections, particularly when compli-
 cating the eruptive fevers.
   63. Consecutive or complicated sthenic laryngi-
 tis generally commences  as above indicated ;
 but the inflammation, instead of advancing
 from the pharynx  to  the  larynx, may com-
 mence in the trachea and extend upward to the
 larynx, as  in  some cases of  croup ;  although
 this course is much more rare than the other.
 This form of laryngitis,  as it appears either
 sporadically or epidemically, or as a  complica-
 tion of the more sthenic eruptive fevers, com-
 monly commences with pain in the throat, dif-
 ficulty of swallowing, and fever.   The tonsils
 are swollen and red,  and present  on their sur-
 faces patches of an opaque whitish concretion.
 If allowed to proceed, the inflammation and the
 membranous exudation spread continuously to
 the soft  palate and pharynx, the glands at the
 angles of the jaws begin to  swell, and degluti-
 tion becomes more difficult. Upon detaching the
 membranous concretion from the inflamed sur-
 face, the redness is increased in it, and a thick-
 er concretion is produced on it, that adheres to it
 more tenaciously than the former one.  Fre-
 quently, some  days after the commencement of
 the attack, the disease becomes milder, less dis-
 posed to spread, and sometimes ceases altogeth-
 er without reaching the larynx ; but, in most ca-
 ses, laryngeal symptoms appear at the end of
 four or five days. A hoarse cough, altered sound
 of the voice, difficult deglutition, and dyspnoea
 supervene.  The breathing soon afterward be-
 comes laborious, sonorous, and quick, inspira-
 tion being prolonged,  and expiration short and
 hissing,  and the voice  extinct.  The  counte- 
LARYNX AND TRACHEA—Inflammation of—Asthenic             789
nance is now pale, leaden, and often livid, par-
ticularly during the fits of suffocation which
occur, and the pulse small and intermitting.
  64. The duration of the disease  is various
The morbid action may continue in the  ton-
sils, palate, and posterior part of the pharynx
for six  or seven days before it extend to the
larynx ; but, after  it has  reached  this part,
death may take place in twenty-four or forty-
eight hours, either from a paroxysm of suffo-
cation,  or  in the slower mode of  asphyxia no-
ticed above (y 57)  as  often terminating the
more simple form of the disease.   In some ca-
ses, the laryngeal disease follows more rapidly
upon the affection of  the throat:  and, in  a
few, it  seems almost  coetaneous  with this af-
fection.  In these cases, especially, the inflam-
matory action extends not only to the trachea,
but frequently  also  to  the  larger bronchi, as
demonstrated  by post-mortem examinations,
and as  more fully shown in the article Croup
(y 13, 35).
  65. Consecutive sthenic laryngitis is some-
times a complication of the more sthenic forms
of scarlatina, measles,  and  smallpox, particu-
larly  in  certain  epidemics.  But when it  is
thus complicated or associated, it  generally as-
sumes a less sthenic  character, and approach-
es, in some cases at least, and especially in the
constitutional affection, the asthenic or the next
form to be noticed.   In these associations the
local affection varies considerably, particularly
as respects the appearances of the albuminous
exudation, which may be scanty,  partial, or al-
most wanting.   (See art. Throat, Diseases of)
  66. b. Asthenic Acute Laryngitis.—This may
occur either as a primary and simple disease,
or consecutively  upon, or as a complication of,
another malady.  It  is comparatively rare  in
its simple form ;  but it  is one of  the most fre-
quent and fatal  complications of eruptive fever,
It sometimes, also, occurs in the course of other
maladies, as will be shown hereafter.
  67. a. Simple Asthenic  Laryngitis.—(Edema
of ike Glottis.—CEdime de la  Glotle, Bayle.—In
simple  sthenic  laryngitis  there  is  generally
more or less swelling of the margins of the la-
rynx and epiglottis, owing to submucous infil-
tration  of serum and lymph;  but in the con-
secutive form, or that attended by albuminous
exudation, such  infiltration takes place to  a
much less extent, this  exudation not merely
mechanically obstructing the passage, but  also
irritating and producing spasm of the glottis.
In the form of laryngitis now to be considered,
the chief alteration which takes place is an in-
filtration of serum, and, in some instances, of a
sero-puriform fluid,  not only in the submucous
cellular tissue, but also in the adjoining cellu-
lar tissue, or in that at the base of the epiglot-
tis and  surrounding parts.   The  disease com-
mences with a continued and an  increasing
impediment to  respiration, and with a feeling
of fulness and constriction in the larynx, and
as if the passage was closed by  some foreign
body.  The voice is at first hoarse, then sharp,
6tridulous, and  hissing, and afterward croupal
or extinguished.  There is  a  dry, hoarse, and
convulsive cough, with fits of suffocation, caus-
ing the  utmost agitation and distress.  While
inspiration is prolonged and  difficult, expira-
tion is comparatively easy.  Deglutition is not
materially impeded, and pain, soreness, or ten-
derness in the laryngeal region  are not much
complained of.  In some instances, however,
these are all more manifest, and considerable
fulness  or swelling is  observed  in the region
and vicinity of the larynx.  The constitutional
symptoms are not acute or inflammatory, and
fever may be slight  or almost  absent ;  but,
as the  disease advances, the pulse becomes
weak, soft, small, quick, and irregular, and the
system  betrays  imperfect  aerification of the
blood.   In some cases, the attendant disorder
is still  more  decidedly adynamic.  The pa-
tient makes numerous efforts to expel  from
the larynx, by  forcible  expirations, matters
which he feels to be a source  of uneasiness
and of obstruction, and to remove them by fre-
quent attempts  at deglutition.   The  fits of
cough and suffocation  generally terminate by
expelling  a little glairy mucus,  which affords
only slight relief.  As the  disease  proceeds,
the dyspnoea becomes more permanent, the fits
of suffocation  more frequent, and the cerebral
functions  disturbed.  At last death takes place
in the manner already described  (y 57).
  68.  j3.  Consecutive or complicated asthenic lar-
yngitis occurs during the course  of scarlatina,
measles, smallpox, erysipelas, low or adynam-
ic fevers,  and of diffusive inflammation of the
cellular  substance of the throat.  Most com-
monly the laryngeal affection is merely an ex-
tension of that of the throat, which commences
■n the  tonsils and fauces,  extending to the
pharynx  and  larynx,  and often, also, to the
other passages connected with  the  pharynx.
The local changes vary much with the nature
of the primary malady and state  of the patient.
In some cases, especially in those consequent
on angina maligna, there is not only much dif-
fused swelling of the  parts,  but also  an ex-
udation of soft,  dark  lymph,  which concretes
imperfectly into  crusts or patches,  and these
irritate  the larynx and epiglottis, especially
when they become partially detached.  Infiltra-
tion  of  the sub-mucous  cellular tissue,  with
swelling and softening, also takes place, the in-
filtrated fluid being either serous, sero-puriform,
or sero-sanguinolent, or of a dark colour, from
the presence of blood globules in it.  The col-
our of the inflamed parts depends partly upon
the character of the infiltrated fluid, upon the
state of the lymph thrown out  upon the dis-
eased surface, and upon the grade of intensity
or malignity marking the constitutional as well
as the  local  malady.   The  affection  of the
throat in these cases, particularly when it ex-
tends to the  larynx, is attended by impaired
vital cohesion of the  mucous and sub-mucous
tissues,  and by a soft  or less tenacious  state
of the lymph effused  on the  affected surface,
which is, in some cases, membranous, but in
others pultaceous, assuming a gangrenous-like
appearance, from its colour and softness, and
from the  odour  exhaled.  In the more malig-
nant cases, the crusts or patches of lymph be-
come darker and more foul, owing to the exu-
dation of dark blood, or of a bloody ichor from
the inflamed surface, when they are being de-
tached from it.   In this form of the disease,
the states of vascular action and tone, and the
condition of the blood, which is always more or
less altered, prevent the formation of a firm con-
cretion  on the inflamed surface, and give rise
to the morbid and gangrenous-like exudations 
790             LARYNX AND TRACHEA—Inflammation of—Chronic.
characterizing it, as more fully shown in the
articles Scarlet Fever and Throat.
  69. When the larynx is consecutively affect-
ed in these asthenic or malignant cases, the
progress of the disease generally is fatally ac-
celerated.  The  breathing becomes laborious
or convulsive;  the inspiration  difficult  and
prolonged ; the voice croupal,  whispering, or
suppressed ; cough frequent, suffocative,  and
harsh ; the veins of the neck distended; the
throat and laryngeal region tumid or  swollen
externally, and tender to the touch.  In  this
state, sunken  eyes, pallid countenance, dilata-
tions of the  nostrils, threatened  suffocation,
restlessness,  anxiety, and distress are rapidly
followed by a leaden or livid countenance  ; by
convulsions, especially in children, or by coma
and death.  In many of these cases, as well as
in the more sthenic complications, the morbid
action invades the trachea to a greater or less
extent, but generally in a much slighter degree.
(See art. Croup, Complications of, T 18.)
  70. C.  Chronic Laryngitis.—Phthisis  La-
ryngca—Under this head have been comprised
a number of chronic affections and alterations
of the larynx, which are often associated with
changes in either the epiglottis or the trachea,
or even  in both.  These affections are  fre-
quently  complicated  still farther with other
maladies, especially with those of the lungs,
and with chronic constitutional diseases. They
may be,  1st.  Primary, simple, or  the chief ail-
ment :  or, 2d.  Consecutive and symptomatic.
They are commonly inflammatory at their com-
mencement ; although the character of the in-
flammation may be either catarrhal, or sthenic,
or asthenic, or specific.
  71. a. Primary and simple Chronic Laryngitis.
—A comparatively slight form of inflammation,
or, rather, a state of catarrhal irritation, may af-
fect  the mucous membrane of the larynx for
several weeks, or even for many months, and
produce merely hoarseness, a frequent husky
cough,  scanty mucous  expectoration, and  a
sense of soreness at the top of the windpipe
This affection may be limited to the larynx, or
be associated with relaxation of the uvula, or
with  indications of a similar irritation in the
fauces, pharynx, and trachea.  It is most com-
mon in persons exposed to cold and wet, and in
the intemperate, and generally follows a  neg-
lected catarrh, or repeated catarrhal  attacks.
This form of chronic inflammatory action  may
exist for a considerable period  without produ-
cing farther change than thickening of the mu-
cous  membrane and submucous tissues ; but it
occasionally gives rise to farther changes, es-
pecially to ulceration, to softening, to serous or
sero-puriform infiltration, and several other le-
sions about to be noticed.
  72. The more severe states of chronic laryn-
gitis  may  commence in  the above catarrhal
form ; they may even follow the acute attacks ;
but  much more frequently they appear with
hoarseness, and with a dry, husky cough ;  and
are considered as catarrhal only, until they are
followed by disorganization and serious consti-
tutional disturbance.  They are thus insidious,
not only in their primary and simple forms, but
also,  as will be noticed  hereafter, in their con-
secutive and complicated slates.   The symptoms
which require the closest observation are those
connected with the voice, the cough, the respi-
ration, the sensibility of the part, the physical
signs referable to the chest, and the expecto-
ration.  The voice  is variously  altered.   At
first the  defect of the voice is apparent only
when speaking loud, or when varying the tone ;
but it generally becomes more and more crack-
ed, until its healthy tone is quite lost.  Hoarse-
ness is then always present, and is, in the more
catarrhal  and slight  cases, loose, mucous, and
deep;  but in the more  severe and  prolonged
instances it is commonly stridulous, dry, and
squeaking, or whispering.   In the  worst at-
tacks it is more  and more affected  until it is
altogether lost.  The cough is, in the early sta-
ges, short, dry, and hacking ;  but in the  latter
stages, and when the glottis is incapable  of be-
ing closed, it is loose, continuous, and hawking
or peculiar, as noticed by MM. Trousseau and
Belloc.   The  respiration is  usually affected
sooner or  later in the  course of the malady.
Difficulty of breathing frequently occurs  in the
night,  and on  any physical  exertion, and is
characterized by spasm of the glottis.  In pro-
portion to the  mechanical impediment  to the
passage of air, and to the degree of  oedema of
the glottis attending the disease, are the dysp-
noea, and the hissing and stridulous noises on
respiration, increased.  After the dyspnoea be-
comes permanent, or amounts to orthopnoea,
death generally takes place in fifteen or twenty
days.  The sensibility of the  larynx  is seldom
very acutely affected, although it  is always
slightly increased.  In one half the cases, pain
is not much complained of; still it is felt, with
a sense of soreness or tenderness when the la-
rynx is handled or pressed, or rubbed against
the  spine.   The  morbid sensibility of  it is
evinced chiefly by the effect of cold air  upon
it, and by the  readiness with which cough is
excited by this or by other causes.
   73. The expectoration is at first scanty and
mucous;  but as the  disease advances to  disor-
ganization, or becomes more intense or acute,
it is muco-puriform, sanious, or streaked with
blood, or  even foetid ; occasionally it is  adhe-
sive and ropy.   Purulent expectoration  some-
times relieves the difficulty of breathing;  and
when this is observed in connexion with pain
and soreness in coughing, and with hoarseness
or loss of voice, ulceration may be inferred to
have taken place.  As the ulceration and dis-
organization  proceed, dead or ossified portions
of the arytenoid and cricoid  cartilages, or cal-
careous substances  formed in the larynx, are
sometimes expectorated, and more rarely they
fall into the trachea and pass into the bronchi,
causing irritation, and consequent inflammation
in the parts where they lodge.
   74. Difficulty of swallowing is  occasionally
felt, particularly when the epiglottis is more or
less implicated, or when irritation extends to
the pharynx.   In these, paroxysms of cough
and suffocation are induced by the attempts at
deglutition, and by portions of the substances
taken passing into the  glottis.  The physical
signs indicating either the  exemption of the
bronchi and lungs from disease, or  the  exist-
ence of disease also  in these parts, are  much
obscured by the impediment to the circulation
of air through the larynx, and more dependance
may generally be placed upon percussion than
upon the  respiratory murmurs in evincing this
exemption.  At almost any period of the prog- 
LARYNX  AND TRACHEA—Inflammation  of—Chronic             791
rpss of chronic laryngitis an acute state of in-
flammatory  action may occur,  generally with
more or  less oedema, or sero-mucous infiltra-
tion of the sub-mucous tissues, and terminate
the life of the patient in a very short period ;
and this may take place almost  at any stage of
the disease, cither previously  or subsequent
to ulceration.   In simple or idiopathic chronic
laryngitis, death is occasioned either by this oc-
currence, or by the paroxysms of orthopnoea,
caused by spasm in addition to cedema, by dis-
ease of the cartilages and other lesions, or bv
the suffocative paroxysms induced by the pass-
age of matters into the diseased larynx.
  75. b.  The complicated and consecutive states
of chronic laryngitis are very much more com-
mon than the primary and simple.  The most
frequent  of these complications is that with tu-
bercular  phthisis.  M. Louis has remarked that
upward of one fourth of the cases of this mal-
ady were complicated with chronic laryngitis,
this latter being the consecutive affection.   It
may also be associated with chronic tracheitis,
with ulceration in  the trachea and large bron-
chi, and with chronic inflammation of the pha-
rynx ; but the association is rarely thus limit
ed, being generally extended also to the lungs.
When chronic laryngitis extends to the trachea,
or when  chronic tracheitis extends to the la-
rynx, and laryngo-tracheitis is thus present in a
chronic form, tenderness and soreness are oft-
en  felt in the course of the trachea; and, in
some instances, I have observed great swelling
of  the throat along the whole tube; but in all
these the lungs were also diseased.   This
swelling  in the  course of the  trachea arises
from the existence of ulceration in the internal
surface of the tube, and from the cedema or in-
filtration of the  cellular  tissue  external to the
cartilaginous rings.
  76. The epiglottis may he inflamed and ulcer-
ated without the larynx itself being materially
affected,  although the epiglottis is often  impli-
cated when the larynx is diseased.  M. Louis
states, that  of eighteen  cases  of inflammation
and ulceration of the epiglottis, the larynx and
trachea  were free from  disease  in  six.   Of
these latter, pain, more or less  severe, was
felt by four in the superior part of the thyroid
cartilage, or between this cartilage  and  the
os  hyoides.  The  pain was compared to that
of  a sore, to a pricking sensation, or to a heat
of the part.  In some  cases it had  lasted  a
month or two, but in others it had  occurred
but a few  days before death.   In  these ca-
ses, although the  pharynx  was healthy, deg-
lutition  was difficult, fluids  sometimes being
thrown back through the  nose.   The  twelve
patients who had  ulcerations  at  once in  the
epiglottis, larynx,  and trachea, complained of
dysphagia, pain, and occasionally  regurgitation
of fluids by the nose.
  77. It has been shown that simple chronic lar-
yngitis is generally attended by great mechan-
ical obstruction  and stridulous breathing;  but
when the laryngeal  affection  is consequent
upon, or  complicated with pulmonary disease,
the obstruction in the larynx is commonly much
less, and  stridulous breathing is hardly remark-
ed.  This is owing to the circumstance of pri-
mary chronic laryngitis  giving  rise  to more
cedema, or  infiltration of the sub-mucous tis-
sues, than laryngitis consecutive upon  pulmo-
nary tubercles.   In this latter the inflammatory
irritation and the consequent ulceration is more
superficial and  less obstructive to respiration
than the former.  In both acute and  chronic
laryngitis, the vesicular murmur becomes  fee-
ble in proportion to the obstruction, as shown
first by Dr. Graves and Dr. Stokes ; and in se-
vere cases it can hardly be perceived, the  fee-
bleness or absence of this murmur being equal
in all parts of the chest.   In order to ascertain
the presence of lesions of the lungs in cases of
chronic laryngitis, more reliance maybe placed
on percussion than on the stethoscope.  Where
the mechanical obstruction is but slight, as Dr.
Stokes remarks, this instrument  may be used
with exactness; but even in cases where the
lung is fully and freely inflated, it will occasion-
ally be next to impossible to determine whether
the symptoms proceed from laryngeal disease
alone, or from its complication with an affection
of the lung.
  78.  The principal fact to be kept in recollec-
tion in cases of chronic  laryngitis is the very
frequent association of pulmonary disease with
it, even when the larynx has been the part seem-
ingly first attacked.   There is no doubt  that
chronic laryngitis is in some cases first devel-
oped,  and that the lungs become secondarily
affected, particularly where a predisposition to
pulmonary disease exists ; and in these espe-
cially the susceptibility- of the larynx to causes
of irritation is much  increased ; but both mala-
dies may commence simultaneously, and even
proceed pari passu, that of the larynx only be-
ing manifest, owing to the nature of its organ-
ization ; and thus the pulmonary disease may
seem to be consecutive, even while it is coeta-
neous  with  the laryngeal,  or  even  primary.
The obscuration of  the  physical signs of pul-
monary diseases by  laryngeal affections  is so
great that the former are generally masked by
the latter from  those  who trust chiefly to these
signs, to the  neglect of those physiological and
rational phenomena which generally accompa-
ny even the early stages of pulmonary consump-
tion, and in  which the closely observing physi-
cian confides more  surely than in the proofs
furnished by the stethoscope.  It  is only in the
far-advanced stages of pulmonary tubercles that
the physical signs are manifested, when  they are
complicated  with chronic laryngitis, as shown
hereafter (y 86).  It may, however, be conclu-
ded, that where there are laryngeal cough, mu-
co-purulent  or  purulent expectoration, hoarse-
ness  or  aphonia,  semi-stridulous respiration,
emaciation, and hectic fever, pulmonary tuber-
cles exist in advanced stages, whether they are
indicated by the physical signs or not;  and this
inference is strengthened by the occurrence of
night perspirations,  irritability of the  bowels,
incurvation of the finger nails, and various oth-
er symptoms.
   79. c. Syphilitic Chronic Laryngitis.—Chronic
laryngitis sometimes occurs in the course of
secondary syphilis, and it then assumes a spe-
cific form, soon passes into ulceration, the ul-
ceration apparently extending from the tonsils
and pharynx by continuity of surface to the la-
ryngeal mucous membrane.  Hence syphilitic
chronic laryngitis is  almost always associated
with syphilitic  inflammation of the tonsils, fau-
ces, and pharynx.  Mr. Carmichael considers
venereal ulceration of the larynx as the conse- 
793              LARYNX AND TRACHEA—Inflammation of—Chronic.
quence of the phagedenic venereal disease ;  and
he believes that the ulceration always propa-
gates itself at its edges by continuity of surface
from the fauces to the pharynx, and thence to
the larynx.
   80. ii. Appearances  after Death.—A. In the
acute forms of laryngitis,  the  lesions observed
on dissection vary with the character and com-
plications of the disease.—a. In the sthenic and
simple forms,  the mucous and sub-mucous tis-
sues of the larynx are  not only red and inject-
ed, but also swollen or  thickened; and these
appearances may be confined chiefly to the la-
rynx, or extended  to the  upper  part of the tra-
chea.   The epiglottis is very red, injected, thick-
ened, or swollen and erect.   The  folds of the
glottis, and the cellular tissue extending from
the epiglottis to the glottis, are red and swollen
from infiltration of serous lymph, or  even of
pure  lymph, patches of which  are sometimes
found on the  mucous surface of the larynx and
the inferior surface of  the epiglottis.   In cases
which have  not proved  very rapidly  fatal,  a
sero-puriform fluid, or  even pus, escapes when
these parts are divided.   Ulceration   is more
rarely observed.   In  the  complicated state of
sthenic laryngitis, or when the disease has been
consequent upon inflammation of the throat,
with  albuminous exudations—or  upon angina
membranacea—a more or less complete  and
consistent coating of albuminous lymph is found
in the pharynx, the larynx, and, to  a greater or
less extent, along the trachea; and  often, in
some degree, also  in  the large bronchi.   The
exudation, however, is either scantier, or con-
sists  of a tenacious or semi-consistent matter
in the lower part of the trachea and in tho bron-
chi.   Occasionally, the false membrane formed
in the larynx seems to have  been  partially de-
tached, and is loose and ragged, or is altogeth-
er removed.  The mucous membrane and sub-
mucous tissues are red  and injected,  and fre-
quently, also, more or  less swollen.
   81. b. The  asthenic form of laryngitis  is at-
tended  by a serous infiltration of the sub-mu-
cous cellular  tissues, causing great oedema and
swelling  of the parts,  the mucous membrane
itself being but slightly injected.  In some ca-
ses, the folds of the glottis  are so infiltrated
with serous or sero-puriform fluid as nearly to
close its aperture.   In  many of these,  the epi-
glottis is but slightly altered ; but in others, the
part close below, or at  the root  of  the  epiglot-
tis, and  at the  anterior and upper part of the
larynx, are  most infiltrated, the former being,
in some instances, separated from the latter by
the effusion in this situation.  In the complica-
ted states of asthenic laryngitis, particularly in
the associations with  scarlet  fever, measles,
smallpox, erysipelas, or with  diffusive inflam-
mation of the cellular tissue in the  vicinity, the
sub-mucous tissues of the larynx and epiglottis
are often infiltrated with a dirty, sero-puriform
matter, or with a foul serum  and lymph, which
fills the ventricles,  and  surrounds the vocal lig-
aments,  and sometimes extends to the  cellular
tissue at the root of the tongue and external to
the larynx, and  even  to  the  adjoining parts.
In these more malignant  cases, all the tissues
are more or less softened and discoloured ; and
the alterations  frequently extend  to the pha-
rynx  and fauces on the  one hand, and to the
trachea on the other.
   82.  B. In chronic laryngitis, the strnctural le-
sions  are" numerous :  l".  The mucous mem-
brane  is red  in patches, and exhibits a granular
appearance, even when it is not ulcerated, ow-
ing to enlargement of its follicles : it  is also,
apparently, thickened ;  but this change  is seat-
ed chiefly in  the sub-mucous cellular tissue, and
causes enlargement and imperfect mobility of
the parts, with partial obliteration or linear con-
traction of the ventricles of the larynx.   2. Se-
rous, puriform, or  tuberculous infiltrations of
the cellular tissue, and of the internal laryngeal
muscles, either with or without softening and
atrophy of these muscles and of the ligaments,
are often observed.  3. Wasting and fibrous de-
generation of the muscles which move the car-
tilages of the larynx, and contractions of the
ligaments, are frequently met with.  These le-
sions account for the loss of voice in this dis-
ease.  4. Purulent collections, or small abscess-
es in  the sub-mucous  cellular tissue, particu-
larly in  the  ventricles  and around the  cricoid
cartilage, are seen  in a few cases.*   5. Ulcer-
ations of the mucous and  sub-mucous cellular
tissues occur in various forms and situations,
and  are among  the most  frequent lesions in
chronic  laryngitis.   The ulcers sometimes are
small  and round, and penetrate only the mu-
cous  membrane ;  occasionally they  are large,
irregular, and superficial, with purulent secre-
tion on their surfaces.  In some instances they
are still more extensive, and, in the syphilitic
laryngitis, accompanied with warty excrescen-
ces.  Ulcers  are not infrequently found in the
ventricles, particularly in cases of phthisis, and
are either rounded and superficial, or deep and
irregular.  The  arytenoid,  and  even portions
of the other cartilages, are occasionally destroy-
ed by ulceration, but chiefly in young subjects.
In most instances, and in older persons, ossifi-
cation takes place in the cartilages before the
ulceration reaches them. Ulcers are most com-
monly seen between  the vocal chords and the

  * [In his work on "Phthisis," published in 1635, M.Louis
states, that he had never met, in a single instance, with tu-
berculous  granulations in the substance, or on the surface
of the epiglottis, larynx, or trachea ; and in the second edi-
tion of his " Researches," recently published by the Syden-
ham Society (1845), he says that, from his additional expe-
rience, it may be regarded as a law of the system, that tu-
bercles, so commonly and abundantly developed in the lungs,
are not  produced, at least after the  age of fifteen, in the
upper air  passages ;  if such an occurrence ever does take
place, it can only be regarded as a singularly rare eiception
to the ordinary course of things (p. 45, Syd. ed.). Dr. Will-
iams, in his valuable work on " Pulmonary Consumption,"
remarks, that " if tubercles be, as we suppose, a degraded
condition of the fibrin or nutrient principle of the blood, we
may expect it to be deposited wherever the nutrition or the
secreting process is carried on; wherever lymph or pus is
occasionally found ; wherever, in short, blood-vessels run.
Tuberculous matter has been met with in coagula in the
heart, spleen, and blood-vessels; and it maybe deposited in
tissues and on surfaces, independently of irritation of these
parts."  Dr. Cars well also observes, that "the mucous
system is by far the most frequent seat of tuberculous mat-
ter ; that the presence of tuberculous matter in the larynx,
in the trachea, and its larger divisions, is not often observed,"
but that " he has met with it in a few instances in the fol-
licles of these parts, and occasionally in the sacculi laryn-
gis."  He  continues : " May it not be owing to the facility
with which tuberculous matter escapes, that we do not find
it accumulated on the mucous surface of the larger bronchi,
or the trachea, or that of the intestines V  Dr. Carswell
evidently believes that tuberculous matter is often  secreted
upon the free surface of the membranes of these parts, but
that, not being entangled or confined in any mucous crypt,
it  Is removed by expectoration as soon as it is poured out.
This fact  should be borne in mind, as it has an important
bearing on the diagnosis of laryngeul and pulmonary affec-
tions.—(See remarks of Dr. Green, in New- York Jour. Med
and Col. Sci., vol. iv., p. 254.)] 
LARYNX AND TRACHEA—Inflammation of—Chronic
793
epiglottis, but they are often found in other
parts of the larynx, and in the laryngeal  sur-
face and edges of the epiglottis, and more rare-
ly at the  lower  part  of the  larynx  and com-
mencement of the trachea.  6. In some cases,
ulcerations, varying in size,  form, and depth,
are  found in the trachea,  especially  its upper
part; and in  one instance I  found a fistulous
opening into  the oesophagus.  The ulcers are
chiefly in  the musculo-membranous portion, es-
pecially when  the affection of the larynx and
trachea is consequent upon disease of the lungs.
7. Ossification of the cartilages is generally ob-
served in the more prolonged cases.  The osse-
ous matter is irregularly deposited,  generally
on the surface of the  cartilages.  The cricoid
and thyroid cartilages become naturally ossified
in advanced life ; but MM. Trousseau and Bel-
loc have shown  that chronic laryngitis of two
years' duration produces the  same change  in
young  persons,  irritation  eccelerating those
changes to which the  tissues are naturally lia-
ble in the  course of time.   8. Instances of ne-
crosis of the arytenoid, cricoid, and even of the
thyroid cartilages, have been recorded by Law-
rence, Porter,  Cruveilhier, Otto, Ryland,
Andral, and others.  MM. Trousseau and Bel-
loc found this lesion in more than one half of
the cases  of laryngeal phthistis which they ex-
amined.   They describe the cartilages to be
denuded of their perichondrium, and of a dull,
dirty hue.  The  sequestrum  of dead cartilage
is not readily thrown off, and the cellular tis-
sue adjoining it  is generally  infiltrated with a
foetid pus. These  purulent  collections often
open and discharge their  contents, sometimes
with dead portions of the cartilages, or with
ossific deposites, or with carious  portions of
the ossified cartilages.  The opening and dis-
charge of these  matters  usually take place  in
the larynx, but in rare instances they have occur-
red into the cesophagus, or outwardly through
the integuments of the neck in still rarer cases.
These mortified portions of  the cartilages,  as
well as carious portions of the ossified cartila-
ges, and phosphatic concretions in the diseased
larynx, are sometimes discharged without any
preceding or attendant abscess, and merely  as
a consequence of ulceration.  When their es-
cape from the larynx is impeded or attended
by much spasm, or when they cause much irri-
tation on  being  detached, they act as foreign
bodies, and occasionally produce  suffocation.
They may even  fall into the  trachea, and pro-
duce effects such as are mentioned when treat-
ing of foreign  bodies in the larynx  and  trachea.
9. The epiglottis is  often  enlarged, thickened,
or  swollen ; frequently, also, it is ulcerated ;
chiefly, however, in the inferior surface, and at
the edges, in connexion with ulceration of the
larynx and disease of the  lungs.  In the syph-
ilitic form of  the  disease, the  ulceration ex-
tends from the lingual to the laryngeal surface,
and sometimes destroys the  whole of the epi-
glottis.  In less common cases, it is contracted
and shrivelled, and  more  rarely expanded and
thinned.   10. Besides the above, cauliform ve-
getations, warty excrescences, tubercles,  and,
more rarely, cancer and hydatids of the larynx
have been remarked ;  and some of these lesions
have been seen extending  to  the  epiglottis.
11. The trachea  has been observed to contain
morbid secretions proceeding from ulceration
     II.               100
of its internal surface, or from disease of the
bronchi or lungs.   It.is sometimes remarkably
thickened from deposition of lymph in the sub-
mucous cellular tissue, and  in a few instances
a similar deposition is observed in the  cellular
tissue external to the cartilaginous rings.  Red-
ness and injection of the internal surface of the
trachea, and  ulceration  as  above mentioned,
are commonly associated with tubercular ex-
cavations in the lungs, and are most frequently
observed in its  posterior or  membranous part.
In some cases, these changes, ulceration par-
ticularly, are confined to, or most remarkable
on one  side of the trachea, which invariably
corresponds to the diseased lung; or, if both
lungs be diseased, to that most affected.  12.
In a remarkable instance which occurred to my
friend Mr. Worthington, of Lowestoft, sever-
al of the rings  of the trachea were  absorbed,
and, in consequence of the fibrous structure be-
ing deprived of its antagonizing power at that
part, the canal was constricted so remarkably
as hardly to admit a quill, and as to suffocate
the patient.   13. Tumours of various kinds, ab-
scesses, aneurisms, &c, have been found press-
ing upon the  trachea, and even on the  larynx,
and causing not only permanent obstruction to
respiration  and spasm of the  glottis, but also
morbid secretions from the internal surface of
these passages, and partial destruction or per-
foration of their parietes.
  83. The lesions just described will, in the va-
rious stages and grades of their development,
sufficiently explain the phenomena of acute and
chronic laryngitis.  When  infiltration  of the
sub-mucous cellular tissue obstructs the pass-
age of air into the lungs, or when the exuda-
tion of  albuminous lymph upon the surface of
the larynx produces the same effect, respira-
tion, voice, and speech are more or less impe-
ded, and the  various morbid phenomena con-
nected  with  these functions  are  developed.
When a thickened, granular, or superficially ul-
cerated state of the mucous membrane of the
larynx is present, the muscles and ligaments be-
ing uninjured, and the mobility of the parts of
the vocal apparatus  is not  materially affected
by infiltration of fluids or other lesions,  respira-
tion is not impeded, but hoarseness,  and alter-
ation of the tone of voice, are present.   When
the muscles  and  ligaments  are diseased, and
when the subordinate parts of the  apparatus
are incapable of the requisite motions,  aphonia
is more or less complete.
   84. iii. Diagnosis.—A. Of  the Acute.—The
stridulous hissing  and difficult breathing; the
prolonged inspiration, the larynx being always
drawn downward most forcibly during  the act,
as first pointed out by me in the article Croup,
and the reference  made  by  the patient to the
top of the windpipe as the source of his distress,
are sufficiently distinctive of the nature of the
disease.—Abscesses in the vicinity of the larynx
may be mistaken  for acute  laryngitis ;  but ex-
amination of the  upper  part of the throat, and
the partial or general swelling and tenderness
observed externally, the confined motion of the
larynx, particularly from  side to side,  and the
difficulty of moving the jaw, will indicate the
nature  of the  affection.  Spasm of the glottis
may be  mistaken for laryngitis; but it rarely
affects adults, and only hysterical persons.   In
these, however, a slight form of laryngitis, as 
794
LARYNX AND TRACHEA—Inflammations of.
that sometimes consequent upon cold and com-
mon  sore throat, is often attended by severe
accessions of spasm,  and may be erroneously
viewed as hysterical spasm of the glottis mere-
ly.   I have met with several instances of this
association of inflammatory and nervous affections
of the larynx, and the importance of recognising
their exact nature has been made apparent in
all  of them.  The previous catarrh, or sore
throat,  the existence  of fever, the  symptoms
referrible to  the larynx, especially the stridu-
lous breathing, the hoarseness or aphonia, and
the mere exasperation of the suffocative feel-
ings by the nervous or  hysterical state of the
patient, will indicate the  association here con-
tended  for,  and  which  consists  of  a  slight
form  of acute laryngitis,  presenting violent ex-
acerbations,  owing  to the  nervous tempera-
ment of the patient.
  85. It has  been remarked above (y 59), that
laryngitis is sometimes complicated with trache-
itis, the complication taking place in two, or per-
haps  three ways: 1st.  The  inflammation may
advance upward from the trachea  to the  la-
rynx.  2d. It may extend from the pharynx to
the  larynx and  trachea.  3d.  It  may attack
both the larynx and the  trachea at  nearly the
same time.  In cases of primary or sporadic
croup, the  inflammation  appears in  either the
first or the third of these modes, and is gener-
ally at the commencement, or at an  early peri-
od  of its course, a laryngo-tracheitis, often ex-
tending, at an  advanced stage, to the  large
bronchi, as shown in the article  Croup.   On
the  other  hand, that  complication of laryngi-
tis  which is  consecutive of, or complicated with
■pharyngitis, and which has been called " croup
in the adult," " secondary croup,"  " epidemic
croup," &c, commences and extends always
in the second of these modes.  Between  these
two kinds of croup, as they have been denomi-
nated by several writers, or, rather, between
these forms of complicated acute laryngitis, as  I
have termed  them, the distinctions are of great
practical importance.   Yet they have not been
made with sufficient  precision.  Dr. Stokes
has pointed out many of the most important of
them, but as some of  them have not been con-
sidered by him with reference to the characters
of certain  epidemics,  1 shall modify a few of
the distinctions he has adduced.
Distinctions between the chief Forms of complicated
                  Laryngitis.
  Tracheo-laryngitis,
         or
   Primary Croup.
1. The windpipe first at-
  tacked.

2. The local disease  the
  chief cause  of the at-
  tendant fever.  The fe-
  ver symptomatic.

3. The fever inflammatory.
4. Children principally at-
  tacked.
5. The disease sporadic,
  and in certain situations
  endemic, but never in-
  fectious.
6. The exudation of lymph
  spreading from the tra-
  chea to the glottis,  or
  from below upward.

7. The pharynx healthy
  Pharyngo-laryngitis,
         or
   Secondary Croup.
1. The laryngeal affection
  consecutive of disease of
  the pharynx and fauces.
2. The local disease occur-
  ring in the course gener-
  ally of a constitutional,
  and most commonly of a
  febrile malady.
3. The fever sub-inflamma-
  tory, adynamic, or malig-
  nant.
4. Both adults and children
  attacked.
5. The  malady frequently
  epidemic, and  geuerally
  infectious.

6. The  inflammation, and
  the exudation  attending
  it,  spreading from the
  throat, or from  above
  downward.
7. The pharynx diseased.
 8. Dysphagia  either  ab-
  sent or very slight.
 9. Catarrhal symptoms oft-
  en precursory to the la-
  ryngeal.
10.  Complication,   with
  bronchial or pulmonary
  inflammation, frequent.
11. Absence of any charac-
  teristic  odour  of  the
  breath.
12. Necessity for antiphlo-
  gistic treatment, and the
  frequent success of it.
 S. Dysphagia common and
  severe.
 9. Laryngeal symptoms oc-
  curring without the pre-
  existence of ratarrh.
10. Complications with these
  diseases rare.

11. The breath often char-
  acteristically Icetld.
                        12. Antiphlogistic treatment
                           very rarely requisite. Re-
                           storative, tonic, stimula-
                           ting, and other remedies
                           necessary.
  86. B. Diagnosis of Chronic Laryngitis —A
peculiar laryngeal cough, a permanent change
in the voice,  difficult and  sibillous breathing,
and pain or tenderness in the larynx, generally
characterize chronic laryngitis.   But difficulty
of breathing and  pain may be wanting  in the
early stages of the disease, or may occur only
occasionally in the advanced  periods.   When
the laryngeal swelling or constriction is consid-
erable, the  difficulty of respiring, and the pe-
culiar sound attending it, are sufficiently indic-
ative of the disease;  and, when these are want-
ing, the stethoscope will detect, as  Dr. Stokes
has shown, a harshness in  the sound of the air
passing through the larynx, suggesting the idea
of a roughness of surface.  When the laryn-
geal constriction and the laryngeal respiration
are slight,  or altogether absent, disease of the
larynx may yet be  inferred as the cause of the
cough and other symptoms by the negative in-
dications of the thoracic organs, the sounds of
percussion  and  of  respiration  being  good
throughout the chest.  In abscess and mortifi-
cation of the cartilages of  the larynx there are
laryngeal cough, foetid purulent expectoration,
and even hectic, and  there may be  no disease
in the chest;  but these cases differ from ordi-
nary phthisis laryngea, particularly in the prom-
inence  and rapidity  of  the  purely  laryngeal
symptoms.  The difficulty of determining the
complication of  the disease  with   pulmonary
tubercles in their earlier stages, or true phthisis
laryngea, should lead to a careful investigation
of the history of the case, with the view of as-
certaining  whether the laryngeal affection was
primary, or whether it supervened upon disease
of the lungs.   If it  be found that the  first
symptoms  were sore throat, relaxed uvula, dif-
ficulty of swallowing, and were  followed by
those of a  laryngeal character, or that a syphi-
litic taint had existed, there is a great probabili-
ty that the first morbid  action was manifested
in the larynx, and that the lungs were unaffect-
ed.  But if, on the other hand, as  Dr. Stokes
observes,  it is ascertained, that  previously to
any. hoarseness, stridor, or dysphagia, there has
been  cough without  the  laryngeal  character,
particularly if it  was at  first dry;  that the
breath has been short; that there has been pain
in the chest about the  collar-bones  or shoul-
ders ; that haemoptysis has occurred ; that hec-
tic has been observed, although the expectora-
tion continued  mucous ; and that  the patient
has emaciated, it is almost certain that the case
is in reality one of pulmonary tubercles, in the
course of which laryngeal disease has occurred.
If, moreover,  the patient is of a scrofulous di-
athes s, or has already lost brothers, sisters,
or a  parent, by tubercular  disease, we may be
certain  that this is the  nature of the case, al-
though  we can detect no physical sign of pul- 
LARYNX AND TRACHEA—Inflammations of.
795
  monary tubercles.  In  examining such cases,
  a careful comparison of the sounds emitted on
  percussion by corresponding opposite portions
  of the  chest, and an investigation by success-
  ive  investigations or at different periods, will
  show the state of the disease.  If, co-existent
  with laryngeal cough, muco-purulent expecto-
  ration,  semi-stridulous  breathing, and hectic,
  we find a notable difference between the sounds
  of opposite corresponding portions of the chest,
  there is almost sufficient evidence of tubercu-
  lar disease  of the lungs.  When there is copi-
  ous  muco-purulent expectoration of considera-
  ble continuance, we may infer the existence of
  suppurating tuberculous cavities in the lungs.
  When there are dulness on percussion, or cav-
  ernous rhonchus in some part of the chest, par-
  ticularly under a clavicle  or scapular  ridge,
  with copious expectoration, night sweats, ema-
  ciation,  &e, an advanced period of the  tuber-
  cular disease is present.
    87. iv.  Prognosis.—A. In acute  laryngitis
  the prognosis is considered more unfavourable
  than in any other inflammatory disease by Drs.
  Cheyne, Bayle, and others.  Mr. Bavle states,
  that  of seventeen cases observed by him during
  six years, only one recovered; but this is much
  below the average  recoveries.   Mr. Ryland
  refers to twenty-eight cases treated by different
  practitioners, and of these ten recovered ;  but
  he believes that this proportion conveys too fa-
  vourable a  view of the usual termination of
  the  disease, a greater  number  of  successful
  than of fatal cases having been recorded. There
  can  be no doubt of the correctness of the  opin-
  ion given by Dr. Williams, that the prognosis
  should be very unfavourable, and the more so,
  the more progressive the difficulty of breathing.
  When the face becomes pallid, and subsequently
  livid, and the  patient lethargic,  the danger is
  extreme.  The  complicated  and  asthenic  forms
  of acute laryngitis are especially fatal, partic-
  ularly when they occur  in an  advanced  stage
  of exanthematous, or epidemic,  or  malignant
  diseases.  Hopes of recovery may be enter-
  tained in the milder forms or states of the mal-
  ady, and when the breathing becomes less dif-
  ficult, and is attended by a freer expectoration.
  The slight catarrhal form is merely a state of
 catarrhal irritation of the glottis, to which no
 risk is attached, unless  it  pass into the  acute
 or chronic inflammatory states.   Mr. Ryland
 found that, of the eighteen cases which termi-
 nated fatally, death  occurred  within the first
 twenty-four hours in four, on the  second day in
 one, on the third day in four, on the fourth day
 in five, on the fifth day in one, on the sixth day
 in one, and on the eighth day in two instances.
   88.  B.  The prognosis of chronic laryngitis en-
 tirely depends  upon  the  states in which  it is
 presented to our observation.  In  its simple and
 mild forms,  a favourable yet cautious opinion
 may be given ;  for, although they will generally
 yield  to  judicious treatment,  exacerbations,
 cedema, or even  ulceration, may take place.  If,
 however, even  these  forms occur in a faulty or
 scrofulous constitution, a  much more unfavour-
 able opinion  should  be  formed of the result.
 If, however, the disease has continued for any
 time ;  if it have  not  been amenable to treat-
ment ; if the expectoration has become abun-
dant;  and especially  if the history and existing
state  of  the case, and  the  presence of  the
 symptoms noticed above (<$ 86), indicate its con-
 nexion with pulmonary disease,  a most  unfa-
 vourable result may with certainty be anticipa-
 ted.  Fcetor of the breath and sputa indicate mor-
 tification of the cartilages, and is very unfavour-
 able ; but in simple  laryngitis there  is still a
 chance of the dead portions  being thrown off,
 but there is no chance of laryngeal disease be-
 ing cured when it is dependant  upon tubercular
 excavations in the lungs.   In the syphilitic form
 of  chronic laryngitis, if the general  health has
 not suffered much, and if  the lungs be sound,
 the patient may recover; but the chances will
 depend entirely upon the degree of local lesion
 and the general state of the frame.*
  89. v.  Causes.—A.  Acute laryngitis may di-
 rectly follow exposure  to  cold, wet, and cur-
 rents of air, continued  or  very  great exertion
 of  the voice, and accidental attempts to swal-
 low acrid, corrosive,  or scalding  fluids t   Mr.
 Porter observes, that when a person attempts
 to drink any of these by mistake,  a convulsive
 action of  the pharynx and upper portion of the
 oesophagus takes place, and throws the offend-
 ing fluid  out through the  mouth  and  nostrils,
 under the epiglottis, thus  irritating and infla-
 ming this  part and the rima glottidis.   Drinking
 boiling water by mistake by children who  have
 been accustomed to drink from the mouth of a
teapot,  as in  the cases  recorded  by Dr.  M.
 Hall ; the inhalation  of very  hot air, or  of
flame, as  in  some cases of burning,  as shown
by  Mr.  Ryland ;  and the inhalation  of  very
acrid vapours, as the strong fumes of ammonia,
or of iodine, or the chlorine gases,  &c., are
also exciting causes of the disease.  I attended
a case many years ago with a practitioner, which
   * [In 193 cases of autopsic examinations of phthisical sub-
 jects by M. Louis, he found the larynx ulcerated 63 times,
 or in somewhat less than one third of the cases ; the epi-
 glottis  35 times in 135 cases; the trachea 76 times in 190
 cases;  the bronchi 22 times in 49 cases examined.  The
 same pathologist states, that in subjects who had fallen vic-
 tims to other affections than phthisis, of a chronic kind es-
 pecially, he, among 180 individuals, found but one example
 of ulceration in the larynx, and two of the same lesion co-
 existing in the larynx and trachea.  Hence M. Louis in-
 fers that ulcerations  of the larynx, more especially  those
 of the trachea and epiglottis, must be regarded as lesions
 proper to phthisis; for in his late  edition, " Researches on
 Phthisis," 1845, he repeats, that among upward of 501 non-
 tuberculous subjects, carried off by chronic diseases, and
 examined by himself, not one presented ulcerations in the
 larynx or trachea.—(Sydenham ed., p. 46.)  There are five
 cases, however, quoted by MM. Trousseau and  Belloc,
 in which death is supposed to have arisen from an affection
 of the larynx, attended with ulceration of its investing mu-
 cous membrane, while the lungs were free from tubercles
 M. Valleix, however, as well as  M. Louis, questions the
 authenticity of these cases. It is,  moreover, worthy of re-
 mark, that MM. Trousseau and Belloc do not appear to
 have themselves observed a single case of laryngeal ulcera-
 tion without pulmonary tubercles.   It has been fully estab-
 lished, by the researches of modern pathologists, that the
 point of junction of the chordae vocales, where  they are
 sometimes superficial, is the most common seat of these ul-
 cerations ; next in order of frequency come the chordiie vo-
■cales themselves, especially at their posterior aspect, the
 base of the arytenoid cartilages, the upper part of the la-
 rynx ; and, lastly, the interior of the ventricles.  This ac-
 counts for the  extreme frequency of aphonia in cases of
 chronic laryngitis.]
  t [The  late  Dr. D. Palmer, president of the Medical
 School of Woodstock, Vt., accidentally inhaled, through a
 glass tube, while lecturing on chemistry at Pittsfield, Mliss.,
 Oct. 12, 1H40, a very minute quantity of concentrated sul-
 phuric acid ; severe inflammation  of the larynx followed
 and although tracheotomy was early performed, the disease
 terminated fatally in  a short time by causing  asphyxia.
 (Bost. Mrd and Surg. Journ., vol. xxii., p. 182.)  We  have
attended two cases where death resulted from the same ac-
cident.] 
796                  LARYNX AND TRACHEA—Inflammations of.
was caused by swallowing a large quantity of
mustard, in order  to produce an emetic effect
after poisoning from opium.  The man recov-
ered.  In the  consecutive or secondary forms
above described ($ 63), the disease  occurs in
the course of Cynanckc tonsillaris, of C. pha-
ryngeal, and of C.parotidea; and in a decidedly
asthenic  form,  in  the course of scarlet fever,
measles,  smallpox, erysipelas, and typhoid fe-
vers   It maybe consequent even upon glossitis,
and diffusive inflammation of the cellular tissue
of the neck or throat.  Mr. Lawrence and Dr.
Williams have met with it in the course of
aneurism in the arch of the aorta.  Acute lar-
yngitis also may supervene at any stage of the
chronic state of the disease.
  90. The circumstances more especially pre-
disposing to an  attack are, frequent or habitual
occurrences of sore throat; indigestion con-
nected with biliary disorder, or with accumula-
tions of bile in  the biliary organs, and of mor-
bid secretions in the alimentary canal; habitual
intemperance, either in eating or drinking; par-
ticularly the latter ; severe or prolonged  cour-
ses of mercury, and unusual exertions of the
voice.  When inflammations of any kind attack
the throat, or parts adjoining, their extension
to the larynx is favoured by accumulations of
morbid secretions and excretions in the abdom-
inal  viscera,  and  by depressed  states of the
powers of life :  a fact of great practical impor-
tance, and hitherto insufficiently attended to
both in our pathological reasoning and in our
therapeutical indications.
  91. B.  Chronic laryngitis may arise  from the
same causes  as have been  now  enumerated;
but it sometimes  succeeds the  acute disease,
and much more commonly it follows the fre-
quent recurrence,  or neglect, of  the  slight or
catarrhal state of irritation mentioned above
(y 52).  Great  or  prolonged exertions of the
voice,  particularly by  those addicted to the
use of spirituous  liquors, and the combination
of neglected catarrh  with  intemperance, are
the most  common  causes.  Mercurial courses,
the  extension  of  syphilitic  ulcers from the
throat, dust or  grosser foreign  bodies inhaled
or passing into the larynx, and injuries of the
throat, also sometimes occasion chronic laryn-
gitis.  Persons of a scrofulous diathesis, those
liable to cutaneous eruptions, or who have been
suffering  for a long time the more severe forms
of indigestion, particularly cardialgia with acrid
eructations, and all disposed to, or already af-
fected by tubercular disease of the lungs, are
especially predisposed to this affection.  Its de-
pendance upon pulmonary consumption is most
frequent and  intimate.   It is most common at
the middle period of life, or probably somewhat
earlier, at least according  to my experience;
and  is nearly equally frequent  in both sexes.
MM. Trousseau and Belloc think that  it af-
fects males oftener than females ; Mr.  Ryland,
that it more frequently attacks the males.
  [According to M. Louis,  ulcerations of the
larynx are more than twice as frequent in males
as in females.  Thus, of nine cases of ulcera-
tion of the epiglottis recently reported (Syden-
ham ed. of Researches,  &c), eight occurred in
males ; of 13 cases of deep ulceration of the
larynx, two only  were furnished by  females;
and of nine patients affected with similar ulcer-
ations of the trachea,  six were males, and in :
: no instance was partial destruction of the rings
 of the trachea observed in a female— (Loc. at.,
 P 43.)]                                 ,  .
   92.  vi. Treatment.—A. In the acute sthenic
 laryngitis, particularly in its primary and uncom-
 plicated form, the  treatment should be prompt,
 early, and decided, in order to arrest  the dis-
 ease before effusion, in any form, or in any sit-
 uation, takes place.   The necessity for having
 a very early recourse to treatment is shown by
 the  rapid fatality  of some cases (y 58).  The
 intentions with which remedial means should be
 prescribed are, 1st. To reduce  inflammatory
 action, and thereby to prevent or arrest those
 consequences of it usually productive of a fatal
 issue ; 2d. If effusion, or infiltration  of the la-
 ryngeal  tissues have taken place so as most
 dangerously to obstruct respiration, to obviate
 such obstruction and its consequences ; 3d. To
 promote the removal of such lesions as have
 taken  place.
   93.  a. The first intention involves a recourse
 to blood-letting; but a cure of thedisease is not
 to be expected from this means alone, although
 it should be instantly and  decidedly employed,
 and in the manner advised by me in the article
 Blood (§ 64), so as to make a decided impres-
 sion on the pulse  without producing syncope,
 and within the first twelve or twenty-four hours
 from the accession of the disease.  After effu-
 sion or infiltration has taken place, so as to in-
 terfere with the purposes of respiration, blood-
 letting will be then too late to be of any service.
 A repetition  of the blood-letting,  and  the quan-
 tity of blood taken, must depend upon the se-
 verity of the disease, the habit and constitution
 of the patient, and the effect produced by it.
 Cupping on the nape of the neck, after the first
 or second venisection, should not be neglect-
 ed.  By its means a very large or small, but
 always a definite  quantity of  blood may be ta-
 ken, and  with a derivative effect.  A recourse
 to leeches is seldom so satisfactory as to cup-
 ping, in this disease.   After the first  blood-let-
 ting, a full dose of calomel—five or six grains,
 with three or four of James's powder, and  a
 third of a grain of opium, as advised by  Dr.
 Cheyne—should be given every third, fourth, or
 fifth hour, until the gums become affected.  I
 have never seen any benefit derived  from the
 application of blisters, and I am sure that I have
 seen them injurious.  Dr. Cheyne properly ob-
 jects  to  them. A recourse  to  strong liquor
 ammoniae, as suggested by Dr. J.  Johnson, may
 be preferable ; still it acts only as a vesicant,
 and, when applied  over the throat, it is so near
 the  seat  of  inflammatory action as  to  excite
 its activity rather than to diminish it by deriva-
 tion.  Romberg, Campbell, and others,  advise
 the croton oil to be externally applied, but it is
 more appropriate in the chronic form of laryn-
 gitis.
   [To show the extent to which blood-letting
 has been carried in this disease,  we may refer
 to the  case of Dr. J. W. Francis,  of New-York,
 as detailed by Dr.  J. B. Beck, in the 12th num-
 ber of the New- York Medical and Physical Jour-
 nal.  Dr. F. had complained for  three days of
 soreness of the fauces and thirst, when he was
 attacked  with pain, difficulty  of  breathing  and
 swallowing,  and a sense  of strangulation, for
 which symptoms 152 ounces of blood were ab-
 stracted, as follows : On the 17th of November, 
LARYNX  AND TRACHEA—Inflammations of.
797
1823, ;xi.; evening, ? xxx.;  18th of November,
Jxvi.; evening, fxvi. ;  19th of November, ?vi. ;
evening, fxvi. ;  20th of November, fxvi. ; 22d
of November, jxii. ; total, 153 5.   For three or
four days after, Dr. F.  was still in a precarious
condition, and required a repetition of the blood-
letting.  Dr. Cheyne, in his valuable  essay on
laryngitis in the  Cyclopedia of Pract. Med., p.
110, has given cases to prove the inefficacy of
blood-letting in  this disease,  and attempts  to
point out the circumstances which should lead
to the employment of this remedy; the princi-
pal of which is, that v. s. will be useful if re-
sorted to early, while  the complexion is good,
and the blood properly arterialized in the lungs ;
and that, after the skin becomes dusky or livid,
it is hazardous to resort to it.]
   94.  For more than twenty years I  have had
recourse, immediately after blood-letting and
the first dose of medicine, to the application of
flannel,  wrung out of hot water and freely
sprinkled with spirits  of turpentine, or with a
combination of this substance with  camphor,
or with  compound camphor liniment, around
the whole neck  and throat.  This application,
when duly managed and  modified as respects
its continuance and the  combination of sub-
stances  used, is the most efficient remedy in
all the forms, simple and complicated, of acute
laryngitis; and, as it does not vesicate, or  at
least very slightly, it  is not in the way of the
operation of tracheotomy, which will  rarely  be
necessary when it  has been early resorted to.
It has a remarkable effect in restraining inflam-
matory action in parts near those to which it
is applied, and in preventing and  arresting the
effusions and infiltrations consequent on inflam-
mation.  The success of this application will
entirely  depend upon the decision with which
it is employed.  Dr. Cheyne objects to the use
of tartar emetic in any way, lest it should ex-
cite vomiting, and, by throwing matters against
the  erect and exposed epiglottis, cause vio-
lent convulsive irritation ; and Dr. Williams,
for a similar reason, argues against the propri-
ety of applying leeches on the tonsils, as pro-
posed by Dr. Cheyne and Mr. Crampton.   The
irritation of the bites, and of the blood proceed-
ing from them, can hardly be supposed to  be
otherwise than  injurious.   The  above meas-
ures may, although early resorted to, only de-
lay the unfavourable  progress of the disease,
may fail  in arresting the inflammation, and in
preventing its consequences from dangerously
or even  fatally obstructing respiration.  It is
now that the second intention must be adopted ;
but the third should not be neglected  from the
commencement; for the removal of the lesions,
or consequences of inflammation  already pro-
duced, should be attempted forthwith ; and the
means best  calculated to attain that end are,
also, those best adapted to fulfil the first  indi-
cation, more especially the free use of mercury,
and the application of the embrocation already
mentioned around the neck.
  95. b.  The second intention must be resorted
to as  soon as the  lesions consequent upon in-
flammation begin to obstruct respiration, so far
as to prevent the necessary changes from taking
place in  the blood.  If the strength fail, and
pallor, with  lividity of the lips, appears, blood-
letting and the other means advised above will
be of no avail, and tracheotomy is then indispen-
sable.  It may have been even too long delay-
ed ; for it should be performed before the blood
is altered so far by the obstruction to respira-
tion  as  to  change its sensible qualities.  Dr.
Cheyne justly remarks, that if the symptoms be
such as to contra-indicate blood-letting, and yet
asphyxia is imminent, the operation should be
instantly performed.  As long as the complex-
ion is good, and asphyxia not threatened,  it
may be delayed.   Mr. Lawrence says that  it
should be resorted to as soon as the symptoms
enable us to ascertain the nature of the dis-
ease ; and, although this may be too precipi-
tate a recourse to a surgical operation in itself
and consequences not without some risk, it  is
preferable to delaying it too long.  The effect
of treatment, particularly of blood-letting and
of the application  around the throat, which I
have advised, should be first observed ;  and  if
these do not give relief in a period varying from
twelve to twenty-four hours, according  to the
urgency and peculiarities of the case, tracheot-
omy should be resorted to.   But no precise
time ought to be assigned before the operation
is performed ;  for the local symptoms, and the
states of the vital functions caused by the la-
ryngeal  obstructions, should  alone guide both
physician and surgeon in respect of it.   There
are pathological circumstances connected with
too prolonged  a delay of the  operation  which
should not  be overlooked, as they  are the
most powerful arguments against such  delay.
These are  the  increased disposition to bron-
chial and pulmonary congestion with obstruc-
tion to the  respiratory function, and with inter-
rupted change of the venous into arterial blood ;
and the fact that these  changes, when they
reach a certain pitch, often lead to fatal results,
although the  obstruction  to respiration  may
have been removed previously to the  occur-
rence of any immediate risk of asphyxia.   Still
the operation may be tried even when asphyxia
approaches, as a few instances have occurred
of its success at the last extremity; but the
engorged state of the lungs and congestion of
the bronchial surfaces, which increase with the
progress of the local obstruction, generally pass
into effusion or into an asthenic state of inflam-
matory  action, when the respiratory actions
are restored by the operation  after having been
too long delayed.   An early  recourse to the
operation is particularly indicated when laryn-
gitis has been caused by swallowing acrid, or
corrosive, or boiling fluids, as the means of cure
recommended  do not act so  rapidly in these
cases as in many others, and an early opening
into the  trachea facilitates the treatment of the
injured parts.
  96.  After the operation, care should be taken
not to insert too long a tube into the windpipe,
as such a one will excite serious irritation ; and
equal care  should be observed that expectora-
tion be  not prevented by constantly expiring
through this tube, otherwise  the accumulation
of mucous or muco-puriform matter in the tra-
chea and bronchi will prevent all benefit from
accruing from  this measure.   The tube, there-
fore, should frequently be closed after a full in-
spiration, and the patient be told to expire for-
cibly through the glottis, so as thereby forcibly
to expel the accumulating matter.   Until the
obstruction in the  glottis is removed by the
mercurial treatment, which should be persisted 
798
LARYNX AND TRACHEA—Inflammations or.
in until  its effects  become  manifest, active
counter-irritants should be applied on the chest
or between  the  shoulders, and the most effi-
cient of these are terebinthinate embrocations
and blisters. These, and a recourse to cup-
ping, or to dry-cupping on the chest, according
to circumstances, will diminish or remove the
congestion of the bronchial surfaces and lungs,
and the disposition to inflammatory  action in
these parts,  which  often destroy patients after
tracheotomy had apparently for a time saved
them, and which generally arise in the manner
just stated,  and less frequently are propagated
along the respiratory passages as the disease
proceeds and the powers of life are reduced.
  [The mustard  cataplasm is a very useful ap-
plication in  these  cases, as  is also a warm
poultice in which the leaves or an infusion of
tobacco have been  mixed, as recommended by
Dr. Chapman (Dis. of the Respiratory Organs,
Phila.,  1845, p. 122);  or a segar may be smoked,
if the  patient is unaccustomed to it.  Active
purgation has also been highly recommended,
and Dr. Regnin  relates two cases in females
where  imminent suffocation was prevented by
the administration  of croton oil.   #  Ol. Tiglii,
gtt. iv.; Extr. Col.  Comp., gr. xx.  M.   Div. in
pil. iv.  : give one every  two hours, till copious
evacuations  are produced.
  Although  we  regard copious venisection as
indispensable in  the  treatment of acute laryn-
gitis, we believe that mercury is a still more
important remedy,  and that without it the for-
mer would rarely prove successful.  We think
very favourably of  mercurial inunction in these
cases,  as well as mercurial inhalation, and cal-
omel should be given internally in doses of one
grain every hour, combined with extract of gen-
tian, until  evident constitutional effects are
produced.   In  this  manner  we prevent the
necessity of the excessive loss of blood, and
recovery is consequently expedited.
  Dr. Chapman (loc. cit.) is an  advocate for the
most energetic bleeding in the early stages of
this disease, carrying it  even  to fainting;  re-
marking that, "less  extensively used, it is al-
together inadequate to  an extreme  emergen-
cy.   The only cases  of the disease I have ever
cured,  or seen cured, were mainly by this ener-
getic course.  Washington's  death, humanly
speaking, may be  ascribed to  his having been
so sparingly bled in the very  commencement
of the  attack.   The subsequent and larger
bleedings were too late, effusion having taken
place.   He was  a  very robust man,  of a san-
guineous temperament,  in whom such an im-
flammatory attack required the freest depletion."
(Loc. cit.)  After free blood-letting, Dr. C. rec-
ommends copious emesis, by calomel, tart, an-
timony, and  ipecacuanha, promoting its action
by the  warm bath.  The  late  Dr. Armstrong
regarded emetics, also, as almost a specific in
the treatment of this disease, repeating their
use as  soon  as the slightest signs of stricture
in the  larynx returned.   If the  disease does
not yield, Dr. C. next advises leeches to the
throat,  then emollient poultices, and, finally, a
blister, with inhalation of the mildest vapours.
The tobacco cataplasm here comes in with fre-
quently beneficial effect.   As soon as the time
has arrived  when the directly depleting meas-
ures can be  carried  no farther, Dr. C.  recom-
mends  recourse  to sweating,  by the Dover's
powder and the vapour bath, continued for sev-
eral  hours.  He also places much dependance
on the alterative influence of calomel, in com-
bination with opium and ipecacuanha, and, as a
last  resort,  recommends tracheotomy.   " By
opening the windpipe in due season," says Dr.
C, " respiration would proceed in spite of the
obstruction of the glottis, the irritated structures
restored  to  quiescence, or, at least, relieved
from the  existing violent agitation, so exasper-
ating in its effects, and which, by continuance,
must produce pulmonary  implication, or effu-
sion  into the cellular tissue of the larynx itself.
From the wound, the danger  is in no respect
enhanced.   The aperture is to be allowed  to
remain open until the inflammation subsides,
and  the  natural passage re-established  by the
subsidence of the tumefaction, or the removal
of other impediments."—(Loc. cit.)
  In that form of acute  laryngitis  attended
with an  cedematous  disposition, as we often
observe in persons of a lymphatic temperament,
the  loss  of blood  is rarely beneficial  ; here
emetics,  with strong counter-irritants  to the
throat, and swabbing the fauces,  and even the
larynx, with a strong solution of  nitrate of sil-
ver,  or alum, will be found the most efficacious
treatment.]
  97. B. The complicated forms of sthenic laryn-
gitis require a different treatment from that ad-
vised in the simple  sthenic form.   In that com-
plication which is consequent upon, or coetane-
ous with tracheitis, and which constitutes a very
large proportion of the cases of croup, nothing
can  be added at this place to what has been
fully adduced in that article,  from a tolerably
extensive experience.  When laryngitis occurs
from the extension  of inflammation, with albu-
minous exudation from the fauces and pharynx
—is consequent upon angina membranacea—and
when the local and constitutional  symptoms in-
dicate a more or less sthenic disease, the treat-
ment should be such as may subdue increased
vascular action, and be especially and early di-
rected to the state of the fauces  and pharynx,
in order to prevent the extension of the morbid
action from them to the larynx.   The  means
most beneficial in this form of disease are fully
described in the article Throat, Diseases of.
When the larynx becomes implicated, a vigor-
ous  recourse to calomel,  and the  application
of the terebinthinate embrocation around the
neck and throat, sometimes preceded by cup-
ping on the  nape of the neck,  are chiefly to be
relied upon.  Venaesection is rarely indicated,
and  as rarely beneficial in this disease,  unless
in its most sthenic states, and in  plethoric and
robust persons, where it  should  be employed
with a careful observation  of its effects; but
the treatment will depend much upon the char-
acter of the epidemic. The topical applications
of alum,  in the form of a paste or otherwise, or
of nitrate of silver, or of muriatic acid,  as ad-
vised for angina membranacea (see  art. Throat),
are now generally of no avail; and if the former
means are inefficacious, tracheotomy must be
resorted  to, and should not be too long delayed,
although a  successful result from it is even
less  to be expected  in this  malady than where
it is  performed in simple laryngitis ; for there
is a  much greater disposition of the morbid ac-
tion  to propagate itself from the larynx down-
ward in the complicated than in the simple dis- 
LARYNX AND TRACHEA-Inflammations of—Treatment.             799
 ease, and patients are more likely to be carried
 off by the consecutive bronchitis.
   98.  C. In the treatment of acute asthenic laryn-
 gitis, blood-letting is inefficacious or injurious,
 whether the  disease appear  in its simple form
 (y 67), or in any of the complicated states (!) 68)
 noticed  above.  The  means which are  most
 likely to be of any service in any of these forms
 of the malady are calomel conjoined with cam-
 phor and opium,  in  large and  frequent doses,
 and  the terebinthinate  embrocation  already
 prescribed, kept constantly applied  around the
 neck, fauces, and throat.   In the intervals be-
 tween the doses of calomel, camphor,  and opi-
 um, stimulants, tonics, and antiseptics are oft-
 en required to support the powers  of  life, and
 prevent  the  progressive deterioration of the
 blood.   In the complicated asthenic laryngitis
 attending cynanche maligna, or any of the  more
 malignant forms of eruptive fevers, or erysipelas,
 calomel  is not often of service, as the laryngeal
 affection generally terminates life  before any
 constitutional effect can follow its exhibition.
 If, therefore, it be  given at all, it should be
 prescribed with camphor, or with camphor and
 opium, either in the form of powder or linctus,
 so that it may act upon the fauces and pharynx,
 and thence upon the larynx.   In  these compli-
 cations,  tracheotomy should be  performed at
 an early  period of the laryngeal disease, if per-
 formed at all;  but at any  period of these the
 chances  of success from it are  very few; for
 the constitutional disease, and the frequently-
 attendant association of congestions or asthen-
 ic inflammations of the bronchi or lungs, reduce
 these chances to almost the lowest calculation.
 In the primary asthenic laryngitis (y 67) trache-
 otomy is more likely  to  succeed,  when early
 performed,  than  in  any of the complicated
 states, inasmuch as the infiltration of  the sub-
 mucous  tissues  is generally  confined  to the
 larynx.  It should be  kept in view that  this
 and the complicated  states of the disease, be-
 ing characterized  originally  by  deficient  vital
 power and a morbid condition of the blood, will
 rapidly become worse in both these respects ;
 and that, if this operation be not  resorted to at
 a very early period, the consequences  of delay
 pointed out above will the more readily super-
 vene, and the  chances of success  from it be re-
 markably reduced.   If purgatives be  resorted
 to at any period of the  asthenic forms of laryn-
 gitis—and they will be required in  many cases
 —they should  be  combined with warm, tonic,
 and stomachic substances, and their operation
 be promoted by stimulating and antispasmodic
 enemata.  Or  enemata may, in many instances,
 be confided in chiefly,  in order to evacuate the
 bowels.  Spirits of turpentine with castor oil,
 sometimes with  common  salt—or  with  cam-
 phor,  asafoetida, &c, according to circumstan-
 ces—generally  are the  most efficacious, and
 most appropriate to the states of the disease.*

  * [Dr. Cheyne has stated,  that the  case of General
 Washington (Cycl.  Pract. Med, art. Laryngitis) is the
 first well-marked  instance of this  disease on record. We
 quote Dr. Craik's report of the same as made at the time.
 " Some time on the night of Tuesday, the 10th of Dec,
 1799  having been exposed to rain on the preceding day,
 General Washington was attacked with an inflammatory
affection of the upper part of the windpipe, called, in tech-
nical language, cynanche trachealis.  The  disease  com-
menced with a violent ague, accompanied with some pain
 in the upper and fore part of the throat, a  sense of stricture
 in the same part, a cough, and a difficult rather than a pain-
   99.  D. Treatment of Chronic Laryngitis. —The
indications of cure in the primary form of chron-
ic laryngitis  are:  1st. To remove the  inflam-
matory action and its consequences in the la-
rynx; 2d. To improve the general health ;  and,
3d. To  relieve  the urgent symptoms.—a. In
order that the first of these intentions should be
the more readily  accomplished, as well as to
prevent exacerbations of the disease, or acces-
sions of severe  cough or spasm of the  glottis,
the patient should avoid  exposure to cold air
and other causes of irritation, particularly dust,
smoke,  fumes,  gases, and every  exertion of
voice or speech.  He should rest the organ as
much  as possible, and  speak only when  it is
necessary, and then in a whisper merely.  MM.
Trousseau and  Belloc think that speaking in
a whisper is attended by no evil.   The  patient
ought to have recourse to a respirator on all oc-
casions of passing from a warm to a colder air ;
and  he  should  pay attention to his diet  and
regimen, shunning everything  that is  difficult
of digestion, or that may offend the stomach or
bowels, or excite the circulation.
ful deglutition, which was soon succeeded by fever and a
quick and laborious respiration.  The necessity of blood-
letting  suggesting itself to the general,  he  procured a
bleeder in the neighbourhood, who took from his arm in the
night twelve or fourteen ounces of blood.  He could not by
any means be prevailed  on by the family to  send for the
attending physician till the following morning, who arrived
at Mount Vernon at about eleven o'clock on Saturday.  Dis-
covering the case to be highly alarming, and foreseeing the
fatal  tendency of the disease, two consulting physicians
were immediately  sent for, who arrived, one at half past
three, and the other  at four o'clock in the afternoon.  In
the mean time were employed two pretty copious bleedings,
a blister was applied to the part affected, two moderate do-
ses of calomel were given, and an injection was adminis-
tered, which operated on the lower intestines,  but all  with-
out any perceptible advantage, the respiration becoming
still more difficult and distressing.  Upon the arrival of the
first of  the consulting physicians, it was agreed, as  there
were yet no signs of  accumulation in the bronchial vessels
of the lungs, to try the result of another  bleeding, when
about thirty-two ounces were drawn without  the smallest
apparent alleviation of the disease. Vapours of vinegar and
water were frequently inhaled ; ten grains of calomel were
given, succeeded by repeated doses of emetic tartar, amount-
ing in all lo five or six grains, with no other  effect than a
copious discharge  from the bowels.  The powers of life
seemed now manifestly yielding to the force of the disorder ;
blisters were applied to  the extremities, together with a
cataplasm of beer vinegar to the throat.  Speaking, which
was painful from the beginning, now became almost im-
practicable ; respiration became more and more contracted
and imperfect, till  half past eleven on Saturday night,  re-
taining  the full possession of his intellect, when he expired
without a struggle.  He was fully impressed  at the begin-
ning of his complaint, as well as through every succeeding
stase of it, that its conclusion would be mortal, submitting
to the several exertions  made for his recovery rather as a
duty than from any expectation of their efficacy.  He con-
sidered  the operation of death upon his system as coeval
with the disease ; and several hours before his death, after
repeated efforts to  be understood, succeeded in expressing
a desire that he might die without farther  interruption.
During the  short period of his illness, he economized his
time  in the arrangement of such few concerns as required
his attention with the utmost serenity, and anticipated his
approaching dissolution with every demonstration of that
equanimity for which his whole life had been so uniformly
conspicuous.  The violent ague with which this case com-
menced was, doubtless, the rigour of incipient inflamma-
tion ; the pam in the upper and fore part of the throat, the
sense of stricture in the same part, and the labour of respi-
ration, showed that inflammation was seated in the larynx.
The difficult deglutition arose from the state of the tonsils,
in which, probably, the inflammation commenced.  The  in-
flammation did not descend into the bronchial vessels of the
lungs, wherein, we are told, there were no signs of  accu-
mulation.   It may be inferred, therefore, as will be apparent
from the sequel, that this was  a genuine specimen of lar-
yngitis."
  This  account is dated Alexandria, Virginia, Dec. 21,1799,
and signed by Dr. James Craik, attending physician, and
Dr. Eli^ha E. Dick, consulting physician.] 
800
LARYNX  AND TRACHEA—Inflammations of—Treatment.
  100. General blood-letting  is sometimes re-
quired in this form of the disease, and chiefly
in plethoric and  robust  persons  at  the com-
mencement of the disease, or when the chron-
ic symptoms become aggravated  into a more
acute state.   Local depletion by cupping, or by
leeches applied to  the sides of the neck, below
the level of the  larynx, are, however,  more fre-
quently of use,  particularly when  pain or ten-
derness of the  larynx is felt, and they should
then be employed with decision.   If the  dis-
ease has been consequent upon suppression of
the  menstrual  or  ha;morrhoidal discharge,
leeches  should  be applied to the tops of the
thighs, or to the anus.
  101. External derivation or revulsion is more
beneficial than vascular depletions when the dis-
ease has been of  some standing, a recourse to
which should then be contingent only  upon cer-
tain circumstances.   Various means of deriva-
tion have been advised, and each has been in
vogue for  a time.    First  the  tartar-emetic
ointment  was  employed, especially in  this
country; and then moxas were recommended,
on the Continent particularly.  Afterward, fric-
tions with croton  oil  were advised, and various
liniments and embrocations containing liquid
ammonia.  Besides these, blisters, the liquor
lyttae, mustard cataplasms, &c, were resorted
to ; and there are few of these which have not
given temporary ease in a few cases, or have
either been of no  avail, or aggravated the mal-
ady in others.  The general error  was,  that
they have been applied either over or too near
the larynx—too close to the seat of irritation
to derive from  or subdue it; and hence, from
their proximity, rather administering to its du-
ration than  arresting it.  These, if  employed
at all, should be applied at a distance from the
larynx, as on the  sides or nape of the neck, or
top of the sternum, as advised by me  in the ar-
ticle  Croup ($ 46).   The only application  that
cm be prescribed with advantage on  the throat
itself is  the terebinthinate embrocation men-
tioned above ; and the inhalation  of  the fumes
from it,  especially when their escape is mod-
erated by a  covering external to the flannel
with  which it is applied, is generally  beneficial.
A caustic, mezereon, or pea-issue, setons, or
open blisters, or  a pustular  eruption produced
by means of tartar-emetic ointment, and kept
freely suppurating or discharging, in the  nape
or sides of the  neck, or at the top of the ster-
num, are the most deserving of notice of the va-
rious modes of procuring a continued purulent
discharge.
   102. Most British physicians have  recom-
mended a mild  mercurial course, in order to ful-
fil the first indication of cure ; and in  a few pri-
mary cases it has been successful, although a
more severe course, and the contingencies con-
nected with  it, have in  some instances  even
caused the disease, especially in those exposed
to atmospheric vicissitudes  and in the intem-
perate.   MM. Trousseau and Belloc adduce
several cases of the  success of a  general mer-
curial treatment, even when the disease  was
not of a syphilitic species, and state that many
cases truly desperate  were cured  by giving
mercury to  salivation.  When  the practice is
determined upon, calomel may be given, tritu-
rated with sugar, in small or moderate doses,
and in the form of linctus or electuary, so that
it may come in contact with  the pharynx and
epiglottis; and its use  should be persisted  in
until the mouth becomes slightly affected,  or
salivation is produced.   A diminution of pain,
or of constriction of the larynx; an improve-
ment of the voice,  and a looser and easier
cough, indicate the good effects of this course.
If it fail, or cease to be farther beneficial, a re-
course to appropriate medicines, prescribed  in
the form of linctus or electuary, or in similar
semi-fluid vehicles, is occasionally of service.
Those which  are demulcent and cooling are
commonly to be preferred ; and  I have gener-
ally employed  various  sirups and  mucilages
containing  small doses of nitre, or of hydro-
chlorate of ammonia,  and of camphor or  of
benzoin, with  narcotics and sedatives,  accord-
ing to the peculiarities of the case ; taking care
not to offend the stomach, or to disorder any
of the several digestive processes.  If these
means do not afford decided benefit, the liquor
potassae  may be given, with small doses of a
solution  of the iodide  of potassium, and with
camphor and  narcotics, either in the form  of
mixture  or linctus.  The inhalation of vapour
or steam imbued with  the  fumes of camphor,
turpentine, narcotics, balsams, &c, as  already
advised by me for the chronic forms of Bron-
chitis (y 98), is sometimes of service, and is, as
just remarked, one of the sources of the bene-
fit afforded by the terebinthinate embrocations
recommended to be applied to  the neck and
throat in this disease.   Narcotics are generally
useful in allaying  irritation and cough.  The
extracts of belladonna and stramonium  may be
added to the warm-fluids used for the purposes
of the inhalation of their steam, or they may be
applied by  friction to the anterior part of the
neck.  The salts of morphia may also be em-
ployed endermically on the back  or nape of the
neck.
   103. The above treatment will generally re-
move the primary form of chronic laryngitis, if
it have been adopted before extensive ulcera-
tion or destruction of the cartilages has taken
place ; and will sometimes be successful even
in the specific or syphilitic form of the disease ;
but, when these lesions exist, slight hopes can
be entertained from any mode of cure.  MM
Trousseau  and Belloc have recommended a
topical plan of treatment.   They observe that
whenever inflammation becomes chronic, and
affects only a circumscribed part of the econo-
my, it commonly resists the most extensive
and active general treatment; and that, on the
contrary, it is almost always modified by topical
treatment,  whatever be the means.   This,  to
a  certain extent, explains the difficulty with
which internal local diseases are cured, com-
pared with  those which are external.  They
consider it, therefore,  obvious, that if by any
means local applications could be made to the
mucous membrane of the larynx without inter-
rupting respiration, many cases might be cured
which are considered incurable ; and this they
believe that they have  done.
   101. The inspiration of dry or moist vapours
has been recommended in phthisis laryngea and
in other affections of the respiratory apparatus ;
but those which have been employed, and oft-
en too empirically prescribed, have been either
too acrid,  stimulating,  or  concentrated;  and
not being confined in their operation to the la- 
LARYNX AND TRACHEA—Inflammations of—Treatment.            801
rynx, but acting upon the respiratory surfaces
generally, have proved  more injurious  than
beneficial.  The action of these cannot be lim-
ited ;  and hence those only which I have ad-
vised above, and in the article Bronchi (chronic
inflammation of), and which are balsamic, aro-
matic, emollient, and  narcotic, and cannot in-
jure the lungs, should only be employed.  MM.
Trousseau and Belloc confine themselves to
those which I had  advised in the above article
long before the publication of their work; but
they  recommend still more  active  and  more
strictly topical means, consisting of both liquid
and dry applications.
   105. The liquid applications  used by these
writers consist  of solutions of nitrate of silver,
corrosive sublimate,  sulphate of copper, and
per-nitrate of mercury.   They  prefer,  howev-
er, the solution of nitrate of silver, from the
application of  which no inconvenience has
arisen.   The solution of corrosive  sublimate,
of the strength of from one to eight grains to
the ounce of distilled water, they found to be
very serviceable in some cases of syphilitic ul-
ceration.  The  solution of nitrate of silver, in
the large proportion of from  one to two  parts
in four parts of distilled water, they apply to
and behind the epiglottis, by a small roll of pa-
per bent  at its moistened end, or with a small
piece of sponge fixed to a rod of whalebone,
bent,  at an inch from the sponge, at an angle
of  80 degrees.  The patient's  mouth being
opened wide, and  the tongue  pressed down,
the sponge is passed to the top of the pharynx;
and as soon  as it  reaches it, a movement of
deglutition is produced, which  carries the la-
rynx upward, at which movement the sponge is
brought forward and  squeezed  under the epi-
glottis, and the solution freely enters the la-
rynx.  Convulsive cough, and sometimes vom-
iting, ensue ;  but the application causes no pain.
MM.  Trousseau  and Belloc  have  another
means of effecting their object.  To  a  small
syringe,  like Anel's, a  canula, at least five
inches in length, and curved at its free extrem-
ity, is attached.   The syringe is filled  three
fourths with air, and one fourth with a solution
of the nitrate of silver.   The canula is then in-
troduced into the posterior fauces, opposite the
larynx, and the piston being rapidly advanced,
the liquid, mixed with the air in the syringe,
falls in a fine shower on the superior part of
the larynx and oesophagus.  The patient is im-
mediately seized with a violent fit of cough,
which, however, need give  no alarm.  He  is
then immediately directed to gargle his throat
with  water  acidulated with  muriatic  acid or
salt water, which decomposes that portion of
the solution which is not combined with the
tissues.
  [The practice of cauterizing the  larynx, as
recommended by Trousseau and Belloc, has
received the sanction of Sir Charles Bell, and
Cusack,  of Dublin, by  both of whom it has
been  practiced.  It is also  recommended by
Williams, Stokes, Vance,  and  others, as  a
mode of treatment possessing peculiar efficacy.
It was early introduced into this city by Dr. H.
Green, who  has employed  it, together  with
constitutional remedies, with considerable suc-
cess in many cases of chronic laryngitis, even
when  complicated with tubercular disease of the
lungs; and Dr. Taylor, as  already remarked,
    II.             101
has reported several cases of aphonia and laryn-
gitis cured or materially benefited by its use.
  In many cases, there is good reason to  be-
lieve that the bent probang and sponge is car-
ried directly into the larynx,  though in  other
instances the  operator is  probably  deceived.
It is now abundantly established that a foreign
body may be carried into the  larynx without
producing much, if any, coughing, or sense of
strangulation.   Dr. Taylor recommends that,
instead of carrying  the probang to the back
part of the larynx, and then waiting for  the
larynx  to be  elevated, as  recommended by
Trousseau and Belloc, the instrument should
be carried sideways over the base of the tongue,
the sponge  looking to the right side;  and, as
the tongue  is requested to be protruded,  the
epiglottis becomes erect, and,  as the larynx is
elevating, the sponge, if not too large, is brought
to a level with the superior opening, and passed
directly into the larynx, and the fluid expressed
by the quick contraction of the posterior mus-
cle of the larynx, which contraction is distinctly
perceptible to the fingers of the operator, and
with a slight motion, or the request to protrude
the tongue,  the probang is removed with ease.
The operation  is made especially easy when
the epiglottis can  be distinctly seen and felt,
the root of the tongue not deep nor broad, or
thick and elevated, nor the tongue long ;  while
in others the tongue is so very long as to pre-
clude the epiglottis from being distinctly felt;
and, again, so deep is the larynx in other cases
that it cannot be reached with the finger.  Nor
must we forget the difference in the size of the
opening of the larynx, that we may judge what
kind of instrument we are to use in each case.
The strength of the solution may vary from 20
to 40, and even 60 grains, to the ounce of water.
(.V. Y. Jour. Med. and Coll. Sci., vol. iv.)
   Dr. Green has reported (Ibid., vol. iv.) sev-
eral cases of chronic laryngitis, which, he states,
were " permanently cured" by this local  treat-
ment, although it is worthy of note that he used
constitutional  remedies, at the same time, in
every  case, as iron, the balsams, cubebs, &c.
" During the last  six months," says  he, " up-
ward of 50 cases have come under my care,
and, in the treatment of these cases, in more
than 500 instances have topical remedies been
introduced  below the epiglottis into the laryn-
geal cavity.  In many instances, where chronic
affections of the throat have existed for years,
and have been attended with ulceration, with
hoarseness, and in some cases with complete
aphonia of  many  months' standing,  the parts
have been restored to a healthy condition, and
perfect vocalization established."  With respect
to  the  practicability of entering the  larynx in
this manner, it is to be borne  in mind that the
epiglottis, or valve to this opening,  except at
the moment of deglutition, is always, by virtue
of its own elasticity, retained in a vertical po-
sition, and  that foreign bodies frequently find
their way accidentally into the larynx and tra-
chea. ' Baron Larrey states (Rel. Chir. deVAr-
mee d'Orient) that, in attempting to  pass  the
elastic tubes, for the purpose of conveying liquid
nourishment to the stomachs of soldiers who,
from wounds of the neck, were unable to swal-
low, " the tube often went into the larynx in-
stead of into the oesophagus," and that, when
this happened, "the mistake was not discovered 
^02            LARYNX AND TRACHEA—Inflammations of—Treatment.
by any particular sensation about the glottis.''
Ryland,  also, in his treatise on "Diseases and
Injuries of the Larynx," says that " an elastic
sound, introduced into the larynx,  docs not
give rise to any peculiar  sensations that will
indicate the occurrence with any degree of cer-
tainty" (p. 241).   We  have also known the
tube of the stomach-pump accidentally passed
into the  larynx, without exciting any marked
irritation.  In the 23d volume of the* Medico-
Chirurgical Transactions of London,  1840, is a
paper by Sir  C.*:sar Hawkins, on the "Diag-
nosis of Foreign Bodies  in the  Larynx,"  in
which cases  are mentioned of foreign bodies,
as  pieces of bone, &c,  being lodged  in the
laryngeal cavity, without exciting  cough  or
other symptoms of irritation.
  In employing the nitrate of silver for a lotion,
it  is  important to  use  that which  comes  in
crystals,  and  not in the cylinder form,  as the
latter is often found to contain a portion of un-
combined nitric acid, which is  of an irritating
nature.   With  respect to the propriety of re-
sorting to this local method of treating diseases
of the larynx, we should say that where, from
general and physical signs, we have reason to
believe that  the  lungs  are  not seriously dis-
eased, it would be advisable to use local appli-
cations  to the larynx, after the manner above
recommended ; but where there  is tubercular
disease existing, the most  that can be expected
from the treatment is temporary relief.   (See
N.  Y. Jour, of Med., vol. iv.)
  Chronic laryngitis has attracted considerable
attention of late years in this country, from its
supposed frequent  occurrence among clergy-
men.  Dr. Chapman, while he admits that it is
often met with among this class, observes that
he  " knows nothing in  their habits or occupa-
tions to dispose them more to such attacks than
various other classes of people, and  especially
the members of the professions of law and
medicine."   When the disease attacks clergy-
men, Dr. C.  supposes that it first invades the
fauces, and extends afterward to the windpipe
(Lectures on Diseases of the Thoracic and Abdom-
inal Viscera, Phila., 1844, p. 119).  Dr. Clymer,
also (Williams " On Dis.  of the Respiratory Or-
gans," Phila, 1845, p. 129), remarks, that " the
vocation of the clergy has been thought  to ren-
der them peculiarly liable  to this disease, espe-
cially in this country, and it has, in consequence,
been called the ' clergyman's sore-throat.'  This
peculiar  susceptibility from the nature of their
pursuits  may  be  doubted.   The disease,  in
fact, to  which they,  in common with  others,
seem particularly liable,  is a chronic pharyn-
gitis, and is popularly known as bronchitis.  On
inspection of the pharynx, its lining membrane
will be found to be injected, and the follicles
greatly enlarged, and resembling split pease."
We have examined this subject at some length
in the N. Y. Literary and Theol. Review for 1838,
to which we refer the reader.  We believe that
chronic laryngitis often commences in derange-
ment of the  digestive organs,  leading to mal-
nutrition, and that the most successful treat-
ment will generally be found  that  which re-
stores them to a healthy condition.  Elongation
of the uvula, with congestion of the  vessels of
the fauces and bronchi,  is for the  most part
 dependant on some of the forms of indigestion,
 and is to be  removed by directing our remedies
to the original disease.   With respect lo other
treatment, we can add nothing to the very sat-
isfactory account  of our author.   The reader
will  do well to consult  Dr. Chapman (he  cit.)
on this disease, as well as Bell and Stokes's
Lectures, &.C.]
  106. Applications in the form of powder to the
larynx  have likewise been  recommended by
MM. Trousseau  and Belloc.  Among these
may be mentioned, in an inverse ratio to their
power, the sub-nitrate of bismuth, alum, acetate
of lead, sulphate  of zinc, sulphate of copper.
Calomel and red  precipitate also produce re-
markable results in cases of ulceration, whether
syphilitic or not, of the  mucous membrane of
the larynx. All these, excepting the sub-nitrate
of bismuth, which  may be applied  pure, ought
to  be mixed  with  finely  powdered sugar or
sugar-candy in variable  proportions, according
to their activity : calomel with twelve times its
weight of sugar;  red precipitate,  sulphate of
zinc, and sulphate of copper, each with thirty-six
times its weight;  alum with twice its weight;
and acetate of lead with seven times its weight
of sugar ; and nitrate of silver with twenty-two,
thirty-six,  or seventy-two times its weight of
sugar.  The last is said to be  most successful
in erythematous laryngitis, with erosions or ul-
cerations.   The powders should be impalpably
fine ; the  least roughness or perceptible  frag-
ment of a  crystal  occasions such cough as ex-
pels the powder.   The powder is  put into one
end of a reed or  glass  tube, and  the other  is
carried back as far as possible into the mouth.
After  a full expiration,  the patient closes his
lips around the tube and inspires suddenly and
forcibly through it, some of the powder being
thereby carried into the larynx and trachea.
The cough, which the powder excites, is advised
to  be restrained as much as possible, so  as  to
 prevent a too speedy expulsion  of it.   This
mode of applying these powders may be resort-
ed to twice, or even oftener, daily, according  to
the nature of the case ; but the mercurial pow-
ders should not, especially at first, be applied
oftener than twice or thrice a week.
   107.  Applications to  the pharynx are  often
beneficial  in chronic laryngitis; for it is well
known that this disease often originates in the
 mucous membrane of the throat  (see article
 Throat), especially in the tonsils,  fauces, &e,
 and extends to the pharynx, and thence to the
epiglottis and larynx; and that it is often  caus-
 ed by enlargement  or relaxation of the uvula,
 often in connexion with other affections of the
 throat.  Caries even  of the  teeth may affect
 the pharynx and  larynx.   In such cases, the
 treatment should be directed to  the primary
 affection.  An elongated uvula should be short-
 ened, and suitable  gargles prescribed.   Ben-
 nati extols gargles of  alum and  sulphate of
 zinc.   MM. Trousseau  and Belloc prefer the
 nitrate of silver, and, when  angina pharyngea
coexists  with chronic laryngitis,  they touch,
 two or three times a week, the tonsils and arch
 of the palate  with a pencil of nitrate of silver,
 or a solution of  the  same;  or they apply  a
 powder consisting of six or eight grains of the
 salt to about a drachm of powdered sugar.   A
 strong solution of corrosive  sublimate, or  of
 sulphate  of zinc,  fulfils the same  intention
 Even when the mucous surface of the posterior
i fauces or  pharynx is not affected with inflam- 
LARYNX AND TRACHEA—Foreign Bodies in.
803
 matory  irritation, the same means have been
 useful in chronic laryngitis.
   108. 6.  The second indication, viz., to improve
 the general health, is generally required, and,
 without attention be paid to it, the local meas-
 ures above advised may be employed in vain.
 The means which should be adopted  in order
 to attain  this end ought to vary with the cir-
 cumstances, and especially with the origin and
 complications of individual cases.  When indi-
 cations  of irritation are observed in the throat
 or  pharynx, or  when the uvula is elongated,
 the digestive functions  will be rarely found un-
 disordered. These should be improved by mild
 tonics and purgatives, and by stomachic aperi-
 ents and alteratives.  The compound steel mix-
 ture with liquor potassae, or the iodide of potas-
 sium with  liquor potassae and sarsaparilla, are
 among the most suitable medicines that can be
 resorted to with this intention, after the secre-
 tions and excretions have been evacuated.   A
 residence in a mild, equable, and congenial cli-
 mate, strict attention to diet and regimen, and
 the use  of mild chalybeate and  deobstruent
 mineral  waters, will very materially assist other
 means of cure.   WThen the laryngeal  affection
 is dependant upon an early stage of pulmonary
 tubercles, these will be especially requisite, par-
 ticularly change to a warm, mild,  and equable
 climate.
   109. In the syphilitic form of the disease, the
 constitutional cachexia must be removed, as al-
 ready hinted at,  by a mild mercurial course, or
 by a course of iodine and sarsaparilla, [dulca-
 mara, or  yellow dock.]  In this species, gar-
 gles, or  the local  application to  the larynx  of
 solutions  of [sulphate  of copper,  sulphate of
 zinc, nitrate of silver, or] corrosive sublimate,
 and the  exhibition of this substance internally,
 in the form either of pills or of  solution, until
 the system is affected, or conjoining  it with
 tonics, sarsaparilla, &e, are sometimes very
 advantageous.
   110. c. The third indication, or the  relief of
 urgent or dangerous symptoms,  is often called
 for  in the  course of the disease.  Several of
 the means already mentioned, and recommend-
 ed to be  conjoined with  other  remedies,  in-
 tended to answer the first intention, as the  in-
 ternal and external use of narcotics, anodynes,
 and demulcents,  particularly stramonium, bel-
 ladonna, <fcc. (§ 99, et seq.), will  be required to
 fulfil this indication.  Still, however skilful the
 treatment may be, these and other combina-
 tions of means  may fail to prevent,  or acci-
 dents may occur to produce impending suffo-
 cation.   In cases where the epiglottis  is so  ul-
 cerated or otherwise injured as  not sufficient-
 ly to protect the rima glottidis, articles of food
 or foreign bodies may become entangled in, or
 may pass the larynx into  the  trachea ; and
 these, or threatened suffocation from other cir-
 cumstances, as from the sudden infiltration or
 abscess of the sub-mucous tissues, may require
 tracheotomy.   When this operation has  been re-
 sorted to, and a canula of sufficient diameter
 introduced, the affection of the  larynx should
 be treated in a suitable  manner,  care being ta-
 ken, in the way above advised (y 96), not to  al-
 low  secretions to accumulate in the trachea so
 as to interrupt respiration.  When the organ
 is capable of performing its functions, the canu-
la may be withdrawn, and the wound will soon
afterward heal.   If the disease of the larynx
be  of such a nature that the  air cannot  pass
through the glottis, the canula must be  con-
tinually worn.  MM. Trousseau  and Belloc
adduce an instance of its having been worn for
ten years.*
  111.  Females suffering under chronic laryn-
gitis  often experience  violent exacerbations
and laryngeal  spasms, sometimes threatening
suffocation.  In these  cases, especially when
occurring in hysterical temperaments, the ap-
plication  of the  terebinthinate  embrocation
around the neck, or  a belladonna  plaster  or
ointment, and recourse  to an enema of spirits
of turpentine with castor oil, and sometimes
with  camphor  or asafcetida, will generally re-
move the attack.
  112.  IV. Foreign Bodies  in the Larynx or
Trachea.—The  consideration of this subject
in connexion with diseases  of the  windpipe
has been neglected by all writers on these dis-
eases, excepting Dr. Stokes and Mr. Ryland,
although numerous instances of this accident,
and minute accounts of the  consequences  pro-
duced by it, are on record.   A somewhat  par-
ticular  notice  of this  subject has, however,
been  taken by Pelletan, Louis, and Porter.
The situations in which the foreign body may
remain,  or into  which  it may pass, are : the
rima  glottidis itself; the ventricles of the la-
rynx ; the trachea ; and the bronchial tubes,
particularly the right.  It may, from the efforts
of coughing, be forced  upward into the  tra-
chea  or larynx, thence  to return  again to its
former position.!   The much greater frequen-
cy of the passage of the body into  the right
than  into the left bronchus, has been imputed
by Dr. Stokes, not to the greater diameter of
the right than of the left tube, but to  the man-
ner in which the trachea divides to form these
tubes, the septum at the bifurcation not being
in the mesian line, but  decidedly to the left of
  * [There are numerous cases on record, where tracheoto-
my has been successfully performed, both in acute and
chronic laryngitis;  as in Lond. Med. Gazette for March 8,
1844; Lond. Lancet, June 7,1845, &c. The operation, in the
acute form of the disease, should evidently be performed, if
possible, while the patient's strength is yet entire, and be-
fore the system is poisoned  by unarterialized blood, and the
lungs congested.  In the Montreal Med. Gaz., 1844, is an
account of a successful case of tracheotomy, for the removal
of a pipe-stem from the trachea of a boy four years of age.
We may remark, that tracheotomy possesses decided advan-
tages over laryngotomy, in cases of laryngitis, as the trachea
is rarely involved in the disease, and an incision through
the inflamed membrane of the larynx, and the subsequent
introduction of a canula, necessarily adds to the existing ir-
ritation.  With respect to the use of a canula, Mr. Liston
says, there  is no sound objection whatever to its introduc-
tion, that it causes very little irritation, and should be em-
ployed whenever it is  necessary to provide for the  free
breathing of the patient.—(Lond. Lan., Nov., 1844, p. 251.)]
  t [Mr. Bartlett relates a case (New-York Jour, of Med.,
1845), where a piece of bone was expectorated, which was
supposed to have been lodged in the bronchus 60 years pre-
viously.  In Braithwaite's Retrospect, part xii., p. ldfi,
is recorded  a case of spontaneous expulsion of a piece of
bone from the larynx  four years  after it had lodged there.
fn the Dublin Hospital may be found the history of a case
where  a piece of wood had been swallowed by a boy and
passed into the trachea, whence  it was spontaneously ex-
pelled, five weeks afterward, by coughing. Dr. Lettsom de-
tails a case where the covering remained in the air-passages
for eight months, when it was coughed up, and the pulmo-
nary symptoms subsided.  Dr. Donaldson gives an ac-
count of an ear of grass remaining in the air-passages seven
weeks, giving rise to severe bronchitis;  it was  then ex-
pectorated, and the patient recovered.  Many other similar
cases are on record, where foreign bodies have remained for u
long period in the larynx, or air-passages, and then expelled
spontaneously, when recovery took place.] 
804                 LARYNX AND TRACHEA—Foreign Bodies a.
it, so that a body falling through the trachea
will most readily pass into the right division.
  113.  WThen the body has passed into the air-
passages, various results are observed : 1st. It
may be expelled forcibly through  the glottis,
after a period of time varying from a few mo-
ments  to  many years.   2d. It  may produce
death by suffocation, from its being  impacted in
the larynx.  3d. It  may cause acute inflamma-
tion of the whole lung, owing to its lodgment
in the  principal bronchus, and the  patient die
before  abscess is formed, or  after  an abscess
has formed in the lung.   4lh. It may occasion
symptoms of consumption, from which the pa-
tient may recover with the discharge of it, or
from which he may die.   These very different
results arise chiefly from the various grades of
organic sensibility of the bronchial tubes in
different persons, from the  state of predispo-
sition to disease in  the lungs, and from the
size, nature, and form of the foreign body.  In
some cases, remarkable pain is produced by it;
in others,  extensive disease takes  place with-
out any pain.
  114.  It is remarked by Dr. Stokes that facts
are wanting to throw light on the  occurrence
of pain, but  that the  chief cause  of distress,
most probably, will be found to reside in the
degree of  mechanical obstruction produced by
the foreign  body,  the distress being always
found to be  great in proportion to the feeble-
ness of murmur in  the affected lung.  Thus,  if
a smooth body, such as  a bean,  enters  the
bronchus,  and so obstructs the tube as totally
to prevent the entrance of air, the distress is
extreme, the patient being suddenly deprived
of the  use of half of his  lungs ;  while, on the
other hand, an irregular body, as a tooth, may
exist long in the same situation, with compara-
tively little distress, because, though to a cer-
tain extent obstructed, the tube is not imper-
meable.  This writer observes, that in  the
great majority of cases  in which chronic con-
sumption was produced, the foreign body was
of an irregular form.  The patients escaped
rapid death  because  the air-passage was not
completely obstructed, and their disease pro-
ceeded from the long-continued irritation caused
by this body.
  115.  A. Diagnosis  of Foreign  Bodies in the
Windpipe.—When  any substance remains im-
pacted in the larynx the symptoms are at once
most  violent, distressing,  and strangulating,
the breathing being croupy, pain in the larynx
more or less severe, the cough incessant, and
attended by paroxysms  of  suffocation.  The
violence of  the  symptoms will  depend  much
upon the degree of mechanical obstruction and
the nature of the body causing it.  The foreign
body may, owing to these circumstances, pro-
duce almost instant  death; or it  may be ex-
pelled  after  a shorter or longer period;  or  it
may fall into  the  trachea or bronchus,  and,
after an interval of comparative ease, be suc-
ceeded  either by  a  return of the  laryngeal
symptoms, or  by acute  or chronic inflamma-
tion of the lung.  Hence cases of this accident
may be divided : 1st. Into those in which the
foreign  body has remained, from the first, en-
tangled in the larynx; 2d. Into those in which
having passed this part, into the  trachea or
iHto a bronchus, it  is  driven upward from the
trachea, to be temporarily caught in the larynx,
again to descend into the trachea or bronchial
tubes, producing  alternations of suffering and
comparative  ease ;  and, 3d.  Those  in  which
the foreign  body, having passed into the tra-
chea or bronchus, produces  either acute dis-
ease with  severe suffering, or more chronic in-
flammation with slight or consumptive  symp-
toms.
  116. a. In the first  of these cases, the suf-
ferings are those stated above ($115); or they
may be of a less severe character, as  when
the body is lodged in the ventricles of the la-
rynx, where it may remain for a considerable
period, but not without producing inflammation
and  its consequences.  M. Pelletan instan-
ces the occurrence of a button-mould having
fallen into the larynx, where it caused severe
cough, and occasional attacks of  suffocation.
The trachea was opened, but although the but-
ton was felt, it could not be extracted untU the
cricoid cartilage was  divided, and  then it was
taken from the left ventricle of the larynx.   A
soldier, after drinking water from  a pool, was
suddenly seized  with symptoms of suffocation,
and died while preparations were  being  made
for tracheotomy.  A  leech was  found in the
right  ventricle,  and  obstructing  the glottis.
The severity of the cough may occasion, in ac-
cidents of this nature, so  great disturbance of
the cerebral circulation  as  to  produce apo-
plexy, or convulsions, according to the age of
the patient; and death may follow from this
circumstance after the foreign body has been
removed.
  117. b. In  the second class of cases,  or in
those in which  the body passes into the tra-
chea or bronchus, and is occasionally driven
up, on expiration,  against the  larynx,  or  is
caught in  it, the greatest variety of symptoms
may be produced, and intervals of ease may
take place.  When fever appears, it is consec-
utive upon the local irritation, and the parox-
ysms of suffering are  induced  either by the
body  being  driven into the  larynx, or  by  its
being impacted into a principal bronchus, so as
to suddenly deprive  the patient of one  lung.
From the  secretion of mucus consequent upon
the  irritation caused  by  it,  a rattling   takes
place in the throat.  As the disease proceeds,
respiration becomes stridulous, but the sound,
according to Mr. Porter, is  never so loud or
so harsh as  in  croup.  M. Louis  has noticed
the occurrence of emphysema above the clavi-
cles.  M. Lescure has adduced a case in which
the lungs were emphysematous throughout.  I
have met with emphysema above the clavicles
in one case of this kind, in a child about  eight
or nine years of age.   Dr. Stokes  considers it
a rare symptom.  The following case by this
physician is interesting, and illustrative of this
subject.
  118. A gentleman, aged twenty, in previous
health, while conversing in the act of eating a
piece of cheese after dinner, suddenly fell from
his chair in a state of insensibility.  A probang
was speedily passed into the oesophagus on the
supposition  that a foreign body  had lodged
there, and in a few minutes he partially recov-
ered.   The  attack  recurred  soon after with
great violence;  the face was congested, and
the breathing spasmodic and stertorous.  He
was then freely  bled, but no improvement fol-
lowed.  A loud rattling in the throat was heard, 
LARYNX AND TRACHEA—Foreign Bodies in.
805
the  patient tossed himself on  the bed, and
threw his arms about so as to expand the chest
as much as possible.  All the muscles of inspira-
tion were in violent action, and the surface of the
body became pale and cold.  Suspicion of as-
phyxia  from tracheal obstruction being enter-
tained,  a  stethoscopic examination  was made.
The chest sounded everywhere clear ;  but the
vesicular murmur could scarcely be perceived
in any portion of the lungs, the  feebleness be-
ing equal and universal, notwithstanding that
the patient made the most violent efforts at in-
spiration.   A loud sonoro mucous rattle, every
moment increasing, was heard in the trachea,
while the slight dilatation of the chest, compared
with the respiratory efforts, clearly pointed out
some obstruction in the windpipe.   The failure
of treatment calculated to  relieve the brain, and
the evident secretion into the trachea, as shown
by the  loud rattle at the  top  of the sternum,
were strongly indicative of the  symptoms not
having  been caused by spasm of the glottis, but
by  a morsel of food passed into the trachea.
Tracheotomy was now performed,  and  a cru-
cial incision made through the  tube ;  and on
the angular portions between the incisions be-
ing removed, a mass of pultaceous matter was
forcibly ejected  through the opening, with in-
stantaneous and complete  relief to the symp-
toms.  Respiration  became easy, the expan-
sion of  the lungs full and  audible; the patient
breathed  through  the glottis, and quite  recov-
ered.
  [It is not unusual for individuals to become
choked by morsels of food or other  substances
being lodged in the. pharynx, at the entrance
of the glottis.   Here pressure should be made
on  the abdomen to prevent the descent of the
diaphragm ; a forcible blow should be made by
the  flat hand on  the  thorax.   The effect of
this is to  induce an effort  similar to that of ex-
piration ;  the larynx being closed, oesophageal
vomiting  takes  place,  and the morsel  is dis-
lodged.   But  if this plan fails, the  pressure
should  be kept  upon the  abdomen, the finger
introduced into the throat, and the same smart
and forcible blow made on the  thorax  as be-
fore.  By the irritation of the fauces, the car-
diac is opened, and by the blow on  the thorax
(firm pressure being made on the abdomen) an
effort similar to that of expiration with a closed
larynx is  made,  and a direct vomiting  occurs,
and the morsel of food is carried away.—(Will-
iams.)  If the body has passed into the tra-
chea, and symptoms of suffocation are urgent,
tracheotomy should be  instantly  performed.
Some time since we were  summoned to visit a
fine  girl of ten years of age, who was  seized
with  symptoms  of suffocation  and strangling
while at  dinner.  Having satisfied ourselves
that the foreign  substance was not  in the pha-
rynx, we  immediately  proposed to open the
trachea, but the parents peremptorily refused
to have  the child's throat cut, to use their own
language, for  the purpose  of saving its life.
Remonstrance was useless, and in ten minutes
respiration  had  entirely ceased.  Post-mortem
examination disclosed a  solid  piece of beef
blocking up the trachea, about midway from the
glottis to the bifurcation.]
  119 It  may be mentioned  here, that  sub-
stances  may pass into the trachea, during deg-
lutition, through an ulcerated fistulous opening
between the trachea and oesophagus, generally
in. the membranous portion of the former.  Of
this I have met with one case, and similar in-
stances have been recorded by  Zeviani, Van
Dceveren, and others.  In these cases, the ul-
ceration, terminating in perforation, may com-
mence in either canal, but generally in the tra-
chea, and is almost always preceded by tuber-
cular cavities in the lungs.  In these cases, the
symptoms  are  not materially  different from
these just noticed, or to those about to be men-
tioned in connexion with the passage of foreign
matters into the bronchi.  This  occurrence
takes place chiefly in the last stage of  tubercu-
lar phthisis, complicated with ulceration of the
trachea and larynx.
  120. c. In the third class of cases, or those in
which  the foreign body passes into a principal
bronchus, and occasions either acute disease
and  severe suffering,  or  chronic consumptive
symptoms  (y 115),  the particular  lesions,  as
well as the phenomena which result, are very
diversified.  These  are chiefly, 1st. Acute  or
chronic inflammation of the trachea, or of the
trachea and larynx ; 2d. Acute inflammation
of the  bronchus in which the body is  lodged;
3d.  Bronchitis with haemoptysis;  4th.  Acute
pleuro-pneumonia ; 5th. Abscess of the lungs;
6th. Asthmatic symptoms ; 7th. Acute or chron-
ic phthisis.
  121. When the foreign body is thus situated,
the consequences, and the symptoms attending
them, are very diversified in different cases,
according to its situation and form.   The diag-
nosis depends on a careful examination of the
history and symptoms and physical signs of the
case.  Generally, the sudden occurrence of ir-
ritation in a large bronchus, commonly  the
right, in a patient who had presented no pre-
vious sign of thoracic disease, is evidence that
a foreign body had passed into it.  The situa-
tion  of the foreign body is often pointed out by
local pain, but not constantly, even when this
body is of an irregular form and irritating na-
ture.   The physical signs depend upon, 1st. Its
situation ; 2d. The degree of obstruction it pre-
sents to  the entrance of air;   and,  3d. The
amount of irritation it occasions.  If it remain
in the  trachea, these  signs are more  obscure
than when it is  lodged in one bronchus ;  for, in
the former case, the respiratory murmur is ob-
scure in both lungs, but in the  latter  it is ob-
scure in one lung only; the obscuration being
in proportion to the degree in which it obstructs
the passage through the bronchus.   Hence the
murmur is greatly lessened, or altogether extin-
guished, in the lung whose bronchus is thus ob-
structed,  while  the sound on  percussion re-
mains the same, and the opposite lung  presents
the puerile respiration.  If, however, the ob-
struction of the  bronchus continue for a consid-
erable time, without the foreign  body being dis-
lodged, or driven upward into the trachea, con-
gestion or inflammation of the obstructed lung
may take place, the air in its cells be absorbed,
and that side of the chest become dull on per-
cussion,  especially  when compared with  the
other side.  Hence the suddenness of the irri-
tation, the existence  of it before the appear-
ance  of  constitutional disturbance,  and  the
completeness of the bronchial obstruction in a
whole lung, should be viewed as indicative of
the occurrence in question, and lead to a more 
LARYNX AND TRACHEA—Tumours compressing the  Windpipe.
minute examination of the history and state of
the case.
  122. B. Prognosis.—Whatever  may be  the
effects produced by the foreign body—and these
will depend not only upon the physical proper-
ties of this body, but also upon the peculiari-
ties of the individual—these effects do not al-
ways  cease upon the removal of it.   However,
this circumstance ought not  to prevent the in-
stitution of measures for removing it; as, when
it is removed, the means, which the manifesta-
tions of the effects produced by it will suggest,
will then more readily be followed by beneficial
results.   The issue, it is obvious, will depend
upon  numerous circumstances; upon the  va-
rious  consequences noticed  above:  upon  the
nature, size, and  situation of the foreign body ;
upon  the local and constitutional disturbance
produced ; and upon the removal or presence
of this body ; it has, however, been unfavoura-
ble in a large proportion of cases.
  123. C. The treatment of  this accident  de-
pends upon the bulk of the  obstructing body.
In most instances tracheotomy should be resort-
ed to early ; particularly when the body is large,
is lodged in the trachea or larynx, and when it
is moveable from a bronchus into the trachea.
If it be firmly lodged in a bronchus, and have
caused the lesions usually consequent upon it
when impacted in this part, little hopes can be
entertained from the operation.  Emetics have
been  recommended,  but they rarely succeed
unless the body  be of a small size.  If it be
large, it may be forced upward during vomiting
and caught in the larynx, and produce suffoca-
tion.  Owing to this reason, Dr. Stokes argues
against having recourse to emetics, and advises
an early resort to tracheotomy.  I believe, how-
ever,  that there  is less risk from the use of
emetics,  or of an emetic, than he infers ; but I
agree with him  in advising a recourse to the
operation early, and before inflammatory action
is developed.  On this subject, the reader  will
consult with advantage the works of Mr.  Ry-
land, Mr. Porter, and Dr. Stokes, and  the
other writings referred  to in the  Bibliography
and References.
  [A  very interesting  case  is  related by  Mr.
Brodie (Clinical Lectures, Lond. Lancet, 1844)
of the celebrated English engineer, Mr. Brunel.
" This gentleman," says Sir Benjamin Brodie,
"in playing with a chdd, flung a half sovereign
into his mouth, and it slipped down the  wind-
pipe.  In the first instance it  produced sick-
ness,  and as he drew his breath, previously to
vomiting, it descended into  the bronchus,  and
occasioned  coughing every  now  and  then.
When his head  was placed down, it could be
felt rolling along the trachea.   We attempted
to remove it by placing him on a moveable plat-
form, so that his feet were up and his head
down, nearly at right angles.   The half sover-
eign descended, and stuck in the glottis, so as
nearly to choke him.   We therefore determin-
ed not to repeat this experiment till we had got
an opening in the trachea, which would act as
a safety-valve.   We made  an opening, some
few days afterward,  below  the thyroid gland;
but the half sovereign was not coughed up, as
a cherry-stone would have been, because it  was
too heavy.  We made some attempts to  use
the forceps, but found it so dangerous that we
desisted.  When he had recovered from the ef-
fects of this operation—in the mean time, pass-
ing a probe  every now and then — we again
placed him on a moveable platform ; bis back
was struck with the hand, and the half sover-
eign escaped from the bronchus.  He could
feel it rolling along the trachea till  it came to
the glottis ; and now, instead of sticking there,
it  passed through, just aa you  would roll  it
through the dead body, and came out of the
mouth.  There was no spasm  of the  glottis,
and the absence of it was  to be  attributed to
the opening in the trachea ; for blood came out
with the half sovereign, which had evidently
passed in from the external wound ;  and where
blood went in you may be sure that the air went
in also.''—(Loc. cit.)  A similar case is related
in "Braithwaite'b Retrospect," part xi, where
an English shilling piece was removed from the
larynx by inversion of the body.   The  patient,
a man, was placed with his shoulders  against
the raised end  of a high sofa, and then, being
seized, by three powerful men, by the loins and
thighs, he was  rapidly inverted  so as lo bring
the head into the dependant position;  and af-
ter a shake or two, the larynx,  at the same
time, being moved rapidly from  side to side,
the shilling passed into the mouth, and fell upon
the floor.  Not  the slightest cough nor dyspnoea
was produced ; the patient was perfectly free
from  uneasiness,  and there was  a  marked
change in the character of the voice.   He had
not the slightest subsequent bad symptom]
   124. V. Of Tumours externa!, to, and com-
pressing the  Windpipe. — Some notice  has
been taken of these, in connexion with  the pro-
duction of spasm of the glottis (() 28, et seq.);
it is, therefore, unnecessary to  add more on
this subject than to enumerate the kinds of tu-
mour that may  affect either the trachea or la-
rynx, particularly the  former.  The effects of
tumours upon the  windpipe may be mechanical
only, or chiefly  vital, or resulting from their in-
fluence upon the nerves of the  tube, or upon
the circulation  through the veins  of the neck;
or  both  mechanical and vital.   The tumours
may be injurious in these ways, either  with or
without compression of the tube, so as to dimin-
ish its caliber, much of the effects produced by
them depending upon their situations, their in-
fluence on the  nerves and blood-vessels, and
the sensibility of the patient.  When they are
situated  above  the sternum or clavicles, they
are less likely to occasion injurious or urgent
pressure on the trachea than when they are de-
veloped under the sternum or upper portion of
the chest.  Those usually met with in  the for-
mer situation are, abscess of the  neck ; en-
largements of the  lymphatic glands ; broncho-
cele ; tumour consisting of aqueous cysts some-
times  developed in the  vicinity of the  thyroid
gland, but not affecting it, and described under
the name of hydrocele of the neck by Maunoir
and O'Beirne ; aneurism of the carotid or thy-
roid arteries ; and solid or  malignant tumours
of the neck.  These may form without  materi-
ally compressing or displacing the trachea, ow-
ing to the yielding nature of the parts external
to them  and  the trachea.   But those tumours
which are formed  under the sternum, and are
more deeply  seated, are generally  productive
of more distress,  by affecting the  trachea in
these  modes in a  severer manner.  They not
unfrequently  rise above the sternum, but their 
LARYNX AND TRACHEA—Bibliography and References.
807
injurious  effects  chiefly depend upon  the un-
yielding state of the parts external to  them,
and the consequent pressure  therefrom result-
ing.   In this  latter class  may be comprised,
aneurisms of the  aorta and  innominata; en-
largement of the  bronchial glands ;  hypertro-
phy, abscess,  or  other  lesions of the  thymus
gland ; tuberculous or melanotic alterations of
the bronchial glands ; cancerous or fungoid tu-
mours in  the posterior mediastinum.
   125. In  these different  circumstances, it is
very rare to find evidence of compression of the
trachea without signs of  farther  disturbance,
particularly great distention  of the veins, dys-
phagia, and paroxysms of dyspnoea or of threat-
ened suffocation ; but dysphagia, in some cases,
and stridulous breathing in others, may  be the
most prominent disorder.   Of the various  tu-
mours now  mentioned, producing pressure on
the trachea,  the  aneurismal  most  frequently
simulate  laryngeal disease.   This Dr. Stokes
explains by  their  greater  frequency, their  as-
cent in the neck, and their close relation to  the
windpipe.   The stridulous breathing caused by
their pressure, like that of chronic laryngitis,
is of variable intensity, and  their influence on
the recurrent nerve produces either attacks of
spasm or aphonia,  thereby more closely resem-
bling laryngeal disease.   The direction  of  the
pressure  produced by these  tumours  is most
frequently lateral.
    126. The diagnosis between laryngeal disease
and the pressure of an  aneurismal  tumour on
the trachea has been well stated by Dr. Stokes.
The symptoms of the latter are, 1. Evidence of
internal pressure, as signs of compression of one
bronchus ; deep-seated dysphagia; turgescence
of one or both jugular veins; oedema  of the
neck ; signs of displacement of  the  lung—all
these are not, however, generally present, but
one or more of them are usually observed.  2d.
Evidence  of solidity  in  the upper portion of the
chest,  as  dulness  on percussion  of the upper
sternal or either clavicular  region ; bronchial
or tracheal  respiration in  the situation  of the
dulness;  and loud resonance of  the  voice in
the same situation.   3d. Proper signs of aneu-
rism : pulsation or bellows-murmur in  the ster-
nal or clavicular  regions; and, 4th. Difference
of the radial pulse.   Attention  to  these  points
will prevent an aneurism from being confound-
ed with tracheal or laryngeal diseases.

  Bibliog. and Refer. — Morgagni, De Sed. et Causis
Morb., epist. xv., art. 13 ;  et ep.  xxviii., art. 9, 10. — Stoll,
Ratio Medendi, vol. i., p. 257.—Sandtfort, Museum Anatom.,
vol. i , p. 274. — Frank, Interpret. Clin., vol. i., p. 182. —
Wathen, in  Mem. of Med. Society of Lond., vol. i., art. 20.
— B. Rush, Med. Observat. and  Inquiries, vol. v.,  p. 96.—
M. Baillie, Trans, of Society for Imp. of Med. and Chirurg.
Knowledge, v. iii.—A.  Sauve, Recherches sur la  Phthisie
Laryngee, 8vo.   Paris,  1602. — T. Clteyne, The  Pathology
of the Larynx and Bronchia, Svo. Edin., 1809 ; and Cyclop.
of Pract. Med., vol. iii., Laryngitis.—J. B. Cayol, Recherches
sur la Phthisie Tracheale, Svo.  Paris, 1610.—Delpit, Diet.
Des Sc. Med., art.  (Larynx), t. xxvii.— W. Sachse, BeitrSge
zur Kenntuiss der Kehlkopfs  und Luftrohrenschwindsw h-
ten, Svo.  Hauu., 1822.— Bedingfield, in Lond.  Med. Re-
pository, vol. v., p. 194.—Fraser, in  Ibid., vol. v  , p. 453.—
Farre, Trans, of Med. and Chirurg.  Soc., vol. in., p. 84 et
333.—Pcrcival, in Ibid., vol. iv., p. 300; and vol. x., p. 297.
—Arnold, in Ibid., vol.  ix., p. 31.—Lawrence, in Ibid., vol.
vi., p. 234.—Travers, in Ibid., vol. vii., p. 150.— J.  .1/. Hall,
in Ibid., vol. x., p.  166.—Porter, in iGld., vol. xi., p. 414.—
Bayle, Diet, des Sc. Med., art. CEcUme de la Glotle.—Louis,
Rccherches, <fec, sur la Phthisie, &c, p. 251; et Recherches
Anut. Puthol. — Howship, Pract. Observ_ &c, p. 150. -
Wilson, Trans,  of Med. and Chirurg. Society, vol. v.—Rob-
erts, Ibid., vol. vi.— Wood, Ibid., vol. xvii., p. 164. — Hill,
Ed. Med. ami Surg. Journ., vol. xii.—Abercrombie, in Ibid.,
vol. xii.—Hood, Edin. Journ. of Med.  Sciences, vol. iii., p.
47 (Spasm of Glottis from enlarged Thymus). — Tacheron,
Recherches  Anat. Pathulog., t. i.—While, Dub. Hosp. Re-
ports, vol. iv., p. 561.—Graves and Stokes, in Ibid., vol. v.,
p. 82.—Marsh, in Ibid., vol. v., p. 618.—M' Namara, in Ibid.,
vol. v., p. 583. — Stevenson, Trans, of Med. and  Chirurg.
Soc. of Edin., vol. ii., p. 128.— Carmichael, Treat, on the
Venereal Disease, 2d ed., p. 174. — C. Hawkins, in Lond.
Phys. and Med. Journ., vol. xlix., p. 273 (Venereal ulcera-
tions of  the  Larynx).—J. Webster, in Ibid., vol. Ivi., p. 430.
—Porter, Pathol, of the Larynx and Trachea, 8vo.  Dub.,
1826.—Montgomery, in Dubl. Journ. of Med. Sciences, July,
1836, p.  431. — Griffin, in Ibid., vol.  xii., p. 364. — T. R.
Blackley, in Ibid., vol.  xiii., p. 384. — F. Ryland, Treat, on
Diseases and Injuries of the  Larynx and Trachea, 8vo.
Lond., 1837.—Gendrin, Hist. Anat. des Inflammat., t. i., p.
545. —Andral,  Pathol. Anat. (Transl.), vol. ii., p. 482; et
Clinique Med., t. ii., p. 204.—Crufei/Aier, Diet, de M6d. et
Chirurg. Pratiques, art. Laryngile; et Anatomie Patholo-
gique, livr. v, pi. 2.—Bouillaud, Archives Gener. de Med.,
t. vii., p. 178.—Ferrus,  in Ibid., t. v., p. 539 (Asphyxia, from
Tumour in).—Bricheteau, in Ibid.,t. vi.,p. 303 (Destruction
of Muscles of).—/. North, Comment, on most Import. Dis.
of Children, ch. iv., p. 256 (Spasm, of Glottis).—R. Fletcher,
Med. Chirurg. Notes and Observat., 4to, 1831, p. 3. — H.
Ley, On the Laryngismus Stridulus,  8vo.  Loud., 1837.—
Cheyne,  Cyclop, of Pract. Med., vol. ii.—.If. Hall, Lect. on
the Nervous System, p. 76 (Spasm of Glottis). — F. J. H.
Albers, Die Pathol, uud Therapieder Kehlkopfskrankheiten,
8vo. I.eip., 1829. — Barde. in Archives  Gener. de Med., t.
vi., p. 140 (a:dema). — A. Trousseau  and H. Belloc, Traite
Pratique de la Phthisie Laryngee, <fec, Svo.  Paris, 1837 ;
analyzed in  Edin. Med. and Surg. Journ., vol. xlviii., p. 461 ;
and in Med. and Chirurg. Review, April, 1838, p. 393— W.
Kerr, in Ibid., Ap., 1838, p. 344 (Spasm of Glottis). —A.
Campbell, Transact, of Med. and Phys. Society of Calcutta,
vol. vii., part ii., p. 468; and Ibid., vol. viii., part i., p. 18
(One case terminated favourably from external application
of Croton oil).—Senn, American Journ. of Med. Sciences,
vol. vi.,  p. 223. — Hirsch, Brit, and  For. Med. Rev., July,
1836, p. 237.—Ibid., Oct., 1836, p. 554 (Croton oil external-
ly).— Kyll, in Med. Chirurg. Rev., July, 1636, p. 228 (Spasm
of Glottis).  — Roots, in Ibid., Oct., 1836, p. 4W.-Dalmas,
Journ. Hebdomad, de Med.t. ii., p. 384.— IV. Stokes, Trea-
tise on  the Diagnosis and Treatment of Diseases of the
Chest, <tc, 8vo.  Dub., 1837, p. 205, et seq. — Hachmann,
Lancet,  Jan. 13, 1838, p. 551.—67. Burrows, Med. Gazette,
Oct. 7, 1837, p. 50 —Ibid., vol. xiii., p. 702-968.—Armstrong,
Ibid., May 20, 1837, p. 274.
   [Am. Bibliog. and  Refer.—Robert Liston, Lectures on
the  Operations  of Surgery;  Am. ed., by T. D. Mutter,
 Phil., 1846 (Chapter  Laryngotomy).—John B. Beck,  in
New-York  Medical and Physical Journal.—John Mackin-
tosh, Principles of Pathology and Pract. of Med. ; Am. ed.,
by S. G. Morton.  Phil., 1844.—Geo.  Gregory, Elements of
the Theory and Practice of Physic, wilh Notes,  by N. Pot-
ter and  S. Calhoun, 2 vols.  Phil., 1831.—/. M.  Good, The
Study of Medicine, with Notes, by  A. S. Doane,  2 vols.
New-York,  1835.—N.  Chapman, Lectures on the more im-
portant  Diseases of the Thoracic and Abdominal Viscera.
Phil., 1844, I vol., 8m.—John Bell and W. Stokes, Lectures
on the Theory and Practice of Physic, 2 vols.  Phil., 1845,
3d  ed. — Sam. Henry  Dickson, Essays  on Pathology and
Therapeutics, <fcc. 2  vols.   Charleston, 1845. — C. J. B.
 Williams, Pract. Treatise on the Diseases of the Respira-
tory Organs, <fcc.; Am. ed., by M. Clymer.  Phil.,  1845, I
vol., 8vo.—R. J. Graves and IV". W. Gerhard, Clinical Lec-
tures.  Phil., 1842, 1 vol., 8vo.—Braithwaile's Retrospect,
parts i. to xii.—C. Rokitansky, A Treatise on Pathological
Anatomy ;  translated from the German, by J. C.  Peters.
New-York,  1845, part  i.—S. G. Gross,  Path. Anatomy, 2d
ed.  Phil.,  1845.—Charles A. Lee, Monograph on Thymus
Gland, in Am. Jour. Med. Sci., N. S., vol. iii. ; and in Bost.
Med. and Surg. Journ., and New-York Medical Gazette ;
et New-York Lit. and  Theol. Review, 1838.—J. E. Taylor
and H. Green, in New-York Jour, of Med. and Collat. Sci.,
vol. iv.—S.  Annan, in Am. Jour. Med. Sci., N. S., vol. xi.,
p. 99. — Benjamin W.  M'Cready, in Am. Jour. Med. Sci ,
vol. xix., p.  322.—Samuel Jackson, in Am. Jour.  Med. Sci.,
vol. xv., p. 289.]
LEPROSY.—Svnon. Lepra Tuberculosa ;  Lep-
   ra Hebraorum ;  Lepra Mgyptiaca ;  L. Lconti-
   na;  L.  Arabium;  the  Tsarath of  Moses;
   i'AeQavriaoic, Aretaeus ;  Elephantiasis Greco-
   rum;  Elephantiasis,  Good,  Cullen,  Sagar;
   Leontiasis;  Lepra Nodosa;  the Djuzam,  or
   Iuzam of Arabian writers;  Lepra Mcdii Mvi,
   or Leprosy of Authors of the Middle Ages;
   Lepre Tuberculcuse; Mai Rouge de Cayenne,
   Fr.   Der  Elefantenaussatz,  der  Aussatz die
   Feldsucht,  Germ.   Tubercular  Leprosy;  Ele-
   phantiasis  of the Greeks. 
I
808                            LEPROSY—D

    Classif.—3d  Class,  3d  Order (Cullen).
      —3d Class, 4th Order (Good).—IV. Class,
      IV. Order (Author).
  1.  Defin.—Dusky  red or livid tubercles of va-
rious sizes on the face, ears, and extremities; thick-
ened or rugous state of the  skin, a diminution of
its sensibility, and falling off of the hair, excepting
that of the scalp; hoarse, nasal, or lost voice ; oze-
na ; ulcerations of the surface and extreme fetor.
  2.  Considerable confusion has arisen from
not distinguishing this disease from elephanlia,
or elephant leg, on the one hand, and from the
squamous lepra,  or lepra Grecorum,  on  the
other—diseases  perfectly distinct  from each
other.   Indeed, most of the tuberculous and
scaly  diseases, especially  the lepra and psoria-
sis of  Willan,  were deemed leprous  and re-
ceived into the lazarettoes.  The circumstance
of the description in the books of Moses of
several forms of cutaneous  disease as  being
leprous, and  the  applicability of parts of that
description to the above squamous affections,
have  contributed to this confusion.  In order
to simplify the subject, it will be preferable to
consider the true leprosy of the Middle Ages en-
tirely apart  from the chronic scaly eruptions
just mentioned ; and to  view the lepra of Wil-
lan, as M. Schedel has done, as a species only
of psoriasis, more especially as the appearance,
nature, and treatment of both these squamous
diseases are very nearly the same.  I shall here
briefly describe tubercular lepra, as  it  appears
to have prevailed during the Middle Ages,  and
down to modern times  in Europe, and as it is
occasionally  met  with  at the present day in
some warm and Eastern countries ;  and after-
ward notice  certain modifications of it observ-
ed in  various countries.   I have viewed the
scaly lepra as a species  of psoriasis.
   3. I. Description of Tubercular Lepra.—
Several writers state that physical and  moral
languor  and  depression often precede the ap-
pearance of the disease  in the skin.  Occasion-
ally  the spots and tubercles characterizing  the
disease appear in the skin with febrile symp-
toms ; but the attack is more commonly very
gradual and slow.  Patches of the integuments
are generally changed in colour, and assume a
darker hue before the development of the tu-
bercles.   The spots become even deeper in  col-
our than the skin in the dark races;  and  yel-
lowish, or reddish, or livid, shining, and slightly
elevated in whites.  These spots are irregular-
ly disseminated, and look as if they were full
of oil, or covered with varnish (Adams).  They
are occasionally quite insensible, but more  fre-
quently feeling is not quite absent in them, al-
though they may be compressed without pain
At first, sometimes, they are more sensible than
the surrounding skin ;  but  this state,  and the
redness  attending it, subside by degrees ; the
flush being followed by  a tawny or bronze col-
our.   The spots, after being stationary for a
period of various duration, are always succeed-
ed by tubercles, some of which  are cutaneous,
others are seated in the cellular tissue under-
neath.   The cutaneous  tubercles  are  small,
soft,  round,  reddish, or livid, varying in  size
between that of a pea and an olive.   They ap-
pear on every part of the face, particularly the
nose and ears, and on the legs, but  in rare in-
stances they have occurred on the legs only.
Commonly in a few years they spread  over the
ESCRIPTION OP.

whole body, although they are more numerous
in some parts than in others ; and the malady
becomes more and more marked.  Of all places,
the face is most effected and most deformed by
it.  The visage is puffed ;  the skin of the fore-
head  is beset  with tubercles, and marked by
numbers of deep transverse furrows.   The su-
perciliary ridges are swollen, furrowed with ob-
lique  lines, and covered by nipple-like projec-
tions.  The hair of the eye-brows and the  cilia
are lost.   The lips become thick and shining ;
the chin and concha of the ear enlarge, and are
thickly covered with livid  tumours.  The  lobe
and alae  of the nose are generally even more
seriously  altered than the rest of the  face : the
nostrils are irregularly dilated, and the cheeks
are swollen.   The whole  of the features, en-
larged and distorted by the puffing Of the  sub-
cutaneous cellular tissue and by the tubercles,
present a frightful deformity.
   4. Arrived at this stage,  tuberculous lepra
sometimes remains stationary for a  very  con-
siderable  period.  The skin then seems princi-
pally  implicated, the chief functions  being but
little  disturbed.  The time which elapses be-
tween the appearance of the first tubercles and
the development of those  which succeed them
varies exceedingly.  Frequently they are rap-
idly evolved;  but they never acquire a  very
large size.  Subsequently, commonly after some
years, the greater number of these  tubercles
inflame,  and either suppurate or are resolved.
Ulceration, according  to M. Rayer, is  preced-
ed by an acute inflammatory state, during which
the tubercles and  the surrounding integuments
become hot and red. The tubercles, which are
ulcerated, soften and discharge a sanious  pus,
that  dries  up  speedily,  and forms adhering
brown  or blackish scabs, which rarely  rise
above the level of the skin.   Sound  cicatrices
are formed under these scabs in rare instan-
ces.
   5.  When the disease appears before the age
of puberty, the growth of  the beard, and of the
hair upon the genitals and axillae, is often  pre-
vented or checked.   In  some,  however, the
beard only is  wanting.  In  adults, the beard,
and the  axillary and  pubic  hair  occasionally,
but very rarely the hair of the  head, are  lost.
 Frequently the sensibility  of the skin is some-
 what impaired; sometimes it is at first increased,
occasionally not changed.   As the disease ad-
vances, it is often very  much impaired in the
extremities, especially the lower.  The tuber-
cles on the upper  extremities follow  the same
course as that above described.   They are less
 numerous than on the face,  and appear chiefly
on the outer and posterior surfaces of the fore-
arm.   The hand  is swollen, but  is rarely the
 seat  of tubercles; it  is commonly livid,  with
 less of the bronze cast than other parts of the
 body. The lower extremities and feet are simi-
larly, but generally more  severely  affected.
The hollow space of the sole is filled up by the
 swelling  of the cellular substance, giving the
 feet  a flat appearance.  The tubercles of the
 buttocks  are large, those  of the soles are flat-
 tened.   Ulceration of the  tubercles of the legs
 is always slow of healing.  The phalanges of the
 toes  occasionally  sphacelate, especially when
 the disease is complicated with serious internal
 lesion, and is tending to a fatal termination.  The
 trunkof the body is seldom the seat of tubercles. 
LEPROSY—Description of.
809
  6.  The  mouth,  the  fauces,  uvula, tonsils,
pharynx, and  nasal  fossae are often studded
with tubercles of a smaller size than those of
the skin.  A longitudinal band of tubercles fre-
quently extends from the superior incisor teeth
backward, along the  roof of the mouth to the
uvula.   The lingual veins are  sometimes vari-
cose.  The  pituitary membrane is generally in-
flamed, and  secretes a sero-purulent fluid, the
inflammation occasioning pain of the frontal
sinuses, and ultimately caries of the cartilages
and turbinated bones of the nose.  The voice
becomes hoarse, nasal, and is finally lost.  The
external parts only of the ears are affected ;
but these are enlarged,  deformed, livid,  and
studded with tubercles.  The sense of smell is
early impaired, and soon altogether lost; espe-
cially when  the  pituitary membrane ulcerates
and discharges a profuse foetid secretion.  The
eyes are  not  materially affected, beyond the
loss  of the  cilia.  The  sense of taste  is not
impaired.  The pharynx becomes covered with
tubercles, but the oesophagus is seldom thus
affected.  The  stomach  and bowels generally
perform their functions regularly, unless they
be disturbed by active medicines.
  7.  The  organs of  locomotion are generally
much enfeebled. If the disease has commenced
before  puberty, the patient  continues weakly,
and  gradually becomes deformed ; but if man-
hood has been attained before  this invasion,
and the person is fully developed, the affection
of the muscular system approaches, and  pro-
ceeds  slowly and  gradually with the progress
of the disease.  The influence of the malady
upon the generative organs has not been pre-
cisely determined.  According to some writers,
the evolution of these organs is always arrest-
ed by it when it occurs before puberty; and it
causes them to fall into a state of atrophy when
it appears  after this period.  Pallas  states.,
that the Tartars affected with the malady show
a distaste of sexual intercourse.  All the pa-
tients  M. Rayer  saw had  the genital organs
well developed ; and none  of them  was tor-
mented by  the libido inexplebilis, mentioned  by
some authors as a frequent  concomitant of the
disease.
   8. Terminations.—Tuberculous lepra is sel-
dom seen in Europe; hence its morbid anato-
my has been imperfectly studied.  But the most
exact accounts which have been furnished con-
cur in showing  that persons who are the sub-
jects of it  are almost always carried off  by
acute or chronic  inflammations of the respira-
tory organs and passages, and of the digestive
viscera; and less frequently by low fever.
   9. On dissection, Peyer's glands have  been
 found  enlarged;  the intestinal tubercles ulcer-
 ated, or about to  become so ; and the mesen-
teric glands enlarged and tubercular in persons
 who have died of the disease.  Small cicatrices
have also been observed in the intestines.  The
liver and spleen have not been materially alter-
ed.  A thickened state of the mucous folds of
the  larynx, tubercles on the  vocal chords, oc-
casionally ulcers which had destroyed the liga-
ments, &c., and  small  ulcers of the mucous
coat of the trachea, have been found after death,
 and account for the affection of the voice du-
ring life.   The lungs  generally contain crude
or softened tubercles scattered through them
Three patients examined by M. Rayer had the
     II.                102
lungs thus affected.  Others who have died at
an advanced period of the disease have shown
distinct marks of pneumonia.  The organs of
circulation, and  the  nervous centres, present
nothing remarkable.  In a coloured man, which
I saw examined after death from this disease,
the heart was smaller and softer than natural.
  10.  II.  Maladies  allied  to  Tubercular
Leprosy.—The leprosy of Iceland, as described
by Dr. Holland and  others ; that of the Faroe
Isles, noticed by Debf.s ;  the cases which oc-
curred in the Shetland Isles, and mentioned by
Drs. Edmonston and Simpson ; those observed
by Dr. Heberden  and  Dr. Adams in Madeira,
as well as those still  met with in Africa and in
the East and West Indies, are identical  with
the disease  now described, the leprosy of the
Middle Ages.  There can be no doubt of the
disease being somewhat  modified by endemic
influences, and by modes of living and other
circumstances proper to the individual, even in
the same  locality; but several maladies very
distinct from it have been confounded with it,
although its  tubercular character offered a suf-
ficient distinction between them.
  11. i. Lepra Taurica.—Leprosy of the  Cri-
mea.—L. of' the Cossacks.— Pallas,  Gautier,
andMARTius have described this disease, which,
they say, was introduced by the Russian troops
engaged  in  the  war against  Persia into the
Crimea.  The description given of it  by Von
Martius  shows  that it is identical, in its ac-
cession, course, progress, phenomena, and ter-
minations, with true tuberculous leprosy.  It is
therefore unnecessary to occupy my space with
an account of it.   The  same remark applies to
the leprosy of Holstein,  as  described by Doctor
Struve.
   12.  ii. Lepra Anvesthesiaca.—This is sup-
posed to be  the  Baras  of Avicenna, and has
been observed by Winterbottom, Robinson,
and myself.  It  is characterized chiefly by re-
markable  absence of sensibility not only from
the extremities, but also  from the general sur-
face, and by  the comparative smoothness ol
the skin, and frequent absence of a tubercular
state of the integuments.   It is probable, how-
ever, that these  are merely modified, or ex-
 treme cases, in which  the anaesthesia and ul-
 ceration of  the extremities are the prominent
 phenomena,  and  the tubercular  changes  less
 manifestly produced, or at a more advanced pe-
 riod of the malady.  It is likewise very proba-
 ble that the several  diseases which were con-
 sidered as leprous in remote ages, among the
 Jews, and in more recent times in Eastern and
 intertropical  countries,  were  more  or  less
 closely allied, and it is  not  unlikely that in
 these ages,  and even in modern times, several
 squamous and cachectic  maladies assumed  a
 more inveterate and irremediable form, in con-
 sequence of  the  nature of the  food  used by
 their inhabitants,  and that these maladies are
 not only remarkably modified from the states
 now presented by them in highly civilized coun-
 tries, but, as respects  some of them, are also
 thereby rendered specifically different.
   13. When we consider that the use of salt
 was  by no  means general  in some countries
 during the early and Middle Ages, that this sub-
 stance was  procured with  difficulty  in  many
 countries, and is  still  scarce  and valuable in
 several, even at the present day ; that all kinds 
810
LEPROSY—Description or.
of animal food, even the richest and coarsest,
flesh-meats and fish, were often eaten in a ran-
cid or semi-putrid state ; that they were rarely
cured otherwise than by smoking, or by drying
them in the air; that in many countries most
of the food used during the greater part of the
year was preserved in this manner, and that
vegetable food was in most of them but little
employed ; that periods of scarcity, or of want
of vegetable  substances or of  grain,  often
heightened the injurious influence of unwhole-
some animal food ;  that the clothing worn next
the skin was generally woollen, and retentive
of the secretions from the surface, thereby ir-
ritating and contaminating it; and that habits
of personal  cleanliness were very imperfectly
adopted, it  will  not  appear  surprising that
chronic cachectic  maladies were  of frequent
occurrence in  the ages and countries thus cir-
cumstanced ; that they assumed various forms,
with the nature and combination of the diver-
sified causes  producing them ;  and that they
have changed their forms with  changes in the
intensity and concurrence of these causes.
   14. The Lepra anesthesiaca has been descri-
bed by  Dr. Winterbottom and by Mr. Robin-
son, and their accounts of it agree in many re-
spects with what I have seen of it in Africa.  It
commences in spots or patches, which are of a
somewhat lighter shade  of colour than that of
the adjoining surface in blacks, and of a tawny
colour  in whites.   These patches appear first
in the feet, hands, legs, and arms, and seldom
on the  face and trunk until a more advanced
period.   They sometimes seem slightly prom-
inent from thickening of the several tissues of
the skin ; and they are shining, rough, and ap-
parently wrinkled, from minute indented lines ;
but the wrinkles do not run into the surround-
ing  skin.  The hairs—if any have previously
existed in the seat of these patches—fall out,
or cease to grow in them.  The  patches  are
insensible, and extend slowly over the legs and
arms to the trunk, until the extremities, and
sometimes also the greater part of the surface
of the  body, are more or less affected, and de-
prived  of feeling.   The affected surface is un-
perspirable, but neither itchy, nor painful,  nor
swollen.  As the disease advances, the pulse
 becomes slow and soft, and the bowels consti-
pated.   The toes  and fingers are benumbed, as
if with cold, shining, slightly swollen, and stiff.
 The soles of the feet and palms of the hands
 present hard and dry chaps ; and  a furfura-
 ceous matter is deposited below the nails, rais-
 ing them and causing ulceration around them.
 The  legs and forearms  next swell,  and  the
 skin becomes rough and chapped.  Ulcers form
 on  the metacarpal  and metatarsal articula-
 tions in the lines  of flexion, and  afterward  in
 the corresponding parts of the articulations  of
 the larger  joints.   These ulcers enlarge  and
 sphacelate, and the fingers and toes drop off
 The lobes of the ears, the alae nasi, and the lips
 are in some cases thickened and enlarged,  and
 ultimately ulcerated, discharging a thick viscid
 matter.  As  the  malady is proceeding to  this
 stage,  tubercles form in many instances in the
 skin of the limbs, face, and sometimes of the
 trunk.   As the small joints are penetrated by
 ulceration  and fall off, so they heal up,  and
 others are attacked  in  succession, until the
 limbs  are deprived,  one by one, of their ex-
tremities.   The voice becomes hoarse and gut-
tural, and  ulceration sometimes  attacks the
throat, but  in  a  less degree than in the more
prominently tubercular form of the disease. Oc-
casionally the extremities, cicatrized stumps,
and portions of the skin are  thickened, tuber-
culated, or  ulcerated.  Food  is taken with an
appetite, and slowly digested.  The intellect-
ual as well as  the vital functions are impaired
and benumbed.  The patient is apathetic, and
merely vegetates ; yet he often lives for many
years in the slighter or earlier stage  of the
malady, or even in the state of mutilation char-
acterizing the  far advanced stage.   At last he
is carried off by diarrhoea or dysentery.
  15. The above account, which is  chiefly from
my own notes, is somewhat different from that
given by Dr. Winterbottom, which, however,
is confused and imperfect, and evidently owing
to his having described as varieties different
stages merely of the  same malady.  Mr. Rob-
inson has also, judging from  my own observa-
tion, and from the accounts given by Dr. Ams-
lie,  described as  a distinct  species what ap-
pears to be merely a modification  of the dis-
ease, in which the  anaesthesia, and the falling
off of the fingers and toes, were the most prom-
inent phenomena.  He, however,  admits that
tubercular changes sometimes show themselves
in the course  of the  anesthetic variety.  This
is agreeable to  my own observation.  As the
cases which I saw in several parts of Africa
were modified, according to  the stages of the
malady, some approaching more closely to the
anaesthesiac, others to the tubercular, I believe
that the two  forms of the disease insensibly
pass into each other.   Mr. Robinson mentions
the occasional occurrence of the chief charac-
teristics of both varieties in  the same patient;
and Dr. Ainslie remarks, that  he never met
with a case of genuine leprosy which was not
distinguished  both by want  of  feeling  in the
extremities, and by tubercles.  Both modifica-
tions are  equally  prolonged, and  both  make
more rapid progress  in  the poor, ill fed, old,
and debilitated,  than in the rich, well fed, and
young.
  " Denique sspe hominem paullatim cernimus ire,
    Et membratim vitalem deperdere sensum:
    In pedibus primum digitos livescere et ungueis ;
    Inde pedes et crura mori; post inde per anus
    Ire alios tractim gelidi vestigia leti."
                         Lucretius, 1. iii., 525.
   16.  iii. Jewish  Leprosy.—The  term Beral
 seems to have  been  applied by Moses generi-
 cally, and  to  have included, 1st. Boak, a form
 of the disease not rendering the person affect-
 ed by it unclean ;  2d. Berat lebena, bright white
 berat;  and, 3d. Berat cecha, dusky berat, spread-
 ing  in the skin.   The second and  third species
 he describes  as being called Tsorat, venom or
 malignity, and  as  contagious.  The form  of
 Berat, called  Boak by the Hebrews, seems  to
 agree with the Lepra vulgaris of Willan. Dr.
 Good considers the third, or Berat cecha, to  be
 the same with the Lepra nigricans of Willan
 and Bateman.  It may be so, but there is  no
 farther proof  of this  than of its being the tu-
 berculous  or  true leprosy of the Middle Ages.
 The second variety, or the Berat lebena, is prob-
 ably the Leuce, or Xevkt), of the Greeks, and the
 third species  of Vitiligo of Celsus.
   17. The. Jewish leprosy has been assimilated
 to  other  diseases.   Bartholinus,  Leclerc, 
LEPROSY—Diagnosis or.
811
 end others  associate it  with tubercular ele-
 phantiasis.   Hillary and Adams think that  it
 was the Frambaesia of Africa.  Lorry and sev-
 eral others regard  it as a distinct malady.   It
 is impossible to form, from the scanty accounts
 furnished us, a just idea of the disease.  It is,
 however, not unlikely  that  the  term leprosy
 was applied by the Jewish priests to various
 cutaneous affections, particularly those which
 were of a chronic, self-contaminating, or con-
 tagious nature ; and it is probable that Fram-
 besia was one of these, as well as other invet-
 erate  cutaneous maladies  arising  from  the
 modes of living, the habits  and circumstances
 of the Jews at that time, and of the Egyptians;
 and that these maladies have  changed their
 characters, owing to changes in the nature and
 combinations of their exciting causes.
   18. iv. The Radesyge, a  disease very prev-
 alent in Norway, has been considered by many
 as a variety of tuberculous leprosy, from  its
 very close resemblance, in  many of its symp-
 toms, to that malady.  But in the article  on
 that disease I have shown it  to be generically
 distinct, that its characters, course, and termi-
 nations are quite different from the leprosy of
 the Middle Ages.   This is still more especially
 the case with Pellagra (which see).
   19. The spedalskhed, a  disease prevalent in
 the  district  of  Bergen, in Norway, has been
 confounded  with radesyge; but,  from  recent
 researches, it is fully proved that  it is identical
 with the leprosy of the Middle Ages, or ele-
 phantiasis of the Greeks—with the leprosy still
 existing in Norway and in Eastern countries,
 and hence quite distinct from the radesyge.
   20. III. Diagnosis. A.—The term leprosy has
 been applied indiscriminately to the elephantia-
 sis of the Greeks, the  lepra of the Arabians ;
 to the leuce of the Greeks, the beras of the Ara-
 bians, or the leprosy of the Jews ;  and to the
 slighter  scaly  affections  to which  the  names
 lepra and psoriasis were  given by the Greeks
 and moderns.   It  seems extremely  probable
 that other diseases, perfectly distinct in their
 natures from one another, and from  those al-
 luded to, were  often included under the  ge-
 neric appellation of leprosy, provided  that they
 possessed the general characteristics  of invet-
 eracy, or a  disposition to self-contamination,
 or to propagate themselves by contact with the
 morbid matter secreted by them.   This seems
 to have  been the  case, especially  among the
 Jews and Eastern races.  From  the very pre-
 cise accounts furnished by the writers  of the
 Middle  Ages, particularly subsequent to  the
 Crusades, the term leprosy was  applied with
 tolerable precision  to the elephantiasis of the
 Greeks—to the tubercular disease.  The monk
 Theodoric, Laxfranc, Bernhard Gordon, De
 Chauliac,  Gilbert, John of  Gaddesden, and
 several others have described this malady, as
 it  occurred during the 14th century, with more
 precision  and  minuteness  than  any  modern
 writer.   As Dr.  J. Y. Simpson remarks, in his
 very learned paper  on  leprosy and leper  hos-
 pitals, the  details which they, and some other
 writers  of that period, have given of the chief
 characters  of the disease are altogether simi-
 lar, and the symptoms are exactly those which
distinguish the Greek elephantiasis. They also
enter most minutely into all the local and con-
stitutional  symptoms, with the view  of faith- j
 fully distinguishing the disease ; and they point
 out  the  mode  in which a  suspected person
 ought to be examined before the existence  of
 a malady which is  to consign  him to a leper
 hospital should be decided upon.
   21. It  seems, however, that the precision
 thus laudably cultivated by the earlier of the
 Middle Age medical writers was  subsequently
 departed from ; for, during the fifteenth and
 sixteenth centuries,  all cutaneous eruptions of
 an obstinate character, or attended by ulcera-
 tions, were deemed  leprous and received into
 lazar-houses, which  were extremely numerous
 throughout all Europe, particularly in countries
 bordering on the Mediterranean.
   22. As recently as  the times  of Horstius
 and  Forestus (the close of the sixteenth cen-
 tury), persons affected by elephantiasis, scabies,
 psoriasis, or psora, or the lepra of the Greeks,
 were treated as leprous and received into those
 asyla.  Even Riedlin, as late as the close  of
 the seventeenth century, remarks that the pa-
 tients admitted into  the leper hospital at Vi-
 enna presented every species of cachectic dis-
 ease, characterized by affections of the skin, or
 ulceration  and gangrene.  At the present day
 the term leprous  is  restricted by the medical
 men of this country, particularly to those va-
 rieties of squamous affections, which the Greeks
 denominated lepra (Xenpa); while, in Continent-
 al countries, and in the East more especially, it
 has been applied to the elephantiasis Grecorum,
 the tubercular leprosy, or lepra Arabum.  I have
 already  stated  my  reason for removing the
 scaly lepra, or the lepra  of the Greeks, and of
 Willan and Bateman, to the genus psoriasis,
 to which it properly belongs, and of restricting
 the term leprosy to the tubercular disease, the
 elephantiasis of the Greeks, the lepra of the
 Arabians, to which  this  term was strictly ap-
 plied by  the writers of the  Middle Ages, and
 by most of the later writers, although several
 other cutaneous affections, besides the tuber-
 cular leprosy, were  received into the leper  or
 lazar houses in more modern times.  It is prob-
 able, however, that  the strictness of diagnosis
 observed during the thirteenth and fourteenth
 centuries  depended  on  the  circumstance  of
 the seclusion of the leprous  being  enforced,
 while, subsequently, persons  suffering under
 chronic maladies supposed to be  allied to lep-
 rosy were  allowed to  enter, for the advanta-
 ges of medical treatment, those leper institu-
 tions possessing the  characters of an hospital,
 and where  medical treatment was resorted to.
   23. Guy  de Chauliac, the celebrated surgeon
 of the fourteenth century, assigns the following
 six symptoms as the most unequivocal of this
 malady:  " Rotundity of the ears and eyes ;
 thickening  and tuberosity of the eyebrows, with
 falling off of their hair ; dilatation and disfigu-
 ration of the nostrils externally, with stricture
 of them within and foetidity of the lips ; voice
 raucous and nasal ;  foetidity of the breath and
 of the whole person, fixed and horrible satyr-
 like aspect."  John of Gaddesden remarks, that
 "no one  is  to be adjudged a leper, and separa-
 ted from  mankind, until the figure and form of
 the face are actually changed.   Hence, ulcera-
 tion  of the  feet, or foul scabbing, must not be
 considered  as arguing the presence of leprosy,
 nor nodosities, unless they appear on the face,
I and wilh the aforesaid conditions." Glanville, 
812
LEPROSY—Diagnosis of—Causes.
another English author, who wrote in the four-
teenth century, " De  Proprietatibus Rerum,"
states, according to the translation of the Vic-
ar of Barkeley,  that  leprous  persons  " have
redde whelkes and pymples in the face, out of
whom oftenne runne blood and matter ;  in such
the noses swellen and ben grete ; the virtue of
smelling faileth, and the  brethe stynkyth ryht
fowle." * * * " The infectyd are unclene, spotyd,
glemy, and guyttery:  the nostryls ben stopyl,
the wasen of the voys is rough, and the voys
is horse, and the  here falls."   No recent, or
even modern writer, has distinguished this mal-
ady with greater precision than the above early
authors.  The definition of Sauvages is perfectly
diagnostic of the malady  : " Fades deformis tu-
beribus callosis, ozena, raucedo; cutis Elcphanti-
na, crassa, uncluosa; in extremis  artubus anes-
thesia."
  24. B. The difference  between  it and  Ele-
phantia—the Elephantiasis of the Arabians—is
very wide.   This latter is not a tubercular mal-
ady, and commences in the lymphatic veins and
sub-cutaneous cellular tissue, and not in the
skin itself, this latter  structure being only  con-
secutively altered. (See art.  Elephantia, or
Elephantiasis of the Arabians.)
   25. C. The differences between tubercular lep-
rosy and tubercular venereal affections are, chief-
ly, the  appearance of leprosy in  Europe very
long before  the venereal  disease, and the char-
acters which are peculiar to each.  The blotches
and tubercles of leprosy are of a shining, brown-
ish tint, of  an oily look,  soft, tawny, irregular,
distinct, separated by fissures, and attended by
a general puffiness, loss  of hair, and occasion-
ally by much insensibility of the skin.   The
tubercles of syphilis are  red or livid, hard, de-
veloped in  the substance of the corion, clus-
tered together;  not insensible, generally  con-
sequent upon venereal ulcers, and not attend-
ed by loss of the hair, of the parts which  they
affect.
   26. IV. Causes—M.  Rayer remarks  that,
first  observed in  Egypt, then in  Italy during
the time of Pompey,  leprosy subsequently ex-
tended, and has  since been seen in the  four
quarters of the globe.  It spread over the whole
of Europe like an epidemic during the Middle
Ages, especially about the period  of the  Cru-
sades.   Since the commencement of the  17th
century, this malady has gradually disappeared
from the countries of Europe, and is now  con-
fined to intertropical regions.  It is more com-
mon  among the  poor  than the rich; in the in-
digent, and in strangers after residence  in  a
warm country.  It has been described by Po-
cocke as it  occurred  in Asia Minor; by Pros-
per Alpinus, Desgenettes, and  Larrev, in
Egypt; by  Bruce, in Abyssinia; Marsden, in
Sumatra ; Marshall, in Ceylon ;  by Robinson
and Ainslie, in  India; by Bergeron,  in  Cay-
enne ; and  by various writers  in St. Domingo,
Martinique,  New-Orleans, the Isle of  France,
coast  of Africa,  &c.   From  these localities
enjoying a warm,  humid, and variable climate,
M. Rayer concludes that such a climate is fa-
vourable to the  development of  the malady.
But it was as prevalent in northern as in warm
countries during  the Middle  Ages; and, al-
though it has almost  entirely disappeared from
the former  of these,  it  is probable that cases
may still lurk in some European localities, the
descendants of those who were subjects of tho
malady.  The disease was prevalent in the
Faroe Islands as late as 1676, when it was ac-
curately  described by  Debes, and  its causes
assigned with greater  truth than by any mod-
ern writer.   It continued also to occur in the
Hebrides and in the Shetland Isles long after
it had entirely disappeared from the southern
parts of Great Britain.  Brand mentions his
observing it in the Shetland Isles in 1700; and
as late  as 1742, the Island of Papastour  con-
tinued to be the place assigned for the seclu-
sion of those affected by it.   In 1736  and 37,
this island  contained five  persons afflicted
with this malady ; and an account  of it was
drawn up by the Rev.  A. Fisken at  that time,
and is in the possession of Mr. Barclay.  It
has  been recently published  by  Dr. Simpson,
and it contains an extremely accurate descrip-
tion of this disease.  In 1772 and 76,  there
was one case in  this island ;  and in  the ac-
count furnished by Mr. Rannie, session clerk,
mention is made of a leprous woman in 1778,
who died in the fields before a house could  be
built for her; that about the same time there
were leprous persons  in the  district of Wat-
ness, and that the son and daughter of a man
were infected and sent to the hospital at Edin-
burgh.  In  1798,  a  young  man,  a  native  of
these isles, was a considerable time in that hos-
pital, affected with this malady;  and  in 1809,
Dr.  A. Edmonston met with a case of it.
   27. The exciting causes of this malady, once
the  most generally diffused, the  most surely
and slowly fatal, and the most permanent of all
those which have  prevailed at any time in the
human species, are veiled in obscurity.   It ap-
pears to have been  prevalent for  several cen-
turies ; and although it may not have been, for
a considerable portion of that time, so common
as  syphilis and scurvy, which followed  it  in
succession, yet it  was more certainly fatal and
dangerous than  they to the posterity of those
who became the subjects  of it.  That it was
believed to have been contagious, is proved  by
the strenuous efforts made to seclude the dis-
eased, and  prevent  their communication  with
the healthy.   In the account, above alluded to,
of  the  Shetland lepers, it  is  mentioned that
" the disease is found by experiment to be very
infectious, and seems also  to run in the blood,
most people that  have taken it without infec-
tion from another having been related to three
families in the isle.  It affects any age or sex,
and young  persons  bear it longer than  those
of a more advanced age, some having lived ten
years under it,  others only two, some  four,
some six, <kc.; but none ever recover after the
symptoms fully appear."
   28. The  Rev. L. J. Debes, whose  curious
and rare work is now  before me, assigns what
appears, as  I have already hinted (y 13), to have
been the chief causes of this malady.  " I find
the cause of the leprosie to be the air and the
dyet;  for here is  a  pretty cold and  moist air,
which usually causeth the scurvy to those that
lead a solitary life, and this hath a great affinity
with leprosy.  Besides, the meat of all, specially
of the poorer sort, is  half-rotten flesh or  fish,
all their nourishment in summer being likewise
fresh fish  and sweet milk, without any salt;
wherefore he that is not of a  strong and good
complexion, may  easily have his blood  cor- 
LEPROSY—Causes of—Treatment.
813
 rupted, the sickness gnawing itself through the
 body before it breaketh out, and when any one
 is so infected, he may easily give it to another
 that is of the same complexion with the sick."
 " It has also been taken notice of, that two liv-
 ing together in marriage, though the one  be
 found infected, they live together as before as
 long as one doth but murmur of it, till the mag-
 istrate doth separate them; and yet the sound
 remaineth uninfected, whereas another is often
 taken with the disease by a very little conver-
 sation."—(P. 312, 313.)
   29.  Dr. Ainslie expresses a  doubt of the
 contagious character of the disease ;  but  he
 admits, with all  others who have had oppor-
 tunities of investigating the nature of the mal-
 ady,  that it  is hereditary.  On  this  subject,
 Dr. A. Edmondston remarks that this disease is
 hereditary, " and has been transmitted to suc-
 cessive generations, without  extending itself
 to  individuals living under the  same  roof,  or
 even  to all the offspring of the same parents;
 nor does it seem to propagate itself by infec-
 tion, unless in those cases where a matter is
 generated  and  discharged from the  sores.
 This is the certain medium of communication,
 and an inattention to this circumstance has
 given rise to contradictory views of its nature."
 —(Edin. Med. and Surg. Journ , vol. vi., p. 164.)
 I believe that there is much truth in the latter
 part of this quotation ; I quite agree with this
 opinion of my late friend.   He  adds, at another
 part, " that it was propagated by contagion can-
 not admit of a doubt.   We have seen  that it
 prevailed  very generally in the Shetland Isles,
 about sixty-five years  ago, and all the  inhabi-
 tants were deeply impressed with a conviction
 of its contagious nature ; and the history of the
 disease but too well confirms the accuracy  of
 the opinion."
  30.  The investigations of Mr. Stewart,  at
 Tranquebar, where tubercular leprosy is very
 prevalent, has induced him to give the follow-
 ing as the results: 1st. That  women are less
 liable to this  malady than men ; 2d.  That it is
 hereditary ;  3d.  Its  being contagious is ex-
 tremely problematical;  4th. That every leper,
 suffering from an advanced stage of the mala-
 dy, doubts whether he is capable of propagating
 his species;  5th. That a fish  diet is  found  to
 render every symptom worse ;  6th. That poor
 living, want of cleanliness,  mendicant misery,
 and exposure to cold and  damp, are but too
 constant attendants of this dreadful affliction.
  31.  From my limited observation of this mal-
 ady, chiefly in  Africa, as well as from other
 sources of information, I  believe that  it owed
 its  origin principally to the  use of smoked,
 wind-dried,  and  semi-putrid  or  rancid flesh
 meats and fish, and of rancid oils; to the want
 or  disuse of salt ; to the use of unripe,  or
 spoiled, or mouldy grain ;  to the want of vege-
 table productions as articles of diet; to inatten-
 tion to personal cleanliness ; to the  nature  of
 the clothing; and to the contact of the matter
discharged from the leprous sores,  when the
 disease was far advanced,  and when the mat-
ter  came  in contact with  the skins  of those
who were already predisposed to it by the
modes of living alluded to, and by want  of
cleanliness.
  32.  V.  Treatment.—Much good may  be
done  by avoidihg the presumed causes of the
malady.   The cure, when the disease is fully
advanced, is hopeless ; but ill the early stages
it may be either entirely removed, particularly
if it have recently commenced, or if the malady
is confined to the extremities, or it may be ar-
rested for many  years  in  its progress.   The
Arabian  physicians trusted chiefly to mercury.
Dr. Hillary avoided mercury, and prescribed
sarsaparilla.   Dr. Towne  thought that anti-
monials  afforded  the  greatest relief, and that
mercury  aggravated the disease.   I believe,
however, that the bi-chloride of mercury, given
with the compound tincture  of  bark, or with
the compound decoction  of sarsaparilla, so as
to produce both a tonic and an alterative effect,
is really  of great service in the early stage of
the malady.   Dr.  Ainslie always endeavoured
first to improve the health by nourishing diet,
cleanliness, and exercise ; and afterward to act
upon the disease  by a cautious use of the  bi-
chloride of mercury and warm baths,  support-
ing the frame at  the  same time by generous
living.   He  also mentions the mineral acids
and the  combination of  antimonials and aro-
matics with approbation.  The Hindoo  physi-
cians consider the white  oxide of arsenic as a
powerful  remedy for this disease ; but Dr. Ains-
lie was disappointed in his trials of it.   Of all
the alterative and deobstruent  remedies,  he
adds, employed by the native practitioners of
India, none is of equal repute with the concrete
milky juice of the Asclepias gigantea, given with
sulphur, and continued for some weeks.  Dr.
Heberden states that he cured a patient in five
months, by means of a mixture of an ounce and
a half of  powdered cinchona and half an ounce
of powdered sassafras root, made into an elec-
tuary with sirup, the patient taking the size of
a  nutmeg twice  daily.   M. Rayer supposes,
however, that a recourse to these and other
tonics, as arsenic, &c., is apt to kindle the  in-
ternal inflammations, which often carry off lep-
rous patients.
   33.  Although I saw several cases of this dis-
ease in different parts of Africa, my residence
in any one place  did not exceed three or four
months.   I  had not, in consequence, opportu-
nities of observing the  effects of treatment.
But a few years ago I was consulted by a phy-
sician who  had resided  for  some years in a
warm climate and treated cases of this malady
in all its stages.  He had had patches of a
tawny colour on his extremities, with thicken-
ing of the corion, and enlargement of the hair
bulbs  and follicles, and loss of the hair of the
parts.  The patches were slightly insensible;
and the  sensibility of the toes and feet was
somewhat impaired.  When I saw him, he had
been the  subject of the affection during fifteen
or sixteen years ;  and, at an early part of the
treatment, the patches in the upper extremities
had nearly disappeared ; but those in the lower
continued, the  highest being situated in  the
flexures of and little  above the knees.  He at-
tributed the disease to contagion, and said that
he fully recollected the  occasion of his infec-
tion.  The disease had retrograded by his  at-
tending to his general health, by his  removal
to a temperate and equable climate, and by the
occasional use  of the  bi-chloride of mercury
with sarsaparilla, or of small doses of Fowler's
arsenical solution, other alteratives and tonics
having been employed in  the intervals.  He 
814                             LEPROSY—Treatment.
 subsequently had recourse to sulphur fumiga-
 ting baths,  and  to  various  medicated  warm
 baths.  His pulse was slow, soft,  and weak;
 the impulse of the heart weak ; and the com-
 plexion  pale and unhealthy.  The patches in
 the lower extremities had been stationary for
 about ten years;  but, during that time,  a few
 tubercles had formed in them, had broken, and,
 after continuing to discharge an ichorous mat-
 ter, had healed up.  The nails of the toes and
 of the fingers were affected as above mention-
 ed.   He complained  of dyspeptic symptoms.  I
 first prescribed for him the chlorate of potash,
 in  decoction of bark; and,  subsequently,  put
 him upon a course of iodide of potassium, with
 liquor potassa, in the compound decoction of
 sarsaparilla.  After this course was continued
 about six weeks, the above symptoms began to
 disappear, and within three months his skin
 and lower extremities were quite clean.  Three
 years afterward  there was  no return of the
 malady.   This case was evidently one in which
 the anesthesia was the most prominent phenom-
 enon. Notwithstanding  the success of  these
 means, I believe that, in the far advanced state
 of the malady, the prognosis of Holler—" Con-
 firmata elephantiasis non curatur" (De Morb.
 Inter., p. 64)—may be viewed as just.
   [Leprosy in Mexico.—One of the forms of lep-
 rosy above described would  seem to be not an
 uncommon  disease  in Mexico.  Kendall, in
 his  Narrative of the Texan Santa F6 Expedition
 (vol. ii., p. 220), thus speaks of the lazarinos,
 or lepers of hospital San Lazaro : " The appear-
 ance of  the unfortunate lepers is  loathsome
 and hideous to a degree that beggars descrip-
 tion.  It makes its appearance by scaly erup-
 tions on different parts of the face and body of
 the victim, and these eruptions are  never per-
 fectly healed.  The  limbs of many, and  more
 especially the hands, at first appear to be drawn
 and twisted out of all shape.  Gradually the
 nose and parts of the feet are carried  away,
 while the features become distorted and  hide-
 ous.  The voice assumes at times a husky and
 unnatural tone, and  again the doomed patient
 is unable to articulate except in a shrill, piping
 treble. With many, when near the last stages,
 all  powers of speech are lost, and  vainly do
 they endeavour to make known their wants by
 sounds which belong not to this earth of ours.
 Death steps in at last to relieve the poor crea-
 tures of their sufferings ; and to them, at least,
 it would seem that the visit of the grim tyrant
 must be welcome."
  Mr. Kendall farther states that there  were
 some 60 males, and more than that number of
 females, affected with the disease in the hospi-
 tal of San Lazaro, when he was there ; that he
 cannot say whether  the disease is contagious
 or not; that there is little doubt of its being \
 constitutional and  hereditary, being never en-
 tirely eradicated from the blood.   He thinks
 the climate has some effect in engendering and
 keeping alive the disease ;  says that the  com-
 mon belief among  the lower classes is, that it
 is communicated by contact, and expresses the
 opinion that the only risk a person runs of taking
 it is from touching the person of one afflicted
with it in its worst stages.  It seems that when
a person is known  to be a leper in Mexico,  he
is at  once sent to this hospital, where he re-
mains till death,  for we are told that " none
 ever recover from the horrible disease" (p. 222>
 " If all the Mexican inmates of San Lazaro,"
 says Mr. K., " were afflicted with leprosy, and
 we were told  that  such was the case, there
 must be three or four different species of the
 disease.  The faces of some of the lazarinos
 were  covered with blotches and  eruptions,
 while their  hands  and  feet  were unmarked.
 Others,  again,  had complexions exceedingly
 fair and unblemished, yet their feet and hands
 were distorted or decayed.  Some of the vic-
 tims  of the dreadful scourge  were  covered
 from head  to foot with sores and ulcers hide-
 ous to  look at;  and then there were two or
 three cases where the patients  presented no
 other marks of the  disease than the loss  of a
 nose.   But the most singular case of all  was
 that of the old Spaniard, whom I have previ-
 ously mentioned  as continually smoking his
 cigarittos.  His flesh appeared to  be  entirely
 gone—dried  up—his skin turned to a bluish
 purple — and  his whole  appearance  was so
 strangely changed and distorted, that he more
 resembled an animated mummy than aught else
 I can compare  him to.   His senses he still re-
 tained, while his actions and conversation con-
 vinced  us  that he was  a well-informed  and
 gentlemanly man."—(P. 241.)
   Leprosy in New Brunswick.—In the year 1844,
 the attention of the Canadian government was
 called to the existence of leprosy at Tracadie
 and Nequac, in the  Province of New Bruns-
 wick, near the  Bay of Chaleur ; and a commis-
 sion was accordingly appointed, consisting of
 Drs. Key,  Skene, Toldarvy, and Gordon, to
 investigate its nature and origin.   The follow-
 ing is extracted from their report to the Cana-
 dian Parliament:  " The disease is the Greek
 elephantiasis—the leprosy ;  not the elephantia-
 sis of the Arabians, but the leprosy of the Mid-
 dle Ages ; the lepre tuberculeuse of the French,
 or tubercular leprosy, which raged over nearly
 every district of Europe  from the tenth to the
 sixteenth century.   It is the decided opinion
 of the gentlemen comprising the commission
 that the disease is contagious;  and, so far as
 they could ascertain, no  person  in the above
 districts who contracted it is ever cured.  It is
 also their  opinion that it has  no affinity to
 scrofula ; and the idea very prevalent that  it is
 owing to the poor diet of the French settlers,
 and their filthy habits generally, is not correct,
 for they found it existing in some of the clean-
 est dwellings and most respectable families.
 It has spread very rapidly during the last year.
 They discovered upward of 20 cases, all of
 which can be traced up to one source.  They
 have every reason to suppose that there were
 a still greater number ;  but  not having power
 to search, and the inhabitants showing a great
 disposition to withhold iuformation, or to point
 out the parties  labouring under  the  disease,
 they could  not  make so minute an inquiry as
 they otherwise would have done,  or as they
 were  desirous of doing."  Dr. Boyle, of St.
 Johns, has also investigated the disease (Lond.
 Med. Gaz., 1844), of  which he has given an in-
 teresting account.  Dr. B. agrees with the com-
 mission that the disease is tubercular elephanti
 asis of modern  pathologists ;  the juzam of the
 Arabians, and the lepra Gracorum of the Middle
 Ages; but he regards the disease as non conta-
gious, and goes into  a long statement of facts 
LEPROSY—Bibliography and References.
815
to  prove this  position.   He, however, thinks
the disease is hereditary, traces its existence
back to  1827, numbering some 20 cases and 12
deaths since that period, although he is  of
opinion that it was introduced into the province
much  earlier.   Dr. B. briefly describes a  case
of the  disease, where " the breath was extreme-
ly offensive,  the face, hands, and legs  covered
with blotches and tubercles of a livid, brownish
colour, and some of them were in a  state of ul-
ceration."
   We are  not aware  that the disease has  ever
been noticed to any extent  in any  part of the
United  States, although  sporadic cases  have
been occasionally observed, as in  a  young girl
a few  years  ago  in the State of New-York, in
whom no  hereditary  predisposition  existed.—
(Worcester, On  Diseases of the Skin, p.  231,
Philad., 1845.)
   In Norway,  in the  Gazette des Hopiteaux, for
April 4, 1844, is  a short  account of a memoir
presented  to the Academy of Sciences, by  M.
Danielssen, physician  to St. George's Hospi-
tal at  Bergen ;  from which it appears that this
disease  has  prevailed  epidemically  for half a
century upon the  coast of Norway, and  that,
out of 200,000  inhabitants,  1200 had been at-
tacked.   In the great number of  autopics the
author of the memoir has had occasion to make,
it was found that the skin and  cellular tissue,
and walls of the sub-cutaneous veins, were one
indurated mass, yellowish, and granulated.  The
same indication  was found in the eyes, larynx,
trachea, bronchial  tubes, pleura, liver,  spleen,
intestines,  and uterus; the lungs  alone escaped.
The disease  uniformly terminated  fatally,  how-
ever treated.*]

  * [Dr. MoTr, who  examined recently for himself  the
Lepra of the  Greeks, in Athens, thus speaks of a patient
whom he was invited to visit: " I examined him with great
care and minuteness, heard the history of his symptoms,
and saw the disease for myself, as it now affected his throat.
I ascertained  that the affection commenced,  in its primary
stage, in the same parts as those attacked by the syphilitic
virus, and that the ulcerative appearances in each bore a
striking resemblance, both in that stage and in the consti-
tutional or secondary form, which latter truth I myself can
attest to from the case under  my inspection.  The primary
ulcerations, as well as those in the throat, were harder, and
with edges more callous, elevated,  and irregular, thau is
usually  seen in common cases of lues ; but they were such
as I have seen occasionally in the lues of our own country.
The same character of ulceration was visible in the throat
of this patient; and, immediately upon looking into it, I re-
marked  to Dr. R., that this was certainly a form of lues, to
which opinion Or. J. gave also  his  full concurrence.  It
passes through the same stages as ordinary lues, from the
throat to the  skin, and, lastly, to th - bones.   I am  there-
fore of the opinion, from what I saw, that the lepra of the
Greeks is a more formidable, and apparently a more chronic
disease,  than  modern syphilis, but legitimately descended
from the same parentage.   If the leprosy of the patriarchs
of old was the same disease as the lepra of Greece, and
which latter I afterward found, to my satisfaction, to be the
same as the lepra of Egypt, it is my opinion that the an-
cient leprosy is the great progenitor of them all, and that
climate,  habits of life, constitutions, and difference of race
make all the modifications it has assumed in different coun-
tries and ages.  I come to this conclusion without any feel-
ing or wish to remove the odium, which is unkindly thrown
upon our country, of having  given  birth to so loathsome a
malady.   These convictions are the result of careful  ob-
servation and  mature reflection  during my journeyings in
Europe  and the East.  We have no doubt, in our minds,
that when the ancient lepra and modern  lues  shall be more
closely studied and accurately compared, their identity will
be made more and more manifest; and if the  leprosy of the
Scriptures be  the same  as the present leprosy of the East,
the question is narrowed down  to small limits, and the in-
ference is legitimate and unavoidable.  It may be cited, in
evidence of their analogy,  that Eastern nations hold a lep-
rous person in the greatest detestation and abhorrence, in-
somuch  that they are made outcasts of society.  They are
  Biblioo. AND REFER.—Lucretius, De Rerum Natura, 1.
iii.,et 1. iv.—Celsus, Medicina, l.ni., 1. xxv.—Galen, Opera.
De Arte Curat, ad Glauconem, 1. ii. ; et De Compos. Medi-
cain. Secund. Loca., 1. v.—(Galen states, thai the disease
was common in Alexandria, owing to  the full and rich liv-
ing, and the heat of the climate.  He  recommends, in itd
early stages, a variety of tonics, stimulants, and alteratives.)
—Aretaus, De Causis et Signis Morb., edit. Boerhaave, p.
69.—C. Plinii  Sec, Hist. Muudi., 1. xxvi., 4 ; et  1. xxviii.,
33-50.—Ceelius Aurtlianus, De Morb. Acut. et Chron., 4to.
Amst.,p. 492— Actius, Tetrab. iv., s. ii.,c. 123.—Oribasius,
Synops., 1. vii., c. 51. — Paulus Mgineta, De Re Medica,
fol.  Par , 1532, 1. iii., ch. i.—Avicenna, Canon. Medieinse,
1. iv., p. 130, fol.   Venet , 1564.—Theodericus et Lanfran-
cus, in Arte Chirurg. Scriptorum Collect., p. 175 et p. 207.
Venet., 1546. — Gilberti  Anglici,  Compend. Medic, tam
Morb. Univ. quam Particul., &c.   Vienna, 1510.—Toannis
Anglici, Praxis Medica, Rosa Anglica dicta, p. 1076, edit.
Schopffin,  1595.—B. Gordon, Lillium Medicin.e, &c.,in Op.
Med.,  p. 49.   Lugd., 1574. — Guy de Chauliac,  Chirurg.
Tractatus  Septem (De Lepra).  Venet., fol., 1470.—J. Fer-
nelius, Universa  Med., p. 579.  Geneva, 1680. — Schenck,
Observ. Med., &c, p. 776.—Stemfels, De Elephantiasi Gra)-
corum, 8vo.  Marl>., 1662. — Zacutus  Lusitanus,  Pr. Med.
Hist., 1. vi.,n. i.—Prosper Alpinus, Medicina ^Egyptiorum,
1. i., p. 56.   (Describes the Elephantiasis of the Greeks, and
the Eleph. of the Arabians.)—L. J. Debes,  A Description
of the Islands and Inhabitants of Feme,  &c.  ; Englished by
J. S , 12mo.  Lond., 1676, p. 312.—Martin,  Voyage  to St.
Kilda, 1698-1749, p. 140 ; and Phil. Trans., 1730.—Pontop-
pidan, Nat. Hist, of Norway, &c, Trans.  Lond., 1755, p. 261.
—Turner, Treat, of Dis. Incident to the Skin.  Lond., 1736, p.
2.—Lorry, Tract. De Morb. Cut., p. 376.—Plenck, Doct. de
Mori). Cut., p. 67.— Sauvages, Nosolog. Method., t. v., p. 229.
—Pococke, A Descript. of the East and other Countries, fol,,
1753.—De  Chamserue et Coquereau, Recherches sur l'Etat
actuel de  la Lepre  en  Europe, &c. ; in Mem. de la Soc.
Roy. de Med., t.  v., p. 199. — T. Heberden, Med.  Trans, of
Roy. Coll.  of Phys., vol. i., p. 35.—Tode, De Elephantiasi
Noiwegica.  Haun., 1785.—F. Ruette, Essai sur l'Elephant.
et les Mai. Lepreuses, 8vo.  Par., 1802.—Casan, Mem. Soc.
MeJ. d'Emulation, t. v., p. 102.—T. Winterbottom, Account
of the Native Africans around Sierra Leone,  &c, vol. it., p.
50, 8vo. Lond., 1803.—Adams, Observ. on Morbwl Poisons,
4to.  Lond., 1807, p. 265.—Alibert, Descrip. des Maladies
de la  Peau.   Paris, 1806.—Jackson, Account of Morocco,
8vo, 1810. — T. Bateman,  Practical Synopsis of  Cut. Dis-
eases,  8vo.  Lond.,  6th ed., p. 413. — Robinson,  Transact.
of Med. and Chirurg. Soc. of Lond., vol.  x., p. 27.—Babing-
ton, in Ibid., vol. i., p. 27. — Lawrence, in  Ibid., vol. vi.—
Southey, in Ibid., vol. vi.— W. Ainslie, Obs. on the Lepra
Arabica, as it appears in India ; Trans, of Roy. Asiatic Soc,
vol. i.—H. H. Wilson, in Transact, of the Med. and Phys.
Society of Calcutta, vol. i., p. 1.— Wise, in  Ibid., vol. vii.,
p. 156.—Pitrquin, Journ. des  Progres des Sc. Med., t. xi.,
p. 140. — iii. Guide, Archives  Gener. de Med., t. xvii., p.
533.—L. A. Struve,  Ueber die Aussatzige Krankheit Hol-
steins, Svo.  Alt., 1820.— H.  Marlius, De Lepra Taurica,
8vo.   Novr., 1827.— Heineken, On the Leprosy of Madeira;
Edin. Med. and Surg. Journ., vol. xxvi., p. 15.—//. Holland,
in Ibid., vol. viii., p.  202. — Cazenave, Sur  l'Elephant. de
Grecs, Journ. Hebdoniod. de Med., t. iii., p. 146.—P. Rayer,
Theor. and Pract. Treatise of the Dis. of the Skin, 2d ed. ;
Trans, by  Willis, 8ro.  Lond., 1835, p. 740. — J.  Y. Simp-
son, Not. of Leprosy and Leper Hospitals in Scotland and
England, in Edin. Med. and Surg. Journ., vol. lvi., p. 301.
— J. A. Raisin, Essai sur l'Elephantiasis des Grecs, 4t0.
Pans, 1829.—Joy, Cyclop, of Pract. Med., vol. i.—Von Vo-
gcl, Encyclop. Worterbuch, vol. x.  Berl., 1834.   (In most
of recent works,  the Synonymes and Bibliography  apper-

placed in habitations  by themselves alone, and forbidden to
have intercourse with their neighbours,  as is illustrated in
some of the Eastern cities, where leprous houses are pointed
out, undergoing as rigid a quarantine as if the disease were
the true plague.  And sometimes leprous subjects are driv-
en outside the gates, and turned into the fields and mount-
ains, as though they were beasts.  One instance of this I
saw afterward on the plains of Argos, in Greece, the poor
victim oeing a man who was wandering alone in the fields,
and obliged to seek shelter in the clefts of the rocks.  One
feature in the character of this disease, by which its iden-
tity with lues is  farther established, is in the similarity of
the remedies for both, which are mercurial and  arsenical.
This 1 ascertained afterward to be the practice in Egypt as
well as in Greece.   The  physicians in both informed me
that, in the early stage of lepra, the mercurial  treatment
was  successful, and  that, in the confirmed or  secondary
stages, where debility and irritability existed, either from
the continuance of the disease or too much mercurial prac-
tice,the tonic treatment byarsenicwas the most efficacious ;
all of which is in general accordance with  the experience
of practitioners in the treatment of lues in  our own coun-
try."   The close  relation existing between lepra and syphi-
lis has been noticed by several writers, and it is very prob-
able that in some instances they have been confounded.] 
816                           LEUCORRHfEA—Symptoms of.
taining to the different forms of Elephantiasis and Lepra
are confounded together.  I may again state, that in the
above article 1 have confined myself to the consideration of
the Leprosy of the Middle Ages, which is identical with the
Elephantiasis of the Greeks and the Lepra of the Arabians,
a disease generally prevalent in Europe for some hundred
years, and still met with in a few places, and in warm cli-
mates ; that the Elephantiasis of the Arabians, Elephantia,
Elephant Leg, Barbadoes Leg, Egyptian Sarcocele, &c, is
altogether different from tubercular leprosy ; and that the
scaly  lepra, the lepra of the  Greeks, <fcc, is also distinct
from both the foregoing maladies, and is merely a variety
of psoriasis (which see).  Doubtless, owing to the numerous
causes above stated (I) 13, 28), cases of the last-named dis-
ease were often aggravated, and others would  assume so
modified an appearance, that some difficulty, particularly in
the early stages of the first of these maladies, might exist
in forming a diagnosis; and this difficulty would be  in-
creased by the slow progress of all of them, and by the op-
portunities of examining and observing them during their
entire course, being frequently wanting.)
  [Am. Bibliog. and Refer.—Good's Study of Medicine,
Am. ed., by A. S. Doane, M.D.,  1840.  New-York, 2 vols.
— Worcester, On Diseases of the Skin.  Phil., 1845.—Caze-
nave and Schledel, On Cutaneous Diseases, Am. ed., by H.
D. Bulkeley.  New-York, 1846.—George W. Kendall, Nar-
rative of the Santa Fe Expedition.  New-York, 1844, 8vo.
—Kidder, Travels in Brazil, 1844.—New-York Jour. Med.
and Collateral Sci., vol. ii.—Report of Commission to  in-
vestigate the Origin and Nature of the Leprosy in New-
Brunswick.—Valentine Mott, Travels in Europe and the
East.  New-York, 1842, 1 vol., p.  221. — Boyle, in Lond.
Med. Gazette, 1843.—Maundrell, Travels.—Rayer, On Dis.
of Skin, Am. ed.,  by John Bell.  Phil., 1846.]

LEUCORRHCEA. — Synon. Fluor Albus,  lev-
  Koppoia (from "kevnoc, white, and peu, I flow);
  fiooc  yvvaiKEioc, Auct. Graec.   Fluxio  Vulve,
  Pliny.   Ulcus Uteri, Sennert.   Cachexia Ute-
  rina ; Menorrhagia Decolor, Sauvages.   Men-
  orrhagia  Alba, Cullen.  Blcnorrhea  Uteri vel
  Vagina ;  Fluxio  Vulve ;  Fluor Muliebris  ;
  Fluor Uterinus ; Menstrua Alba; Catarrhus
  Genilalium,  C.  Vagine  et Uteri, Auct. Var.
  Hysterorrhea Mucosa, Swediaur.  Medorrhea
  Vagine et Uteri, Frank.   Fleurs Blanches, Ca-
  tarrhe Uterin; Lcucorrhee, Perte Blanche, Fr.
  Das  Weisse; Weisser Fluss, Germ.   Flusso
  Bianco, Ital.  Weakness, White Discharge, the
  Whites.
     Classif.—1. Class; 4.  Order (Cullen).  5.
        Class; 1. Order (Good).  II. Class ; I. Or-
       der (Author).
  1. Defin.—A light-coloured discharge from the
female  genitals, varying in hue from a whitish or
colourless to a yellowish light green, or to a slight-
ly red or brown; in consistence, from a limpid se-
rum to  a tenacious, ropy substance; and in quan-
tity, from a slight increase of the healthy secretion
to several ounces in the twenty-four hours.
  2. Various forms of this disease have been
pointed out by writers, according to its pre-
sumed  seat or source, and to the several cir-
cumstances connected  with  it.   Most  of the
older writers treated it as a consequence of lo-
cal relaxation, or of general debility.   Dewees
viewed it as generally proceeding from local
inflammatory  excitement;  Pinel considered
that it was sometimes accidental, constitution-
al, and vicarious.  Dr. Churchill has described
it with reference to its seat, as vaginal and ute-
rine.   Dr. Ferguson has divided it into acute
and  chronic;  and Dr. Ashwell  into the com-
mon, the inveterate, and the symptomatic.  Sir
C M. Clarke arranged the varieties of leucor-
rhcea chiefly with reference to the character of
the  discharge, believing that the appearances
presented by  it are indicative not only of its
source, but also of the state of vascular action
and of structural lesion in that source.  A some-
what similar mode was adopted by J. P. Frank ;
but  the arrangements  of these two eminent
physicians were formed more as a means of
distinguishing the inflammatory and organic dis-
eases of the female organs, than with reference
to the functional disorders of these parts.
  3. Leucorrhoea, in every form, and  in most
of the  circumstances  in which it  occurs,  is
merely  symptomatic, either of functional,  in-
flammatory, or  organic diseases of the female
organs, or of disorder of the general  health.
It is  unnecessary, therefore, at this  place, to
attempt to give a full  account of the several
states in  which it appears in practice,  as  its
chief symptomatic forms are necessarily com-
prised in the articles on the principal diseases
of the vagina and uterus.
  4. Leucorrhoea may occur at any period of
life from earliest infancy to advanced old age ;
but it is most frequent between the  ages of 15
and 50.  In  childhood  and  early infancy  dis-
charges from the vagina and vulva  are not in-
frequent,  and are commonly the consequence
of irritation  or inflammatory action; the mu-
cous membrane of the genitals partaking in the
general disposition of mucous membranes to be
irritated or inflamed at this period of life,  and
to furnish a copious  mucous or muco-puriform
secretion.  About 45 years of age the disease
becomes less frequent, and after 50 it is seldom
observed, unless as  a symptom of organic le-
sions of the uterus.  In childhood the discharge
proceeds from the vagina and  pudenda, and is
a simple and primary disease ; in old age it  is
chiefly  from  the uterus and os uteri, and is gen-
erally symptomatic.   During the period of ute-
rine activity, it proceeds from either the vagina,
the os uteri, or the internal surface of the uterus
itself, or  from  any two, or all, of these situa-
tions ;  and is more  frequently a consequence
of pre-existing  disorder than a  primary affec-
tion.   Owing not only to the situation or source
of the discharge, but also to the state of vascu-
lar action and vital  tone of the  vessels which
yield it, various appearances are presented by
it; and hence, in the difficulty attending the in-
vestigation of the exact states of disease pro-
ducing  it, the  importance of determining the
connexion of its several appearances with the
particular morbid conditions upon which they
respectively  depend.   The accomplishment of
this object is not easy, nor probably can it be
attained with great precision ; still, if reached
with  even tolerable accuracy, it furnishes  an
important aid to the diagnosis, not only of the
more primary states of this affection, but also
of all the maladies of which this is symptomat-
ic.   Hence the attempts of J. P. Frank and of
Sir C. M. Clarke to arrange uterine and vaginar
diseases according to the appearances of the
discharges attending them, have not been de-
void of great practical utility.
   5.  It is most evident that, to ascertain the
particular part or parts chiefly or solely furnish-
ing the morbid secretion constituting  leucor-
rhoea, is of equal importance with a knowledge
of the  state of vascular action  and vital tone in
that  part; and, consequently, that  both these
objects should be made the principal pathologi-
cal points or facts to which medical treatment
ought to be directed ;  and, although both are
attended  with difficulties, still these difficulties
should not prevent the examinations requisite
to  the  attainment of satisfactory information.
The scat or source of the discharge is therefore 
LEUCORRHCEA—Description of—Vaginal.
817
 a matter of the  first consideration, and hence
 becomes the most  legitimate basis of an  ar-
 rangement of its several forms.  That the  se-
 cretion  is, in many instances, chiefly vaginal,
 is shown by the circumstance of pregnant  fe-
 males being often the subjects of it; although,
 even in them, it may partly proceed from the
 mucous follicles of the os or cervix uteri.  That,
 again, the discharge may proceed from the  in-
 ner surface of the  uterus itself, is shown in
 some cases of prolapsus uteri, and by a variety
 of circumstances about to  be noticed (y 35);
 and, as Dr. Ferguson observes, there is no rea-
 son for doubting that other causes of irritation
 than those  dependant on uterine disorganiza-
 tion  may likewise rouse  the inner  membrane
 of this viscus to  unhealthy secretion.  In  se-
 vere forms  of leucorrhoea, whether  chronic or
 acute, the cervix uteri is rarely unaffected, be-
 ing generally softer, larger,  and moister, and
 not infrequently more  sensitive  than natural.
 The  portion,  too, of the lining membrane ex-
 tending through the cervix into the orificium  in-
 ternum  is especially  formed for  active secre-
 tion; the palmaj  plicatae  which  radiate on  it,
 and which  become  greatly  developed in  the
 progress  of utero-gestation,  and which  pour
 forth such a quantity of mucus in the progress
 of labour, prove that it can be the seat of active
 secretion, and therefore of deviation of its nat-
 ural  function.  That the  discharge may pro-
 ceed not only from the cavity of the uterus, but
 also even from the  interior of the Fallopian
 tubes, appears to be shown by the histories  of
 some cases, as more particularly mentioned  by
 Frank  and  others.  In the following account
 of leucorrhoea, I shall describe its forms  with
 reference to their seats or sources, and to the
 grades of action characterizing them.
   6.  I.  Leucorrhoea Vulvae.—Leucorrhea In-
 fantilis.—Infantile Leucorrhea.—i. Description.
 —A discharge occasionally proceeds from the
 vulva and orifice of the vagina.  In children it
 proceeds from the general surface of the exter-
 nal genitals, and more rarely from the vagina,
 unless in delicate and relaxed children, subject
 to catarrhal and bronchial affections, attended
 by a copious defluxion,  when  it assumes a ca-
 tarrhal  form, or in those affected with worms,
 or other causes of intestinal irritation.  When
 this form occurs in adults its source  is often
 more partial or limited.   In  both children and
 adults it may assume either  an  acute, or sub-
 acute inflammatory character, or a chronic state.
 In  the former  state, its  commencement  is
 evinced by itching or local uneasiness, and  by
 scalding in passing water ; and the surface  of
 the vulva is somewhat swollen and red.  This
 condition is  soon followed by a colourless, thin,
 mucous discharge, which becomes  more and
 more copious, thicker, and of a white or yellow
 hue.  It is sometimes so acrid as to excoriate
 the surface,  and even the skin at  the margin of
 the vulva.   There is little or no symptomatic
 fever.  In delicate, sickly, and relaxed children,
 the symptoms  are  milder, and are  more dis-
 posed to the chronic form, which, however, may
 supervene upon the acute or sub-acute attack.
 In chronic infantile leucorrhoea the discharge is
 more profuse, milky, or puriform,  and is attend-
ed by less pain,  smarting,  or inconvenience.
In cachectic, plethoric, and scrofulous children;
in those confined in hospitals, or in crowded,
     II.              103
[ ill-ventilated, and low apartments, or in the ill
 fed and dirty, the disease may assume a very
 serious and totally different form, or may give
 rise to a state of phagedenic ulceration or gan-
 grene, which is noticed in the article  Vulva.
 Occasionally  infantile leucorrhoea presents a
 catarrhal form, and is then sometimes associa-
 ted with slight bronchitic or catarrhal fever, or
 even with ozaena.   In these cases, the secre-
 tion from the mucous surfaces generally con-
 sists, at  first, of a thin or watery mucus, and is
 thicker and more glutinous as the affection be-
 comes more chronic.  It is usually the result of
 irritation, and proceeds frequently from the va-
 gina as well as from the vulva.
   7. ii. Treatment.—If the irritation be  consid-
 erable, the parts should be fomented with a de-
 coction  of marsh-mallow  leaves,  or  with any
 other  emollient decoction, three or four times
 a day.  After each fomentation, the black wash,
 or a weak solution of the  sulphate of zinc, or
 of the acetate of lead, may be applied.  When
 the affection becomes chronic or obstinate, a lo-
 tion of nitrate of silver, of gr. vj. to xij. to the
 ounce of water, is the most efficacious.   If the
 irritation extend up the  vagina, a little of the
 lotion may be injected by means of a small syr-
 inge.  The patient must be debarred from rub-
 bing, or having recourse to friction of the parts,
 and be kept quiet.   Care ought  to be taken that
 the urine be not retained too long from fear of
 the smarting  felt when passing it;  and when
 smarting is much complained of, the vulva may
 be fomented,  or  bathed  with warm  water  or
 poppy decoction after each evacuation.   Cool-
 ing, diaphoretic, and aperient medicines may be
 given  occasionally.   The diet should be light,
 and chiefly farinaceous, and the bed-clothes light.
 If there be any tendency to adhesion of the la-
 bia vulva, lint and a little ointment may  be
 placed between them.  The parts ought to  be
 duly examined, lest such adhesion should form.
 If  they are early detected, they are readily de-
 stroyed by forcibly separating the labia.
   8. ii. Leucorrhcea Vaginae.—Vaginal Leucor-
 rhea.—i.  Symptoms.—This form of the disease
 is sometimes acute,  and very frequently chronic.
 —A. In  the acute form, it is simple vaginitis, or
 inflammation of the mucous surface of the va-
 gina ;  and, in the more severe forms, is with
 difficulty distinguished from specific inflamma-
 tion of the vulva and vagina (see Vagina and
 Vulva, Gonorrheal  inflammation  of).—a. The
 earliest symptoms are a sense of heat or sore-
 ness in the vagina, often with itching of the ex-
 ternal parts.   To these are subsequently added
 pain or smarting, with a sensation of tightness
 as  if the vagina were swollen.   If the attack
 extend along  the vagina, there is sometimes a
 feeling of weight or bearing down, or pains ex-
 tending down the thighs.   The discharge, con-
 sisting of a thin, acrid, and colourless fluid, ap-
 pears soon after these symptoms,  seldom later
 than a day or two ;  but it soon becomes thick-
 er, whiter, or yellowish, more purulent, and re-
 sembling cream.   As the discharge increases,
 the uneasy symptoms abate ; and  it frequently
 continues varying in quantity and appearance
 in a more chronic or sub-acute form.  In the ear-
 ly  part of the acute stage, the mucous  mem-
 brane  is swollen, and the  canal of the vagina
 is diminished, and  it is hot and  tender; but
 these  soon  subside  as the discharge becomes 
818
LEUCORRHCEA—Acute—Chronic.
copious.  There is  no breach of surface nor
erosions of the membrane.  In some cases, the
labia and vulva  are swollen, and more  rarely
the glands  in the groin are enlarged.   When
the complaint is slighter, the  local symptoms
are less severe,  and little or no constitutional
disturbance may attend it; but the more se-
vere attacks are often accompanied with slight
rigours or chills, followed by pain  in the back
and loins, by languor, thirst, and quick  pulse,
and cosliveness, with  high-coloured urine, and
smarting on passing it.  The terminations of
this state of the  complaint are : 1. In the grad-
ual subsidence  of the symptoms and diminu-
tion  of the discharge ;  2. More frequently in
chronic disorder, characterized chiefly by the
continuance of  the  discharge, and of the lan-
guor.
  9.  B.  The diagnosis of this state of leucor-
rhoea from gonorrhea is frequently difficult, par-
ticularly when the requisite examinations are
not permitted.   Sir C.  M.  Clarke seems to
think it impossible in most cases.  M. Ricord,
however, states, that it is easily determined by
the aid of  the speculum uteri.   Whenever the
peculiar erosions or minute superficial  ulcers
of the mucous membrane covering the  cervix
uteri, which have been  noticed by M. Ricord,
are discovered, there  can be  no doubt  of the
goriorrhoeal origin of the disease.  These ero-
sions and small ulcers are met with, he  states.
in nineteen out  of twenty cases of the  gonor-
rhceal  discharge.   An  urethral discharge  is
much more frequent in gonorrhoea than  in
simple acute leucorrhoea.   M. Ricord  states
that, of two hundred cases  of the former, eight
in every twelve  had the urethra affected.  The
glands of the groin are also much less frequent-
ly enlarged in leucorrhoea than  in gonorrhoea.
In general, the  symptoms  are much more se-
vere, the calls to pass water more frequent, and
the pains attending it  greater, the extension of
the disease to the uterus much more common,
with the symptoms indicative of  such  exten-
sion more  acute, than in simple acute vaginal
leucorrhoea.—(See art. Vagina, &c.)
   10. C.  Chronic leucorrhea  vagina — chronic
vaginitis of Dr. Churchill—is a most common
complaint.   From the constitution and state of
health of some  females, and frequently owing
to the continuance of the affection itself, it has
been very  generally viewed as a consequence
of debility, local or general—of local relaxation.
But a closer attention will  often show that the
local affection is often the result either of sim-
ple or of  inflammatory irritation, more espe-
cially at its commencement.  In many cases,
also, it commences in the  acute form already
noticed, and passes into the chronic, the acute
state being sometimes  slight or of short dura-
tion.
   11. a.  The symptoms  of this form  of  leucor-
rhoea are chiefly a  more or less colourless or
whitish and bland  discharge from the vagina.
In some cases, however, it is of a deeper hue,
being greenish, yellowish, or brownish, and oc-
casionally  so acrid as to excoriate the edges of
the  vulva,  and in some  cases the insides of the
thighs.   There is scarcely any increase of heat,
and little or no pain or tenderness.  The ingui-
nal glands are not enlarged.   The patient oft-
en complains of weakness and of languor, or
 weariness  after exertion, particularly if the dis-
charge be profuse.  The countenance becomes
pale,"and, if the complaint be prolonged, weak-
ness or aching of the loins, and various dyspep-
tic symptoms are felt.  When vaginal leucor-
rhoea is neglected, it may, especially in its more
acute  states, extend to the os and cervix uteri,
or even to the interior of the uterus.  Ultimate-
ly, it may be followed by  prolapsus, or descent
of the uterus, and increased constitutional dis-
order.
  12.  b. Diagnosis. — Chronic vaginal  leucor-
rhoea is distinguished, 1st. From gonorrhea, by
the local  irritation being  much less in the for-
mer than in the latter ; by the absence of sym-
pathetic enlargement of the inguinal glands ; by
the whitish or colourless appearance of the dis-
charge ; by the absence  of irritation or dis-
charge from the urethra, and of  scalding on
passing urine; and by the less  frequent calls
to pass it;  2d.  From uterine leucorrhea, by the
absence of the more prominent and constant
phenomena attending that  form of  the com-
plaint, by its not being increased before  or af-
ter the menstrual period ;  and by the much less
severe constitutional disturbance, and  much
less marked sympathetic  phenomena.
  13.  D.  Causes of the Acute and Chronic vaginal
Leucorrhea.—a.  The causes of the acute or in-
flammatory state of this complaint are, chiefly,
cold, violence, excessive indulgence; the cir-
cumstances connected with  the transition from
the virgin to the married state,  rape, exertion
soon  after delivery,  inflammation extending
from the vulva or labia ;  high or rich living, in
connexion with habitually sitting on hot cush-
ions ; sitting on very cold seats, on stones, or
on  the ground,  especially if accustomed  to
warm seats; irritation from foreign bodies  or
stimulating injections, or from inflammatory
haemorrhoids, or other inflammatory diseases
of the rectum.   This form  of the  complaint is
not frequent in unmarried and elderly females,
and it is much  favoured by the habits,  modes
of living, and disposition of the patient.
   14.  b. The causes of the chronic form of the
complaint  are both local and constitutional or
general.  The local causes  are the acute state
of the disease ;  irritations of various kinds, as
of a pessary, or of excessive sexual excitement;
displacement of the womb ; frequent child-bear-
ing, or abortions ; the irritation of worms in
the rectum, haemorrhoidal or other affections
of  the rectum ;  the local application  of cold
when unaccustomed to it, or warm, or relaxing
ablutions or fomentations ; sitting and riding on
warm cushions, and excessive  indulgence in
warm bathing.  The general and constitutional
causes are chiefly full and rich living and a neg-
lect of exercise, favouring the  determination
of the circulating fluids to the genitals, as duly
insisted upon by Sir C. M. Clarke ; the influ-
ence  of cold  and vicissitudes of season and
weather on the frame, but more especially of
warm, humid, and miasmal climates, as evinced
among Europeans residing  in the East Indies,
and in other warm and intertropical countries;
the abuse  of spirituous and fermented liquors,
previous debility and debilitating diseases ; the
excitement connected with hot and crowded
rooms, with music, dancing, and mental  im-
pressions.  The period  of female life during
which this form of the complaint is most com-
mon  is from the appearance to the termination 
LEUCORRHCEA—Chronic—Treatment.                      819
 of the menstrual epoch of life—the term of ute-
 rine activity.  It  may, however, occur  either
 before or subsequently to this term.
   15.  E. Treatment.—a. In the acute state of
 vaginal  leucorrhoea, local  or general vascular
 depletion, according to the age, habit of body,
 and strength ofthe patient, may be prescribed.
 If the symptoms be acutely inflammatory, this
 will be the more requisite, and should be aided
 by fomentations, by vaginal injections of warm
 water, and by hip baths.   Subsequently, injec-
 tions of a solution of acetate of lead or of sul-
 phate of einc may be resorted to.  The patient
 should preserve the  horizontal position,  and
 sleep on a cool mattress, with light bed-clothes ;
 and the bowels ought to be kept gently open by
 means of the cooling saline aperients.   Refri-
 gerant diaphoretics may  also  be  prescribed.
 The diet should be light and spare, and the bev-
 erages cooling.
   16.  b. The chronic state of  vaginal leucor-
 rhoea very rarely requires even local depletion.
 Much more  frequently tonics and astringents,
 either vegetable or mineral, are  found neces-
 sary, and when  the patient is debilitated or ca-
 chectic, they should  not  be neglected   The
 balsams, especially copaiva balsam, have been
 recommended by  many.   I have often given,
 with  much  advantage, the copaiva  and  other
 balsams in the  form  of pills with  magnesia ;
 and if this combination acted upon the bowels,
 I have added either small doses of opium or of
 the compound ipecacuanha powder, or of the
 compound storax pill, with increased benefit.
 Dr. Dewef.s  has employed the tincture of can-
 tharides : I have had no experience of it in this
 complaint.   It may probably be advantageously
 conjoined with the tincture of the sesqui-chloride
 of iron, which I have often  prescribed with ben-
 efit in this disorder.   Dr. Blundell and others
 advise the cubebs in tincture or powder, and the
 compound tincture of benzoin.   These, and oth-
 er  tonics usually prescribed, are of great ser-
 vice when the complaint is limited to the vagi-
 na, and when there is irritation about the ure-
 thra ;  for the cubebs, benzoin, and even  the
 balsams, operate chiefly upon the urinary passa-
 ges.   In  many cases,  however, they are infe-
 rior to the preparations of cinchona conjoined
 with mineral acids, or the  sulphate of quinine.
 When there are marked  debility,  relaxation,
 and pallor, the combination of the sulphate of
 iron,  quinine, camphor, &c, as in the follow-
 ing pills, is very beneficial:
  No. 286.  R Camphors rass, Ferri  Sulphatis, Quinina;
 Sulphatis, 5S 3j.; Ext. Anthemidis, 3ij.; Balsami Peruvi-
 ani, q. s. ut fiant Piluls, xxxvj.; quarum capiat duas vel
 tres, bis terve quotidie.
  17. Various local means  have been resorted
 to with advantage ; and, when the uterus is al-
 together unaffected, and the system is not pre-
 disposed to suffer from the sudden suppression
 ofthe discharge, they maybe prescribed, but with
 more caution than I have known them to have
 been prescribed by several practitioners.  Of
 these the most generally efficacious are the decoc-
 tion of oak bark, or of cinchona, or other astringent
 barks, with or without alum ; and solutions of
the sulphate of zinc, or of alum, or of nitrate of
silver, thrown up by means of a suitable female
syringe.   The strength of  these astringent so-
lutions, usually advised, is  frequently too great
at the commencement of the treatment.  I be-
lieve it to be more beneficial, as  it is safer, to
prescribe at first only one drachm of the first,
half a drachm of the second, and a scruple of
the third of these salts to eight ounces of wa-
ter, and gradually to increase the strength of
the solution, according to circumstances. These
injections should  be employed at first  tepid,
and the temperature may be gradually reduced.
They should be administered slowly, while the
patient is in the recumbent position,  and twice
daily.   During the treatment, the cold shower
bath, or the cold douche on the loins and hips,
will be of service.   The patient ought to take
gentle and regular  exercise  in the open air,
and attend to diet  and to the state of the  bow-
els.
   18. Swelling and painful  affections of the
joints  have been mentioned by Dr. Jewell as
having sometimes  appeared after the sudden
suppression of leucorrhoea by injections.  I  have
met with still more serious, and even  fatal con-
sequences, resulting from the use of  strong in-
jections, particularly when the uterus has been
affected.  Some years ago, especially, such oc-
currences were  not infrequent, for the excel-
lence of a practitioner was too often considered
great,  particularly  by coarse or vulgar minds,
in proportion to his boldness or temerity ; and
even now, when the individual organs and mem-
bers  of the body are taken under the especial
protection of their respective  physicians—now,
when there is a physician for the brain, another
for the lungs, a third for the heart, a fourth for
the liver, a fifth for the stomach, a sixth for
the bowels, a  seventh for the urinary organs,
an eighth for the female organs, a ninth for the
spine,  and so  on for every  prominent viscus,
feature, sense, and limb of the human micro-
cosm—now that the division of labour and the
numerical calculations, which are applicable to
mechanics, to political economy, and statistics,
have  been transferred to  medical practice by
the small minds who are incapable of grasping
anything beyond a few  palpable entities or ob-
vious truths, or of extending their views to the
numerous connexions, combinations, and suc-
cessive states o'f morbid action—now, when the
scientific physician,  who pursues his vocation
with elevated ideas of its relations to all other
branches of knowledge, and  of its tendencies
and objects, finds the very circumstances which
improve  his intellects, enlarge his views, and
extend his mental  vision to the more compre-
hensive, remote, and influential  agents, rela-
tions, and results of disease, the strongest bar-
riers he has to surmount in pursuing a success-
ful career of practice—now, when ignorance,
presumption, impertinence,  absurdity,  plausi-
bility, and humbug  play their several parts in
forming the medical character, and  in taking
advantage of popular errors in the modes of ex^
ercising  it — and  now,  when cant, rant, and
quackery in  religion, politics, government, and
morals  have infected the public mind, given
currency to worthless pretension, and extend-
ed its  influence  to medical science—the re-
flecting will not be surprised, nor  will the judi-
cious be disappointed, when they find  physi-
cians, whose minds are duly imbued with liter-
ature and science, and  who  believe that  the
human economy, both in health and in disease,
can be successfully studied  only as  a whole,
and in all its parts, relations, and connexions. 
920
LEUCORRHCEA—Uterine.
altogether overwhelmed by the crowd of noisy
pretenders who obstruct the paths of science,
knowledge, and honesty.
  19. III.  Leucorriicea  from  Inflammatory
Irhitation of the mucous Glands of the Os
 nd Cervix Uteri.—This variety of leucorrhoea
was first distinguished and connected with its
source by Sir C. M. Clarke.  It is characterized
by the white appearance of the discharge, by
pain  in the lowest part of the sacrum, and by
the state of the os and cervix uteri.
  20. A. The symptoms are aching or pain at
the lower part of  the  sacrum, or at the  os co-
cygis, and behind the pubis, increased by cough-
ing or straining, or other actions ofthe abdom-
inal muscles, and by sexual intercourse.   The
bladder and rectum are often irritable ;  and
menstruation is occasionally difficult.  The dis-
charge, particularly in the more acute cases or
early stage, is opaque, white, and resembling in
consistence a mixture  of starch and water with-
out heat, or thin cream.  It is readily washed
from the finger after an examination, and is ca-
pable of being diffused  in water.  It is often
much thicker than cream, and very tenacious.
In this case it does not flow off, but remains in
the vagina  until exertions to empty the rectum
squeeze out, at the same time, the contents of
the vagina.  When it  becomes more chronic, it
is often connected with some degree  of vaginal
discharge, by which it is rendered more fluid ;
and  it may be associated with uterine leucor-
rhoea, when it will be attended by the charac-
teristic signs (y 27) of that variety.   An inter-
nal examination detects nothing unusual in the
vagina, but the os and cervix uteri feel swollen,
and are very painful when pressed.
  21. Although irritation or inflammatory ac-
tion  of the glandular  apparatus of these parts
may generally be attended by a white discharge,
still  it must be admitted that a similar  dis-
charge sometimes attends other sexual diseas-
es without the os and cervix uteri being mate-
rially affected. During the earlier stages of
this  affection, constitutional symptoms are ei-
ther slight  or absent;  but if the complaint  con-
tinue long, or if it be associated with discharge
from the vagina or uterus, debility, pallor, and
some degree of anaemia, difficult or scanty men-
struation, costiveness, and various  dyspeptic
symptoms commonly result.   Sir C. M. Clarke
suspects that this state of disease, particularly
when neglected, sometimes precedes the more
serious organic or malignant lesions to which
this part is liable.  This is not improbable, es-
pecially when the disease occurs, and proceeds
unchecked, in faulty constitutions, and  where
there is a tendency to malignant or  structural
changes.  The character of  the  discharge in
connexion with the state ofthe parts  just men-
tioned forms the diagnosis ofthe complaint.
  22. B. The causes  of this variety  are those
already mentioned (§  13), and  more  especially
cold, irregular habits, excessive indulgences,
especially after marriage, great muscular exer-
tions, the suppression of the catamenia, men-
tal excitement, high-seasoned food, late hours,
balls, the other forms of leucorrhoea, &c.
   23.  C. Treatment.—During an early stage of
the complaint, cupping on the loins or sacrum,
abstracting blood according to the severity of
the symptoms, and constitution, and habit of
body of the patient, is generally requisite ;  and
a repetition of it may be necessary.  If the cat-
amenia be difficult or scanty, a number of leech-
es should be applied below each groin a day or
two before the expected return of this evacua-
tion.   The hip  bath, or fomentations  to  the
lower parts of the abdomen and back, once or
twice daily, will often afford additional relief.
Injections of tepid water into the vagina three
or four times a day, or of a tepid decoction of
poppy heads, if pain continue, or if the bladder
be irritable, and the horizontal  position,  are
generally  beneficial.   The  bowels should  be
kept open by gentle and cooling aperients, such
as the tartrate of potash, the super-tartrate of
potash with confection of senna, or castor oil.
Active purging, especially by resinous  purga-
tives, ought to be avoided.
  24. When  this complaint  becomes  chronic,
its removal is difficult, particularly if it be as-
sociated, as it often is, with uterine or vaginal
leucorrhoea.   In these cases, the horizontal po-
sition ; frequent vaginal injections of tepid, an-
odyne, and gently astringent fluids ; attention
to the secretions and excretions, and particu-
larly to the state of the bladder ; regular, light,
and spare diet, and alteratives suited to the pe-
culiarities of the case, are usually required.   I
have seen benefit arise from the super-tartrate
of potass, with precipitated sulphur, and either
with confection of senna or with any aromatic
sirup, taken every night, so as  to procure one
copious pultaceous evacuation in  the morning
If the bladder  be irritable, demulcents, with the
compound tincture of camphor and liquor  po-
tassae, will be  serviceable, particularly if aided
by tepid anodyne injections.  If tenesmus  oc-
cur,  a small cupping  on the sacrum,  and a
starch enema, with  a little sirup of poppies,
will be of service.  In other respects, the treat-
ment may be  much the same as that advised
for uterine leucorrhoea ($ 41).
  25. IV.  Uterine Leucorrhoea.—It is some-
times difficult to determine whether the dis-
charge from the female organs proceeds from
the vagina, or from the uterus, or from both ;
still, a tolerably accurate inference  may be
drawn, and it  is often of consequence, as  re-
spects the treatment, that  a  correct opinion
should be formed as  to this point.  That the
uterus often  is the  affected organ, has been
proved by the quantity of whitish or colourless
fluid found in it  after death, the female having
been subject to leucorrhoea during life.   Blat-
tin states that, in nine cases  out of twenty-
four that he examined, the discharge proceed-
ed from the uterus.  The older writers believed
that  the  uterus  was  the source of it  in  com-
mon with the vagina, without, however, sta-
ting the symptoms which are proper to the af-
fection of this organ.  Many modern authors
entertain a similar opinion.  Baglivi, Friend,
Astric,  Manning, and Leake consider that
the discharge proceeds chiefly from the ute-
rus.   Denman, Burns, and Hamilton distin-
guish,  although briefly and  imperfectly, the
uterine and vaginal  leucorrhoea.   Dr. Locock
thinks it difficult to establish a distinction, and
does not attempt it.  Dr. Blundell treats of
vaginal leucorrhoea only ; whde Gardien, ('a-
puron, Duges, Lisfranc, and Nauche consider
the complaint as  one chiefly  of the  uterus.
Siebold, Joerg, and  Churchill have  descri-
bed the uterine variety at due length, and have 
LEUCORRHCEA—Uterine.
821
insisted upon the importance  of recognising
the existence  of the  uterine  affection.   M.
Marc d'Espine has given the results of his ex-
aminations with the speculum in 193 cases, and
they have  been referred to by some very re-
cent writers, but without remarking that these
examinations were entirely of patients  in a
venereal hospital: a circumstance that entire-
ly vitiates his data, if made the basis of infer-
ences as to the female  community in general.
Bearing, however, in mind the description of
persons  thus examined, the results  may be
worth recording.  In 23 of 193 cases, the ute-
rine orifice was found  dry; in 40 there  was
only a drop of discharge in the orifice ; and in
130 the discharge was abundant.  The orifice
itself was in some quite healthy and pale ; in
others,  red, or deep red;  and in some  deep
red, granulated,  and  bloody.  The following
table exhibits the character of the discharge,
and the state of the uterine  orifice in 111 cases :
Aqueous discharge .  .  .  .
Albuminous transparent dis-
  charge  .......
Albuminous semi-transparent
  discharge streaked  blue,
  gray, or yellow  ....
Opaque discharge streaked .
Orifice
healthy.
Orifice deep
 red and
granulated.
10
  [Dr. W. C Roberts, in  the N.  Y. Journ. of
Med. and the Coll&t. Sciences, vol. iv., v., has, in
a very able and  comprehensive essay on the
pathology of leucorrhoea, given a summary of
the views of preceding writers in relation to
its  pathology, together with his  own  views,
derived from a very extensive experience with
the speculum.  Dr. It. thus concludes his ob-
servations :  " We have now presented to the
reader fifty-nine authentic  cases in which leu-
corrhoeal discharge depended upon organic le-
sion of the womb, or vagina;  it  would  have
been easy to have increased the  number, but
this would be unnecessary, for unless it can be
shown that, which is contradicted by the united
testimony of all who have  published the result
of their observations,  leucorrhoea is also fre-
quently seen to exist in the absence of any ap-
preciable morbid  state, these are  surely  suffi-
cient to establish the real and symptomatic na-
ture of the flux in question.  In forty-six out
of these fifty-nine cases, it is distinctly stated
that the neck of the uterus was either swelled,
red, livid, or granular;  in two or  three only  it
presented a natural appearance as to size and
colour, the redness being confined  to the inter-
nal lining membrane.  In thirty-three out of the
fifty-nine, ulcerations existed ; in forty, the dis-
charge was distinctly to be seen escaping from
the os uteri; in others, this is not noticed ; in
five, the vagina was red ;  and in two only was
the discharge chiefly follicular.  The last state-
ment  sets at rest the idea that leucorrhoea is,
for the most part, a  vaginal disease ; whereas
its almost constant connexion with an inflamed
state  of the neck and internal mucous lining
of the uterus  and vagina  is  clearly demon-
strated  by evidence which we firmly  believe
cannot be shaken, and the truth of which far-
ther observation will  serve only  to confirm.
The progress  and effects of the  inflammation
are not the same  in all cases ; in some we find
only the  mucous membrane of the womb vas-
cular and secreting an increase of its natural,
or a somewhat modified discharge.  In others,
ulcerations of a more or  less depth,  extent,
vividity,  and  variety of appearance are met
with;  in many cases associated  with  general
or partial swelling and redness  of the  neck,
with granular tubercles or papules, and with
more or  less redness of the vagina, in which
case the follicular discharge of that  part  is
usually much increased.  Which of these le-
sions is the starting-point  it is difficult, though
practically not unimportant, to decide ; but it is
perhaps  sufficient  to  know that such  is their
mutual dependance on each other, that  each,
when met with, requires special  attention be-
fore coexisting ones can be removed.   Thus, a
muco-hysteritis may cease upon, or its cure re-
sult  in the disappearance of a congestion  of the
neck ;  while the latter has equally been seen to
subside upon the cure of an ulceration,  or an
ulceration to  require the removal of one or both
of the other morbid states, before it could  be
made  to cicatrize.   Such we believe to  be,
even in cases which present the appearance of
great constitutional debility, the true pathology
of leucorrhoea ;  and we flatter ourselves that
we have, in the foregoing  pages, drawn the at-
tention of the profession to the fact, scattered
about, we acknowledge, in many volumes, but
not  before  insisted upon  and illustrated with
equal force and distinctness, of the dependance
of leucorrhoea upon certain phlegmasial  states
of the vagina and uterus, of its being  not a
disease per se, but a mere symptom of disease
in the parts by which it is secreted, and seldom,
if ever, the result of simple atony of those parts,
as has so long been surmised.  Nor is the dis-
charge alone, we apprehend, often,  if ever, the
sole cause ofthe debility which confessedly so
often attends it, but which depends rather upon
the  constitutional  irritation and derangement
of the general health, consequent upon the ex-
istence of a chronic local phlegmasia.  The er-
ror which Broussais so ably exposed relatively
to certain cases of dyspepsia has been extend-
ed to the disease in question ; the morbid effects
of chronic gastro-enteritis and muco-hysteritis,
and, to a certain  extent,  their pathology,  are
analogous, and their cure  depends alike upon a
judicious employment of  a  suitable antiphlo-
gistic treatment, and the avoidance of the nat-
ural and  artificial stimuli ofthe organs diseased.
But, while we have questioned its frequency,
and adduced abundant evidence  to justify our
incredulity, we have not wholly denied  the rare
but  possible occasional indubitable occurrence
of cases  of either, dependant, if the  reader will,
upon a simple atony ofthe part, or an increase
not  appreciably morbid of the secretory irrita-
tion, upon which  the phenomena of either de-
pend.  The term  ' weakness' has long been a
cloak for ignorance, and the more enlightened
pathology of modern times has established that
of all chronic fluxes upon  a more rational and
scientific basis.   Few are not now known to
depend upon a state  of inflammation  more or
less acute:  if there be other causes for the
uterine,  we have not encountered a case which
countenances the  idea. The lesions of the va-
gina and uterus, with which we have shown
that leucorrhoea is so invariably connected, are
not  sufficiently appreciable and seldom curable 
822
LEUCORRHCEA—Uterine.
without the aid ofthe speculum, an instrument
as indispensable in the treatment of the dis-
eases of these organs, as  the  stethoscope in
those ofthe heart and lungs, and to the non-use
of which the errors of our predecessors on the
subject of the uterine catarrh are referable.  It
is not even now—for two very obvious reasons,
the disagreeable nature of the investigation,
and the natural repugnance of  both physician
and patient to  its use—the custom to employ it
in  the treatment of leucorrhoea   But  if the
physician can but become assured of its value
and necessity in these cases, he will, in justice
to  his patient and himself, recommend and em-
ploy it.   Its use will then become custom, sur-
prise at its proposal will soon  cease to be felt;
nay, surprise  may even be expressed  if the
usual means of full investigation be not resort-
ed to, and the sufferer with leucorrhcea will
look to be examined with the speculum with as
much certainty as the phthisical one does to be
percussed and auscultated.  The objections to
its use must yield  to the sense  of its necessity
and utility; and when conscientiously and prop-
erly urged, there will  be found, after all, few
sensible and right-minded females who will ob-
ject to  its employment; when  properly used,
few will refuse to consent to a repetition.  We
trust that no other than a conscientious  belief
in both, founded upon  our ideas of the nature
and cure of the affection,  and  the opinion of
others, impels our  advocacy of it in the disease
in question ; and whenever it shall come to be
generally employed,  much suffering will  be
speedily obviated,  many errors in  diagnosis
corrected, many a barren woman will become
the joyful mother of children, and many  a case
of ultimate degeneration into incurable  malig-
nity will be prevented."]
   26. That it is important to explain the differ-
ences in the local and constitutional symptoms
characterizing uterine  and  vaginal leucorrhoea
cannot be questioned, and these have been well
shown by Dr. Churchill.   That the discharge
may proceed from both the uterus and vagina
in the same case, must be admitted ; and that
the vagina is seldom exempt  when the  uterus
is  affected, the discharge from the latter gener-
ally keeping up some degree of affection in the
former, may also be conceded ; still, a knowl-
edge  of the symptoms attending the affection
of the uterus  aids us remarkably in determin-
ing whether or not  this organ is the chief source
ofthe complaint.
   27. A. Symptoms.—Uterine leucorrhcea is a
more or less profuse discharge of fluid from the
internal  surface of the uterus,  varying in col-
our ;  and is neither accompanied nor followed,
necessarily, by organic change.   It may affect
females of all ages, from the time of approach-
ing puberty; and it may assume  acute, sub-acute,
and chronic forms;  the first and second of these
states occurring chiefly in  the  young, robust,
or middle-aged.  It may occur in every tem-
perament and  habit of body,  but with varying
local and constilutional phenomena.
   28  a. Acute uterine leucorrhea is not so rare
an  affection  as Dr. Churchill supposes.   I
have seen several  cases of it; and, in  some,
the symptoms have been so severe as to amount
to inflammatory action, the disease being rath-
er hysteritis, with copious  discharge from the
internal surface ofthe uterus, than simple ute-
rine leucorrhoea.  When gonorrhoea  occurs fn
the female, it is very apt to extend to the ute-
rus, and to simulate an extremely acute form
of leucorrhcea, or to cause inflammation of the
uterus.  Acute uterine leucorrhcea is attended
by considerable  local suffering  and  constitu-
tional disturbance; more or  less pain  or un-
easiness is felt between the sacrum and pubis,
or in the hypogastrium, and is increased upon
firm pressure in  the latter situation.   The un-
easiness extends to the perinaeum and vulva ;
and the patient  complains of dragging  or un-
easiness in the loins, sacrum, hips, and thighs,
sometimes with  frequent desire to pass  water,
or with  spasmodic  retention of  it.   These
symptoms are generally increased by standing,
walking,  or exertion,  and are  often  accom-
panied with  hysterical symptoms, quickened
pulse, and  thirst.  On examination  per vagi-
nam, the cervix uteri is sometimes  tender to
the touch, or slightly swollen.  The  discbarge
varies  in  quantity and  appearance; it  some-
times is copious, and evacuated in considera-
ble quantity, affording marked relief, when  it
becomes scanty or ceases for a time;  and  it
afterward  reaccumuJates, and  is discharged
more abundantly. In these cases, the local and
constitutional  symptoms, varying  much with
the severity of the  disease, and the state of the
patient, indicate inflammatory irritation of, or
vascular determination to, the internal surface
of the uterus, with increased secretion  in this
situation.   In some instances,  the  secretion
seems  to accumulate in the uterine cavity, and
occasions an increase of the symptoms, espe-
cially of the uneasiness or pain  in the vicinity
of the uterus, and of the lassitude, malaise, and
pains of the joints  before its  discharge.  In
some instances it has presented  a puriform ap-
pearance, but  it varies  in different  cases, and
even in the same case.
  29. b. The sub-acute state is merely a milder
form of the preceding, and differs from it only
in the  greater mildness of the symptoms.   If
either this or the more acute state be  not cured,
it gradually subsides into the chronic, present-
ing,  however,  several  exacerbations  in its
progress, particularly before or after the men-
strual period, which it may in some cases even
replace, with so marked an aggravation of all
the symptoms as to amount to  a form of in-
flammation of the  uterus described in the arti-
cle on that organ.
  30. c. Chronic  uterine leacorrhoea  is a very
common complaint;  and, although it occasion-
ally follows the preceding states, it much more
frequently  commences  in slight disorder, or
with a mild state of the symptoms above enu-
merated.  As the complaint proceeds, languor,
weakness in the loins, headache, aching in the
joints after exertion, pallor of the countenance,
with a darker shade of colour under the eyes,
and increased discharge from the genitals, es-
pecially at intervals, or shortly  before  or for
some time after menstruation,  are commonly
present.   When it  has become persistent, or
so chronic  as to affect the general health, and
especially if it have superseded the catamenial
evacuation, the  local and general symptoms
are much more severe.   A constant  aching or
pain is felt between the pubis  and sacrum, with
a sense of dragging in the loins, or  of weight
and occasionally of bearing down in the pelvis. 
LEUCORRHCEA-1
•Uterine—Diagnosis.
823
  31. The  patient  now  often  complains  of
headache, of languor, and indisposition to ex-
ertion, of exhaustion after slight exertion, and
sometimes  of vertigo  and faintness,  which,
with  the  headache, are owing to  debility and
insufficient  circulation  in the brain.  Pain is
occasionally felt in the spine, or in the back of
the head, and is unattended by intolerance of
light  and noise.  Sympathetic pains are often
felt in different parts.  The tongue is loaded,
sometimes dry, yellowish, pale, sodden, or flab-
by, and often  indented by the teeth.  The ap-
petite is impaired  or capricious ;  the bowels
and liver become torpid or insufficiently active,
the face pallid, the eyes sunken and surround-
ed by dark circles,  and eruptions of acne punc-
tata appear  on the forehead and face.  At last
the pulse is small, quick, and weak ; the sur-
face is flabby and  pale, the ankles swell, and
the countenance is waxy, yellowish, or chlo-
rotic.
  32. On examination  per vaginam, the  body
of the uterus  feels somewhat enlarged.  The
os uteri is a little more open than in the healthy
state; but its sensibility  is not materially in-
creased.   The French practitioners, and a few
British, who delight in the parade of this mode
of research, inform us that the speculum uteri
shows the cervix uteri pale,  slightly rose-col-
our,  deep-red, or spotted ; yet I suspect that
few reflecting physicians will consider them-
selves much enlightened  by the discovery, or
will be  induced  to prescribe according to the
shade of colour thus detected.  Yet, the great
fuss, parade, and seeming pains evinced, with
the apparent object of getting at the truth, es-
pecially when  it lies deep, are not without their
influence upon the mind of the patient; and the
knowledge supposed to be obtained thereby is
considered  great in proportion to  the trouble
and difficulty of procuring it.
  33. The discharge varies much  in quantity.
It is sometimes profuse.  In most  instances it
is colourless and semi-transparent; in others it
ra opaque,  and  presents  either  a  yellowish,
greenish, or brownish tinge.  It varies in con-
sistency, from a very thin or watery mucus,
to a gelatinous mucus resembling the white of
a raw egg, or  to a curdled-like matter in a few
instances (Hamilton, Nauche, &c).   It  is
usually bland ; but Dr. Churchill has observed
it so acrid as to excoriate the labia and adjoin-
ing skin.  I have observed this acridity in two
instances  of the complaint occurring in con-
nexion with the accession ofthe catamenia.
  34. Chronic  uterine leucorrhoea may continue
for a very  long period,  and prove inveterate,
however judicious the treatment may be   Its
duration will depend upon the  constitution of
the patient, and the causes which occasioned
it. If those causes continue in operation during
the treatment, as is very frequently the case,
the complete removal of the complaint is not
only  difficult,  but nearly impossible,  until a
change takes place in the patient's habits and
feelings.
  35. B. Diagnosis.—a. The circumstances more
especially diagnostic of uterine leucorrhoea are,
as Dr. Churchill  has  justly shown, 1. The
occurrence of  the discharge in young, delicate
females at one, two, or three of the monthly
periods preceding the evolution of  the catame-
nia, these causes indicating  incipient activity
of the uterus, with deficient vascular determi-
nation.  2.  The  discharge  of whites  during
subsequent  monthly periods, where menstrua-
tion has  been suppressed.  3. An  increased
discharge during two or three days previous to
menstruation, and immediately after it, in those
cases  where leucorrhoea  is more persistent ;
in these, the leucorrhoea may gradually dimin-
ish the catamenia, until it entirely supersedes,
or becomes  vicarious of it.  4. The occurrence
of menorrhagia in connexion with leucorrhcea,
the latter preceding or following, or  both pre-
ceding and following the former, sometimes in
great abundance, and occasionally continuing
during the intervals between the menorrhagia.
5. The discharge of whites about the cessation
of the menses, and the substitution of it for the
menstrual evacuation.   6. The appearance of
leucorrhcea  in place ofthe menses, in chlorotic
females, as  not infrequently observed.   7. The
termination of abortions, or of the  coloured
discharge  attending them, in leucorrhcea.  8. A
similar transition of the  lochia, after delivery,
into the  colourless  secretion.   9. To these I
may add, the copious discharge of the morbid
secretions at intervals, and sometimes after an
exacerbation of the local symptoms ;  and, 10.
The local and constitutional symptoms  char-
acterizing this form of the complaint, as above
described.   It should, however, be kept in rec-
ollection  that uterine and vaginal leucorrhoea
both often coexist in the same case ;  that the
glandular  irritation  of the  os and cervix uteri
(Y 19) may be associated  with  either or with
both ; and  that, although vaginal leucorrhoea
may often exist alone, uterine leucorrhcea, es-
pecially in a chronic form, and when the fluid
is at all acrid, will be accompanied with a dis-
charge from the vagina, and occasionally even
from the vulva also.
  36. b. This  variety is with difficulty  distin-
guished from uterine gonorrhea, unless the su-
perficial erosions, described by M. Ricord, be
present.   Still, attention  to the history of the
case, and the greater severity of the symptoms
than even in the acute state of the complaint,
will indicate its nature.   In two cases of ute-
rine gonorrhoea, which were treated  by me in
1839 and 1841, and which occurred in recent-
ly married ladies, the symptoms were still more
acute than  those above  described, and were
consequent  upon  the affection  of the  vulva,
urethra, and vagina. There were much heat,
swelling, and pain in the parts, and in the re-
gion ofthe uterus, the uterine symptoms being
exacerbated at intervals, and followed by a co-
pious discharge of yellowish, opaque, puriform
matter, occasionally coloured with blood, and
generally increased immediately after the  ex-
acerbations.   The discharge assumed a  green-
ish  hue after  a time, and  the  disease  subse-
quently appeared  in the usual form of chronic
uterine leucorrhoea, presenting many of  the
features of  gleet  in the male.  The severity,
character, and history of the  case, and what
has already  been advanced on the subject, will
generally disclose the nature of the complaint.
  37. c. Inflammatory irritation of the glandu-
lar apparatus of the os and cervix uteri is  distin-
guished from uterine leucorrhcea by the  regu-
lar white puriform  discharge, and the tender-
ness of the  part on pressure, these character-
istics being only occasional or accidental in the 
824                     LEUCORRHCEA—Uterine—Treatment.
latter.   The slightest attention to the history
of the  case will prevent the  discharge of the
contents of an abscess ofthe uterus, ovary, cel-
lular tissue, or adjoining parts, by the vagina,
from being mistaken for this complaint.
  38. C. The causes of uterine leucorrhcea are
diversified, and are oftener inferred from va-
rious circumstances than from direct testimo-
ny or satisfactory proofs.   They are constitu-
tional, local, and mental; and individual caus-
es belonging to these classes of influences may
be variously combined in their operations in
different cases.  Delicate,  susceptible,  and
scrofulous  persons  seem most predisposed to
this complaint; and the inordinate indulgence
of the emotions, especially of the desires, often
concurs with other causes in producing it.  Lo-
cal excitement, venereal excesses, masturba-
tion, and sedentary habits, or indolence, are
certainly influential agents in  developing it.
Fatigue, over-exertion, cold, humid, and mias-
matous  localities, sedentary occupations,  fre-
quent abortions or child-bearing, undue or pro-
longed  suckling, the use of emmenagogues, or
of stimulating  injections,  or of pessaries; a
too rich, stimulating, full, or  heating  diet  and
regimen ; the suppression of other discharges ;
the too  frequent  use of resinous purgatives,
and  the irritation  of intestinal worms, may
severally, or in various  combinations, be con-
cerned in producing this form of leucorrhcea.
  39. D. The nature of uterine leucorrhcea can
hardly  be  mistaken.  The concomitant signs
of debility lead many to infer that it  is a  dis-
ease of debility, and proceeds entirely from re-
laxation ofthe internal surface and parietes of
the  uterus.  This may be the case, in some
degree, especially after the complaint has con-
tinued  for a considerable time.  Others, again,
believe  that the discharge is  altogether owing
to acute, sub-acute, or chronic inflammation of
the interna] surface of the womb, according to
the  forms  it  assumes, and that the local and
constitutional  symptoms are owing  to these
states  of vascular action in the organ.  Prob-
ably there  are many cases  in which inflamma-
tory action truly  exists; and others, in which
debility, as respects the states of both the in-
ternal  surface, and  of the  parietes of the or-
gan, performs its  part.   Still, I believe that too
much is imputed  exclusively to the one or the
other;  and that  a  third state, not necessarily
connected  with either, although sometimes as-
sociated with one  or the  other, is  most fre-
quently concerned in producing the discharge.
If the  circumstances connected with the  oc-
currence of the complaint  be duly considered,
there is much reason to infer that it is often
owing  to  the vascular determination to  the
uterus  and female organs,  generally  conse-
quent upon the excitement or irritation of the
nerves  supplying these organs or parts; and
that such  excitement, and the vascular deter-
mination consequent upon it, are in some ca-
ses carried almost to the pitch of inflammatory
action,  as  in the  acute states ; while in others,
as  in the  more  chronic, it is attended by im-
paired  tone of the  extreme vessels in the in-
ternal surface of the organ, and probably also,
in some instances, with deficient tone of the
parietes of the organ itself.   The importance
of entertaining correct views as to the nature
of the individual  cases occurring in practice is
manifest; for upon these views must the treat-
ment be altogether  based
  40. E. Terminations.—When uterine leucor-
rhcea is  neglected, it may give rise  to very
serious diseases, both local and constitutional.
Amenorrhcea, anaemia, chlorosis, sterility, phthi-
sis, and  even dropsy, are occasionally conse-
quent upon  neglected or  protracted states of
this affection.  These contingencies should in-
fluence our  prognosis in many instances;  but
generally a  favourable result may be expected
in the less protracted cases, and when the  ex-
citing causes are avoided.
  41. F. Treatment.—On  this subject, the ob-
servations of Dr. Churchill are extremely just,
especially as regards the use of astringent in-
jections, and  agree with  those  which I have
promulgated for many years.—a.  In the acute
and sub-acute stales of the  complaint, the local
abstraction  of blood by cupping on the  sacrum
or loins, or  by applying a number of  leeches
below both groins, or to the vulva, [or os uteri,]
when the catamenia are scanty or suppressed,
is generally requisite;  and, in some cases, a
repetition of the depletion is necessary.  The
hip bath, and injections of warm water per va-
ginam, are subsequently of service.  The bow-
els should be kept gently open by  means of
cooling aperients and laxatives, such as those
mentioned above (v 23);   and small doses of
camphor, of the liquor  ammonia; acetatis  and
spiritus aetheris nitrici, to which small quanti-
ties either of the vinum ipecacuanhae or of the
liquor antimonii tartarisati may be  added, ac-
cording to circumstances, should be given every
four or five hours.   After the more acute symp-
toms have  been  removed  by  these remedies,
the application of a blister on the sacrum, as
advised by Dr. Leake and  Dr. Churchill,  and
the repetition of it oftener than  once, if the
case be obstinate,  will  be found of great  ser-
vice ; or either of the liniments (Nos. 296, 298,
311) in the  Appendix may be kept applied, on
two or three folds of flannel, as an embrocation.
  42. b.  In  the chronic  state of uterine leucor-
rhcea, blisters on the sacrum, or the  terebinthi-
nated embrocation  on the sacrum, or  loins, or
on both ; the occasional recourse to an enema
with  about  an ounce of the spirits  of turpen-
tine  ; and the sulphate of quinine, with camphor
and  capsicum, in doses of about two  or three
grains of each, taken twice or thrice daily, are
the means which I  have found most beneficial.
Dr. Churchill states that the medicines which
he has found most  useful are :  1st. The balsam
of copaiba,  in pills, or otherwise, increasing the
dose from  fifteen  minims; 2d. The  sulphate
of iron, with blue pill, or the compound rhubarb
pill;  3d. Decoction of logwood; and, 4th. The
ergot of rye, in doses of five grains, three or
four time a  day.
  43. The tincture ofthe sesqui-chloride of iron,
with tincture of cantharides; the sulphate of
iron, with camphor and rhubarb;  and  the  sul-
phate of zinc, with  aromatics,  &c, have sever-
ally  been prescribed by  me  with advantage.
Iodine has  been advised  by Brera, Gimelle,
and  Sablairolles, especially in very chronic
and  obstinate cases.   My experience  of  th/8
medicine leads  me to recommend a trial of it
when the disease is associated with scanty or
difficult  menstruation,  and when the system
presents a pallid, anaemic, or chlorotic appear- 
'LEUCORRHCEA—Uterine—Treatment.                       825
anc(?, and then tne iodide of iron,* and the prep-
arations of guaiacum, will often be of service.
The ergot of rye  has  been  recommended by
Roche, Dufrenois, Negri, Ryan, and Church-
ill, and  may be  given in larger  doses than
those  prescribed by the last  of these writers,
conjoined with some aromatic powder or spice.
It is most serviceable in those cases which are
connected with  menorrhagia or excessive men-
strual discharge, in which cases I have found
the arsenical solution also productive  of great
benefit.   Besides these, the ammonia-citrate, or
the ammonia-tartrate of iron, the preparations of
krameria, or of uva ursi, or ofthe pareira brava,
or of the diosma crenata,  [or  pyrola umbellata,]
may he employed, especially  in the more obsti-
nate cases.   M. Nauche advises the use of aro-
matics;  Dr. Hunt, of the capsicum;  Drs. Fis-
cher,  Roberton, and Dewees, the tincture of
cantharides; Hecker, the cascarilla bark; Lange,
camphor with oil of amber and  nitre ;  Marcus,
the aromatic sulphuric acid of Haller ;   Lett-
som, the ammonio-chloride of iron, in the infusion
of  quassia;  Hufeland,  the  muriate  of lime;
Ranoe, cinchona with lime-water; Stoerck and
Quarin, the conium, both  by  the mouth  and in
injections ; White, the willow bark; and Zacu-
tus Lusitanus, the insertion of a seton, or issues.
   44.  An occasional recourse should be had to
aperients of a stomachic and  tonic kind, as the
sulphate or super-sulphate of potash  with rhu-
barb, or the compound  infusions of gentian and
senna;  and the operation of these may  be aid-
ed by suitable enemata.   Advantage will often
accrue from the use of chalybeate mineral  waters,
[as those of Saratoga,] in connexion withchange
of air ;  and from sponging the back, loins, and
hips, and lower part ofthe abdomen with tepid
or cold  salt and water, or vinegar and water.
Afterward the shower bath,  the  cold douche on
the loins, or cold sea-water bathing will be of
 service.   Dr. Leake advised  tonic infusions in-
 ternally, blistering the sacrum,  and the " use
 of the Tunbrtdgc, or Pyrmont  water for common
 drink ; or the artificial Spa water, impregnated
 with  iron  and  fixed  air,  as directed  by Dr.
 Priestley."  If these occasioned costiveness,
 he prescribed senna tea, or imperial drink with
 manna.
   45. If pain or local irritation exist, the prep-
 arations of opium, henbane,  or conium  may be
 conjoined with the remedies  prescribed, or may
 be administered  in enemata.   If the acridity
 of the  discharge  occasion  excoriation  of the
 labia, or of parts in the vicinity, lotions contain-
 ing the  acetate of lead, or sulphate of zinc,
 with  vinum  opii,  may be used.  The  utmost
 care should be taken to wash away the morbid
 discharge  by tepid injections,  with or without
 small doses of anodynes, or the poppy decoc-
 tion ;  yet no  benefit  will result, but, on the
 contrary, much risk may be  incurred, in this
 variety of the disease, from employing  astrin-
 gent or stimulating injections per vaguiam.   I
 have  been called  to cases where recourse  to
 these had been followed by inflammation of the
 uterus, and by the appearance of disease in the
 lungs, and other ill consequences.
    46. Strict attention ought Jo be directed to
   * This preparat.on~aT.Tthe iodide of sulphur were made
 by Mr. Mohson, at my suggestion, as eary as 1826, and De-
 scribed by me in various disease since that time. The S RUP
 i. the  best preparation of the todxde of iron, as  all others
 are readily decomposed.
     II.                104
the states of the digestive functions, and partic-
ularly ofthe bowels ; and derangements of the
menstrual discharge should be ascertained and
removed.
   47.  The diet and regimen always require regu-
lation.  I have met with cases, particularly in
connexion with a too copious or too  frequent
menstrual discharge, which appeared to have
been prolonged by a  too  full and  stimulating
diet, in connexion with other indulgences.   In
these cases, the quantity and quality of the food
and drink of the patient should be strictly pre-
scribed ;  and  a separate  sleeping apartment,
and  cool  but  sufficient clothing of the  loins,
hips, and limbs, early hours, and removal from
the dissipations of the metropolis, ought to be
directed, and  continued  according to circum-
stances.*
   [There is no disease in  which treatment is
more apt to  be  empirical than  leucorrhcea.
This  arises from incorrect notions  as  to  its
pathology and true nature.   The various forms
of the malady vary very widely from each other
in degree, and require corresponding variations
in treatment.   If the discharge is of a mucous,
transparent character, it will yield to very sim-
ple management, as astringent injections, rest,
abstaining from sexual intercourse,  &c. ;  but
if the disease is inflammatory, marked  by a
purulent  discharge, hard  pulse, increased heat
about the genital organs, with swelling, or pain
in  the loins and hypogastric region,  the anti-
phlogistic treatment must be promptly resorted
to, as general and local bleeding, by leeches to
the vulva, or os  uteri  (Dr. Ashwell recom-
mends  scarifying  the cervix  with   a  lancet

   *  [Few disorders of a more perplexing nature fall within
 (he scope of the medical prescriber than  those connected
 with the disturbed condition of the uterine function under
 the various forms of leucorrhoea.  As a general  rule, we
 may safely class  them under the two heads of acute and
 chronic ; those associated more especially with the vagina,
 and those which involve the condition of the uterus itself.
1 Vaginal discharges, by continuance of the infirmity, almost
 always, after some duration, involve the state ofthe uterus;
 and, in a medico-legal point of view, as well as in their re-
 sults upon the constitution at large, are to be deemed of se-
 rious import.  When the discharge is of a puriform charac-
 ter, we have the strongest reason to believe in its acute or
 inflammatory nature.  The principle arising from consider-
 ing these discharges either of a passive or chronic nature,
 or of an acute character, necessarily points out  our best
 remedial measures. That the complaint is, in many in-
 stances, owing to the great vicissitudes of our climate, is a
 recognised fact; and the preposterous use of cold applica-
 tions must also be pronounced a frequent source of it.  Nor
 are we to forget that the disorder is sometimes dependant
 upon a gonorrhoea! cause.  This last form of the disease  is
 ever to be treated in reference to its specific origin. The
 active treatment of the complaint, when of an inflammatory
 nature, must be  urged upon the practitioner, consisting of
 repeated losses of blood by the arm and by local measures,
 together with saline purgatives, the infusion of senna, and
 the like.  Among the most valuable local remedies for the
 inordinate discharges which mark leucorrhcea, the introduc-
 tion, lately, of tannin, gives promise of much benefit.  One
 or two drachms of tannin, dissolved in sixteen ounces  of
 pure water, is an admirable wash for the purposes indicated
 in this disease, and, as an injection, can often be advanta-
 geously used.  American physicians, from the recommend-
 ation of Dr. Dewees. have made free use ofthe tincture  of
 cantharides internally, with the view  that by its general
 tonic and stimulant effects it would mitigate the evils of leu
 corrhtea, and restore the system to its .ordinary functions
 It has unquestionably proved-serviceable in many instances:
 as a lotion, however, for the many annoyances which the,
 female suffers from leucorrhcea, the tannin seems destined
 to hold a  favourable place.  According to Dr. Francis, it
 has many advantages over a great number of astringents for-
 merly much in use.  M. Gibert, one of the physicians  of
 the hospital of St. Louis, has very lately introduced the al-
 coholic extract of tannin as a new astringent vaginal injec-
 tion, for the cure of leucorrhceal discharges.] 
826
LTCHENOUS RASHES—Description of.
mounted on a  piece of  whalebone), together
with emollient and soothing injections, and the
other  means  usually  recommended  in  such
cases.
   In the  treatment of leucorrhoea,  especially
when chronic, we  have  found an  injection of
the nitrate of silver very successful in arresting
the discharge;  also of tannin.   Creasote  may
also  be used with great  advantage by  mixing
20 drops of it with 31J.  of a solution  of potash,
Z\). white sugar, rubbed together, with jviij. of
water, for an injection, to be thrown up three
times a day.   We have  also known  an injec-
tion of iodine succeed, after other remedies had
failed.   It should be employed by way of injec-
tion,  prepared by mixing  9iv. of iodine with y.
of alcohol, and jviij. of water;  one fourth  part
to be employed  night and morning,  using  the
compound tincture of the same article internal-
ly.  A bit  of sponge soaked  in this solution,
and passed high up the  vagina, to  remain in
contact with the os uteri over night, will often
be followed  by the best  effects.  A decoction
or infusion  of pyrola umbellata,  diosma crenata,
or the pareira brava, we have found almost  spe-
cific  in  correcting the  unhealthy state of  the
vaginal secretions, and restoring healthy action.
   Dr. Kopp, in  a recent  number of  Hecker's
Annalen, recommends the following  mode of
treating leucorrhcea, which he says he has fre-
quently employed with  advantage : A piece of
sponge, of proper size to  fill completely the va-
gina, is to be dipped into the following solution,
and  introduced into it at  night, before going to
bed :  # Decoct. Ratanhie,  f xii. ; Extr. Ratanhie,
jss.; Tinct. Catechu, 3JSS.; Tinct. Kino, 3Jss.  M.
Dr. Cless  states that he cures almost all the
cases of leucorrhcea that  occur in his hospital,
at Stutgard,  with cubebs.]
  Bibliog. and Refer. — Hippocrates, Opera. Ed. Fees.,
p. 566, 637, 621. — Oribasius, Synopsis,  1. ix., c. 48, 49.—
Avicenna, Canon., 1. iii., fen.  21, tr. 3, c. 23.—Primerosius,
De Morb. Mulieb., 1. i., c. 8. —  E. Jorden, A Rational Ac-
count of the Natural Weaknesses of Women, 8vo.  Lond.,
1620.—T. Raynald, The Birthe  of Mankinde.  Lond.,  1634.
—Zacutus Lusitanus, Med. Pract. Hist., t. i.,1. iii., No. 11.
— Zacchias, Quiest. Med. Leg.,1. ix., tit. iii., qua;st. 5.—G.
Charleton, De Causis Catameniorum et Uteri Rheumatismo
(Leucorrhcea), 8vo.   Lond., 1685. — Friend, Emmenologia,
p. 105.—Morgagni, De Sed. et  Caus. Morb., Epist., xlvii.,
art. 11,25, 26.—Lange, Miscell. Veritates,  p.  77.—Mauri-
ceiu, Malad. des Femmes, &c,  t. i., p. 457; t. ii., p. 147.—
Stoerck, Libellus de Cicuta, p.  107; et Ann. Med., vol. ii.,
p. 213.—/. Leake, On Dis. of Women, &c, vol. i., p. 95.—
Stoll,  Rat. Med., P. vii., p. 155. — Whytt, Works, &c, p.
528.—Ranoe, in Acta Reg. Soc. Med. Hafn., vol. i., p. 436.
—Quarin, Tenlamma do Cicuta, Cas. 12.—Trnka de Kroz-
wiz. Hist. Leucorrhcea, 8vo.  Vindol., 1781. — Lettsom, in
Mem. of Med. Society of Lond., vol. i. — Cookson, in  Dun-
can's Med. Comment., &c, vol. iii., p. 68.—G. A. Roederer,
Abhandlung von dem Wiessen Fluss der Frauen nach Rau-
lin, 8vo.  Nur., 1793. — White,  Observat. on the  Willow,
Bark, &c, Svo.  Bath, 1798. —  J. B. Blattn, Du Catarrhe
Uterin ou des Fleurs Blanches, 8vo. Paris, 1801.—Fischer,
Bemeik. iiber die Englische  Geburtshulfe, No. iv. — Joer-
den', in Hufeland, Journ. d. Pr. Heilk., b. ix., St. i., p. 141.—
Hufeland, m Ibid., b. xvii.,st. 3, p. 181.—Roberton, in Med.
and Phys. Journ., vol. xv., p. 413.—Thilenius, in Hufeland,
Journ. d. Pr. Arzneyk, &c, b. xii., st. 3, p. 26. — Marcus,
Magazin fur die Spec. Therapie, b.  ii., p. 374. — G. W.
Hecker, der Weisse  Fluss, &c, 8vo.  Pima, 1807.—J. P.
Frank, De  Cur. Horn. Morb., 1.  v., p. 250. — C. M. Clarke,
Observat. on Dis of Females attended with  Discharges,
8vo.  Lond., 1814-1822.—/. Latham, in Med. Trans, of
Coll.  of Phys., vol. v., 1815.—Pinel and Bricheteau, Diet.
des Sc. Med., t. xxviii., art. Leucorrha .—G. M. Sporer, Ca-
tarrhus Genitalium pathologice et therapeuticc Disquisitus,
Bvo.  Wien., 1820.—V. Lepere, Traite des Fleurs Blanches,
8vo. Paris, 1823. — Lagneau, Diet, de Med., t. xiii., p. 100.—
M. Nauche. Des Maladies propres aux Femmes, Svo. Paris,
1829, p. 288.— W. P. Dewees, Treatise on Dis. of Females,
Bvo.  Philad., 1828, p. 211.—Boivin et Dugts, Traite Prat.
des Mai. de l'Uterus  et de ses Annexes, Ac, 2 tomes, Svo.
Paris, 1833. — G. Jewel, Pract. Observat. on Leucorrhn-a,
Fluor Albus, or " Weakness," 8vo.   Lond., 1830.—J. Bal-
birnie. On Org. Dis. of the Womb, &c, 8vo.  Lond., 183b.
—Marc oVEspine, in Archives Gener. de Med., Fev., 1836.
—LococJfc, in  Cyclop, of Pract. Med., vol. in., p. 34.— F.
Churchill, Outlines of the Principal  Dis. of Females, 8vo.
Dubl., 1838 ; and Med. and Chirurg. Rev., vol. xxix., p. 417.
- S. Ashwell, A  Pract. Treatise on the Dis. peculiar to
Women, part i., p  158.  (See, also, Bibi.ioq. and Refer.
to arts. Vagina and Uterus.)
  [Am. Bibliog. and Refer.—W. P. Dewees. A Treatise
on the Diseases of Females. Svo.  Phil., 1826.—W. C. Rolf
erts, in New-York  Jour, of Med. and Collateral  Sciences,
vols, iv.and v.—J. E. Taylor, in New-York Med. and Surg.
Journal, 1841.-7. C. Beales, in New-York Med. and Surg.
Journal. 1841.—7. H. Bennett and Wm. P. Buel, in Am.
Jour. Med. Sci., N. S., vol. vii., p. 96. — R. La  Roche, in
Am. Jour. Med.  Sci., N. S., vol.  xiv., p. 30.  (Dr. L. rec-
ommends highly bals. copaiva in leucorrhaia, after employ-
ing means to abate  inflammatory action.)—Edward Warren,
Remarks on  Leucorrhaea, in Bost. Med. and Surg. Jour.,
vol. xxiii., p. 281.— S. Ashwell, A Practical  Treatise on the
Diseases peculiar to Women, Am. ed., by Paul B. Goddard,
M.D.  Phil., 8vo. 1845 (ArcA. fur Medizin  Erfahrung).—
Samuel Jackson (of Northumberland), in Am. Jour. Med.
Sci., vol. xi., p. 303.  (Dr. J. highly recommends a succes-
sion of blisters over the back  or sacrum, alternated with
cupping, and keeping up a discharge by savin cerate.)—C.
G. Carus, in Am. Jour. Med. Sci., vol. v., p. 415.—Harvey
Lindsley, Monograph on Leucorrhcea,  in Bost.  Med. and
Surg. Journ., vol. xxix., p. 153. — Thomas  Close, in Bost
Med. and  Surg.  Journ , vol. xvi., p. 312. — J. Eberlt, in
Western Med. Gazette (recommends iodine in leucorrhcea
(qtt. x. of tinct.)  three times a day). See various Works
on Diseases of Females.]
LICHEN.—Syn.  TiEixriv, Papule ; Papule sic-
  ca ;  Petigo;  Scabies sicca, Auct. var.   Sca-
  bies agria;  Scabrities, Licheniasis adultorum,
   Young.   Exormia Lichen,  Good.   Der  Zit-
  terich,  Flechle, Germ.  Dartre pustuleuse mi-
  liaire; D. furfuracie colante poussie, Fr.   Li-
  chenous Rash.
     Classif.—1.  Order;  1. and  2.  Genus (Wil-
       lan).   III.  Class ;  I. Order (Author).
  1. Defin.—An eruption of papula of a red or
white colour, clustered  together  or irregularly dis-
seminated over the surface of the skin ; attended or
not  with fever, or derangement of the digestive
organs ; usually terminating in slight desquama-
tion, and very liable to recur.
  2. The term lichen was used by Hippocrates,
perhaps  in  the same acceptation  as  it  is  at
present; but this is uncertain.  It  was  applied
by  modern  writers  to impetigo, and various
other affections, till  the time of Willan, who
restricted it to a form of papular eruption,  in
which sense it has always since been employed.
  3. I. Description.—In  treating  of this  dis-
ease, I shall follow M.  Biett, and  his editors,
MM. Cazenave and  Schedel, in referring  to
the genus lichen the  various  papular affections
generally  included  under the separate heads
of  lichen and  strophulus,  these  differing little
but in the period of life at which they occur.
  4. According to this  arrangement, lichen  is
divided into two species, L. simplex,  and L. ag-
rius, and of these the several forms enumerated
by authors  are considered as  varieties.
  5.  i.  Lichen  Simplex.—This consists in  an
eruption of minute papulae of a red colour, often
acuminated, but containing neither pus nor se-
rum.  The  papulae  are distributed  irregularly
over the surface of the skin, and are  attended
with a sense  of heat, itching,  and  tingling.
They appear first  on the face or arms, and in a
few days extend  to  the trunk and lower ex-
tremities. The  eruption usually lasts for seven
or  eight  days,  and terminates in scurf;  it  is
seldom  attended  with  any febrile  symptoms
unless  when unusually abundant.   The fore-
going description  applies to the  acute form of 
LICHENOUS RASHES—Description of.                     827
lichen simplex.  In some  cases, one crop of
papulae has no sooner disappeared than another
is thrown out, and so on in succession for many
weeks or months,  and sometimes  even for
years.  The varieties of lichen simplex are :
  6. a. L. Pilaris.—In this the papulae are de-
veloped at the roots of the small hairs which
beset the surface ofthe skin.  The eruption is
almost always of a chronic  character,  and  is
accompanied with great irritability of the skin.
Bateman says that it is not infrequently con-
nected with derangement of the digestive or-
gans, induced by ardent spirits.
  7. b. L. Lividus.—This form is not common,
and is nearly confined to  constitutions broken
down  by  want and misery, or to a cachectic
habit of body.  The eruption  appears chiefly on
the legs, and consists of dusky red papulae, in-
terspersed with petechiae differing little, if at all,
from those  of purpura simplex.  The disease
is often protracted through many weeks by the
occurrence of successive eruptions  The papu-
lae,  when declining, become  of a dark  brown
colour, and finally disappear with slight  exfoli-
ation.
  8.  c. L.  Circumscripta.—Sometimes the
papulae of lichen, instead of being irregularly
scattered over the surface, are collected in
groups of a somewhat circular shape, having a
well-defined margin, and the disease then ob-
tains the above  name.  The patches extend
from their circumference  by the development
of new papulae, while those at  the centre dis-
appear with slight desquamation. The patches
in this manner often coalesce,  new ones are
formed while the old  are  desquamating, and
the disease may thus be prolonged for an indef-
inite period.   This  form of lichen occurs indif-
ferently on  the face, trunk, or  extremities;  it
is most frequent in early youth.
  9. d. L. Gyratus.—This name has been given
by M. Biett to a rare form  of the disease, in
which the papulae are arranged in  a kind of
tortuous  stripe or band.  MM. Cazenave and
Schedel describe a case  in  which this  band,
commencing at the anterior part of the chest,
passed along the  inner side of the arm, follow-
ing exactly the course of the ulnar nerve, and
twisting on itself till it reached  the extremity
ofthe little finger.  Rayer says he has seen it
forming a kind of collar in front of the neck ex-
tending from one ear to the other.
  10. e. L. Urticatus.—In this  the papulae are
much larger than in the preceding forms, and
coalesce into wheals somewhat resembling the
sting of a  nettle.  L. urticatus is most frequent
in children, but  is occasionally met with in
young persons of both sexes,  and in females of
more advanced age.  It is usually confined to
the  neck and  arms, but may also extend over
the  trunk and extremities.   It sometimes dis-
appears and recurs several times in succession,
and is sometimes succeeded by a  slight des-
quamation.  It is occasionally attended with
slight  febrile  symptoms,   especially  towards
night, when the eruption causes more irritation.
This form of lichen occurs principally in  spring
and autumn.
  11. g. L. Strophulus.—This includes several
varieties of papular disease, which are all most
frequent in infants at the breast.   The papulae
are  sometimes red, irregularly scattered, and
intermixed with small  erythematous patches:
this is the strophulus intertinctus of Willan and
Bateman, commonly called the red gum. Some-
times the papulae are smaller, but more numer-
ous, and collected in large red patches, consti-
tuting the strophulus  confertus  of the above-
named authors, and commonly called the rank
red gum.  Less frequently, the eruption consists
of small patches of papulae, which appear and
desquamate successively on different  parts of
the body : this is the strophulus volaticus of Wil-
lan and  Bateman.  In other cases the papula;
are of a whitish colour, small,  hard, rather
elevated, and sometimes, though rarely,  sur-
rounded  with a  slight redness: this is the
strophulus albidus.  At other times, again, the
papulae are of a whitish colour, but much larger,
smooth,  and glossy:  this is called strophulus
candidus.   The last two varieties are known by
the popular name of white gum.   All the forms
of L.  strophulus  are frequently connected with
dentition,  and derangement  of the digestive
organs; but they often occur, also, independent-
ly of these sources of irritation,  and without
any derangement of the general health.
  12. ii.  Lichen  Agrius—ayptoc, Papula agria,
Celsus : Lichen ferus, Good.—This species is
characterized by acuminated papulae of a vivid
red colour, very  numerous,  and accompanied
with an erythematous redness,  which  extends
to some distance around the  margin of the
patches.   The eruption is attended with a sen-
sation of itching and burning, which is so severe
that the patient cannot refrain from scratching :
this, however, greatly increases the irritation,
and by tearing off the summits  of the papulae,
occasions small  ulcers, from which a  sero-pu-
rulent fluid is discharged,  forming yellowish
crusts, which are detached  and  replaced by
others somewhat thinner.  The inflammation
often subsides, and the scabs are cast  off in
about a fortnight; but sometimes  the disease
assumes a  chronic form ;  the  scabs  become
successively thinner,  and terminate in  furfu-
raceous desquamation.  This chronic  form is
often attended with  thickening of the  skin,
which in inveterate cases becomes indurated,
rugous, and deeply figured.  In this state the
disease continues for many months, and may
even last for years.  L. agrius is often attend-
ed with gastric derangement, and in its acute
form, with febrile symptoms.   It may appear
as an original affection, or succeed to some of
the forms of L. simplex.  It is  most  frequent
in spring and summer.
  13. There is a  form of L. agrius called Lichen
tropicus,  or prickly heat,  or summer rash—the
Sudamina of various  authors ;  the Essera of
Ploucquet—which is very  frequent, and  a
source of intolerable  annoyance in warm cli-
mates.   It usually  appears  in  the shape of
numerous  pimples of a  vivid red  colour, not
larger than a pin's head, situated on the chest,
neck, arms, and  thighs, and sometimes on the
forehead.  It is accompanied with insufferable
pricking, itching, and tingling.  The eruption
often  disappears  almost entirely when the pa-
tient is cool, but  the moment he becomes heat-
ed by exercise, or by taking any  warm  or stim-
ulating liquid, it recurs with  as  much violence
as ever.   New-comers to a warm climate are
more  liable to it than long residents or natives.
A form of lichen, closely allied  to  the prickly
heat, if not identical with it, is sometimes met 
828              LICHENOUS RASHES—Cai

with  in  temperate climates  during hot sea-
sons.
  14. II. Causes.—Lichen very often  occurs
without  any assignable cause, but it is also fre-
quently attributable to exposure to heat, errors
in diet, fatigue, and depressing passions of the
mind.  L. agrius, in particular, is  often occa-
sioned by  heat and the abuse of  alcoholic li-
quors.   M.  Rayer observes, that the arms and
forearms of cooks, founders, smiths, and others
habitually  exposed to high temperatures, [to
whom may be added  millers,  grocers, and oth-
ers who handle  pulverulent  substances,] are
frequently attacked with lichen  simplex, or a
papular  eruption  having the  same  characters.
In children the eruption seems to  be often de-
pendant on intestinal irritation.
  15.  III.  Diagnosis.—Lichen  may be con-
founded with various  diseases.  L. simplex has
been mistaken for prurigo, scabies, and  eczema.
Prurigo is distinguished by  its papulae  being
larger, flatter, and  more of the natural  colour
ofthe skin than those of lichen ; the itching in
prurigo  is also much more severe than in lichen
simplex, and of a different character, being of
a burning nature, and not accompanied with the
tingling sensations of lichen.  Scabies  will be
easily distinguished from lichen by its vesicular
character, though a few vesicles are sometimes
interspersed  among the  papulae  of  lichen.
Scabies appears chiefly on the inner surface of
the arms and wrists, between the  fingers, and
on the abdomen,  while lichen affects rather the
outer and back part of  the extremities ; lichen
also frequently attacks  the face, scabies hardly
ever.  Eczema may be mistaken for lichen sim-
plex, but  only through carelessness,  it  being
easily distinguished by its  transparent vesicles.
 Syphilitic papular eruptions cannot be confound-
ed with lichen, as they are indolent, free from
itching, and have  the characteristic  copper
colour of venereal affections  ofthe skin.
   [This form  of lichen sometimes simulates
impetigo and psoriasis, but it  may be  distin-
guished from the former by its small, thin, soft,
slightly adherent scabs, which are generally
surrounded with  inflamed papulae; and from
psoriasis by the squamous crusts  of the latter
being thicker than Ihe furfuraceous desquama-
tion of chronic lichen agrius ]
   16. Lichen agrius, in its chronic form, is very
liable to be mistaken for the corresponding form
of eczema, and where the  skin is thickened, as
frequently  happens in  the latter  disease, the
diagnosis is extremely difficult.  On careful in-
spection, however, a few of  the original vesi-
cles of eczema, or papulae of lichen, may gen-
erally be detected, which, with the history of
the case, will determine the  nature of  the dis-
ease.
   17. IV.  Treatment.—Lichen simplex, in its
acute form,  usually  requires but  little  treat-
ment ;  a moderately antiphlogistic diet, a sa-
line laxative, avoidance of exposure  to heat,
and a few tepid  baths  being all that is neces-
sary.  For allaying  the  itching,  lotions with
hydrocyanic  acid  are   highly  recommended;
slightly  stimulating lotions are also serviceable.
In those few cases where the disease is attend-
ed  with fever,  gastric derangement,  &c,  a
moderute venaesection should be practised, and
a decidedly  antiphlogistic  treatment pursued.
The infantile forms of lichen, or strophulus, re-
ses—Diagnosis—Treatment.

quire no treatment apart from that ofthe morbid
states which they may accompany, as intestinal
irritation, the disturbances caused by dentition,
&c.  (See art. Dentition.)
   18.  Lichen agrius, in its acute  form, even
when  not attended  with fever, is benefited by
decided antiphlogistic treatment;  and a venae-
section tends greatly to relieve the irritation of
the skin.  Leeches applied around the most in-
flamed patches  are  very serviceable, but care
must be  taken  to  place them quite beyond the
limits of the erythematous surface.  Other local
means are seldom  of much use ; among the
best  are emollient  poultices,  applied scarcely
 lukewarm.  Tepid baths are  beneficial, as in
the simpler forms of the disease.
    19. The chronic forms of lichen generally re-
 quire a  tonic  treatment.   Decoction of bark
 with sulphuric acid  is often very beneficial, and
 in obstinate cases the arsenical solution may
 sometimes be used with great advantage.  In
 the advanced stages, when all acute inflamma-
 tion  has subsided,  alkaline  and  sulphureous
 baths are among the best remedies that can be
 employed.   An ointment  containing  calomel
 and camphor, or the proto-ioduret of mercury,
 has been recommended by MM. Cazenave and
 Schedel, to be applied to the  diseased  sur-
 faces.
    20. The lichen lividus may  be considered as
 an entirely adynamic  affection  resulting from
 distress and starvation, or from a state  of gen-
 eral  cachexia, and  therefore only to  be reme-
 died by improved circumstances, change of air,
 particularly when occurring in the inhabitants
 of large towns, by  nutritious diet, tonics, and
 restoratives, conjoined with alteratives  and de-
 obstruents, according to  the peculiarities of
 the case.*
  * [" Lichen," says Dr. Bulkley (Am. ed. of Cazenave
and Schlegel on the Skin, p. 205), "in all its forms, is
most frequently connected with some disorder of nutrition,
and, in many cases, especially of the' acute forms, symp-
toms of gastric or of intestinal derangement, or of both, are
very evident.  In  such cases, the removal of the disease
must of course depend upon the removal of this disorder as
a cause.  In many cases it will not be discovered on a su-
perficial examination, and will be connected with the sec-
ondary process of digestion instead of the primary ; and its
removal depends not upon emetics and cathartics alone, but
on a judicious course of alterative remedies adapted to the
particular case, as indicated by the character of the differ-
ent secretions, and aided by long-continued attention to diet
and hygeine.  In fulfilling the indication in different cases,
acids  may be required in one case and alkalies in another,
and perhaps tonics, either with or without these, in anoth-
er ; and with the  particular remedy indicated the  general
regimen and diet  must be made to correspond.  In cases
which resist these remedies,  and when there is no contra-
indication, preparations of sulphur, or of mercury, or of
arsenic will sometimes be required, which will be assisted iu
their  action by some form of  sarsaparilla, or the extract or
infusion of taraxacum, or of the yellow dock.  The chrome
forms of lichen are among the most intractable of cutaneous
diseases, and, when neglected or improperly  treated, last
for years, imbittering  life by  the constant irritation which
they produce.
  " To relieve the itching, which often constitutes the most
troublesohie symptom, and sometimes  becomes a truly dis-
tressing one, a  great variety  of means are recommended;
but their success is so uncertain that they sometimes afford
no relief at all, and, at other times, produce only temporary
benefit.  Among those which  I have found most useful, are
camphor mixture, either alone or in combination with ace-
tate of lead, 5 grs. to fj. of the mixture ; a dilute solution
of chloride of soda or of lime ; a lotion of muriate of ammo-
nia, with vinegar  and water,  say fj. muriate of ammonia,
I iv. of vinegar, and oj. of water ; pyroligneous acid, 3j. or
more  to oj. water.  Sometimes a weak solution of nitrate
of silver affords relief, especially when there is a discharge.
Sometimes one application will succeed after another one
has been used with benefit for a time, and then lost its effect. 
LIVER—Causes of  its Diseases.                          829
  BlBLIOO. AND REFER.—Bontius, De Med. Indorum, 8vo,
Cap. 18. — Clark, On the Dis. of Seamen, vol. i., p. 34.—
Bisset, Med. Essays and Observat., 8vo, 1766.—Hillary, On
Climate and Dis. of Barbadoes, 8vo.—Cleghorn, Dis. of Mi-
norca, Svo, chap. 4.—Lorry, Tractat. de Morbis Cutaneis,
4tn, 1777. — M. Poupart, Traite des Dartres,  8vo.  Paris,
1782,—E.  Rigby, An Essay on Animal Heat and on  Cut.
Eruptions, 8vo.  Lond., 1785.—/. F. Carrere, Traite de la
Douce Amere dans les Dartres, Svo. Pans, 1789.— Willan,
On Cut. Dis.,4to. Lond., 1808.— Underwood, On the Dis. of
Children, 8vo, edit, of 1827.—T. Bateman, Pract. Synopsis
of Cut. Dis., edit, by A. T. Thomson, Svo.  Lond., p. 4,17.
—S. Plumbe, Pract. Treat, on Dis. ofthe Skin, Svo.  Lond.,
1824.— W. C. Dendy, A Treat, on the Cut. Dis. incident to
Children,  8vo.  Lond., 1827.—Cazenave et Schedel, Abrege
Prat, des  Malad. de la Peau, 8vo. Paris, 3d ed., 1838.—/.
Green, Pract. Comp. of the Dis. of the Skin, <fcc.,8vo.  Lond.,
1835, p. 175.—P. Rayer, Theoret. and  Pract. Treat, on the
Dis. ofthe Skin, trans, by R. Willis, Svo. Lond., 1835, p. 574.
—R. Willis, Illustrations of Cut. Dis., &c, fol.  Lond., 1839.
—(See Bibliography o/Acne, Lepra, Icthyosis, <&c]
LIVER—Its Diseases.—Synon. Hepar, ynap ;
   Jecur.  Foie, Fr.  Die Leber,  Germ.  Fegato,
   Ital.
   1. The importance ofthe liver in the animal
ceconomy has been variously estimated in  dif-
ferent times and  by different writers   The
ancients considered this organ  to be the origin
of  the venous system, and  the  laboratory in
which the red blood is prepared.   Some recent
physiological writers believe  that the liver per-
forms an assimilating as well as a  secreting
function, while others  contend that it is re-
stricted  to the discharge of this latter function.
It is, however, impossible to determine by ex-
periments, in a satisfactory manner, how far an
assimilating function is performed by this or-
gan ; but there is much reason to infer that it
aids in changing the chyle in the portal and the
general  circulation  into red blood—the extent
of  aid  being,  however, doubtful.  Admitting,
therefore, its chief function to be that of secre-
tion, an  additional question arises, namely, how
far this function produces, at the same time, an
excreting or depurating effect upon the blood,
and on the ceconomy in general.  A number of
years ago (in 1815) I entertained this question,
and endeavoured to show that  the combination
of those elements of bile  existing in  the  blood
in order to form this fluid necessarily tends to
depurate the blood; and that the superabun-
dance of these elements in the blood, and the
circumstances conducive to such superabun-
dance, generally give rise to an exuberant se-
cretion or bile, provided that the vital  endow-
ment and organization ofthe liver admit ofthe
discharge of its functions ;  but  to this  topic
more attention will be  directed in the sequel
Thus, viewing the functions of the liver  to be
1st, and chiefly,  that of secretion, 2d, and con-
tingently that of excretion, 3d, and concurrently
that of assimilation; and having mentioned the
nature ofthe functions performed by this organ,
although the exact amount of each,  especially
ofthe second and third  of these, cannot be as-
certained, I proceed to consider, 1st. The chief
causes which disturb these functions.  2d. The
principal disorders to which these functions are

  When chronic and local, ointments of different kinds may
be used ; of these, besides those mentioned in the text, one
first introduced  into use in this city by Dr. Crane, now of
Brooklyn, L. I.,  consisting of nitrate of bismuth, 3ij., citrine
ointment, fj., and lard, J ss., is often very effectual; also, a
modification of it, which may be made by substituting stra-
monium ointment for the lard.  Other ointments deserving
a  trial are, one of sulphur and carbonate df potash, or soda,
3j. or 3ij. of the former, and 3ss. or 3j. of the  latter to 5j.
of lard ; and creasote ointment, gtts. xx. to xl. to fj.  lard.
The stramonium ointment also frequently affords decided
relief."]
liable ;  and 3d.  The diseases affecting the cir-
culation and structure ofthe organ.
  [The three great depurating organs of the
system, says Budd, are the lungs, the liver, and
the kidneys.  Nitrogen predominates in the com-
pounds which escape through  the last-named
organ, while  the  two  former separate princi-
pally hydrogen and carbon.  But it is to be no-
ted, that in the lungs, the hydrogen and carbon
pass off burned; that is, in combination with
oxygen, as water and carbonic  acid ; while  in
the liver they escape uncombined with oxygen,
and still uncombustible.  Of course, the larger
the amount  of  these  elements discharged by
the lungs as water and carbonic acid, the less,
cateris  paribus, must remain unburned to form
constituents of bile.  It is  important for the
practitioner  ever  to bear  in mind this funda-
mental relation between the secretion of bile
and the great function of respiration.
  Liebig supposes, on the  authority of Haller
and Burdach, that a man in health secretes
daily from 17 to 24? of bile; and he assumes
that this bile contains 90 per  cent, of water,
which  gives from 816 to 1152  grains of dried
bile.  Now Berzelius found that there were
only 9 parts  of  a  substance similar to  bile in
1000 parts of fresh human faeces.  Reckoning
from this proportion, the daily faeces of a man,
which  do not, on an average, weigh more than
5^5, contain only 24 grains of dried bile at most,
so  that, according  to this computation, the
whole quantity  of bile  secreted exceeds the
quantity that can be  detected  in the matters
discharged from the alimentary canal in at least
the proportion of 816 to 24, or 34 to 1.  The
chief part  of the bile is, therefore, reabsorbed,
and, as Liebig argues, no traces of it are found
in the  other  excretions ; the hydrogen and car-
bon it contains  must  evidently be discharged
through the lungs in union  with oxygen (" burn-
ed") as carbonic acid and water, whatever in-
termediate purposes it may serve.  Of course,
it might easily be shown  that  the carbon fur-
nished by the bile can be but a small proportion
of that given out in respiration, as 13^ oz. of
carbon escape daily through the skin and lungs
of a healthy adult, as carbonic  acid (for 816
grains  of dried  bile which contain only about
sixty-nine per  cent,  of carbon, give but 563
grains  of  carbon, or about  l^th ounce).  Al-
though it cannot, therefore,  be maintained that
it is one of  the chief purposes of the  bile  to
support respiration and animal heat, as Liebig
maintains, yet it  is  evident that the  bile  is
chiefly  reabsorbed and applied  to this purpose
after having served other  at present  unknown
uses ;  for  which, indeed, it is well fitted by its
great solubility,  and the large amount of carbon
and hydrogen it contains.
  It is, however, a popular doctrine  in physiol-
ogy, that the bile  is mainly excrementitious, and
is voided by the  intestines, carrying off all mat-
ters rich in  hydrogen  and  carbon that  result
from the waste  of the tissues, and are not dis-
charged from the lungs in union with oxygen.
Of course, in this  view, these organs, the lungs
and liver, are strictly vicarious  in their office ;
and in support of this doctrine,  it is stated that
throughout the animal kingdom, whenever the
lungs  are  large and  active, the liver is  small,
and vice versa.  Thus, in  all cold-blooded ani-
mals—in which respiration is very feeble—the 
830
LIVER—Causes of its  Diseases.
liver is very large and excessively developed
when compared with the lungs.   But it  is a
very strong objection to this  vicarious theory,
that in serpents, whose respiration is extremely
feeble, the excrements do not  contain a particle
of bile.  Still, the relation of bile to respiration
is direct and fundamental, as already shown;
and as the activity and effects ofthe respiratory
function are largely under our control, and as we
have the power of modifying these by appropri-
ate regulations having reference to the condi-
tions  of air, exercise, temperature,  and food,
we  have means much more effectual than any
other in dealing with biliary disorders.  (See
Budd on Liver, Phil., 1846.)]
  2. I.  Causes of Diseases of the Liver.—In
order to prevent unnecessary repetition, while
considering the several diseases of the liver,  I
shall  take a general  view of the causes which
usually occasion them. These causes may pro-
duce  various effects, or associated effects, ac-
cording to the temperament, constitution, hab-
its, &c, of the individuals subjected to them ;
and as respects the  liver and biliary apparatus
in general, the  specific effects of these  causes
will vary with those and with other predisposing
circumstances.
  3. A. Age, Temperament, Diathesis, Habit of
Body,  &c.—Disease of the liver very seldom
occurs until after puberty, unless in the children
of Europeans residing in the East Indies or oth-
er  intertropical  countries, and when a change
to a more temperate climate has not been adopt-
ed  for them.   It is  more frequently observed
in  the sanguine, sanguineo-melancholic,  and
irritable temperaments ; in the scrofulous diath-
esis,  and in a plethoric habit of body, than in
others.  In young or middle-aged persons the
diseases which affect the liver are  chiefly acute
and inflammatory : at advanced periods of life
they  are most frequently congestive  and struc-
tural.   The infrequency ofthe affections ofthe
liver until full puberty has been reached, is evi-
dently owing to the  much less frequent opera-
tion of their exciting causes before this period.
In  warm climates,  diseases  of the  liver are
more  common  in males than in females who
are natives of Europe, owing  to the greater ex-
posure of the former to the exciting causes;
but in temperate climates, and in this country,
as  far as the returns to the  Registrar-general
of  Births,  Deaths, &.C.,  show the fact, these
diseases are as frequent, or  nearly so, in fe-
males as in males, especially in large towns.
  4.  B. High ranges of atmospheric temperature
and the circumstances connected with them exert a
very manifest influence in occasioning diseases
ofthe liver, although various other causes con-
cur with these  in producing the effect.  It was
long since proved by the experiments of Craw-
ford, Lavoisier, Sequin, Prout, Fyfe, and the
author, that the quantity of carbonic acid gas
formed during respiration in a  given time is
much diminished  in a high  temperature,  and
under  circumstances  which  lower  the  vital
powers.  Drs.  Prout and Fyfe  observed, in
their experiments, that the changes induced in
the blood  by respiration were diminished du-
ring  sleep,  by  the depressing passions, by fa-
tigue, by spirituous  liquors, low diet, and by all
depressing  agents.  I found, in 1817, that the
changes effected by the  air in respiration  in a
warm, humid,  and  miasmatous  climate were
even to a less extent, and furnished much IflM
carbonic acid gas in a given time, than in those
experiments which I performed in an artificial-
ly increased temperature in a cold climate ; and
this farther diminution of the changes produced
upon the air during respiration in a very warm
climate I imputed to the presence of malaria,
and to the greater humidity of the atmosphere
in this latter than in an artificial high temper-
ature.   If, therefore, less carbon and its com-
binations be evolved from the blood by respira-
tion in a given time in a warm climate than in
a cold one, while the quantity of carbonaceous
materials conveyed into  the circulation is equal-
ly great, it must follow that this  substance will
soon  be greatly in  excess, provided that the
elimination of it from the blood  is not effected
by some other organ.  Thus, one of two states
may  be expected to supervene  during high
ranges of atmospheric heat, or upon the migra-
tion of Europeans  to intertropical countries;
namely, that, owing to diminution of the chan-
ges effected  by respiration on the blood, this
fluid will possess highly venous characters, and
abound in the elements  usually eliminated from
it during an active state of the respiratory ac-
tions ; or it will experience changes equivalent
to those produced by active respiration, owing
to the increased actions of other organs; the
diminution of the one function being compen-
sated by the vicarious increase of others. Now,
when  the office  of the lungs is insufficiently
performed for the state and want3 of the cecon-
omy, those very elements which pass  out of
the blood by  this channel accumulate in it, and
furnish the materials for  increased biliary se-
cretion ; the liver,  aided by the  skin, the kid-
neys, and the intestines, performing vicarious-
ly an increased function, and supplying  the de-
ficiency in the function of the lungs, until the
ceconomy becomes  accustomed  to the change.
   5.  In a high temperature also, when  the air
is saturated  by moisture,  a much less quantity
of aqueous vapour is discharged  from the lungs
than  in  a  cold and dry state of the air; and
thus  the aqueous part  of the blood  soon  be-
comes excessive, if it  be not excreted more
freply by some other  part  of  the ceconomy.
Hence the fluid excretions of the skin, of the
mucous surface of the intestines, and  of the
liver, become so frequently augmented in warm
and humid seasons, and in Europeans residing
in hot climates.
   6.  C. Climate, and the various physical cir-
cumstances  constituting  climate and endemic
influence, have great influence in producing the
several functional and  structural diseases of
the liver.  Some part of the influence  arising
from climates is referrible to a  high  range of
temperature, to malaria, and other states of the
air; and yet it  is difficult to account  for the
greater prevalence  of hepatic disorders in one
country than in  another, when the physical cir-
cumstances  constituting climate appear to be
nearly equal  in both.  Thus,  in  Jamaica, these
disorders are neither prevalent  nor fatal; and
yet in parts of the East  Indies, where the same
range of atmospheric heat and humidity is  ob-
served as in  this island, and where other phys-
ical circumstances, as sources of malaria, &c,
seem  nearly  equal, they  are  ten times more
prevalent than in it.
   7.  It is  difficult to determine the exact in 
LIVER—Causes  of its  Diseases.                         831
fluence of great dryness or of great humidity of
the air in the production of hepatic diseases.
Probably more may be imputed to a very high
range of temperature than to either.  The in-
fluence  of malaria in this respect,  and of its
combinations with humidity ofthe air, is prob-
ably rather indirect than direct and immediate,
periodic fevers being the first morbid effect of
this cause, and biliary disease a complication
or consequence of these.  In  many places of
India, where the  range of temperature is very
high, and at seasons when the air is very dry,
primary acute hepatis is often  frequent among
Europeans, while in warm, moist, and miasma-
tous localities, the hepatic disease is generally
consecutive  of other  maladies.   It would  ap-
pear from the statistical report of the troops in
the West Indies,  that diseases  of the liver are
about three times as prevalent among them as
among the troops in the  United Kingdom, and
occasion nearly rive  times  as high a  rate  of
mortality, while Mr.  Annesley, and other wri-
ters on the  diseases  of the East Indies, esti-
mate the average annual per centage of these
diseases in the East to be treble what it is in
the West Indies.
   8. There are various localities, particularly in
the East Indies, where hepatitis appears to  be
endemic, and where the peculiarities of climate,
especially in respect of humidity, temperature,
and the usually recognised sources of malaria,
seem insufficient to  account  for the circum-
stance.  How far the nature of the water and
other physical agents  may concur with  the
states of the air in producing this effect, cannot
be determined in the present state of our knowl-
egde.
   9. D. Exposure to the sun's rays, to vicissitudes
of temperature, and to various allied causes, cer-
tainly aid in producing biliary disorders.  The
action of the sun's  rays on the head, and on
the nervous system generally ; exposure to the
night air and  dews, or sleeping in the open air,
particularly after having been subjected to the
rays of a very hot sun ;  sleeping on the ground,
as in bivouacs aud  encampments; sudden al-
terations or  transitions of temperature,  and
sleeping in the sun, occasion  not unfrequently
the more acute forms of biliary disease, espe-
cially in very hot seasons and climates.
   10. E. Diet and regimen, next to temperature
and climate, are most productive of hepatic dis-
orders.  Eating largely or frequently, especial-
ly of animal, rich, and  highly  seasoned food ;
stimulating the appetite and palate by a variety
of incongruous dishes, and sauces, and spices,
and wines, particularly in warm countries and
seasons,  are  most influential causes of these
disorders.   It is probably owing to such full
and stimulating  diet that hepatic diseases are
more common in the officers than in the troops
serving in the West Indies.
   11. The use of spirituous or other intoxicating
liquors, especially in excess,  is productive of
the diseases of this organ—in warm climates,
of the more acute ; in temperate countries, of
the more chronic and structural maladies—al-
though not,  perhaps, to the extent generally
supposed, especially when active, continued, or
fatiguing duties and occupations are performed.
It is probable that some liquors are more inju-
rious than others; that  brandy and whiskey
disorder the liver more than gin and rum ; that
the strong and brandied wines are more hurt-
ful in this respect than the French and Rhenish
wines, and that spirits are injurious in propor-
tion  to the degree of concentration or strength
in which they are used.
  12. It is difficult to ascertain what influence,
if any, should be  imputed to unwholesome food,
and to impure water.  The disorder of the bil-
iary  organs which  may result,  probably, will
have some relation  to  the  nature of  these
causes, to the kind of ingesta, and to the impu-
rities existing in the water.   It is to be pre-
sumed that,  when  the  ingesta,  whether con-
sistent or fluid, is of a septic kind, the  func-
tions of the  liver will be thereby  impaired or
otherwise disordered ; or that congestion of its
vessels, or accumulations of bile in its ducts,
will  be thereby promoted.
  13. F. If irritating matters, whether dietetic
or medicinal, taken into the stomach, pass into
the portal  circulation, they may occasion dis-
ease of the liver, particularly  if they  act con-
jointly with other causes.  It  is probable that
unwholesome or too rich and heating food, and
impure water, act in this way ; the influx of an
unusual quantity of insufficiently elaborated, or
stimulating, or otherwise injurious chyle, and
of hurtful  fluids, into the general  and portal
circulation, irritating and  inflaming the secre-
ting  structure of the organ and the portal ves-
sels, or occasioning congestion of these vessels
and  alterations of the biliary secretion.
  14. Mercurial preparations exert an undoubt-
ed influence in producing disease of the  liver,
either of an inflammatory or of an obstructive
character.   Dr. Sherwen and Dr. Dick first no-
ticed the occurrence of chronic disease of this
organ after mercurial courses prescribed for
venereal  complaints.   The most  convincing
proofs,  however, of this  effect  of mercurials
are  adduced by Dr. Nicholl.   Dr. W. Thom-
son  states, that Dr. Chap,man, of Philadelphia,
ascribed the prevalence of hepatic complaints
in his neighbourhood  to the use of mercury for
the  cure  of autumnal fevers; some old  prac-
titioners remarking that, previously to the in-
troduction of the mercurial practice, hepatitis
was scarcely known in  it.   Dr. Nicholl re-
marks that disease of the liver followed syph-
ilis  and chronic ophthalmia  in a great propor-
tion of the cases treated by mercury.
   [Dr. Chapman  remarks on this subject, that
" mercury, more than any other article of the
Materia Medica,  has the power of  exciting the
actions ofthe liver,  and it  is a law of our nature,
that all high  excitement  is  followed  by  a cor-
respondent degree of debility.  From the cir-
cumstance  of the  prodigious employment of
calomel in the treatment of our autumnal  fevers
and  other diseases, it seems to be no unreason-
able supposition that the hepatic apparatus, thus
over-stimulated,  should fall into collapse, and
in this condition of exhaustion, torpor to take
place in the  portal circulation, productive of
congestion, eventuating in phlogosis, induration,
and  other  derangements.  Doubtless in this
mode do miasmata and high temperature, sep-
arately or unitedly, and the habitual consump-
tion of ardent spirits, operate to the same ef-
fect.  As confirmatory of this view, it  is  stated
by Dr. Somervail, a most respectable physician
of the south of Virginia, who has practised med-
icine for nearly half a century in  that section 
832
LIVER—Causes or its  Diseases.
of the country, that till the introduction of mer-
cury, a comparatively modern event there, into
the treatment of autumnal diseases,  hepatitis
was  hardly known, and subsequently it has
most widely prevailed."—(Lectures on the more
important Diseases of the Thoracic and Abdominal
Viscera, 8vo.  Phil., 1844.)]
  15. The absorption of morbid or facal matters
from the digestive canal, especially during con-
stipation,  may act like other irritating and in-
jurious matters already alluded to (v 13).  MM.
Cruveilhier, Andral, and Percy believe that
these and all other irritating matters,  when in-
troduced into the abdominal venous circulation,
exert an  especial  effect upon  the  secreting
structure  of the liver, and that they act in this
way rather than by the extension of irritation
from the  duodenum along the  common bile-
duct to the other ducts and parts of the biliary
organs,  as supposed by many  writers.   Dr.
Saunders  states that the diseased  structure
maybe traced in dram-drinkers along the  ducts
to the gall-bladder and liver, the ducts being so
thickened and  contracted as not to admit of
the passage of bile.
  16. G.  Indolence and sedentary occupations ex-
ert a manifest influence in causing the more in-
sidious, slow, chronic, and obstructive diseases
of the liver.  It would seem  that bodily  exer-
cises, especially such exercises  and occupa-
tions as bring the abdominal and other muscles
of the trunk  into play, promote the portal cir-
culation  and  the  biliary secretion,  and still
more remarkably the free discharge of the bile
into  the duodenum.  Inactivity, particularly in
connexion with full living, favours not only con-
gestion of the liver, but also accumulations of
bile  in the ducts and gall-bladder, morbid states
of this secretion,  jaundice, the   formation of
gall-stones, and structural changes ofthe organ.
  17. H.  The influence  of mental emotions on
the functions ofthe ljver is generally admitted,
and  is evinced by the occurrence of jaundice
or of inflammations of the organ after violent
fits of passion, and of functional  and structural
diseases of it after the continuance of anxiety
and  other depressing emotions.  The mental
depression, which often causes biliary disorder,
is, in its turn, increased by the disorder it  occa-
sions, until at last the circulation and structure
of the liver are more or less altered.  Sorrow,
anxiety, and  other  lowering  feelings have an
evident effect in weakening the abdominal and
portal circulation, and in impairing  the  func-
tions of the liver to the full extent of function
I have imputed to this organ (t) 1).
  18. I. The occurrence of abscess in the liver
after injury of the brain has been often observ-
ed, and generally imputed to an  intimate  sym-
pathy existing between both these organs. But
there is every reason to believe that the  ab-
scesses formed  in the liver in  such  circum-
stances have often been consecutive  upon in-
flammation of the veins or sinuses within the
cranium.   Abscess of the  liver  is  sometimes
also consecutive of purulent collections in other
situations, or caused by the absorption of mor-
bid secretions or puriform matters from  other
quarters,  and by injuries  of the joints,, frac-
tures, surgical  operations and other occasions
of phlebitis,  as shown in  the article Abscess
(y 24, 27, et seq.).  However, it is not improba-
ble that  severe injuries, as concussions  of the
brain, sympathetically affect the  substance of
the liver,  and develop  acute disease  of it.
There can be no doubt that the exposure of the
body, and more especially of the head, to the
rays of a hot sun, is  often concerned in  pro-
ducing those Insidious forms of hepatitis  rapid-
ly passing  into abscess,  so often observed in
India, particularly when aided by intemperance,
and by exposure to cold and the night air, or
by sleeping without, or with insufficient cover-
ing.  Injuries of the liver itself,  blows on the
region  of the organ and concussions  of it, in
falls, &c, are also  not infrequently followed by
the worst forms of inflammation to  which it is
liable, particularly in the East.
   19. K. Other diseases are, perhaps, the most
frequent causes of affection of the  liver, more
especially  in warm, humid, and miasmatous
climates.—a. In these the  hepatic malady is
generally consecutive of periodic  fevers  and
other ailments;  while in very hot and dry re-
gions, diseases of the liver are more generally
primary and  acute among Europeans exposed
to the sun.   Various dyspeptic symptoms pre-
cede the more chronic and insidious affections
of the liver, and  comparatively  few cases of
intermittent  or remittent fever  occur in  hot
seasons, and more especially in  hot  climates
and in  India, without the liver becoming  prom-
inently affected if the fever continue but for a
short time.   In many cases, also, of continued
fever, in these seasons and climates, the liver
is prominently affected, and the  local  disease
may continue in a  chronic or latent form after
the fever has been subdued ; or it may be pro-
duced or developed into an acute  state, by ex-
posure either to the sun, or to vicissitudes of
temperature, or by intemperance, during con-
valescence or soon afterward.
  20. b. Affections of the liver, particularly ob-
structions  to the  discharge of bile, are  often
consequent upon, or otherwise connected with
duodenitis, or with congestion of  the villous
coat ofthe duodenum. In some of these cases
the common duct may be obstructed by  the
swelling of the villous coat at. the  opening of
the duct, and thus give rise to jaundice.  Some
writers suppose that the affection of the duo-
denum, or  ofthe stomach and duodenum, acts
sympathetically on the liver, and interrupts or
otherwise disturbs the functions aud  circula-
tion of this organ, so  as to manifest this and
other related phenomena.  According  to M.
Ribes,  Andral, and  others, disease may  be
propagated, not  only  from the villous  surface
of the duodenum along the interior ofthe ducts
to the  liver,  as indeed supposed  by Dr. Saun-
ders and others, but  also from any portion of
the intestinal canal along the veins  to the por-
tal ramifications   in  the  liver.   In this way
some  recent writers  have attempted to  ac-
count for the occurrence of hepatitis, or, rath-
er, of puro-hepatis in  connexion with dysen-
tery : the  puriform  collections found in  the
liver in these cases are supposed to have been
consequent either upon  the passage of puri-
form or other morbid matters from  the bowels
into the portal circulation, whereby irritation
or inflammation ofthe ramifications ofthe por-
tal vessels had been occasioned, or  upon  a true
phlebitis of  the mesenteric veins  propagated
from the origin of these veins in the ulcerated
intestines  to the portal vein and its ramifica- 
LIVER—Causes  of its Diseases.
833
tions.   This subject, however, requires farther
investigation.
   21. c. The connexion of  impaired  function,
or torpor of the liver, with severe or prolonged
dyspepsia, is  very manifest.  They  are  both
adynamic  affections generally  so intimately
connected, that the one is soon followed by the
other, that of the stomach being most frequent-
ly the  primary affection.   A similar remark
also applies  to costiveness  and constipation.
It was  supposed by some writers that accumu-
lations  of faecal  matters  in the large bowels
may so press upon the duodenum and ducts as
to prevent the  discharge of  bile into the intes-
tines, and that morbid secretions or other mat-
ters may so obstruct the  opening  of  the com-
mon duct as to produce the same effect. There
can be  no doubt that, if the  causes assigned as
productive of the obstruction, were ascertained
to be sufficient to occasion it, and  if the ex-
istence of these causes in such a grade of suf-
ficiency was satisfactorily proved, they should
be viewed as efficient agents in the develop-
ment of hepatic disorders ;  but, of themselves,
it is probable that they are not sufficient or fre-
quent causes, and that they only  concur with
other circumstances, and are most influential
when the bile itself is inspissated or does not
flow readily along the ducts.
   22. d. Of all diseases,  the most intimately
connected  with hepatic abscess are  dysentery
and chronic diarrhea, particularly  in  the East
Indies.  From the accounts given of this as-
sociation  of disease, as well as  from intimate
observation of the cases themselves,  it is most
difficult to determine which is the primary af-
fection. I believe that either may follow the
other ;  that both may be coetaneous ; and that
more frequently  the bowel complaint is  the
consequence  of  puriform collections silently
and insidiously formed in  the  liver, without
giving rise to symptoms so  severe as to  alarm
the patient, and to cause  him to relinquish his
avocations, or so marked  as to enable the phy-
sician to determine the nature and seat of the
malady.  As soon, however, as matter is form-
ed, or collected to an extent calculated  to af-
fect the organic  sensibility  of the organ, par-
ticularly in its surfaces,  and to  awaken  the
sympathetic sensations of adjoining or related
parts ;  or  when  the local   irritation, or  the
passage, by absorption of a  portion of the con-
tents of the abscess into the circulation, then
indications of its existence are manifested :  in
the first case, by pain, uneasiness, &c. ; in the
latter, by hectic, chronic,  diarrhoea, or dysen
teric symptoms.  The history of many of these
cases will  show  various  dyspeptic and slight
biliary disorders to have  been complained of,
weeks,  months, or even years before  the bow-
el complaint had occurred ;  and in  some ofthe
cases, where the  hepatic affection seemed to
follow the removal of the dysenteric  attack, it
had evidently existed previously to the disorder
of the bowels,  the removal or suppression  of
the one  rendering the other,  which had pre-ex-
isted, merely more prominent.
  23.  e. The occurrence of disorders ofthe liv-
er consecutively  upon  diseases of the  heart
and lungs has  been  acknowledged  since the
connexion was insisted upon by Paisley, Cor-
visart,  and Powell.  In these circumstances,
particularly when  the heart is diseased, con-
    ii.              105
gestion of the hepatic veins, often extending
to the portal veins, is the first and chief disor-
der produced.  The frequent connexion of fatty
degeneration of the liver with pulmonary con-
sumption is remarkable, and will be considered
hereafter.  Many writers have  noticed the co-
existence of diseases of the liver and of the
brain, and have been at a loss  to  account for
the  circumstance.   The  coexistence is fre-
quent, but  not uniform, nor even  general.   It
is sufficiently common, however, to deserve
explanation, and is observable  both when the
mind is  deranged  and when it  is unaffected.
When we consider that both the liver and the
brain are supplied, as respects their  organic
actions and functions, only with ganglial nerves;
that these organs are hence intimately con-
nected through the medium of this system  of
nerves ;  and that the circulation of both is pe-
culiar, and in  some  degree removed from the
circle  of the general circulation,  and is to a
great extent influenced by the ganglial forma-
tions supplied to each, we cannot be  surprised
at observing disorder and organic change  often
coexisting in both, seeing that their circulation
and  functions are  actuated  by  the same sys-
tem, and by the powers exerted by  that sys-
tem ; disorder of one part being soon followed
by disturbance of other parts intimately related
to it.
  24. /. Suppression  of accustomed discharges
—of the  haemorrhoids, or of the catamenia,  or
leucorrhoea, &c.—is sometimes followed by hep-
atitis.  The  disappearance  or drying up  of
eruptions, ulcers, &e, and the closing of sinu-
ses, or fistulas, as fistula in ano, and operations
for haemorrhoids or fistula, have been also some-
times followed by diseases of the liver.
  25. Many of the causes above adduced may
be insufficient singly to produce well-marked
disease ofthe liver, although each  may predis-
pose to it, or even excite it,  when  acting  in an
intense form, or without intermission.   More
frequently two or several of them are combined,
or act conjointly or in close succession, in de-
veloping the morbid effect; and so various are
such  combinations and successions  of  these
causes in different persons, circumstances, and
localities, that it is impossible to instance even
a part of them.
  26. L. Of the several races or varieties  of the
human species, the white or fair races are the
most prone to diseases of the liver, and  more
especially to that state of disease which passes
insidiously and silently on to abscess.   Of  these
races, the sanguine temperament, the fair  com-
plexioned, and the scrofulous diathesis, the last
especially,  are most liable to this extremely
unfavourable form  of hepatitis, particularly du-
ring  very hot seasons, or after emigration to a
hot climate.  On the other hand, the melan-
cholic and the irritable temperaments, and the
sallow and  meager habits of body, are the  most
liable to  experience  the slighter or functional
disorders, and the  more chronic structural le-
sions of the liver.   Numerous exceptions,  how-
ever, occur to these  general rules.  Owing  to
the predisposition arising out of temperaments
and constitutions, hepatic complaints  are  often
hereditary, or prevalent in the branches ofthe
same family.
  27. The immunity  of the dark races, partic-
ularly of the negro, from diseases of the liver, 
834
LIVER—Functional Disorders or.
 is very remarkable, even in climates where
 these diseases may be considered endemic.  I
 have, in other works, ascribed the immunity of
 these races, from these and other maladies, to
 the  several points of difference  existing be-
 tween their organization and that of the white
 races.   The former are constituted to live in a
 climate injurious to the latter—in warm, hu-
 mid, and  miasmatous  regions ;  while  the fair
 races are organized so as to endure, without
 material injury, the severities of winter, the
 changes ofthe seasons, and the vicissitudes of
 weather under which the great mass of the
 darker races  would sink.  In the negro—the
 extreme grade of the dark varieties—the liver
 is small, and performs a more limited range of
 function, compared with the fair  races.  The
 same remark applies to the lungs ; for I ascer-
 tained, by experiments made in a hot climate
 many years ago, that the lungs of a negro fur-
 nish much less carbonic  acid gas in a given
 time than those of an European  of the same
 size and similarly circumstanced.  The skin of
 the dark races, however, performs a compensa-
 ting function—one, in  some respects, subsidia-
 ry to both respiration and biliary secretion, par-
 ticularly as regards the depuration of the blood.
 The brain, also, in them, is better protected by
 nature from the injurious influence of a vertical
 sun  than  that of the fair races,  and is less lia-
 ble to experience the effects of such influence,
 either in the more sudden and severe forms of
 sun-stroke, or in those less appreciable states
 and affections of  innervation, which disorder
 the hepatic functions  more severely than even
 the  cerebro-spinal influence  and  locomotive
 powers.
   28. M.  The causes which produce hepatic dis-
 ease in Europeans  in warm climates have been
 already noticed ; but there are certain  combi-
 nations of them that  may be briefly enumera-
 ted.  It is generally overlooked by medical wri-
 ters, and is certainly neglected by those chiefly
 concerned, that nature intends  the food  and
 clothing of the inhabitants to be suited to the
 circumstances of  the  climate  in  which  they
 live.  The suggestions arising out of our sen-
 sations, reflections,  and observation are  un-
 heeded  in the quick succession and crowding
 of contending  desires, and habits, and fashions ;
 and health is sacrificed, and life endangered, to
 pamper the palate, and to follow the mode rath-
 er than adopt what reason approves of and our
 feelings suggest.   The full, rich, and stimula-
 ting animal diet, which might be required, and
 readily disposed of in cold countries, by per-
 sons engaged in active avocations, is no longer
 suited  to  the  European constitution when re-
 moved to  a hot climate, and the more injurious
 does it become the more frequently it is indul-
 ged in, and  the more  it  is accompanied  with
 the use of the heating wines and other ferment-
 ed liquors suited only to northern or temperate
 regions.   The clothing, also, of those who leave
 the latter to reside in warm climates is rarely
adapted to the novel physical circumstances in
which they are placed.   The head of the Euro-
pean, which nature has protected sufficiently in
his native climate, is dangerously exposed with-
in the tropics,  and requires a greater protection
than is generally given it.  In this particular,
 is well as in several  others,  fool-hardiness is
 iiaracteristic of many. The common error is
a total disregard of those accommodations of
clothing to the differences and changes of tem-
perature which often occur with remarkable ra-
pidity in intertropical countries, and are more
hurtful in these than in temperate climates.
  29. Intemperance of all kinds, but  particu-
larly in  eating and drinking; exposure to the
sun, and subsequently to the night air, or  to
cold or wet, especially when the body is per-
spiring ; copious draughts of cold fluids during
fatigue, or in a state of perspiration ; repletions
of the stomach after long fasting ;  addiction to
spirituous liquors; sleeping with  insufficient
clothing after  fatigue and exposure to  the sun,
particularly either  upon or near the  ground;
disappointments, grief, and the depressing pas-
sions generally, and the diseases above men-
tioned (y  19, et seq.), are the most influential
causes of the diseases of the liver in hot coun-
tries, and those to which  soldiers  and sailors
in those climates are most exposed.
  30. II.  Of  the   Functional  Disorders  or
the Liveti.—Under the  head of functional dis-
order may be comprised all those conditions
of the biliary secretion which differ from the
healthy state and lead to farther disease. These
conditions generally are manifested in the quan-
tity and quality of this secretion, and, although
connected with changes in the state of the
blood circulating in the liver, are not necessa-
rily allied to inflammatory action or structural
change; these latter slates, however, being also
and necessarily attended by alterations from
the healthy  function of the organ.   This latter
circumstance—this frequent dependance of dis-
ordered function  upon  alterations of vascular
action, or of  structure,  or  of  both — requires
from the  physician the  utmost care in deter-
mining the state and amount of disease.  Even
when the  disorder of function is ascertained to
be independent of these more serious changes,
it should be recollected that it often passes into
inflammatory states, or even into structural le-
sions.  Indeed, these latter generally proceed
from this source, either immediately npon the
first functional disorder, or after  repeated  or
prolonged attacks  of it.  The chief disorders
which fall under this  head are : 1st. Diminish-
ed secretion of bile ; 2d. Increased secretion
of bile ; and, 3d. Secretion of morbid or altered
bile.  To  these might be added, accumulations
of bile in the gall-bladder and  ducts;  but  as
these arise  from various circumstances, both
functional and organic, and are followed by sev-
eral changes both  in the bile itself and in the
parts containing it, this subject  is more appro-
priately considered in the  articles Gall-blad-
der and Ducts, and Concretions, Biliary.
  31.  The three functional disorders of the liver
about to be considered have been  usually de-
nominated bilious,  without,  however, any pre-
cise idea being annexed to the term, which has,
even by professional persons, been applied to a
deficient  secretion  of bile equally with an  in-
creased secretion.  These  disorders  may be
referred to  two principal  pathological condi-
tions :  1st. The state of the blood, as furnish-
ing the elements of bile ; and, 2d. The state of
organic nervous or vital influence, as actuating
both the hepatic circulation and the biliary se-
cretion.
  32.  I have contended above (y 4-8),  and in
other  works, that the blood abounds, more or 
LIVER—Functional Disorders of.
835
less, according to modes of living and ranges
of temperature, with the materials for biliary
secretion.  According to such  abundance  or
deficiency, and to changes experienced by the
blood during  its circulation in  the organ, so
may it be supposed that  the bile will be either
abundant, or deficient, or altered.
  33. That the vital or nervous influence will
act not merely dynamically in promoting or im-
peding the circulation and the secreting func-
tion of the liver, but also qualitatively, may be
admitted, although this tatter change may de-
pend more upon the state of the blood than upon
the condition of the nervous or vital power.
Much will depend, however, upon the states of
intimately allied or connected  organs, especial-
ly in modifying the vital power and functions
of the liver.   The states of the stomach  are
often influential in  promoting  or impeding bili-
ary secretion.  When  the vital  actions of the
stomach are  energetic, those  of the liver  are
usually co-ordinate with them ; and when these
actions are impaired, the functions ofthe liver
equally suffer.  Hence the general association
of torpor or inactivity of the liver with indiges-
tion ; and the frequent supervention of biliary
disorders, even  of a severer character than
these,  upon  dyspeptic  complaints, especially
when the latter are neglected and  prolonged.
Disorders of  the  duodenum  have a similar,
and sometimes even a more remarkable influ-
ence on the  functions of the liver;  and,  be-
sides occasioning sympathetic effects, such  as
those which are produced by the stomach, they
sometimes completely interrupt the passage of
bile into the intestines, thereby disordering the
secreting function and the secretion itself; and,
if the  interruption  continue, ultimately affect-
ing the circulation and structure of the organ.
34. i. Diminished Secretion of  Bile.—Torpor
  of the Liver—Torpor of the Biliary Organs.
    Classif.—I. Class ; I. Order (Author).
  35. Defin.—An irregular or costive state  of
the bowels, the stools being insufficiently coloured
with bile; flatulency and various dyspeptic symp-
toms ; a sallow or muddy  appearance of the coun-
tenance ; and lowness of spirits.
  36. A. The circumstances more  especially occa-
sioning  impaired  action  of  the  liver are,  the
neglect of exercise ; sedentary occupations ;
indolent indulgences ; exposure to cold, humid-
ity, or malaria after fatigue or excessive  per-
spiration ; copious draughts of cold fluids ;  ha-
bitual over-excitement ofthe stomach and liver,
from eating and drinking rich  and heating arti-
cles, particularly when these are suddenly with-
drawn ; and a neglected state of the  bowels,
or accumulations of secretions and faecal mat-
ters in the intestinal canal.  When the duode-
num and intestinal canal are weakened, and
when mucous or other  secretions accumulate
on  their villous surface, the  ingesta and bile
poured into them fail of  exciting their healthy
action.   Hence the emulgent effect usually pro-
duced on the ducts from continuity of surface
and consent of action is inefficiently performed,
if at all ; and thus a similar state of function
to that  existing in the digestive canal is  ex-
tended to the liver.  Habitual  inattention  to
the due evacuation ofthe bowels thus becomes
one ofthe chief causes of inaction ofthe bilia-
ry organs.
  37. B. The symp/oms of impaired action ofthe
liver  are  not always very manifest;  and it is
often very difficult, or even impossible, to de-
termine, even when these symptoms are well
marked, whether or no they depend merely upon
diminished energy, or upon change ofthe struc-
ture ofthe organ and of its appendages, unless
we are acquainted with  the patient's  habits,
and with the nature of his  former ailments.
When the patient complains—after having en-
joyed good health, or without having experien-
ced, on former occasions, either acute or chron-
ic affections of the liver or stomach, or other
severe  disease  likely to  have  implicated  the
former organ—of dyspeptic symptoms,  with a
costive or irregular state of the bowels,  the
stools being pale or clayey, and the urine dark
or high-coloured, or thick, after having  cooled
—of want of appetite, drowsiness or pain over
the eyebrows, lowness of spirits and hypochon-
driacal feelings—of flatulency of the  stomach
and bowels, a foul  and loaded tongue,  and a
bitter or disagreeable taste of the mouth, par-
ticularly in the morning—and of a dark, sal-
low, or muddy appearance of the countenance
and skin,  but without any pain, febrile  move-
ment towards night, or thirst, or chills followed
by heat or hardness of the pulse, or fullness or
tenderness in the region of the liver, it may be
reasonably inferred that the functions  of  the
liver are simply impaired.
  38.  When, however, the above symptoms oc-
cur in a person  who has lived intemperately
as respects either eating  or drinking, or who
has resided long  in a warm climate, or who has
suffered former attacks of hepatic  disorder or
protracted periodic  fever, it may  be inferred
that the impaired function is associated with
congestion, inflammatory  action, or with some
organic lesion of the biliary apparatus, more
especially if any or all  of the  symptoms last
mentioned be present.
  39. When the vital energy of the biliary ap-
paratus is impaired by any of the above causes,
or exhausted by  drunkenness, dissipation, &c,
bile is formed either in  diminished quantity or
of depraved quality, and  sometimes it is both
the one and the other.  When this state  exists,
and particularly if it have been of considerable
duration, congestion ofthe portal vessels  should
always be dreaded, and  its existence,  as far as
may be ascertained, ought to be  carefully in-
quired after.  Portal congestion having  super-
vened upon torpor of the  secreting function of
the liver, the two morbid states tend to perpet-
uate and increase each other by mutual reac-
tion, until enlargement of the organ, or  chron-
ic, or even acute attacks of inflammation of its
substance take place, according to the concur-
rence of exciting causes and the predisposition
arising out of the diathesis or constitution of
the patient.
  40. Torpor ofthe liver, then, may arise sim-
ply from a depressed or exhausted state of the
vital energy of the  organ ; or from this state
associated with  accumulations of bile  in  the
gall-bladder and  hepatic ducts, or  with conges-
tion of the blood-vessels of the organ, or with
both ; the former disorder gradually inducing,
and becoming complicated with, the latter de-
rangements.  Impaired secretion of bile  is gen-
erally associated, also, with dyspepsia; and it
often originates in  that disorder, particularly
in protracted cases.   In many of these  instan- 
836
LIVER—Functional Disorders or.
ces, the bile is not merely diminished in quan-
tity, but  it is also changed in its appearance
and properties : it becomes viscid or otherwise
vitiated,  so as to flow with difficulty along the
ducts, thereby causing a loaded state  of them,
obstruction, and, ultimately, vascular conges-
tion, biliary concretions, and organic lesions.
  41. It  is comparatively rare that  inaction  of
the liver is so complete as to amount to an en-
tire suppression  or arrest of its functions, un-
less  in pestilential cholera, and in  organic le-
sions ofthe organ and biliary passages.  When
the vital  action ofthe liver is so far  suppressed
as to render it incapable of combining the ele-
ments  of bile into this fluid,  however scanty
or morbid, the circulation of these elements  or
materials in the blood, as shown in the articles
Blood (y 115-121) and Disease (y 97), becomes
most injurious and  vitally depressing to the
economy.  This is fully shown in the pestilen-
tial malady just  mentioned, and even in other
cases and diseases where the actions of the
liver are not entirely suppressed.  In many of
these latter (particularly when the inaction ap-
proaches and proceeds more gradually than  in
that malady), other organs, as the kidneys and
skin, seem to compensate, in some  degree, for
the torpor of the liver, and  to eliminate from
the blood a portion of the injurious materials
accumulated  in it, owing  to this cause.  The
connexion of this subject with the functional
disorders of the gall-bladder, more particularly
with inaction of,  or  accumulation of bile in the
gall-bladder and ducts, with biliary concre-
tions and with jaundice, will  suggest a refer-
ence to these articles.
  42. C.  Treatment. — The means  usually re-
sorted  to in this  and in warm climates, in  or-
der to  increase the  biliary secretion, are mer-
curials in some form or other, and particularly
calomel  and  blue pill, given  at  bedtime, and
followed in the  morning  by a saline or other
aperient draught. Various modifications of this
treatment have been advised; in some cases
large doses of calomel, in others moderate do-
ses of Plummer's or  of blue pill at  bedtime,
frequently saline  purgatives, often  a combina-
tion of tonic infusions, with the infusion of sen-
na, and with salts.   Each of these may answer
the purpose, if judiciously employed.   It is gen-
erally advantageous  to combine Plummer's pill
with soap, and to give, at the same time, full
doses of taraxacum.  Different modes  of ac-
counting for the action of mercury in these ca-
ses have been adduced.  Some  suppose that
the mercury has  the effect of stimulating the
biliary apparatus; others believe that it acts
only in the digestive mucous surface, by remo-
ving mucous colluvies from it, and exciting it
so as more fully to  emulge the  biliary ducts.
It would seem, from  experiments tried on some
ofthe inferior animals, as well  as from the well-
known effects of the preparations of  mercury,
that they diminish inflammatory irritation  of
the villous surface of the stomach  and duode-
num, and carry off  mucous matters  from the
intestinal surface.   In this way they may  di-
minish  congestion  around the  orifice of the
common duct, remove spasm or irritation  of
the ducts, and thereby favour a free discharge
of bile  into the intestines.
  43. The next most efficient means of procu-
ring a free secretion  of bile, especially after
mercurials have been prescribed, are the hilar-
irate of potash with confection of senna and ex-
tract of taraxacum ; but the potash should be
given in large  doses, or in smaller  doses  with
the biborate of soda.   Instead of  exhibiting
mercurials in  so large or frequent doses as
have been usually prescribed, these medicines,
or those about to be  mentioned, should be re-
sorted to, and  a full or decided dose of a  mer-
curial ought only occasionally to be  given ; but
generally it should be fairly bnt cautiously tri-
ed in the first instance.   In some cases, Plum-
mer's or the blue pill may be given every night,
for some days, with the purified extract of al-
oes and soap, and a saline, or a bitter stomach-
ic aperient in the morning.
  44. If these  means fail, and  if no symptom
appears to contra - indicate the practice, an
emetic may be  exhibited, and its operation pro-
moted by diluents or the warm infusion of cham-
omile flowers, with bitartrate of potash and bi-
borate of soda dissolved in it.   Subsequently,
blisters may be applied over the  hepatic region;
or the mtro-muriatic acid may be given internal-
ly, and  also employed in  the form  of a lotion
over the hypochondriac and epigastric regions.
After blistering, I have seen advantage derived
from wearing a large plaster over these regions,
consisting of the emplastrum picis compositum
and  emplast. ammoniaci cum  hydrargyro.  In
cases of torpor of the liver unconnected  with
congestion of  the blood-vessels, gentle tonics,
with alkalies,  taraxacum, iodide of potass, or
aperients, may prove beneficial; but when the
torpor results  either from a passive engorge-
ment of the biliary ducts, or from  congestion
of the portal or hepatic veins, recourse to these
might be  injurious, by developing  chronic or
acute inflammation ofthe organ.  Much advan-
tage, however, will be often derived, when the
torpor is  thus associated, from the continued
use of deobstruent aperients, and an occasional
recourse to a full dose of calomel, followed by
a cathartic draught, with  the view of carrying
off the  bile accumulated in the ducts, and the
viscid secretions often adhering, in these cases,
to the  villous surface  of the intestines.  In
these latter circumstances, the  bitartrate of
potash  and biborate  of soda,  conjoined  with
other medicines, according to the peculiarities
of the cases, are often beneficial.
  45. It is sometimes requisite to conjoin with
the medicines  employed to excite  the liver a
substance which may prove a substitute for the
bile which is deficient.  I have for many years
prescribed inspissated ox-gall in this way, usu-
ally with the aloes and myrrh pill, or the puri-
fied  extract of aloes, soap, taraxacum,  blue
pill,  &c.
   46. Several of the deobstruent and aperient
mineral waters, as  the  Cheltenham,  Beulah,
Seidchutz, Pulna, [Avon,  Saratoga,  and  the
Virginia  Sulphur,] or other waters, may be
taken in order to excite the action ofthe liver,
and remove obstructions in the ducts.   The
causes of the  disorder should be avoided ; and
change  of air, travelling, and  horse exercise
recommended.
   47. ii. Excessive Secretion of  Bile.—In-
creased  Biliary Secretion.
   Classif.—II. Class ;  I. Order  (Author in
     Preface).
   48. Defin.—Copious, fluid, alvine  evacuations, 
LEVER—Functional Disorders of.                           837
highly coloured with bile, often preceded by griping,
by nausea, and sometimes by vomiting, or attended
by this latter, and acceleration of pulse.
   49. Excessive biliary secretion is more fre-
quently inferred from circumstances than prov-
ed by  unequivocal evidence.   Accumulations
of bile may have formed in the gall-bladder and
ducts, and when their discharge into the bowels
has commenced, they may so excite increased
exhalation from the intestinal villous surface,
and so deeply tinge the stools, as to give rise
to all  the phenomena  of increased secretion
when only an increased discharge of previously
obstructed or accumulated bile has taken place.
In this climate, particularly in summer and au-
tumn, these occurrences are common, and  are
merely minor grades of the  same pathological
states  which,  in  a higher degree,  constitute
bilious diarrhosa or bilious cholera (which see).
Still, in warm  climates, and in warm seasons
in cold or temperate countries,  a more than
usually abundant secretion of bile sometimes
takes place, without amounting to severe diar-
rhoea or  to cholera ; the stools being fluid,  bil-
ious, and copious,  and continuing in this state
for a considerable time.  This occurs more fre-
quently in  persons who have recently removed
to a  hot climate, owing to the cause above as-
signed (v 4-8).  It is  evident from this, that
excessive biliary secretion belongs to the same
category with the disorders just mentioned, and
that  its  pathology and treatment involve  the
same principles as they.*
   " [We have stated that Burdach and Haller have es-
timated the amount of bile secreted, under ordinary circum-
stances in  a healthy adult, to be from 17 to 24 %; but  it
varies, of course, with the activity of respiration, and with
the quantity and quality ofthe food, if not with the quanti-
ty of  matter thrown off by the skin.  A very  interesting
case, showing the great amount of bile that is sometimes
secreted for a considerable time together, was recently re-
ported to the Medico-Chirurgical Society of London (Trans.
Med. Chir. Soc., vol. xxvii., p. 378), as follows: " A strong,
healthy man, 54 years  of age, injured himself by lifting a
heavy ladder, on the 28th of August, 1843.  When seen by
Mr. Barlow, the same day, he complained of so much pain
in the region of the liver, that a rupture of that organ was
apprehended.  He was very faint, in a cold sweat, and the
pulse  could scarcely be felt.  Some brandy and water was
given  him, and he recovered sufficiently to be taken home,
a distance of some three miles.  Five grains of calomel and
a grain of opium were given him at night, and Jj- of castor
oil the following morning, which operated and produced
several natural evacuations.   On the 29th he was bled, and
continued the calomel and opium, with a dose of saline mix-
ture every  five hours.  On the  30th, it was observed that
the evacuations from the bowels were white and without
bile, while the urine was dark, as in jaundice.  Five grains
of blue mil were ordered every six hours. As the pain in
the region of the liver continued, the bleeding was repeated
at different tunes, and a blister was  applied over the right
hypochondrium. The same medicine was continued till the
23th of September, when a swelling, the size of a walnut,
was observed over the region of the liver.  This gradually
increased, and, on the  9th of October, was so  large,  and
caused so much pain by distention, that it was thought
proper to lap it.  Seven quarts of fluid  were drawn off,
iehich,from its colour and taste, appeared to be pure bile.
The pain was immediately relieved, and the swelling en-
tirely subsided.  The fluid collected again, and it was ne-
cessary to repeat the tapping on the 21st of the same month,
when six quarts and a  half of fluid were  drawn off.  This
fluid was analyzed by Dr. Pereira, Dr. G. O. Rem, and
Mr. Taylor, and found to be composed  in great  part of
bile.   Dr. Rees guessed the  proportion of bile in the fluid
to  be at least eight parts in ten.  On the 31st of October he
was tapped again, and seven quarts were drawn off.  On the
9th of  November the operation was repeated for the fourth
time, when six quarts were withdrawn. On the 18th of No-
vember he was taken to St. Bartholomew's Hospital,  and
lapped again, when nine pints of fluid escaped.  On  the
26th of November  he was tapped for the last time, when
only three pints escaped. The cyst was not emptied, as on
the former operation, and he suffered extreme pain from the
tapping, which he  had  not previously done.  On the  fol-
   50. Dr. Abercrombie suspects " that the term
bilious stools is often applied in a  very vague
manner, to  evacuations  which  merely  consist
of their faeculent matter mixed with mucus from
the intestinal  membrane."  There can be no
doubt of the vague manner in which pathologi-
cal phenomena are observed by many, even of
those who are  the most critical, and in  appear-
ance the most precise.   But no  one who has
seen bilious evacuations  could  confound them
with those  Dr. Abercrombie  has  mentioned.
Those  who are conversant with  the diseases
of hot climates well know that copious and fre-
quent discharges of bile, the stools sometimes
containing a large proportion of this fluid, sim-
ply  from excitement of the  organ, caused by
the  abundance of the  biliary elements in the
blood,  not  infrequently  take place,  and that
similar discharges occur during bilious  fevers,
and when determination of blood to  the  liver is
favoured by circumstances increasing or accel-
erating the  abdominal  venous  circulation, or
by causes irritating the liver itself, and even by
the irritation produced by an abscess in a por-
tion ofthe organ.
   51.  There is the best  reason  to  suppose,
namely, the evidence furnished by observation,
that an augmented secretion of bile  sometimes
follows the  more violent mental emotions, and
occasionally precedes and even attends  certain
states of inflammation of the organ.  It some-
times  also attends or follows those affections
and diseases,  in  which the requisite changes
are not effected by respiration on  the blood.
   52. Respecting  the  causes,  symptoms, and
treatment of  increased biliary secretion, it is un-
necessary to  add to  what has  been already
stated, both in the foregoing  remarks,  and in
the articles  bilious Diarrhoea, bilious Cholera,
and Gall-bladder.
   53. iii. Vitiated Biliary Secretion.—Mor-
bid Bile.—A. There  is every reason  to suppose
that the bile is not frequently possessed of mor-
bid appearances or properties at the moment of,
or just  after its secretion ;  but that  it acquires
these  properties  after  it  has passed into  the
hepatic ducts and  gall-bladder, and that during
its remora  or  accumulation there,  such prop-
erties are developed, either by the reaction of
its elements or components on  each  other, or
by the  absorption of its watery or  more fluid
parts.   That, however,  the bile is  sometimes
secreted with  remarkably altered  appearances
and properties, is proved  by the  pale  watery
and albuminous state of that which  is found in
the gall-bladder and ducts of a few  cases after
death ;  but these alterations are only  met with

lowing day bile appeared in his stools, and  the urine was
lighter coloured.  On the 3d of December the motions were
of proper colour, containing plenty of bile.   The  swelling
gradually subsided, and towards the end of the month he
became quite convalescent, and soon entirely recovered.
Thus it appears that, from the 9th of October to  the 21st,
thirteen  pints  of fluid accumulated in the sac; and if, as
Dr. Rees believed, four fifths of this consisted of bile, near-
ly ten pints and a half of bile must have been discharged—
not far short of a pint a day.
  Another case is related by Mr. Fryer, in the 4th vol. of
the Med. Chir.  Transactions, where a boy,  13 years of age,
was affected in a similar manner, and the quantity of bile
discharged still larger in proportion to the intervals.  In
this case, as in the former, mercury was given.  We are
not warranted, of course, in assuming from these cases that
the samo amount of bile is secreted under ordinary circum-
stances ;  or, at  any rate, in drawing from such an  estimate
any important  physiological  inference not warranted by
other reasons.—(Budd.)] 
838
LIVER—Neukaloic Arrscnow or.
in connexion with chronic structural change of
the organ.  That the bile often presents a very
dark greenish or greenish brown hue, or is tar-
like in consistence and colour, and thicker and
more acrid than natural, is indisputable.  These
characters are often presented even in the evac-
uations, but more unequivocally in dissections,
■the gall-bladder and ducts being loaded with
bile of this description.  Although it probably
acquired these characters during its  accumula-
tion in these situations, yet it is not impossible
that it possessed them in some degree from the
first, especially as bile of this kind is often se-
creted after indications of an unusual accumu-
lation  of  the elements or  materials  of biliary
secretion  in the blood have been manifested.
   54. It is unnecessary to  adduce proofs of vi-
tiation of the  bile while it still remains in the
system, as this has been  proved by chemical
analysis, and by the irritating effects sometimes
produced  by it when applied to several tissues,
and even  to the skin, although protected by the
cuticle.   These more vitiated or morbid condi-
tions are, however,  observed  chiefly in malig-
nant or pestilential maladies ; the slighter mod-
ifications  only of the secretion occurring in the
more simple functional and inflammatory states
of the organ.   It is probable, that in cases of
congestion of the portal and abdominal venous
circulation, the bile is secreted with modified
characters, and that it then often assumes a
darker appearance, and more acrid properties.
   55.  A  vitiated state of the bile may attend
either a deficient or an increased secretion of it.
The former association  is in a few instances
observed  in dissections, what has  been infer-
red to exist during life  being actually proved
by inspection  after death.  An increased, and,
at the same time, a morbid or vitiated secretion
and discharge of bile, is observed upon recovery
from pestilential cholera,  when, owing to the
suppression ofthe vital actions of the liver, and
to the abdominal congestion, the materials of
biliary secretion have accumulated in the blood,
and the restored function  of the organ, acting
upon a redundancy of these materials, furnish
an increased as well as modified supply of this
fluid.  A similar state ofthe bile is  sometimes
observed after partial asphyxia, and during or
after an asthmatic attack, particularly when the
functions ofthe liver are roused by chologogue
purgatives. In these cases, the obstructed func-
tion of the lungs having caused an accumulation
of the elements of  bile  in the blood, the liver,
when  its energy  is restored, combines  them
into this  fluid, which, owing to the redundancy
of these elements, is not only increased in quan-
tity, but  is also more or  less modified in its
characters.
   56.  It  is, however, most  probable that the
bile becomes  vitiated in  the majority of  cases,
or chiefly after it has accumulated in the gall-
bladder and hepatic ducts ; that the acrid prop-
erties it thpre acquires sometimes promote its
discharge into the duodenum; that  its  action
upon the intestinal mucous surface greatly in-
creases the secretions and exhalations in this
situation ; and  that  its  deep  tinge is more or
less imparted in the fluid stools thus produced,
the secretion and discharge of bile thereby ap-
pearing greater than it really  is.
   57.  B.  The  treatment most appropriate to viti-
 ated,  morbid  states of the bile should depend
upon the phenomena attending it.   If it give
rise to diarrhoea, griping, &c , diluents, demul-
cents, the warm bath, and other means advised
in the article Diarrhoea (y 27), small doses of
ipecacuanha, with alkalies, anodynes, and gentle
aperients, are often of service.  If the irritation
proceed so far as to give rise to symptoms ap-
proaching to bilious cholera, the means then
advised should be employed.
  58.  iv. Neuralgic Affection of the Liver
—Synon.   Hepatalgia ;  Dolor Hepatis ;  Colica
Hepatica, of various Authors.—Severe Pains of
the  Liver.—This affection  has been  noticed
by Avicenna, RoLriNCK,  Zacutus  Lcsitanus,
Bartholin, Bianchi, and several other writers;
and recently  by Grosman, Andral,  and Dr.
Stokes.
  59.  It consists of very severe pain in the re-
gion of the liver—which  is not accounted for
by any organic  lesion of this viscus  or of  its
execretory ducts that can be discovered during
life or after death—of severe pain without fever,
swelling, or other indication of structural disease
of the liver.
  60.  It is most frequently observed in the
nervous temperament,  and in hysterical per-
sons.   Dr. Stokes states that he has met with
it only in females, and that in some of those a
decidedly hysterical  tendency existed, while in
others this disposition  was not indicated.  In
one case  it seemed connected with  what has
been called " spinal irritation."
  61.  A. The principal symptom of this affection
is the pain, which is more or less constant, but
subject to occasional and violent exacerbations
in some cases, and in  others are  more inter-
mittent, the state of health being tolerably good
during  the intervals.   The  exacerbations, or
returns of the pain,  are often owing  to mental
emotions, over-excitement, derangement of the
bowels, fatigue, irregularity of the catamenia,
or the return of this discharge.  The pain, du-
ring its exacerbations,  is  apparently more  in-
tense than in acute  hepatitis, and  is  generally
attended by tenderness of the hypochondrium
and epigastrium.  There  is  sometimes, also,
slight  jaundice ; but generally there is no sign
of structural lesion of the organ, except pain.
Neither fever, nor swelling, nor thirst, nor bil-
iary obstruction is present:  the tongue is not
loaded ; the urine is not dark, turbid, or scanty;
the stools  are natura),  or not materially disor-
dered ; and the functions of the stomach not
greatly affected.  Dr. Stokes remarks, that in
several cases the patients were subject to neu-
ralgic  affections in other situations, as the face
or extremities :  in one  severe case, dysmenor-
rhea had long existed.   I have seen this affec-
tion connected  with excessive menstruation,
and with other disorders of the uterine  func-
tions.   I have  referred it, in  more  than one
case,  to excessive  bleeding, and  the use of
mercury,  and other exhausting or depressing
causes.
  62.  The nature of the pains—their severity,
the suddenness of their succession and disap-
pearance,  their  intermissions,  the  good  stale
of health in the intervals—all lead to the belief
that they are the result of morbid sensibility,
manifested in the nervous filaments or plexuses
of the liver —of the nerves supplied  by the
great sympathetic or pneumogastric.  Whether
or no there may be, in some cases, latent caus- 
LIVER—Congestions of.                               839
es of irritation of these nerves, as biliary con-
cretions lodged  in  the ducts, or in the gall-
bladder, although not productive either of bil-
iary obstruction or of vascular disturbance, has
not been fully ascertained.  M Andral states
that he has not found them in cases which he
has  inspected ;  but in one  case, where hepa-
talgia had  been  complained of for many years,
the gall-bladder contained a number of concre-
tions ; and in another, the palient had once ex-
perienced an attack which had been recognised
as having arisen from the passage of gall-stones
into the duodenum.   The following is abridged
from Dr. Stokes's treatise, as similar instances
have occurred in my practice.  A lady of luxu-
rious habits and nervous temperament had been
attacked, when in India, with pain in the region
of the liver, which was imputed to acute hepa-
titis.  She was largely  bled and affected with
mercury, without relief.   On  her  passage to
England, she was bled several times, and twice
mercurialized.  After her arrival, she  experi-
enced returns of the  violent pain, for which
she was also  bled, leeched,  blistered, and mer-
curialized.  These means had afforded tempo-
rary  relief;  but the complaint  returned with
increased  severity, her constitution  became
shattered,  hysterical paroxysms were frequent
and violent, and the stomach irritable.  Find-
ing that fever was absent, the right hypochon-
drium supple, the lower part of the chest sound-
ing  clear,  the tongue clean, the complexion
clear, the  above treatment  was inhibited,  and
generous diet, change of air, and full doses of
the carbonate of iron were  prescribed   In the
course of a few weeks the lady had recovered.
Another lady had been treated  for hepatitis.
A physician  was consulted, who could  not de-
tect any evidence of hepatic disease besides the
pain.  She was treated by the carbonate of iron
with complete success.
  63. A lady who  had resided  in  India,  and
experienced hepatic disease, for which she had
been bled,  mercurialized, &e, on her return to
this country consulted an eminent accoucheur,
on account of leucorrhcea and uterine disorder.
She was hysterical and much weakened ; and,
in this state,  she suffered a severe attack of
hepatalgia, which was mistaken for hepatitis,
and treated accordingly, with marked aggrava-
tion of the pain.  The  disease was viewed as
neuralgic,  upon my visiting her, and  a treat-
ment conformable to  this  view soon restored
her to health.  Instances, however, are contin-
ually occurring  of disease—not  merely of this
kind, but also of various seats and forms—be-
ing aggravated, and the constitutional  powers
injured, by the  empirical and routine  practice
Of  bleeding,  mercurializing, over-dosing,  and
over-drugging ;  and although  these practises
are less remarkable now than twenty or thirty
years ago, they are  still notorious,  and furnish
arguments for the knaves of homoeopathy, of
hydropathy, and of other kinds  of  humbug, to
assail the public mind.
  64. B. Of the Treatment  of hepatalgia, it  is
unnecessary to  add anything to what is stated
respecting the removal of hysteric and neuralgic
affections.  The  same means  as are  recom-
mended  for these disorders  are also applicable
to this, with such modifications as the varying
features and  associations of particular cases
may suggest.
I   65.  Connected with functional disorders  of
 the liver, the reader is referred to Bilious Diar-
 rhoea and Cholera ; to Concretions, Biliary ;
 and Gall-bladder and Ducts.
   66. II. Congestions of the Liver, Sanguin-
 eous  and Biliary.
     Classif.—I. Class ;  I. Order (Author).
   67. Dkfin.  Dyspeptic symptoms;  costiveness
 or irregularity of the bowels, the stools  being more
 or less unhealthy;  loaded tongue; oppression at
 the  scrohiculus cordis; a pale, sallow, or muddy
 state of the complexion, and often an increased bulk
 of the liver, as shown by percussion.
   68. Congestions of the liver are of frequent
 occurrence, but in various grades and associa-
 tions.   Congestion, as shown by Mr. Kiernan,
 may be confined chiefly to the hepatic veins, or
 it may exist in the portal vessels, or in both.
 These states  of sanguineous congestion may be
 associated, especially when considerable or pro-
 longed, with biliary congestion.
|   69. The slighter states of congestion, more
j particularly partial congestion, are  often met
 with in dissections, particularly when the pa-
 tient has died from disease attended  by difficult
 circulation through the heart or lungs.  These
 states often can hardly be considered as amount-
 ing to actual disease, but  are  rather  conse-
 quences of the changes immediately  preceding
 and attending dissolution ; but they  frequently
 assume more  decided and serious forms ; and,
 although the attendants, or merely the precur-
 sors of several serious  maladies, they often
 present themselves as primary and  simple  af-
 fections.  They may be  arranged as follows:
 1st. Partial  Sanguineous Congestion of the Lit-
 er : a. Hepatic  Venous  Congestion—b. Portal
 Congestion; 2d. General Sanguineous Congestion
 of the Liver ; 3d. Biliary Congestion.
   70. A. The first, or partial congestion, may
 exist in either  of the series  of vessels con-
 cerned  in the double circulation  of  the liver.
 But before I proceed to notice the two varieties
 of partial congestion, I  may premise that the
 researches of Mr. Kiernan have shown that the
 differences which  have arisen between Mal-
 phigi, Ruysch, Ferrein, Autenreith, Meckel,
 Mappes, and others, are owing to the circum-
 stance of these anatomists having  examined
 livers in different  states of congestion  in  re-
 spect of the hepatic and portal veins ; that the
 structure of the lobules* is similar, and the
  * The lobules are small granular bodies, about the size
of millet seeds.  Each lobule is composed of a plexus of
biliary ducts, of a venous plexus, formed by branches of the
portal vein, of a branch (intralobular) of an hepatic vein,
and of minute arteries ; nerves and absorbents, it is pre-
sumed, also enter into their formation, but cannot be traced
into them.  Examined with the microscope, a lobule is ap-
parently composed of numerous minute bodies, of a yellowish
colour, and of various forms, connected with each other by
vessels.  These minute bodies are the acini of Malpighi.
If an uninjected lobule be examined and contrasted with an
injected lobule, it will be found that the acini of Malpighi
in the former are identical with the injected lobular biliary
plexus in the latter, and the blood-vessels in both will be
easily distinguished from the ducts.—(Kiernan.)
  Thus each lobule  receives a brunch of the  portal vein,
which ramifies into its margins and a minute artery, the
portal vein and artery being distributed to it; and gives or-
igin to an hepatic duct and an hepatic vein, which vein
forms a small trunk in its centre, and returns the blood,
circulated into the lobule by the portal vein and artery, to
the general venous circulation.
  The following excellent summary of the anatomy of the
liver is given by Mr. Erasmus Wilson, in his admirable
work on anatomy : " The liver has been shown to be com-
posed of lobules; the  lobules (excepting their bases) are in- 
840
LIVER—Congestions of.
same throughout;  that one part of a lobule is
actually not more  vascular than another; and
that there is,  therefore,  no distinction of  red
and yellow  substances  in the liver,  the  red
colour resulting  from congestion only, and,  ac-
cording as the congestion is  in the hepatic or
portal veins, appearing in the central or mar-
ginal portions  of the lobules.
  71. As Mr. Erasmus Wilson has succinctly
and clearly stated, each lobule is a perfect gland,
of  uniform structure, of  uniform colour, &c.
" It is the seat of  a double venous circulation,
the vessels of the  one (hepatic) being situated
in the centre  of the  lobule,  and those  of  the
other (portal) in  the circumference.   Now  the
colour of the lobule, as of the entire liver,  de-
pends chiefly upon the proportion of blood con-
tained within  these two sets of vessels; and
so long as the  circulation is natural, the colour
will be  uniform.  But the instant that any cause
is developed which shall interfere with the free
circulation of  either,  there will be an  immedi-
ate diversity in the colour of  the lobule.
  72. " Thus, if there be any impediment to
the free circulation of the venous blood through
the heart or lungs, the circulation in the hepat-
ic veins will be retarded, and the sublobular
and the intralobular veins will become congest-
ed, giving rise to a more or less extensive red-
ness in the centre of each of the lobules, while
the marginal of non-congested portion presents
a distinct border of a  yellowish white, yellow,
or green colour, according to the quantity  and
quality of  the  bile it may  contain.  This is
'passive congestion1 of the liver, the usual  and
vested and connected together, the vessels supported, and
the whole organ enclosed, by Glisson's capsule; and they
r.re so arranged that the base of every lobule in the liver is
in contact with an hepatic vein (sublobular).
  " The  portal vein distributes its numberless branches
through portal canals, which are channelled through every
part of the organ; it brings the returning blood from the
chylopoietic viscera ; it collects, also, the venous blood from
the ultimate ramifications of the hepatic artery in the liver
itself.  It gives off branches in the canals, which are called
vaginal, and  form a venous vaginal plexus; these give off
interlobular branches, and the latter enter the lobules, and
form lobular venous plexuses, from the blood circulating in
Which the bile is secreted.
  " The bile in the lobule is received by a net-work of mi-
nute  ducts, the lobular biliary plexus ; it is conveyed from
the lobule into the interlobular ducts; it is  thence  poured
into the biliary vaginal plexus ofthe portal canals, and thence
into the excreting ducts, by which it is carried to the du-
odenum and  gall-bladder, after being mingled in its course
with the mucous secretion from the numberless muciparous
follicles in the walls of the ducts.
  " The hepatic artery distributes branches  through every
portal canal, gives off vaginal branches, which form a va-
ginal hepatic plexus, from which the interlobular branches
arise, and these latter terminate ultimately in the  lobular
venous plexuses of the portal  vein.  The artery ramifies
abundantly in the coats of the hepatic ducts, enabling them
to provide their mucous secretion, and supplies the vasa va-
sorum ofthe portal and hepatic veins, and the nutrient ves-
sels of the entire organ.
  " The hepatic veins commence in the centre of each lobule
by minute radicles, which collect the impure blood from the
lobular venous  plexus, and  convey it into the interlobular
veins; these open into the sublobular veins, and the sub-
loeular veins unite to form the large hepatic trunks by
which the blood is conveyed into the vena cava.
  " The physiological deduction arising out of this anatom-
ical arrangement is, that the bile is wholly secreted from ve-
nous blood, and not from a mixed venous and arterial blood,
as is believed by Mueller ; for, although the portal vein
receives  its blood  from two sources, viz., from the chylo-
poietic viscera and from the capillaries of the hepatic artery,
yet the very fact of the blood  of the latter vessel  having
passed through its capillaries into the portal vein, or in ex-
tremely small  quantity into the capillary net-work of the
lobular venous plexus, is sufficient to establish it* venous
character."
natural state of the organ after death ; and, as
it commences with the hepatic vein, it may be
called the first stage of hepatic-venous congestion.
  73.  " But if the causes which  produce  this
state of congestion continue,  or  be from the
beginning of a more active kind, the congestion
will extend through the lobular venus plexuses
' into those branches of the portal  vein situated
in the interlobular fissures, but  not to those in
the spaces, which, being larger, and giving ori-
gin to those in the  fissures, are the last to be
congested.'   In this second stage  the liver has
a mottled appearance, the non-congested sub-
stance is arranged  in isolated,  circular, and ra-
mose  patches,  in  the centres of  which the
spaces and parts of the fissures are seen.  This
is an extended degree  of hepatic-venous conges-
tion ; it is ' active congestion1 of the  liver,  and
very commonly attends diseases  of the heart
and lungs.
  74.  " There is another form of partial venous
congestion which commences in the portal vein ;
this is, therefore, portal-venous congestion.  It is
of very rare  occurrence, and Mr.  Kiernan has
observed it in children only.   In  this form the
congested substance never assumes the  deep
red  colour which characterizes hepatic-venous
congestion ; the interlobular fissures and spaces,
and the marginal portions of the lobules are of
a deeper colour than usual; the congested sub-
stance is continuous and cortical, the non-con-
gested substance being medullary, and occupy-
ing  the centres of the lobules.   The second
stage  of hepatic-venous congestion, in which
the congested substance appears, but is not cor-
tical, may be easily confounded with portal-ve-
nous congestion.
  75.  " These are instances of partial conges-
tion, but there is sometimes general congestion
of the organ.  ' In general congestion the whole
liver is of a  deep  red colour, but the central
portions of the lobules are usually of a deeper
hue than the marginal portions.' "
   76.  The second stage of hepatic-venous con-
gestion, when combined with biliary congestion,
gives  rise  to those varied  appearances which
are called dram-drinker's or nutmeg liver.
   77.  When the circulation of the  liver is im-
peded  in  consequence of  depressed organic
nervous or vital power, or of any other cause,
or when the circulation through the capillaries
of  the lungs is interrupted, or  when the gener-
al circulation is embarrassed by disease of the
orifices or valves ofthe heart, congestion takes
place  in the liver.   A slight degree of obstacle
in the lungs or heart causes congestion of the
hepatic veins only, the venous turgescence being
limited by the lobular venous plexus.  A greater
degree of obstruction  produces congestion of
the lobular venous plexus itself;  and if the ob-
stacle continue, or is increased, the congestion
extends through the  interlobular fissures  into
the neighbouring lobules, and, in a more ad-
vanced degree, it spreads itself throughont the
whole ofthe lobules and becomes general. From
the liver the congestion extends to the aliment-
 ary canal, occasioning haemorrhoids, intestinal
 haemorrhages, ascites, &c.  When sanguineous
 congestion  becomes general, as  respects both
 the portal and the hepatic veins, and especially
 when  it is associated  with  biliary congestion,
 the colour  of the organ is much deeper, and
 varies with the colour of the bile in the ducts. 
LIVER—Congestions op.                             841
The liver at the same time, particularly in hot
climates,  is more or less swollen,  so as to ex-
tend, in some cases, below the margins of the
ribs,  but  more frequently to rise  higher  than
usual in the right thorax.
   78. B. Biliary congestion is often present, but
in various degrees.  In the slighter grades it
may  be  the chief lesion,  and in these  it is
merely one of function,  depending principally
upon deficient vital energy of the organ, or
upon temporary impediments in the way ofthe
passage of bile along the common or hepatic
duct.  In its more chronic, general, or severe
states, it  may be consequent upon hepatic ve-
nous congestion, which causes pressure  upon
the lobular biliary plexus and interlobular ducts.
It may also  proceed from  temporary or  pro-
longed turgescence or thickening of the mu-
cous lining ofthe ducts, or from capillary con-
gestion or inflammatory action, diminishing the
caliber ofthe ducts.  This obstruction, as Mr.
E. Wilson remarks, may subside after a short-
er or longer period ; or it may become chronic,
and be a permanent impediment to the current
of bile.  Congestion, however, of the bile ducts,
is probably more frequently caused, when slight
or temporary, by causes affecting the states of
organic, nervous, or vital influence of the or-
gan, and,  when more chronic  and severe, by
morbid states ofthe bile itself, rendering it dis-
posed to become viscid and thick,  and  thus to
flow  with greater  difficulty along the ducts
("Difficili  bile tumet jecur."—Hor.),  and by
mechanical obstacles in the large ducts.  Of
these latter, the most common are the impac-
tion of biliary concretions in the ductus com-
munis, or  hepatic duct, inflammation of these
ducts, enlargement of the absorbent glands in
their vicinity, and the pressure of these  or of
other tumours, disease  of  the pancreas, tur-
gescence  ofthe mucous coat ofthe duodenum,
and  other changes fully described in  the  arti-
cles Gall-bladder and Ducts,  and Jaundice.
   79. In  proportion, generally,  as  the obstacle
is complete, so are the ducts loaded with bile,
which imparts a deep yellowish, or yellowish
green, or  deep green, or greenish brown tint to
the organ.  Much,  however, both ofthe tume-
faction and depth  of colour depends upon the
degree of hepatic,  venous, or portal congestion
attending the biliary congestion,  the  hepatic
veins being generally loaded in chronic cases
of biliary accumulation.   When one of the bile
ducts is obstructed by a biliary  concretion, the
branches above the obstruction become dilated
and filled with bile, which is thick and viscid
when the obstacle  has been of some continu-
ance ; but this subject  is more fully discussed
in the articles just named, and in that on Con-
cretions, Biliary.
  80. C. Causes.—Whatever directly or  indi-
rectly depresses the vital energy of the liver,
necessarily impairs the  tonicity  of the veins
and  favours  congestion of them.  That the
portal veins  are more frequently  the  seat  of
congestion than is usually supposed, may be
inferred from  their removal beyond the direct
current of the circulation, and from their form-
ing a circulating  system of themselves, de-
pending entirely upon their own  vitality and
that  of the liver for the  due performance  of
their circulating function.   The circumstance
of the portal vessels being found less loaded I
    II.              106
than the hepatic veins after death, is no proof
of the absence of congestion of them  during
life ; for, being endowed with certain  of the
properties  of arteries,  they also  possess,  in
some degree, that of contracting or of empty-
ing themselves partially at the moment  of dis-
solution.
  81. The ingestion of much food  and fluid
farther promotes congestion of the portal sys-
tem, inasmuch as a part of these materials find
their way directly into  the  veins which pour
their contents  into  the  portal vein ; and, al-
though such supply of new materials may not
materially  affect the robust person  who pro-
motes  the circulating and secreting  functions
of the  liver by regular and sufficient  exercise,
yet, when  inordinate, it must load the  portal
and the hepatic veins of the weak, the dyspep-
tic, the predisposed  to disorder of the  biliary
organs, particularly  if they  be indolent and
doomed to sedentary occupations, and  favour
a morbid secretion of bile, and accumulations
of it in the ducts and gall-bladder.  Ofthe caus-
es ofthe congestive conditions ofthe liver, the
most influential are high ranges of tempera-
ture followed by sudden changes, and  expo-
sure to cold or to moisture and malaria; too
much animal food ; intemperance ; want of ex-
ercise,  particularly  in the open air ;  periodic
fevers, and the  other  causes above  adduced
(Y 19, et seq).
  82. It ought not to be forgotten that  an ac-
curate  examination will detect congestions of
the  liver—sanguineous, or biliary, or both—at
the  eommencement  of many diseases,  espe-
cially of periodic and continued fevers, and of
inflammations of the organ.   They not infre-
quently originate, when neglected or improp-
erly treated, other  maladies, particularly in-
flammations, bilious fevers, dysentery, cholera,
haemorrhoids, &c.; and they often attend or
follow  periodic  fevers, and diseases of the
brain,  of the lungs, and of the heart,  of the
aorta, &c.
  [We believe, with Dr. Budd (Dis. of Liver,  p.
54), that congestion of the liver may also re-
sult from a faulty state of the blood, quite in-
dependently of any mechanical impediment to
its  course  through the lungs or heart,  as we
often see  in purpura hemorrhagica, scorbutus,
&c.  From the late  researches of M. Andral,
it would seem that a great  diminution  in the
proportion  of fibrin is the change in  the blood
that most disposes to such congestions ]
  83. In warm climates, especially in  the East
Indies,  congestions of the liver frequently as-
sume very  active states, and more prominent
features than in temperate climates ;  and, ow-
ing  to  the  general  association of biliary with
sanguineous congestion, and the great amount
of both, it is much more difficult to determine
the  exact share which each portion of the cir-
culation ofthe organ bears in the production of
the  morbid appearances.  Generally, however,
the  viscus is much increased  in size, particu-
larly the right lobe, and  the  increase in bulk
often takes place chiefly in the direction  ofthe
thoracic cavity, the  right lobe rising up into
the  chest.   The difference of colour observed
in different cases, and even in the same,  seems
to  depend  upon the particular set of vessels
chiefly  affected, and  upon the absence  or co-
existence of biliary congestion, and the  colour 
842                             LIVER—Congestions of.
of bile in the ducts.  The surface of the con-
gested liver is  of a  dark brown,  greenish-
black, occasionally passing abruptly into a red-
dish or light brown tinge.   Sometimes it is
mottled, or streaked, or clouded with tints of
various deepness.   The  shades of colour are
usually most remarkable  upon the convex sur-
face, and most frequently observed there.  In
some cases the surface of the liver is very
dark, yet, upon dividing its substance, the in-
ternal texture is of the usual colour,  but more
commonly it is darker, and much black fluid j
blood escapes.  The bile found  in cases  of bil-
iary congestion varies in its characters, but it
is  commonly darker and thicker than natural,
and as described in the article  Gall-bladder
and Ducts.
  84. Passive or mechanical congestion  of the
liver  is not infrequently met with in infants,
owing to asphyxia upon coming into  the air at
birth.  Those who die in this state present the
liver enormously congested.
  85. D. The symptoms of sanguineous and bil-
iary congestions ofthe liver cannot be individ-
ually depended upon ;  they should be viewed
in connexion, and duly estimated.  We may,
however, infer the existence of  these disorders
when several ofthe following phenomena pre-
sent themselves.   A pale, sallow, anxious, or
muddy hue of the countenance ; a white, load-
ed, or furred tongue ; costiveness or irregu-
larity of the bowels, the  stools being watery,
dark, or otherwise morbid,  and preceded by
griping, difficult or slow digestion, with flatu-
lence or nausea, and various dyspeptic  symp-
toms ; uneasiness, weight, or oppression, par-
ticularly after a meal, at the pit  of the stom-
ach and region of the liver ; oppressed or heav-
ing respiration ; the sudden occurrence of pain,
fulness or  weight at the  epigastrium, hypo-
chondrium, or across the  shoulder-blades, or
below the right scapula, the  uneasiness being
increased by full inspiration  and pressure ; a
full, slow, oppressed, or irregular pulse ; a cool,
clammy, dingy state of the skin, a turbid state
of the urine ; and headache,  restlessness, dis-
turbed sleep, and unpleasant dreams.  Upon
examination  of the region of the liver by per-
cussion, the  sphere of dulness will  be  found
extended, particularly toward the right  thora-
cic cavity.   Many of  these symptoms, indeed
most of them, are observed  in inflammations
ofthe organ, but they are then attended by in-
creased frequency and hardness of pulse ;  by
heat of skin and feverishness, particularly at
night; by thirst, sometimes with retchings, and
by aggravation  of the symptoms enumerated.
Hence it is as much by the absence ofthe symp-
toms characterizing the more serious diseases
of the liver as by the absolute  value of those
mentioned that we infer the existence of con-
gestions ofthe organ.
  86. The pulse in congestions is variable, and
cannot often be depended upon.   Although  a
dull or aching pain, weight, or oppression about
the epigastrium, or under the scapulae, charac-
terize in general inflammation ofthe substance
of the liver, yet these are often signs of con-
gestion also, especially when they occur sud-
denly,  and are attended by many of the  symp-
toms already described.  Inflammation  does
not arise or reach its acme in a few hours, but
congestion  may.  Neither can pain be always
considered indicative  of inflammation,  since
the membranes ofthe liver are often stretched
by congestion  so  as  to occasion pain.   When
biliary congestion is  at the same time consid-
erable, uneasiness at  the  epigastrium, a sal-
low, dingy,  or even jaundiced state of the
countenance and skin, slowness of pulse, low-
ness of spirits, inactivity, &c, become prom-
inent symptoms.  If an increased secretion of
bile follow this state, the  congested state of
the vessels is relieved, and the circulation ren-
dered more free and natural.  But if the con-
gestion  continue, inflammation and other con-
sequences already noticed, very often ensue.
  [Professor Chapman has treated (" Lectures
on the more  important Diseases of the Thoracic
and Abdominal Viscera, p. 339") of a  chronic
disease  of the  liver allied to hepatitis, which he
terms hepaticula, which is extremely frequent
in the southern parts of our country, and which
is doubtless a passive congestion of  this or-
gan.  " It is characterized," he observes, "by
a sallow complexion, more of a lemon  than an
orange  tinge,  or sometimes by a dingy white,
by  much laxity of the integuments, with the
aspect of bloatedness, particularly ofthe abdo-
men, which is exceedingly tumid ; occasional-
ly cedema of the lower limbs ;  dry, husky, un-
perspirable skin ; shortness of breath on the
slightest exertion ; by anorexia, and imperfect
digestion ;  foul tongue ; costive bowels ; clay,
ash, or  slate-coloured stools ;  deficient, dark,
or loaded  urine ; sluggishness of body ; hebe-
tude of mind ; peevishness of temper, and de-
jection  of spirits.  The pulse is mostly little
affected, sometimes, however,  feeble ; while
in other instances  it is  full, slow, and may
be  intermittent, or  otherwise irregular.  No
acuteness of pain is  felt  in the region of the
liver, or tenderness  betrayed  on pressure, the
complaint being of a  disagreeable  ache, or a
severe sense of distention.  This state of things
may continue  for a long period without much
alteration, prone, as it generally is,  to farther
degenerations.  Commonly these are  a wast-
ing, slow, irritative  fever, heightened by  an
exacerbation at night, subsiding with  copious
perspiration, ultimately followed by colliquative
diarrhoea,  or it more  speedily eventuates in
haemorrhage of dark blood, or general dropsy,
or the whole united, or some other fatal disor-
der.  It is  familiarly called  throughout our
Southern States, where it abounds, inward fe-
ver.  Examples of this affection are  to be met
with among persons of all ages, though  more
so in  children habituated to the influence of
miasmata.   Being partially acclimated, as it
were, this cause of fever, and ofthe more spe-
cial disturbances ofthe liver in such  positions,
operates with comparative lightness, and hence
the only sensible effect is to swell and derange
that organ.  But it  is also consequent, some-
times, on  ill-cured intermittent and  other fall
fevers."  Dr. C. refers these symptoms to ve-
nous engorgement of the liver, induced by tor-
por of  the  portal circulation, from constant
exposure to the operation of miasmatic influ-
ence.
  In this affection, which may be distinguish-
ed from chronic hepatitis by the general physi-
ognomy and absence  of acute pain, there is a
deficiency ofthe biliary secretion, although the
popular  opinion is, that there is an  excess of 
LIVER—Haemorrhage  of.                             843
bile ; that the patient is bilious, and that this is
the cause of all his sufferings.  The  mistake
is doubtless owing to the fact that both these
opposite  conditions are attended by the same
Bymptoms,  as headache, loss  of appetite, nau-
sea,  depraved  digestion,  nervous wretched-
ness, &c.   We  believe this  condition of the
liver to be very  common in females of very in-
dolent habits, who indulge especially in much
animal food, strong tea and  coffee ;  and it is
also one of the  most frequent causes of head-
ache, languor, debility,  and want of appetite in
literary men, who take but little active exer-
cise.   The  remedies are  : a change of habits,
country air and  exercise,  a regular state ofthe
bowels, the  flesh-brush, blue pill,  with com-
pound extract of colocynth occasionally ;  and
especially the natural sulphur waters of Vir-
ginia, Avon, Sharon, Clarendon, &c,  and the
Saratoga  waters]
   87. E.  Treatment.—When  the  symptoms of
active sanguineous congestion  of the liver are
well marked, and when the patient is strong,
young, or plethoric, or is  recently arrived in  a
hot climate, general  or local blood-letting, ac-
cording to the peculiarities of the case, is re-
quired.   The state of the pulse  in this affec-
tion should  not preclude  having recourse to
this practice if  other circumstances show the
propriety of it.   In some instances, where  a
repetition of the bleeding  may be necessary, in
order to prevent the appearance of inflamma-
tory reaction, which is apt to follow the con-
gestion,  particularly in warm climates, when
bleeding  has been  neglected or insufficient,
subsequently a  full dose of a mercurial  medi-
cine, followed by deobstruent and  saline ape-
rients, and  by enemata if requisite, and a blis-
ter applied over the epigastrium and right hyp-
ochondrium, will  generally remove all  disor-
der.  When, however, much  biliary congestion
or accumulation  is associated with vascular
congestion, a frequent recourse to chologogue
purgatives is required.  In many of these ca-
ses an emetic may be  given  with  advantage,
after vascular  depletion   has been practised
where it  has been indicated.  In the more se-
vere  cases,  however, of vascular congestion,
emetics  are hazardous unless copious deple-
tion has been resorted to, and the state of the
biliary function  indicate the propriety of pre-
scribing them.  However slight vascular con-
gestion may seem, it should be recollected, par-
ticularly by the  East Indian practitioner, that
it often originates the  most dangerous forms
of hepatitis, and that abscess may quickly fol-
low inflammation consequent upon the  con-
gested state.
   [Free cupping, or leeching over the hypochon-
driac region, is  of the highest importance in
many of these  cases of  hepatic congestion ;
free vomiting immediately after  vascular  ful-
ness has  been thus reduced will often be  fol-
lowed by decided relief.   In many cases of re-
laxed fibre and  debilitated constitution,  diffu-
sive and energetic stimulants may be employed
to advantage at the same time we are prac-
tising local depletion.   External revulsives of
a powerful kind, as mustard, turpentine, &c,
should never be omitted ;  while soda, from its
effect in  thinning the bile, and thus emulging
the biliary ducts, should be freely administered.
The congestion  above described  is frequently
one of the early symptoms of the cold stage of
the malignant autumnal  and intermittent fe-
vers of our Western and  Southern States, and
seems to be brought  on by extreme heat and
moisture, combined with the malarious princi-
ple.   A high state ofthe dew-point, as we  have
shown elsewhere, has much agency in inducing
this form of congestive disease]
  88. In the passive states of vascular  conges-
tion of the  liver consequent, upon interrupted
capillary circulation in  the lungs, or upon im-
peded circulation through the  heart or aorta,
or  associated with adynamic periodic fevers,
scurvy, &c, the treatment  must  entirely depend
upon  the nature and state of the primary af-
fection,  and upon  its  pathological  relations.
In  several  of  these,  particularly  when the
lungs are congested or inflamed, vascular de-
pletions   are  necessary;  but  in  asthmatic,
chronic bronchitic, and similar affections, the
hepatic  congestion  thereby caused  requires
chologogue  purgatives, occasionally  emetics,
and deobstruents.  If the hepatic vascular  con-
gestion be produced by affections of the heart,
blood-letting may be injurious ; it ought to be
cautiously employed,  if employed at  all, the
chief attention being paid to the regulation and
correction ofthe secretions and excretions, and
to the support ofthe vital  powers.
  89.  III. Hae.MORRHAGE of the Liver.—Haem-
orrhage into, or from the  liver, is very rarely
observed. When the blood is effused into some
part of the  substance of the organ, producing
what the French pathologists have termed apo-
plexy of the liver, the extravasation has been
consequent  either upon passive congestion of
the organ, owing to impeded circulation through
the heart, aorta, or lungs, or  upon deficient
tone of the  capillaries of the organ, or soften-
ing of the part, the seat  of haemorrhage.  In
an  interesting case, recorded by Sir G. Blank
(Trans, of Soc. for Imp. Med. Knowledge, vol. ii.,
p. 18), the haemorrhage seemed to have been
consecutive of the latter  changes, as it  was
associated with purpura.   It had formed  cav-
ities in the  substance of the organ ; these had
burst,  owing to return of the  extravasation,
and effused  their contents into the abdominal
cavity.  M.  Andral supposes that haemorrhage
may take place in the  structure ofthe organ in
consequence of acute  inflammation, but this is
not very probable.  The extravasation is rare-
ly owing to  the  rupture of a considerable  ves-
sel, but rather to exudation from a number of
capillaries, giving rise to  several minute  col-
lections of fluid  or coagulated blood.   M.  An-
dral supposes, from specimens furnished  him
by MM. Rullier and  Reynaud, that the fibrin
of these collections, when deprived of the red
particles,  gives origin to  certain new  produc-
tions, encephaloid and others, that are found in
the  liver; but this requires farther proof.
  90. Several writers have supposed that haem-
orrhage may take place from the liver along the
hepatic ducts, the blood passing into the radi-
cles of these ducts, or into their branches or
trunks, owing to laceration of the part where
the  extravasation occurs ;  but no satisfactory
proof  of either occurrence has  been adduced.
The blood, however, may possibly pass into the
commencement  of the hepatic  ducts in cases
of extreme congestion.   This subject deserves,
but does not  readily admit of farther elucidation. 
844
LIVER—Inflammation of.
  91. Haemorrhage from the liver is most fre-
quently caused by  external injury and rupture
of the organ.   When the liver  is  congested,
and at the same time softened—changes occa-
sionally produced  in humid and miasmatous
situations, either primarily or in connexion with
adynamic  remittent or intermittent  fevers—
comparatively slight external injuries have rup-
tured the organ and caused  fatal haemorrhage
into the abdomen.
  92. Ulceration of one of the hollow viscera
may  occur,  and the inflammation thereby  in-
duced in the peritoneal covering maybe follow-
ed by adhesion to the liver; the ulcer ultimate-
ly penetrating into  the substance of this organ,
eroding one or more of the vessels, and thus
producing fatal haemorrhage into the alimenta-
ry canal.  I have seen altogether three instan-
ces of this kind of haemorrhage : two where the
ulceration commenced in the stomach, extend-
ing through the  peritoneum, which  was firmly
adherent to the liver, and terminating in the
parenchyma of the  latter;  and  one where it
originated in the right flexure ofthe colon, and
proceeded in a similar manner.—(See Stomach,
Ulceration of.)
  93. In all these cases the source  of haemor-
rhage can be determined only by examination
after death.  Granting  the  possibility of the
passage ofthe blood from the portal veins into
the biliary ducts, and thence from the bowels,
the symptoms are  not such  as will indicate it
during life, for we  have no means of determin-
ing whether the blood voided from  the bowels
proceeds from the liver or from the small  in-
testines.
III.  Inflammation  of  the  Liver. — Synon
   'Hnaririr- (from  tjirap,  the liver), hepatitis;
   vovooc; finarKin,  Galen,   nvperoc  ucreptudnc:,
   Graec.  Morbus jecinoris, jccoris vomica, Cel-
  sus.  Inflammatio hepatis,  Sennertus.  Hepa-
   titis,  Auct. Mult.  Hepatalgia Apostematosa,
  Sauvages.   Cauma Hepatitis,  Young.  Em-
  pressma hepatitis, Good.  Hepatite, Inflamma-
  tion du foie, Fr.   Entziindung der leber, leber-
  entzundung, leberkrankheit, Germ.  Inflamma-
   zion di fegato, epatite, Ital.  Inflammation of
  the Liver, Hepatic Inflammation.
     Classif.—1. Class, 2. Order (Cullen).   3.
       Class, 2.  Order (Good).   III. Class, I.
       Order (Author in Preface).
  94. Dekin.—Pain, aching, tenderness, or ful-
ness in  the right hypochondrium  or epigastrium,
the pain often extending to the right shoulder-blade,
and  other parts ;  inflammatory fever ; furred
tongue; frequently  cough  or bilious vomiting;
costive or irregular  bowels ; scanty, high-coloured
urine; a slightly yellow  tinge of the face, and
sometimes complete jaundice.
  95. Inflammation of the liver frequently ori-
ginates, silently and insidiously, in some one of
the functional disorders already noticed.  In
warm  climates  particularly, it  is  sometimes
preceded by increased secretion of bile, marking
excitement of the organ, with febrile symptoms,
diarrhoea, or slight dysentery, which often  at-
tract the chief notice and mislead the physician.
In some cases, the biliary congestion becomes a
cause of irritation  to the circulation of the  or-
gan, and kindles the inflammatory  action it is
already prone to undergo ;  and this is the more
to be dreaded, if vascular congestion is also pres-
ent ; such congestion being commonly the an-
tecedent of inflammation in some one or other
of its forms.  It is comparatively rare that hep-
atitis occurs in a  previously sound state ofthe
functions  of the  organ, unless  the exciting
causes are energetic, and  in  warm climates,
especially among the  new residents.   When
inflammation thus originates in any of the func-
tional disorders of the liver, it is most  difficult
to date its commencement; for a slight or ear-
ly grade of inflammatory  action, affecting a
part  only, as  it usually does, of the  substance
ofthe organ,  may give rise  to the symptoms of
anyone of these disorders,  those indicating in-
flammation being  so slight  as to escape atten-
tion.
  96. Inflammation may be limited  to  the fol-
lowing parts ofthe organ, namely, the superior
or convex surface, the  inferior or concave sur-
face, the internal  or parenchymatous structure,
and  the right or  left lobe.  The right lobe is
most frequently the seat of  inflammation ; next
the right and left together; and the left lobe
only, the last in frequency.   The  inflammatory
appearances in  the superior surface ofthe liver
are often limited by the broad ligament.  When
the surface is the seat of the  morbid vascular
action, the adjoining internal structure of the
organ generally participates in it to a  greater
or less extent; and likewise when it commen-
ces in the parenchymatous structure, it some-
times extends to the external surface ;  but this
more rarely  occurs, especially  in  warm  cli-
mates, than  the  former mode of  extension ;
the internal structure being the seat of inflam-
mation  more  frequently  than  the surfaces,
which seldom  participate  in  it  until an  ad-
vanced stage of the  disease.  Sometimes, how-
ever, inflammation  of  the  surface of the liver
may arise from inflammation and the exudation
of lymph from an adjoining viscus, as from the
stomach or duodenum ; and, in these cases, the
surface is the chief seat of disease, which may
be either limited  to it or extended  partially to
the substance of  the organ.  When inflamma-
tion originates in the  surfaces, or  extends to
them consecutively, coagulable lymph is gen-
erally thrown out on them, and  the peritoneal
covering is then or has been inflamed ; but the
parts immediately subjacent may present every
mark of inflammatory action, and  yet the in-
vesting membrane may not participate in it, to
the extent at least  of throwing out coagulable
lymph.  In warm climates, particularly in the
East Indies, the substance  of the liver is often
the seat of acute  inflammation, or of large ab-
scesses, without  any decided  mark  of inflam-
mation of the envelope of the organ, besides al-
terations of colour merely, in some cases, which
alterations are often independent of the inflam-
mation, or connected with  the state  of the bil-
iary congestion.  Abscesses may even proceed
to their utmost extent,  and ultimately break
into  the abdominal cavity, without having in-
duced  inflammation of the serous  membrane
where they point, without having produced co-
agulable lymph on its surface, and, consequent-
ly, without having formed adhesions to adjoin-
ing parts.
  97. The relations, connexions, and integral
structure  of  the  organ being so various, the
seat of inflammation being often limited to a
particular part or tissue, and the character and
intensity of the disease also varying greatly, it 
LIVER—Inflammatio
may be expected that  the symptoms will also
differ accordingly in different cases ; that they
will be often  obscure  or equivocal; and that
they will be still more so when hepatitis is com-
plicated, as  it  often is, with gastritis,  or with
duodenitis, or with dysentery or chronic diarrhea.
  98. Owing to the varying seat and intensity
of hepatitis, the different forms of it  have been
arranged, accordingly,  into inflammation ofthe
surface  and of the  substance;  into  acute and
chronic.  These and other  arrangements are
merely, however, conventional;  and although
the terms acute and chronic indicate chiefly ex-
treme grades of the disease, the division they
mark is, upon the  whole, the most practical,
keeping in recollection that every intermediate
grade of action or  intensity may be presented
by this disease.  Many writers have consider-
ed that acute hepatitis commences or is seated
in the surface of the organ, while the chronic
form  affects the  parenchymatous  structure.
But although inflammatory action, commencing
in the surface of the  viscus,  almost always
assumes an acute  form, yet, when seated  in
the substance  of it, the chronic form is not the
only one assumed,  or if assumed at first, it is
not generally  preserved.  In warm, and even
in temperate climates, the most  acute inflam-
mation  of the  liver, as respects many of its
symptoms as well as its duration, affects both
the substance of the organ and some part of its
surface, or the former only.  It has likewise
been supposed that, as suppuration takes place
in the  substance of the organ, it is most com-
monly a consequence of chronic inflammatory
disease.  But this is not the case, especially in
India and some other warm climates, for ab-
scess often follows  with great rapidity the most
acute form of the disease, as regards the quick-
ness of its  progress.
   99. Investigation  of the diseases ofthe liver,
more especially of  those which are inflamma-
tory, should be made patiently and attentively;
and an ocular as well as a manual examination
of the region of the liver ought always  to be made.
Even in cases where the nature of the disease
is obvious, this ought not to be neglected.  Al-
though such investigation may give us but little
information in the  functional disorders, or in
the early stages of inflammatory diseases  of
the organ, yet it should be resorted to.   Infor-
mation, even of a  negative kind, is  always re-
quisite in hepatic affections, and particularly in
those which are acute.   The trunk of the body
should be exposed  to view,  so as to ascertain
the existence  of bulging or fulness in any part
of  the hypochondrium  or its vicinity.  When
making manual examination, one hand should
be  pressed gently on the part between the base
ofthe right  shoulder blade and the spine, while
with the other the physician endeavours to de-
tect tenderness, fulness,  or  distention,  either
beneath the false ribs,  or at the  epigastric re-
gion, or to  the left of this region, or between
the right hypochondrium and umbilicus.  The
state of the intercostal spaces  should also be
examined on  the  right side ;  and  if pain  be
complained  of in any  of these situations,  its
nature ought to be ascertained by careful and
varied pressure, while counter-pressure is made
on  the back, in the place just named, and du-
ring full inspiration  and forced  expiration.
When the examination is going on, the patient
n of—Symptoms.                         845

 should be directed to bend or move his body in
 various directions, and to stand, stooping  for-
 ward, leaning with his hands on the top of the
 back  of a chair.  If fulness, swelling, or  dis-
 tinct  tumour be felt, the physician should  en-
 deavour to ascertain its nature and connexions,
 by gentle and varied pressure with the points
 of the  fingers;  and the  existence of tender-
 ness, and the degree of tenderness, the  depth
 at which it seems to be seated, and the pres-
 ence  of fluctuation, whether obscure or palpa-
 ble, ought  to be inquired into with as  much
 dexterity as possible.   A rough, rude, or forci-
 ble examination ought to be avoided, as caus-
 ing contraction  of the muscles, and as being
 productive of pain, and even of serious injury,
 in abscess of the organ, or in states of inflam-
 matory congestion of the parenchyma,  when
 more or less softening also often exists.
   100.  i. Acute  and sub-acute inflammation may
 affect either the parenchymatous structure or the
 surface of the organ; but it may also implicate
 both,  although either one or the other in a great-
 er degree or extent.—A. When the substance of
 the organ is solely or chiefly inflamed, the  dis-
 ease may commence either with chills or rigour,
 or with diarrhoea, or without either, particular-
 ly after exposure to cold, wet, currents  of  air,
 the night dew, or to malaria. When chills ush-
 er in the attack,  then many of the symptoms in-
 dicating vascular congestion ofthe viscus (y 85)
 are usually present, and  generally attend  the
 inflammation  during its course.   The patient
 complains of oppression, weight, or uneasiness
 in the right hypochondrium and at the pit of the
 stomach, extending sometimes to the ensiform
 cartilage, and in the direction of the diaphragm
 to  the  back and shoulder-blades.   These  are
 usually increased on a full inspiration, when
 pressure is  made beneath the ribs, or upon the
 stomach and back at the same time.  The pulse
 is  hardly affected  at  this early period of the
 disease ; but it soon becomes quicker at night.
 It is sometimes slow and oppressed, and occa-
 sionally irregular, or even  intermittent.  The
 countenance is now pale, sallow, or somewhat
 anxious; the spirits much depressed; the tongue
 white or yellowish, or more or  less foul, with
 an unpleasant taste of the mouth, sickness, and
 loss of appetite.  The bowels are at first often
 costive or irregular, or diarrhoea may exist, and
 the urine is scanty and high coloured.  Oppres-
 sion at the chest and epigastrium ; slight dysp-
 noea  and  sighing ; headache  and disturbed
 sleep, with night fever and restlessness, are
 also generally present.
   101. a. As the disease advances, the pulse
 becomes quicker, fuller, and more irritable, du-
 ring  the evening and  night, and  is often op-
 pressed or embarrassed during the morning and
 day.  The uneasiness in the region ofthe liver
 and epigastrium is augmented ;  and if vascular
 fulness of the organ be great, and if the disease
 has followed congestion, the patient complains
 of a heavy  dragging pain, increased by  sudden
 motion, or  by turning quickly in  bed.  There
 is sometimes a  short, suppressed  cough, dysp-
 noea, shortness  of breathing, a catch in full in-
 spiration, particularly  after sudden motion. On
 examination, tumidity of the viscus is  evinced
 by the protrusion, or dulness on percussion be-
 neath the  ribs and scrobiculus  cordis,  and by
 the dulness of  sound  extending  higher than 
846                       LIVER—Inflammation of—Symptoms.
usual in the right thorax. A dull pain or aching
is often felt in  the region  of the liver, in the
lower part of the thorax, and in the  epigastri-
um, occasionally extending from the right side
under  the  shoulder-blade to the spine.  It  is
sometimes  referred  to  the top of  the  right
shoulder, frequently to the right shoulder-blade,
occasionally to  both  scapula?,  or only to the
loins.  In a few instances, it is felt in the right
clavicle and side of the neck;  and, in others,
it extends  downward to the  right thigh.   It
more rarely affects the left  shoulder and shoul-
der-blade only.   When  pain is present in the
top  of the  right shoulder, it indicates  disease
of the right lobe of the liver;  but this symp-
tom  is often absent.  In some cases it  is  in-
creased, or excited when not  previously felt,
upon any sudden concussion of the trunk,  or
upon quick motion, or making a false  step,  or
turning suddenly from one side to the other.
But, in many cases, there is little  or no  pain;
or it is complained of on these latter occasions ;
or there  is merely a sense of aching or  drag-
ging, with oppression at the praecordia, anxiety,
and  frequent sighing.  Pain is seldom acute,
tensive, or pungent, unless the surfaces or lig-
aments become affected.   It occasionally ex-
tends from under the ensiform cartilage,  in the
direction of the mediastinum,  to the  back  or
shoulder-blades, and it is then attended by dysp-
noea, oppression or a sudden catch in breath-
ing, and a dry cough.
  102. The position of the  patient varies with
the severity and seat of pain.  Frequently he is
easiest in a semi-recumbent posture.  Difficulty
of lying on the right side is not often  felt, un-
less the  pain  in it is acute.   In many  cases,
any position may be preserved for a time with-
out pain, although uneasiness and  a change  of
posture may follow.   Occasionally the patient
prefers to sit gently bent forward.
  103. In proportion  to the attendant conges-
tion or tumefaction of the organ, the right cav-
ity  of the  chest is encroached upon by it, as
shown by  the  extended sphere of dulness  on
percussion.  In this case, there is also greater
fulness observed  in the right  hypochondrium
and epigastrium, the margins of the ribs being
pushed slightly outward.  Oppressed breathing,
frequent dry  cough, occasionally acute pain,
owing to stretching of the  envelopes of the or-
gan, and increased discharge of bronchial mu-
cus, are complained of; and these symptoms,
with exacerbation of pain  in the chest on  full
inspiration, or  on coughing, the flushed  or full
appearance of the countenance, occasioned by
the impeded circulation through the lungs, may
lead the inexperienced to mistake the disease
for pneumonia ; but,  in these cases, there  are
pain or uneasiness about the scapulae, or  top of
the  right shoulder;  occasionally numbness  of
the right arm, with pain about the insertion of
 the deltoid muscle, or at the wrist; and more
rarely, numbness or pain extending to the right
hip or thigh ;  symptoms indicative of the seat
of the malady.
   104. Nausea and vomiting are often concom-
 itants of the most acute attacks ; but, when ur-
 gent or continued, there  is reason to believe
 that the concave part of the liver is affected, or
 that the inflammation extends thence  to  the
 stomach, or that  it proceeds in the course of
 the hepatic ducts to the gall-bladder  and duo-
denum.   In these cases, the patient complains
of a sense of fluttering,  weight, or fulness in
the right hypochondriac and epigastric regions ;
sometimes of pain in the abdomen, and reclines
chiefly on the left side or back.  The stools are
generally  watery,  frequent, scanty, and dark
coloured, with tenesmus, occasional discharges
of blood, and other symptoms of dysentery, for
which it is often mistaken.   Even when little
sickness at stomach is present, there are loss
of appetite, and heartburn, or gripes, about  an
hour or  two after a meal, with  thirst and low-
ness of spirits.
   105. b.  As inflammation of the substance of
the liver advances, the febrile symptoms, par-
ticularly the evening exacerbations, become
more marked, and the pulse  more  irritable.
The tongue is covered by a white or yellowish
brown fur—moist  in  the early, but dry in  the
advanced stages.  Where the disease has fol-
lowed disorder of  the alimentary canal, or re-
peated attacks of hepatic disorder, the tongue
is often smooth and glossy, marked by fissures,
and lobulated, particularly in the most  severe
cases, and in those about to terminate  in, or
which have already terminated  in abscess.   In
other cases, especially when congestion, san-
guineous or biliary, has passed into inflamma-
tion, the papillae of the  tongue are large  and
distinct, and the surface  of it foul and coated.
   106.  The countenance  and skin at the inva-
sion of the disease, or when chills or rigours are
present, are pale or sallow.   But  as the  in-
flammation is developed,  the countenance  fills
out more fully, particularly when there are ful-
ness and oppression in the region of the liver
and chest, and a dusky redness appears in  the
cheeks.  The  face and  eyes,  however, still
possess a muddy or sallow hue, and  a dark
circle surrounds the  eye, particularly beneath
it. The patient often complains of pain in the
forehead  or  over the eyes.  The skin on  the
trunk is warmer than natural, especially towards
evening, sometimes with a greasy feel, and a
scanty  or partial perspiration.  When the per-
spiration is more copious, it  is often offensive.
Jaundice frequently occurs in the hepatitis of
Europeans, particularly when passing on to ab-
scess, but it seldom  takes place in warm cli-
mates,  unless the gall-bladder or ducts  are in-
volved, or when hepatitis follows biliary calculi
or obstruction of the ducts.  The eyes  and
countenance are always deficient in clearness,
and present  a slight yellowish or sickly hue.
   107.  Deficiency of bile in  the stools is often
observed in connexion  with hepatitis, but in
warm climates it does not often occur, although
it  is remarked more frequently than  a  too
abundant  secretion.   When hepatitis  is con-
nected  with congestion, or with accumulations
of acrid or morbid bile in the hepatic ducts and
gall-bladder, the stools are disordered from the
commencement;  they are foul, dark-coloured,
 foetid, watery, and frequent;  or dark green, and
 offensive ; or at first feculent  and brown, and
 afterward morbid and dysenteric.   There is
 generally  tenesmus,  owing to the irritation ol
 the morbid  secretions on the  mucous surface
 of the  rectum, and this,  with other dysenteric
 symptoms, often masks the hepatic disease.
  " 108.  The urine is  scanty, high-coloured, de-
 posites a lateritious or  pinky sediment,  and
 scalds  the patient in  passing it.  If the bile be 
LIVER—Inflammation of—Symptoms.
847
obstructed, a brown, or dark, flaky sediment is
often deposited.
   109. c. The progress of inflammation of the
substance of the liver is commonly such as now
described, both in temperate and in warm cli-
mates, until it is resolved by treatment, or has
passed into suppuration.  But  it may present
certain modifications.  It may commence as bil-
ious  inflammatory fever, with a full, strong,
and frequent pulse, great heat of skin, vomit-
ing, thirst, and various  symptoms referrible to
the liver and bowels, and indicating predomi-
nant affection of them.   This form is common
in robust, plethoric persons, and particularly
those who have  recently arrived  in a warm
climate.
   110. In some cases, inflammation affects the
substance ofthe liver, and proceeds to suppura-
tion in a more obscure and insidious a manner
than  that above described.   The patient  may
have complained merely of dyspeptic symptoms,
and irregularity or looseness  of the bowels,
when shivering, followed by heat of skin, and
profuse clammy perspirations, ushering in true
hectic fever, indicates the supervention of sup-
puration.  In most of these, the case is neg-
lected, or its nature overlooked, until the inflam-
mation either extends  to the coverings of  the
liver, or  has given rise to abscess; the symp-
toms, produced by the one or the other, being
those which first attract attention, and disclose
the true state ofthe disease.
   111. d. The duration of acute and sub-acute
inflammation ofthe substance ofthe liver varies
from three  or  four days to as many months,
with the  severity of the attack,  the intensity
of the exciting causes, the habit and tempera-
ment of the patient, and the  treatment em-
ployed ;  and, as these circumstances may com-
bine, so  will the disease be disposed to termi-
nate in resolution, in abscess, or in  some other or-
ganic change.
   112. B. Inflammation of  the Surface  of the
Liver assumes a more acute and definite char-
acter than that ofthe parenchyma.—a. Inflam-
mation of this part, acute sero-hepatitis, may oc-
cur primarily or consecutively: in the  latter case,
the morbid action extends to the  surface from
an adjoining part of the substance of the organ,
or from the peritoneal covering of an adjoining
viscus.  In this state ofthe  disease, the febrile
reaction is prominent, and generally consequent
upon chills or rigours.   The pulse is much ac-
celerated and  hard ;  pain in the right hypo-
chondrium is more or less  acute ;  and when
the upper surface of the right lobe  is affected,
or when  the lobe is much tumefied, so that it
rises into the chest, considerable tension and
pain are felt also in the right thorax, and under
the ensiform cartilage and sternum,  resembling
an attack of pleuritis.   Cough,  increased pain,
or a catch on  full  inspiration,  and  tenderness
on  pressure, especially at the time of a  full
inspiration, are also present.  When the whole
of the upper surface of the  organ is inflamed,
the disease may be mistaken for pneumonia, if
the chest be not accurately examined by  the
stethoscope  and percussion  ; oppression, diffi-
culty of  breathing, pain in  the course of  the
diaphragm, and under the sternum, being gen-
erally considerable.  Heat and  dryness of  the
skin, thirst, and the other constitutional symp-
toms, are more fully  developed  than in the
former variety of hepatitis,  and are such as
usually accompany acute inflammations of se-
rous membranes.
  113. The stools are generally disordered and
variable.  They are at first scanty, infrequent,
and costive;  more rarely  loose.  They are
often deficient  in bile;  but in warm  climates
this is comparatively rare, unless sero-hepatitis
has followed torpor or congestion of the organ ;
more frequently the bile seems unhealthy, and
occasionally redundant.  At an advanced stage,
the bowels are often more relaxed, and the bile
is increased.   Sometimes diarrhoea, tenesmus,
or even dysentery, supervenes in warm climates
during the advanced periods of the disease,
apparently owing to an increased discharge of
morbid bile.  The urine is generally  high-col-
oured.
  114. b.  When the superior surface of the liver
is affected, and there are much tumefaction and
congestion of the  organ, the symptoms are
partly referred to the chest.  Coagulable lymph
is often thrown  out upon  this surface, and in-
flammation is thereby induced in the peritoneal
surface of the diaphragm.  Hence,  symptoms
of diaphragmitis often  supervene,  associated
with those of the liver, and with considerable
congestion of the lungs.  In these  cases, the
distress and febrile symptoms are very promi-
nent.   The patient breathes chiefly by the in-
tercostal muscles, and expresses anxiety at the
epigastrium and  praecordia, with a sense of
tension or stricture across the chest, and an
inability to sit or lie otherwise than bent for-
ward.  Cough is frequent, hard, and suppressed,
with great increase of the pain, inability to take
a full inspiration, and occasionally  slight mu-
cous expectoration.  There are also often ful-
ness at the false ribs and epigastrium,  short-
ness of breath, inability of motion or exertion,
headache; a full, dusky, and  anxious  state of
countenance.
  115. When the outer surface and  part ofthe
right  lobe is chiefly affected, the pain is most
severe in the right  hypochondrium,  and  at the
margins of the  ribs, sometimes extending to
the right scapula and top of the shoulder.  A
fulness is often perceptible under the margins
ofthe ribs, with tenderness on pressure.  The
temperature in the region ofthe liver is  some-
times higher than in any other part.  The pa-
tient most frequently lies on  his back, or in a
semi-recumbent posture.
  116. c. When the concave surface ofthe liver
is the seat of the  disease, and  the posterior
part or margin is affected, or  when the inflam-
mation extends to these situations, the func-
tions  of the stomach are then prominently de-
ranged.  Nausea and vomiting are often pres-
ent soon  after  substances are taken  into the
stomach.  Thirst, anxiety, and pain  in the epi-
gastrium, or in the back, are urgent;  and some-
times the pain  extends to the  right shoulder
and right side of the neck. The pulse is vari-
able, but generally irritable, quick, small, con-
tracted, or hard.   There are  often a sense of
fluttering  at the scrobiculus cordis,  a  heavy
dragging pain  in the same situation,  anxiety,
frequent  sighing, and  occasionally, at an ad-
vanced stage, hiccough, particularly after cold
fluids are taken into the stomach.  The patient
generally lies on the right side, or on his back.
  117. d. When the inflammation extends to 
848                       LIVER—Inflammation  of—Symptoms.
the gall-bladder or ducts, or to the stomach or
duodenum, all the symptoms become more se-
vere.   The vomiting is frequent and distress-
ing when the disease implicates the stomach or
duodenum; and burning heat and  fulness are
felt at the epigastrium, with frequent and pain-
ful eructations of flatus, and great tenderness
at the  epigastrium and right hypochondrium;
sunk, anxious countenance, increased heat of
the trunk, cold, clammy hands, and quick pulse.
If the ducts and gall-bladder be affected, the pain
darts to the right side  and back, from the epi-
gastrium ; it  is also often felt in or near the
angle formed by the spine and base of the right
scapula.   Sometimes it extends from under the
ensiform cartilage to the umbilicus, and back
to the right   hypochondrium.   Singultus and
acrid eructations  are not infrequent in the ad-
vanced course ofthe disease.  The patient can
seldom bear pressure on the right side and epi-
gastrium, the uneasiness being increased on a
full inspiration   In most of the cases of sero-
hepatitis, uneasiness or pain is aggravated not
only on a full inspiration, but also on a forced
expiration; for this latter mode of ascertaining
the seat of pain ought  never to be neglected in
our  investigations  of diseases  of the  liver.
Restlessness, want  of sleep, a foul, loaded
tongue, irregular or disordered bowels, scanty
urine,  and sometimes  jaundice, attend inflam-
mation ofthe concave surface ofthe liver ; and,
if the ducts are implicated, the jaundice is gen-
erally complete.
   118. e. If the  left lobe is  alone inflamed—a
very rare occurrence—the  more acute symp-
toms are referred to the left side.  If this lobe
is affected, the right is generally still more af-
fected, and the local symptoms are correspond-
ent, or are most  severe towards the epigastri-
um.  Flatulent  distention of  the  stomach  is
sometimes urgent, and so great as to push the
liver more than is usual to the right side, or to
embarrass respiration.  In these cases, the
stomach often becomes implicated, if the  lower
surface ofthe lobe is inflamed.
   119. ii. Chronic inflammation ofthe liver may
be seated either in the substance or in any part
of the  surface of the organ.  It may occur pri-
marily, or the acute or sub-acute forms of the
disease may have been so far subdued  as to
subside into  a slow, inactive state.—A. When
chronic hepatitis is primary, it is usually seat-
ed in the substance of the organ, often gives rise
to  few local symptoms,  and occasions  very
slight  constitutional disturbance.  But chronic
is a term conveying no precise idea, and merely
signifies a slow state of disease,  presenting ev-
ery grade from that state which may be viewed
as only slightly deviating from health.   When
chronic hepatitis follows the acute, it is usually
seated in the substance  of the organ ;  but it
may affect the surface, or both.  Inflammation
may also commence in a chronic form, and, af-
ter an indefinite time, be aggravated  into the
acute  state,  either  by  the continued operation
of the  exciting causes, or by injudicious treat-
ment.
   120. As chronic disease of the substance of
the liver may present  every grade, down from
the acute state to the  slightest deviation from
the healthy function, so the symptoms attend-
ing it  must vary, and assume more or less pre-
cise characters.—a. In the slighter, or more ob-
scure forms, the nature ofthe disease is seldom
evinced by distinct phenomena.  Various dys-
peptic symptoms, flatulency, acid or acrid eruc-
tations ;  sometimes nausea, and less frequent-
ly vomiting ;  loss  of flesh ; muddy or  sallow
complexion ;  dry cough, or embarrassed respi-
ration ;  torpid state  of the bowels ;  aching or
pain in the back, or in the right hypochondrium,
or a sense of weight or tenderness in the re-
gion of the liver; an  irregular state of the bow-
els, or dark-coloured, offensive, slimy, green-
ish, or watery or muddy evacuations ; dark or
saffron colour of the  urine ; slight acceleration
or irritation of the pulse  in the evening;  in-
creased  heat and  restlessness in the  night;
heat ofthe palms of the hands and soles ofthe
feet in the evening, and chilliness in the morn-
ing ; white, foul, or rough tongue ; bitter taste
of the mouth ;  sickly or yellowish hue of the
countenance ;  depression  of spirits, and, in
some cases, elevation ofthe shoulders, are the
chief symptoms of  this  variety  of hepatitis ;
but some of them may be absent, and others
may be  very slight or evanescent, or slightly
manifest.
   121. b. In the severer states ofthe chronic  dis-
ease, the symptoms  are often nearly the same
as  those attending  the  sub-acute  form, only
differ in  degree, and more distinctly mark the
organ and part affected ;  but in the slighter ca-
ses they are less precise, more equivocal,  and
less to be depended upon in forming a diagno-
sis.  They may even preserve this character
until the inflammation passes into suppuration,
or a large abscess forms, when similar phenom-
ena to those which indicate it in the more acute
disease begin to appear.   Chronic hepatitis, in
any of its grades and states, is often associated
with  slight  or  chronic inflammatory irritation
of the gastro-intestinal villous surface, and hence
several of the symptoms of both affections arc
associated in many-cases.
   122. B. If the surfaces of the liver become in-
volved in this disease, the symptoms are then
more distinct and acute.—Chronic sero-hepatitis.
Pain  or  aching is more  defined and marked;
and as the superior  or the inferior  surface is
chiefly affected, so is it referred to the chest in
the one case, or to the stomach and bowels in
the other.  When the  superior  and  exterior
part of  the  right  lobe is affected, the  patient
then lies with most ease on the right side,  and
often feels, at  an  advanced  stage of the  dis-
ease, more  or less  acute pain, or  a dragging
sensation, upon turning to the left.  If this lat-
ter occur, the existence  of adhesions between
the liver and right side may be inferred.   He
therefore prefers the semicumbent position, or
lies on his back or right side.
   123.  C. In many cases of  chronic  hepatitis,
the disease affects both the  substance and the
surface of the  organ, although either may be
more especially implicated. In these, the symp-
toms are variously manifested.  There is gen-
erally much loss  of flesh, and frequently en-
largement of the viscus may be detected.   Tu-
mefaction or enlargement may arise from three
conditions :  1st. From congestion, sanguineous
or biliary, or both ; 2d. From the more chronic
deposition of lymph between  the  lobules, or
from other lesions of structure ; and,  3d. From
suppuration  and the  formation of an abscess or
abscesses in the substance of the organ.  The 
LIVER—INFLAMMATION OF--CONSEQUENCES.                    849
Jirsl of these generally soon subsides after de-
pletion  and an active  recourse to chologogue
purgatives ; the second is more obstinate, is per-
sistent, and attended by symptoms about to be
noticed; and the third gives rise to a regular hec-
tic remittent, and other phenomena, local  and
constitutional, which will  be considered in the
sequel.
  124.  iii.  Terminations or Consequences of Hep-
atitis.—A.  The acute and  sub-acute states of the
disease : 1st. Terminate in resolution with  a
more or less gradual subsidence of the morbid
phenomena ; 2d.  They pass  into  the chronic
state, and the  various organic lesions connect-
ed with it; 3d. They give rise to suppuration
and its  several states and consequences ; 4th.
They may occasion exudations  of  lymph on
some portion of the surface of the organ,  and
extension of the disease to adjoining  viscera or
parts;  and, 5th,  and  most rarely,  the most
acute state may produce gangrenous  softening.
The other changes observed, in consequence
of acute hepatitis, are  rather parts of the mor-
bid process, especially in  its progress to  sup-
puration, as red  and grayish  softening of the
structure, infiltration ofthe serum or of lymph,
&c, as will more fully appear hereafter.
  125,  In the course of the disease, and partic-
ularly of the  more unfavourable cases, vari-
ous complications arise, and favour a  fatal is-
sue.  When suppuration occurs, such complica-
tions more readily and generally take  place, and
sometimes destroy the patient, or aid the he-
patic malady in producing this result, even be-
fore the abscess has opened into any other vis-
cus.  Some of these complications  may arise
independently of  continuity of surface or ana-
tomical connexion or  proximity, and entirely
from the passage  of morbid  matter  into the
circulation, or over continuous surfaces, or
from constitutional irritation, affecting parts
predisposed to disease.
  126.  B.  As in  the more acute forms of the
disease, so in the chronic  states, several of the
changes usually mentioned as terminations of
hepatitis should be rather viewed as advanced
stages ofthe inflammatory Slate, and others as
the usual consequences of this state in certain
constitutions or  diatheses, since the morbid
vascular action still continues, although some-
what modified in character or activity.  Chronic
hepatitis : 1st. May terminate in resolution, and
a return of the healthy functions ; 2d. It may
pass into the acute or sub-acute states, and the
several resulting structural changes ;  3d. It may
give rise to suppuration and abscesses ; 4th. It
may occasion enlargement and  other organic
lesions  ; 5th. It may implicate the ducts  and
gall-bladder, and  occasion various changes of
them, of the bile,  &c, with jaundice ;  and, 6th.
It may  give rise  to various complications or
serious  maladies of adjoining or related organs,
owing either to  exudations of lymph on  the
surface  of  the organ, to  the extension of in-
flammatory irritation along continuous parts, to
the  irritation of morbid secretions on the in-
testinal villous surface, and to the absorption
of such secretions into the blood.  The most
important of the  above terminations  and con-
sequences  of acute  and chronic  hepatitis  re-
quire a  more particular notice.
  127. A. Resolution is indicated by subsidence
of pain, uneasiness, and fever ; by the tongue
    II.              107
I becoming cleaner, the urine paler and more
 copious, and the stools more natural;  and by
 the subsidence of the  thoracic or the  gastric
 symptoms, according as either may have been
 present.   Tumefaction of the organ also rapid-
 ly subsides, as shown  by the  extended clear-
 ness of sound on percussion in the lower part
 of the chest; and by the diminished fulness and
 tension of the right hypochondrium and  epi-
 gastrium.  The existence of swelling is one of
 the chief indications of the persistence of the
 disease, in a less acute  form, if the other symp-
 toms  are ameliorated,  or of the supervention
 of suppuration.
    128. B. Abscess  is one  of the most frequent
 and dangerous consequences of hepatitis, par-
 ticularly in warm climates ; and occurs chiefly
 in those  insidious  states  of the disease which
 are not attended by acute symptoms, although
 often rapid in their progress.  It may follow any
 grade of  inflammatory  action—the acute, sub-
 acute, and chronic ; and it may occur with any
 rate of rapidity; but it is most  frequent, and
 the most to be dreaded, in  the  sub-acute  in-
 flammation of the  substance of the  organ, at-
 tended with tumefaction  and with  much  dis-
 order of the bowels.  It is especially favoured
 by the scrofulous diathesis and sanguine tem-
 perament,  and  is with  difficulty  prevented
 when  there is difficulty in determining whether
 affection  ofthe liver or dysentery is the prima-
 ry disease, or when, if the former does not oc-
 casion the latter, it is a concomitant or a conse-
 quence of it;  when hepatitis is marked at an
 early stage with much swelling, oppression, or
 a dull aching, and much irritability of pulse to-
 wards evening ; when swelling  or fulness of
 the hepatic region continues, and  more espe-
 cially if it increase after the more acute  symp-
 toms  are  partially subdued; and  when  the
 patient is exposed to hurtful influences during
 the treatment, or at an early period of conva-
 lescence, or indulges in stimulants or too much
 food during this period, or before  the healthy
 functions of the stomach and bowels are  re-
 stored.   In these circumstances, and in debil-
 itated  persons of  a  scrofulous diathesis  and
 sanguine temperament; in the fair-haired and
 complexioned, the blue-eyed, the relaxed  and
 enervated, those subject  to  bowel complaints
 and the sedentary, abscess often forms sudden-
 ly and unexpectedly, no very prominent  symp-
 tom preceding or marking its occurrence.  In
 these persons there is often little or no sign of
 existing inflammation, or the symptoms are ill-
 defined, by no means acute and equivocal, pre-
 senting more of a passive  than of  an  active
 character, although the course of the disease is
 frequently rapid.   In those, even when suppu-
 ration takes place, there is often no definite in-
 dication of its occurrence, although the  physi-
 cian may be aware of the existence of hepatitis.
 In these  circumstances patients  often neglect
 themselves, until abscess has actually formed,
 and some consecutive disease, as dysentery and
 chronic diarrhoea, may have made its appear-
 ance,  which may mark the primary malady, and
 engage the chief attention of both  patient  and
 physician.
   129. On  the other hand,  the  inflammation
 preceding abscess is often active, acute,  and
 attended  by evident local symptoms and  in
 flammatory symptomatic fever in strong, pleth 
850                    LIVER—Inflammation of—Consequence*.
oric, and unimpaired constitutions.   When the
attack is very acute in these, particularly if the
scrofulous diathesis is present, and if the organ
be  congested  and tumefied, abscess  rapidly
forms if the disease be not actively and prompt-
ly treated; and it is generally preceded and at-
tended by symptoms enabling the physician to
prevent and  to ascertain its occurrence.  It is
often owing to the diathesis, to previous dis-
order, or to some fault in the state ofthe organ,
that abscess appears in these more acute and
well-defined cases, when early and judiciously
treated.
  130. The pre-existence of congestion, sanguin-
eous or biliary,  or both,  favours greatly the
occurrence of suppuration  as a consequence of
inflammation of  the liver.  The previous con-
gestion  also increases the swelling generally
consequent upon inflammation ofthe substance
of the organ.  When the swelling, or the signs
indicative of it, attend the commencement  of
hepatitis, coincident congestion may be infer-
red ; and when they follow the  disease, or ap-
pear at an advanced stage, they  indicate the ef-
fusion or infiltration of lymph in the interstices
between the small lobules, and  denote a simi-
lar  state of parts to that accompanying inflam-
mation of more superficial and tangible glands,
often, however, in connexion with vascular and
biliary congestion.  When  suppuration  com-
mences, and as it proceeds, tumefaction of the
liver, fulness of the hepatic region, the sphere
of dulness on percussion in the infra-mammary
region of the right thorax, oppression, weight,
and aching  at the epigastrium  and  hypochon-
drium, are generally increased.   When the in-
crease of bulk, owing to incipient suppuration,
is chiefly  in the  lower or  concave part of the
organ, it is less evident upon examination than
when it is  seated in the  superior  and outer
portion.
  131. a.  When suppuration occurs the pulse
becomes quicker and  softer, or more  irritable,
and shiverings are often observed, either with
or  without  perspirations.  The countenance
becomes pale,  or sallow, or more sunk ; the op-
pression, uneasiness, or weight in the hepatic
region increases ;  and the perspiration sour or
otherwise offensive.   As suppuration proceeds
the hectic fever  attending it is  more distinctly
marked, and  is  never  wanting.  The other
symptoms vary with the constitution  and pre-
vious health of the patient, with the part of the
organ diseased, and with various other circum-
stances.  But when a large abscess is formed
in the liver, or when it is seated towards the
upper and outer portion of the  right lobe, the
following  phenomena  are usually  observed:
1st. Tumefaction of the organ, without any sign
of fluctuation, but with a  doughy, cedematous,
or boggy feel of the hepatic region, or in some
part of it; 2d.  Distinct swelling or tumours be-
low the margins of the ribs, or  at or near the
epigastrium  ; 3d. Bulging of the false ribs with
increased  fulness  of  the  intercostal  spaces ;
and, 4th.  Fluctuation becoming more or less
manifest in such tumours.
  132. In some cases, the pain in the right side
has  been  confined to a particular spot, which
has corresponded with the situation of the ab-
scess ;  and frequently increased heat has been
felt in the part more especially tumefied.  In a
few instances  the enlargement  has been found
low in the right  hypochondrium, or even ex-
tending to the left hypochondrium, across the
epigastrium.  However, these local symptoms,
if no fluctuation or doughiness be felt, and if
the constitutional signs of suppuration be not
present, may indicate only that state of parts
about to pass into abscess, and may exist  for
some  time before the local and general  signs
of this change present themselves.
  133. b. The constitutional symptoms of abscess
of the liver are often as equivocal as the local
signs.   In persons whose constitutions are bro-
ken down, in the phlegmatic  and the  scrofu-
lous, the nature of the disease may altogether
escape detection, until disclosed by post-mortem
inspection, more particularly when suppuration
has followed chronic  inflammation, and has
been  attended  by dysentery or chronic diar-
rhoea.   Rigours are  not always complained of,
but slight shudderings and formications are oft-
en substituted.    When, however, they occur,
and are followed by copious night perspirations,
after states of disorder above described, there
being no reason to infer the existence of ague,
they indicate the formation of matter  in the
organ.  In some instances,  an internal sense
of throbbing  and fluttering in the  region of the
liver, followed by a soft pulse and night perspi-
rations, with clamminess of the extremities, in-
dicate this change, particularly when viewed in
connexion with the previous disorder and con-
comitant phenomena.  In the advanced prog-
ress of abscess, cold sweats and faintness, or
leipothymia, often occur, with anxiety and op-
pression at the praecordia. If these symptoms
appear in a person whose system has not been
affected with mercury, given with  this object,
we may the more certainly infer the existence
of abscess.   The impossibility of affecting the
mouth by mercury when suppuration has com-
menced is  acknowledged by all  experienced
writers on the disease.
   134.  In connexion with the hectic produced
by abscess, the state of the tongue  varies ; but
it  becomes at last brown, red, smooth, lobula-
ted, &c, or dry and parched.  The stools are
always disordered,  and  present  in  different
cases, and at different periods in the same case,
every  possible appearance, with  straining,  te-
nesmus, discharges  of blood from the bowels,
and frequent calls  to  evacuation, particularly
at n ight.  When d isease of the bowels becomes
complicated with  abscess, both the small and
large  intestines are affected ;,at first function-
ally, and afterward organically; and the patient
is  often carried off by the bowel disease, before
the abscess has made its way either externally
or into any other viscus.  In some cases  of
hepatitis, in  warm  climates,  associated with
dysentery, especially of chronic hepatitis, the
termination  in abscess  is either accelerated
or caused by the sudden arrest of the dysente-
ric affection; or the hepatic malady becomes
more  severe and apparent as  the  affection of
the bowels subsides.
   135.  In an advanced stage of abscess, espe-
cially when seated in the posterior parts ofthe
liver, and pressing upon the diaphragm, anxiety
and oppression at the praecordia become urgent,
with attacks of dyspnoea  and  hiccough.  The
position preferred by the patient depends upon
the seat and direction of the abscess.  He most
frequently reclines on the back, or  on the left 
LIVER—Inflammation of—Consequences.                     851
side, or in a semi-recumbent posture ;  and he
sometimes has  most ease  when  sitting and
leaning forward.   Pain  is  a very uncertain
symptom.  During  the tumefaction of the or-
gan preceding the formation of matter, pain is
often considerable,  and is afterward converted
into  a beating or throbbing  sensation,  some-
times attended by shooting or darting pains in
various directions, or merely by prickings chief-
ly in the situation ofthe abscess.   In the more
chronic cases, these latter sensations may be
the only painful feelings  complained of,  unless
occasionally  on sudden  motion, on sneezing,
coughing, &c.  The countenance generally be-
comes sunk, sallow, or jaundiced; and  when
jaundice does not appear, the eyes  are general-
ly either yellowish  or of a pearly  hue.   Ema-
ciation increases, and is  most apparent  in  the
extremities, the upper regions of the abdomen
appearing fuller than  usual.  The  urine some-
times becomes turbid, and in rarer instances pu-
riform or muco-puriform.
   136. Suppuration of the liver, however, has
occurred where the symptoms of hepatitis have
not  been observed, and where the abscess
which has formed has not been suspected du-
ring life-rpain, tumour of the hepatic  region,
jaundice,  &c, not  having been present.   In-
stances of this kind  have  been recorded by
many writers in  this country, and by most of
those who have treated of intertropical mala-
dies.   In many cases, the disease has not been
recognised in consequence ofthe imperfect ex-
amination  of the case ;  in  others,  from the
complications or forms in which it has  occur-
red.   Its association with gastro-enteritis, with
pneumonia, or with dysentery, or its appearing
consequently upon  continued or remittent bil-
ious fever, or after ague, will  sometimes  en-
tirely mask it from the superficial or careless
observer.  There is much truth in the remark
of Mr. Twining, that he has never seen  a case
terminate in abscess without being able to de-
tect  the disease  that  is in progress by a care-
ful examination  before suppuration commen-
ces ;  but then, as Mr. Martin justly adds, the
examination  must  be most  rigorous, and re-
peated daily  until we are quite satisfied as to
the nature of the case.
   137. Abscess may have formed  in the liver,
and death ensue before it  makes its way beyond
its seat.   This result is owing, 1st. To the con-
stitutional irritation produced by it; 2d. To the
absorption into the  circulation of a portion of
the puriform matter as it  is formed  ; 3d. To the
consecutive disease thereby occasioned in oth-
er organs.   The hectic fever attending abscess
is probably caused by the passage  of the mor-
bid matter into the  blood, and the bowel disor-
der, which so freqently attends it, may  be the
result of this circumstance.  There can be no
doubt, however, that the  disease of the bowels
is sometimes so severe, and the organic lesions
found in them so extensive, as to fully account
for the death of the patient before the abscess
had opened into any part.   Consecutive disease
in the lungs and  in the brain may likewise be
occasioned before abscess has made its  way
from the liver, and  prove the more immediate
cause of death.  Pneumonia and coma are not
rare in such cases.
  138. When abscess makes its way beyond its
seat, or through the coverings of the liver, the
direction it takes much depends upon the part
of the organ in which it is seated.   If, in con-
sequence of the absence of inflammation from
that part of the surface or coverings of the liv-
er, the seat of abscess, or of the inflammation
not being productive of coagulable lymph, no
adhesions are formed between the external sur-
face of the abscess and the part opposite to it,
the matter will  be  necessarily effused into the
peritoneal cavity, where it will produce perito-
nitis.   But if adhesions form through the me-
dium  of coagulable lymph with the parts oppo-
site, the abscess will proceed accordingly,  and
open into an adjoining viscus.  Hence, abscess
of the liver terminates as  follows : 1st, and
most  frequently in death, (a) owing to its ef-
fects on the constitution and to the complica-
tions  induced without having opened or passed
from the organs ; (b) in consequence of having
opened into adjoining parts, and of the addi-
tional  disease thereby  induced, as well as  of
the persistence  or increase of the lesion ofthe
liver;  2d, and  more rarely  in recovery, (a) in
very rare instances, without opening ofthe ab-
scess  into adjoining parts, the matter  having
been absorbed and eliminated  by the  kidney ;
(b) after it has opened in certain situations.
  139. The situations  in  which the  abscess
opens  are, 1st.  Without having formed adhe-
sions  into the  peritoneal cavity; 2d. Having
formed adhesions  externally through the  ab-
dominal parietes ; 3d. Through the diaphragm
into (a) the pleural cavity;  (b) the  lungs and
bronchi; (c) the pericardium;  4th.  Into  the
stomach ; 5th.  Into the gall-bladder or ducts,
passing thence  into the duodenum; 6th. Into
the colon, duodenum, or some portion of the
small intestines, particularly the former; 7th.
Most  rarely into the right kidney, or into  the
vena cava.   Certain of these terminations may
be recognised  during life, and recovery may
take place in a  few instances.
  140. a. The external opening of an abscess of
the liver is preceded by much swelling in the
hypochondrium and epigastrium, and often  by
increased heat.  As the matter makes its way to
the surface, the swelling becomes less diffused,
assumes more the form of a distinct tumour, and
appears obscurely acuminated or concentrated,
with a very deep-seated base, the integuments
over  its  apex  becoming discoloured  and in-
flamed ; and it becomes softer and more fluctua-
ting in this situation, while it continues hard to-
wards the base.   The softness and the discolor-
ation which take place in the integuments over
the apex or centre  of the tumour, are the only
indications which can be relied upon ofthe ab-
scess  having formed an  adhesion to the exter-
nal parietes of  the abdomen, and are the only
circumstances in which an operation should be
resorted to; if  they are absent it ought not to
be attempted.   Owing to the neglect of these
indications, J have seen great mischief result
from having recourse to an  external opening;
and I  have farther seen the  tumour caused by
a distended gall-bladder mistaken  for an  ab-
scess, and an operation on  the point of being
performed.   Owing to pressure on the common
duct,  or to permanent closure of it, the accu-
mulation of bile in the gall-bladder may pro-
duce  so great distention of it as to simulate
abscess of the  liver so closely as to be distin-
guished from it  with great difficulty.  The elis-
or 
852
LIVER—Inflammation or—Consequences.
tention of the gall-bladder may even be asso-
ciated with or caused by abscess, in which case
the diagnosis becomes still more difficult, as all
the antecedent and concomitant symptoms of
the latter are observed.   But attention to the
inationdics just named will guide the  physician
aright.  The diagnosis is  very fully  stated in
the article Gall-bladder (y 22).  The abscess
may make its way externally, not only at the
margins of or below the ribs, but also  by a fistu-
lous opening between the  ribs, or beneath the
axilla, or in  the back.
  141. ji. The passage of matter from an ab-
scess in the liver through the diaphragm into ei-
ther the plural cavity or into the lungs is not in-
frequent.  In these cases the peritoneal surface
of the diaphragm adheres to  the part of the
covering of the  liver external to the abscess,
and  generally a similar adhesion  of  the  oppo-
site surfaces of the pleura  also takes  place, and
the  matter  passes into the bronchi.  In this
case the patient  sometimes recovers: but, in
the comparatively rare  instances of the effu-
sion of the matter into the pleura, fatal pleuri-
tis results.  When the matter is about to make
its way into the lungs, many  of the symptoms
of diaphragmitis  and  of pleuritis of the dia-
phragm are  present, with severe dry cough,
pain, constriction, and oppression at the base
of the thorax, hectic fever, hiccough, anxiety,
dyspnoea, rarely jaundice,  the semi-recumbent
or sitting posture, and absence of the auscul-
tatory signs of pneumonia ;  and. as soon as
the abscess  bursts into the bronchi, the patient
experiences  a sudden  feeling of suffocation,
followed by a copious expectoration of puri-
form matter, attended  by diminution of the
swelling, fulness, or tumour in the hepatic re-
gion ; the lung (commonly the right) into which
the  abscess had burst having lost its  respira-
tory murmur, and become dull on percussion.
Generally, as the matter is evacuated, the lung
recovers, or  partly recovers  its permeability,
the bronchi  emptying themselves in the course
of two or three days.   The passage, however,
of  matter  into  them  induces more  or less
bronchitis, which often continues, even in the
most favourable cases, for a considerable time.
The matter expectorated in such cases is usual-
ly well-formed pus, but it  sometimes is mixed
with some blood.
  142. y. When abscess points upon  the  stom-
ach or duodenum,  there are generally  much dif-
fused swelling and hardness at the right hypo-
chondrium and  epigastrium,  frequently  jaun-
dice, urgent and distressing vomiting,  especially
soon after substances are taken into  the stom-
ach, occasionally attacks of dyspnoea, difficulty
of swallowing,  flatulent eructations, and sin-
gultus.  After an exacerbation of these symp-
toms, with clammy perspirations, coldness of
the extremities, &c, the patient throws  up  a
quantity of purulent matter, sometimes mixed
with a  little blood, and the  hepdtic swelling
subsides.  When the abscess opens into an in-
testine, diarrhoea  suddenly appears, the stools
consisting chiefly of purulent  matter.  When
there is only a single abscess of the  liver, and
the organ is not otherwise diseased, and the
malady  no  farther complicated,  the opening
into the alimentary canal may close, and the pa-
tient ultimately recover ;  but more  frequently
a fistulous  opening remains,  and matter con-
tinues to be discharged from time to time Off*
til the patient sinks.
  143. r). Of the  opening of the abscess into
the peritoneal sac, or into the pleural cavity, or
in any other situation,  it is unnecessary to of-
fer  any remark.   Of these, rupture into the ab-
domen is the most frequent.   When this oc-
curs,  the consequent peritonitis is most acute.
Cases have occurred of rupture of the abscess,
both into the digestive canal and  into the peri-
toneal cavity.   A case of this kind is recorded
by Dr. Stokes ; and  one has been adduced by
Dr. Graves, where the abscess  opened into
the stomach by  three  perforations, and also
into the pericardium.   Cases have also been
recorded of an abscess making  its way both
into the lungs and into the  bowels; and oth-
ers have occurred when it has  been opened
externally and afterward burst into the digest-
ive canal, or some other situation.   In  these
cases there have  probably been more than one
abscess.
  144. C.  Chronic enlargement of the liver is a
frequent consequence  of inflammatory states,
particularly of repeated attacks of chronic in-
flammation, and even of the several states of
congestion and of functional disorder, compli-
cated with, or consequent upon, remittent and
intermittent fevers.  The liver is generally en-
larged in a gradual manner, but also so per-
ceptibly as hardly to  be mistaken.  Its func-
tion is much impaired, the  bile  being scanty
and depraved.   The urine is also much disor-
dered.  A frequent, hacking, dry  cough, a sal-
low, pasty  complexion, dyspepsia  in  various
forms, emaciation, general ill health, and ca-
chexia, with lowness of spirits and despond-
ency, are usually present.  A careful exam-
ination of the hepatic  region, and due consid-
eration  of  the history  of the case, will enable
the physician to distinguish this stale of disease
from  chronic pleurisy with effusion, with which
some writers believe that it may be confounded.
  145. The diagnosis insisted upon by Doctor
Stokes  as  marking  the  differences  between
these two  diseases may be here noticed: in
both,  the physician will find  extensive  dulness
of the side on percussion, absence of respira-
tion, and the other stethoscopic  signs nearly
the same, with a full or dilated  side,  and de-
cubitus  upon it.  The  swelling in the hepatic
region may be the same, that arising from dis-
placement  nearly equalling that caused by en-
largement ofthe organ.  But when the side is
dilated by  a fluid, the intercostal spaces  are
raised either to a level with the  ribs, or even
protruded  beyond them, and  the side has a
smooth  and rounded  appearance.   "On  the
other hand, when the  dilatation is caused by a
solid tumour, the  reverse of this occurs; the
pressure being  made upon the ribs, these are
pushed outward, but the intercostal spaces pre-
serve their relative positions  with them, and
the  side does not present anything ofthe smooth
and rounded appearance described."  Doctor
Stokes, however, places more reliance  upon
this distinction than  it  deserves ; and it alto-
gether forms a  piece of nice speculative diag-
nosis, which will not be generally realized in
practice ; for, as  I have  observed for many
years, however firm or unyielding the enlarged
liver may be, it is rarely such, if the enlarge-
ment be considerable, as not to be indented by 
LIVER—Inflammation of—Diagnosis—Complications.
853
the pressure of the ribs, and thus to protrude
the intercostal spaces as much as  fluid effu-
sion.   Attention to the extent and  sphere  of
dulness on percussion, in different  positions, to
the history of the case, and to the toute ensemble
of phenomena, will  be a surer guide  to  the
thinking observer than dependance upon single
points, however nicely distinguished.
  146. There is often greater difficulty in dis-
tinguishing the chronic enlargement of the liv-
er, now under consideration, from that attending
or preceding abscess; and the importance of
the diagnosis is sometimes great.   In both in-
stances there is enlargement; therefore, as to
this, no distinctions can be offered.  The ques-
tions are:  1st. Is an  abscess formed 1 and if
this be answered  in the negative ;  2d. Is there
one about  to form!  The answer to the first
question can be made only from the evidence
of abscess above furnished ($ 131, et seq.), or
from the want of such evidence.   The answer
to the second question is furnished by the symp-
toms of inflammation preceding suppuration, by
the symptomatic fever, with the other phenom-
ena attending it;  and by the  general and local
symptoms  of chronic enlargement.   In  the
former we have more or less evidence of in-
flammation in a state of progression ; in  the lat-
ter, the consequence only of inflammation is
presented to us, the increased vascular action
that occasioned it and the attendant fever hav-
ing  subsided.  In chronic enlargement there
are  more  decided proofs of general cachexia
furnished,  which  are either not seen, or seen
only in a less degree, in the  enlargement pre-
ceding suppuration.
   147. The changes observed on dissection of fatal
cases  of hepatitis and its consequences are fully
stated in the section on  the Structural  Lesions
presented by the Liver.
   148.  iv.  The Diagnosis of Hepatitis will not
detain  me, as the  descriptions given above
comprise the chief distinctions between those
states and consequences of the  disease and
other  maladies which most closely resemble
them.   A  very slight attention will distinguish
between gastro-enteritis, or duodenitis, and hep-
atitis.   The seat of pain or uneasiness ;  the
swelling in the hepatic region ; and the inflam-
matory character of the symptomatic fever,
with the attendant phenomena, will point out
the disease.  In  gastro-enteritis these charac-
ters are wanting, the fever attending it being
more  adynamic than in  hepatitis.   (See  art.
Gastro-enteric Disease, y 12, 13.)
   149.  The details furnished above also serve
to  distinguish chronic  pleurisy with effusion
from chronic enlargement and from abscess of the
liver, as well as the differences existing between
the several functional and inflammatory affec-
tions ofthe organ.
   150.  v.  Complications of Hepatitis.—The
several states and consequences  of hepatitis
very frequently occur in connexion  with other
diseases, the hepatic malady being  either pri-
mary or consecutive of these diseases. Although
I cannot, within  my limits, describe the sev-
eral complications which thus arise, yet I  will
briefly notice the chief of them,  as the mere
suggestion of them will often lead to their rec-
ognition in practice, and to the not unimportant
inquiry into the nature of their connexion and
succession.
  151. A. I have already mentioned the great
influence of remittent and  intermittent fevers in
causing hepatic  disease.  In many  cases, the
latter is  almost coetaneous with the  former ;
and, in some instances, hepatic disorder  pre-
cedes the periodic  fever, and  becomes  devel-
oped into acute inflammatory, or even  struc-
tural disease, as the fever proceeds.   In these
the fever presents  more or less of what has
been called the bilious character ; and the  spe-
cific cause of the fever superadds a constitu-
tional malady to the local  affection, and there-
by  aggravates  it.  Such  complications  soon
become familiar to  physicians in warm, mias-
matous climates.  Again, in many instances,
the hepatic affection is developed in the prog-
ress ofthe fever, and in others it does not ap-
pear until the decline  of,  or during convales-
cence  from the latter.  In  these circumstan-
ces, the substance of the  organ is principally
affected,  and the form and course of the local
disease are frequently obscured.  In all cases
of periodic fever, therefore, and especially if the
attacks have  been frequent  or prolonged, the
functions and state of the liver, and the region
of the organ, should be carefully examined  both
during and after the disease.   (See  Fevers,
Remittent.)
  152. B. The  complication of  hepatitis  with
dysentery, diarrhea,  or  gastro-enteric disease  is
one of the most frequent  and most important
which comes under the observation of the in-
tertropical and Indian physician.   The asso-
ciation often escapes observation, owing to the
seat and nature of the hepatic malady; and the
exact procession of the morbid changes is sel-
dom so manifested  as to admit of recognition.
In some  cases, the morbid secretions from the
liver, either attending  or preceding inflamma-
tory disease  in it,  seems so  to  irritate the
gastro-intestinal mucous surface as to inflame,
and ultimately to disorganize  it.   In others,
disease of both the bowels and the liver ap-
pears  to be  contemporaneous ; and  in many
the gastro-intestinal irritation is primary, and
seems to be propagated from the duodenum
along the ducts to the substance ofthe liver.
This is,  however, not  so  frequent a  mode of
extension as is supposed by some pathologists.
In  most cases  of the association  of  hepatitis
with dysentery or diarrhoea, this can hardly be
considered to obtain ;  and although the vitia-
ted secretions  from a  diseased  liver may irri-
tate and inflame the  internal surface of the
large bowels, thus  occasion diarrhoea or  dys-
entery, and indicate the priority of affection to
be  in the former viscus, still  other instances
will, if accurately observed, show  an  opposite
course of disorder to this, namely, indications
of diseased liver appearing either in the course,
or  upon  the  decline or disappearance  of the
dysenteric affection.   In  these cases  it has
been supposed that, phlebitis having been pro-
duced in Ihe veins arising in  the ulcerated
bowel, it has  been propagated to the portal
vein and its ramifications, giving rise to  infil-
trations  of pus in the  interstices between the
lobules that have ultimately formed themselves
into larger collections or abscesses.   Others,
again, believe that  morbid secretions or other
matters  have been  imbibed by the veins, and,
mingling with the blood, have  been carried to
the capillaries  of the liver, where they  have 
854
LIVER—Inflammation or—Prognosis.
 excited suppurative inflammation  in  the  sub-
 stance ofthe organ.
   153. Without  denying the probability of ei-
 ther of these views, a change closely allied to
 them evidently takes place in many cases, and
 the purulent collections so often found in the
 liver after  chronic dysentery bear the same
 relation to that  disease as other consecutive
 or symptomatic  abscesses bear to  maladies in
 which phlebitis occurs, as erysipelas, &c.  In
 dysentery, therefore, it may be  inferred  that,
 in the  progress  of ulceration, phlebitis of the
 capillary veins of the bowels sometimes oc-
 curs ;  and that the matter or pus thus formed
 in these veins passes with the blood  into the
 portal circulation, where it irritates or inflames
 the minute ramifications of the  portal vessels
 and the structure of the  liver, giving rise to
 purulent infiltrations and collections in the or-
 gan similar to those consequent  upon  phlebitis
 in other parts,  but always occurring in the
 liver, and there only, because the morbid  mat-
 ter  passes  directly from the bowels  into the
 portal circulation.  As in  other forms of con-
 secutive or symptomatic abscess of the liver,
 so in this, the formation of matter is unattend-
 ed by active or acute symptoms, or by the
 tumefaction of the organ  generally preceding
 abscess consequent upon primary or active in-
 flammation of it,  as described above. (See sec-
 tion on Structural Lesions  ofthe Liver.)
   154.  C.  Of the association of inflammation
 of the liver with gastritis  some notice has al-
 ready  been taken (y  118).  The extension of
 the disease from  the concave surface of the or-
 gan to the stomach  is  not unfrequent, even
 without an  abscess  having formed;  and in
 these  cases the  gall-bladder,  ducts, and even
 the duodenum, are sometimes involved.  More
 rarely, the inflammation seems to have extend-
 ed from these parts to the concave surface of
 the  liver, as  shown by extensive  organic le-
 sions in the former,  and by adhesions to the
 latter.   In several instances of chronic disease
 of the digestive organs, with complete jaundice
 and obstruction of bile, with vomitings, &c, I
 have found the  duodenum, the  pylorus, and
 sometimes a portion of the stomach, firmly ad-
 herent to the liver; the pancreas  greatly en-
 larged ;  the gall-ducts involved in the disease ;
 the  pylorus thickened and indurated, and its
 caliber remarkably reduced ; the stomach enor-
 mously distended ;  the liver and gall-bladder
 variously altered, and the hepatic ducts loaded
 with dark  bile.   (See  art. Gall-bladder and
 Ducts, y 18-24, et seq.)
   [Dr. Budd, in his recent elaborate work (On
 the Diseases of the Liver, Am. ed., Phil., 1846),
 has made the following divisions of the inflam-
 matory diseases ofthe liver, viz. :
   1st.  Suppurative inflammation, or  that which
leads to suppuration and abscess.
   2d. Gangrenous inflammation.
   3d. Adhesive inflammation, or  inflammation
that causes effusion of coagulable lymph.
   4th.  Inflammation ofthe veins  ofthe liver.
   5th.  Inflammation of  the  gall-bladder  and
ducts.
   Suppurative inflammation, he supposes, ei-
ther arises from  a  blow or from suppurative
inflammation of some vein, and  the consequent
contamination of  the blood by pus ; or from ul-
ceration  of  the intestines, the stomach, gall-
 bladder, and  ducts — parts which return thin
 blood to the portal vein, to be thence transmit-
 ted through the capillaries of the liver.
   The association of suppurative inflammation
 of the liver with phlebitis, as in cases of surgi-
 cal operations, is  too well known to need par-
 ticular  remark; and it doubtless arises from
 the irritation of the pus globules in the capilla-
 ry vessels of  the  liver, as when quicksilver is
 injected into the veins.   Of 29 cases of abscess
 of the liver recorded by Annesley, in 21 there
 were ulcers,  more or  less  extensive,  in  the
 large intestine.  Dr. Budd maintains, with much
 plausibility, that in dysentery complicated with
 hepatic abscess, the liver does not become in-
 volved  by spreading of the  inflammation,  but
 by contamination  of the portal  blood by pus,
 formed by suppurative  inflammation of one of
 the small intestinal veins ; or by matter of oth-
 er kind, resulting from softening of the tissues;
 or by the foetid, gaseous, and liquid contents of
 the  large intestine, which  must be absorbed,
 and conveyed immediately to the liver.   He
 thinks it probable that contamination of the
 first kind usually gives  rise to  small, scattered
 abscesses ;  of the last,  to diffuse inflammation,
 and a larger, perhaps single, collection of pus.
 If the morbid matter be such  that it does not
 mix readily with the blood, as globules of pus
 or mercury, it will cause small,  circumscribed
 abscesses in the rest of the liver. If, on the
 contrary, the  morbid matter be readily diffusi-
 ble in the blood, all the blood  will be  vitiated,
 and diffuse inflammation result.   In this view
 of the subject, suppurative inflammation of the
 liver is,  in a large majority of cases, a purely
 secondary affection, consequent  on the forma-
 tion of pus in some other part of the system;
 but many observations and facts  are still want-
 ing to establish this doctrine on a permanent
 footing.   We  believe, with Dr.  B., that spirit
 drinking produces adhesive inflammation and in-
 duration of the liver, not suppurative inflamma-
 tion and abscess.]
   155. vi. Prognosis.—A.  In the acute and sub-
 acute states  of hepatitis, the prognosis will de-
 pend upon the part of the  organ especially  af-
 fected, and  upon the progress  and consequen-
 ces  of  the  disease. In temperate climates,
 when hepatitis is treated early and is duly rec-
 ognised, it terminates favourably in  most  in-
 stances—probably in 39 cases  out of 40 ; but
 in warm climates,  and  especially in the East,
 the proportion of fatal cases in those attacked
 by the disease varies from  1 in 20 to 1 in 7, as
 shown in the subjoined abstract from the returns
 made to the Army Medical Board.   In warm cli-
 mates, the natives are less subject to hepatitis
 than the inhabitants of temperate countries.
   ["Of hepatic affections," says  Dr. Forry
 (Climate  of the United States, p. 301),  "inclu-
ding acute and  chronic  hepatitis, and  icterus,
there are reported,  in  the Northern division,
98 cases and  3  deaths; and in the Southern
and Middle, 166 cases and 4 deaths.  The ratio
of cases and of deaths per 1000 of the strength
given in different countries is as follows:
                              Cases. Deaths.
     United States......   6     2
     Canada, Nova Scotia, and New-
      Brunswick   ......   8     2
     United Kingdom.....   8     5
     Mediterranean stations   ...  16    7
     Bermudas........14     5
     West Indies, white troops . .   18    5
     -----------black "...  15    7] 
LIVER—Inflammation  of—Treatment.
855
Canada.......    ......
Nova Scotia and New-Brunswick  .....
Gibraltar..............
Ionian Isles.............
Malta...............
Bermudas.............
Windward and Leeward Command, West Indies
Jamaica..............
Western Africa...........
St. Helena.............
Cape of Good Hope..........
Mauritius.............
Ceylon   ..............
Tenasserim Provinces.........
Bombay..............
Bengal..............
Madras..............
 Aggregate
 Strength
during manj
  Years.
64,280
46,443
60,269
70,293
40,826
11,721
86,661
51,567
 1,843
 8,W73
22,714
30,515
42,978
 6,818
17,612
38,136
31.627
 Attacked
 with He-
patitis anil
Jaundire.
 488
 384
 759
1168
 857
 168
1946
 539
 150
 171
 496
2508
2382
 488
1084
2412
3372
 12
 10
 22
 58
 47
  6
161
 51
 II
 24
 25
122
213
 29
 62
174
190
Proportion*
of Deaths to
Admissions.
1 in 40$
1 in 38}
1 in 34
1 in 20
I in 18
1 in 28
I m 12
1 in 11
1 in 14
1 in  7
1 in 20
I in 20|
1 in 11
l in 17
1 in 17£
1 in 14
1 in 17$
  156. The circumstances which more partic-
ularly indicate danger are, the occurrence of the
disease in cachectic, broken-down, or debilita-
ted constitutions, especially among Europeans
resident in  warm climates, or in those previ-
ously the subjects of hepatitis ; its affecting the
substance of the organ, and its insidious  prog-
ress and association with other diseases,  espe-
cially with those of the bowels;  its  advanced
progress before treatment had been prescribed,
and the failure of judicious means employed at
an early stage;  and symptoms of incipient or
advanced abscess,  and fully-developed hectic
phenomena : in  short, while the  symptoms of
resolution ($ 128) show a favourable termina-
tion ofthe disease, those which attend the oth-
er terminations and consequences of it (Y 129)
evince more or less risk; and, although  they
may not indicate  extreme danger in several
circumstances and in  many cases, yet in oth-
ers, particularly where suppuration and hectic
have been established, the chances of ultimate
recovery are but few.
  157. B. The prognosis in the chronic states of
hepatitis varies with the changes and conse-
quences ofthe disease, as manifested in differ-
ent forms, stages, and cases of it; and depends
upon circumstances connected with the patient
and with the causes which produced  the mala-
dy, as  well as with those which may still con-
tinue to perpetuate or to aggravate it.  Hence
the physician will be guided in forming his opin-
ion, not only in this form of the  disease, but
also in the acute and sub-acute states of  it, by
circumstances so numerous and  varying  as to
preclude the possibility of adverting to  them
with  sufficient  or  satisfactory  particularity.
The soundness of his prognosis must necessa-
rily depend upon the accuracy of his diagnosis,
and of his recognition  of modifying, exaspera-
ting, or countervailing circumstances and in-
fluences—upon his  natural acumen, knowledge,
and powers of observation.
  158. vii. Treatment.—A.  In the  acute  and
sub-acute states of  the  disease, the propriety,
and, indeed, necessity of having  recourse to
energetic measures as early as  possible  are
manifest.   In warm climates, the delay, even
of a few hours, may place the patient in  dan-
ger.   The  first  and most important  means of
cure is blood-letting; and, especially  when the
substance of the organ is. affected ($ 101), it
should be promptly and energetically  practised.
Mr. Martin justly observes,  that, "however
long the disease  may have  existed, provided
there be no  symptoms indicative of suppuration,
general blood-letting—repeated as  the  symp-
toms may demand—and copious in relation to
age, health, and length of residence in  India,
must he instantly had recourse  to;  and the
measure of depletion should be the sense of lo-
cal and general relief, with softening of the skin."
This advice is equally applicable to the acute
hepatitis of other warm climates,  and of tem-
perate countries.   The patient should be seen
in from six to eight  hours after the first  bleed-
ing ; and if vascular reaction has returned or
has increased, as often observed, venisection
must be again prescribed and performed in the
manner so  often advised in this work.
   159. Instantly after  the first blood-letting, a
full dose of  calomel,  conjoined with  James's
powder, or with some other preparation of anti-
mony, ought to be given, generally in the form
of a powder, and a saline purgative should be
taken a few hours afterward.  These may be
repeated at intervals, according to their effects,
until the system be  brought under the moder-
ate influence of  mercury.  In the  course of
treatment,  local  depletions may be  required.
When this  is the case, leeches may be applied to
the anus, or to the hypochondrium  or epigastri-
um, and be followed by fomentations and poul-
tices, or cupping  may  be performed under the
shoulder-blades.  Blisters are  generally bene-
ficial  when applied after vascular  depletions
have been duly practised ; but  they should not
be employed  until depletions  are no longer re-
quired.  During the treatment the more cooling
diaphoretics should be  given at short intervals,
and in such doses as will not offend or irritate
the stomach.
   160. The above comprises the most efficient
means of treating  the more  acute states of
hepatitis ; yet there are others which are power-
ful aids; and one  of  those which have been
mentioned  requires  more particular notice, as
respects not only the  propriety,  but also the
mode of prescribing it.  I shall, therefore, and
particularly on account ofthe great importance
ofthe mattec consider the latter of  these sub-
jects before I discuss the former, and  examine
the questions: 1st.  As to the propriety of em-
ploying mercurials in hepatitis ; and, 2d. As to the
mode of prescribing  them in cases where  their use
appears to be  required.
   161  B. Of the Use of Mercurials in Hepatitis.
—a.  The question as to  the propriety of employ-
ing these medicines in  hepatitis has  been very
generally answered  in the affirmative by most
physicians, and yet  few  agree as to the states
of the disease in which they either should or 
856                      LIVER/—Inflammation of—Treatment.
should not be prescribed.  There can  be  no
doubt that these medicines have been employ-
ed, especially in India, in  a  most indiscrimi-
nating and empirical manner, and to a most in-
jurious extent; and that even those who have
used them the most liberally have themselves
had no precise idea of their modes of operation,
and even of the existing pathological conditions
for which they were prescribed.  Some physi-
cians in the East Indies have contended that
hepatitis  there is a  different disease from that
which occurs in this country ; and, consequent-
ly, that views of the treatment of it in the one
climate cannot be extended to the other.  This,
however, is only partially true :  it is essentially
the same malady, although occasionally some-
what modified in both climates; and  the prin-
ciples of practice are the same in both, for sim-
ilar states of the disease slight alterations only
being required, arising out ofthe persistent in-
fluence of the causes producing it, and the cir-
cumstances of individual cases.  The mistakes
and numerous evils to which they lead, of con-
sidering the  hepatic diseases of India to be dif-
ferent from those of Europe, and of employing
mercurials empirically in  their cure, will soon
become manifest to the  practitioners  in the
former, if, indeed, they are not already mani-
fest  to many, and  especially to the best edu-
cated and the most  enlightened.  I know, from
repeated observation, that inflammations of the
liver may be cured without mercury, in this
country,  quite as well, as safely, and as quickly
as with it; but that there are certain states and
consequences of these inflammations that re-
quire this medicine, and that are benefited by it
more rapidly than by any other;  and  I believe
that the same will  be found to be the case in
India, and in warm countries in general.
   162. Some physicians prescribe mercurials
in hepatitis with the intention of emulging the
bile  ducts; others simply as a  purgative ; and
some with the same view as  in other inflam-
mations, when it is  desired to affect the consti-
tution with them,  and thereby to change the
state of  capillary action in the affected organ.
Now these several  views have been promulga-
ted without any examination of the  mode  of
operation of mercurials upon the biliary organs,
and  upon the assumption that they actually ex-
cite  the  organ, and enable it to discharge  its
functions.  This  assumption has arisen from
the circumstance of an increased discharge of
bile  having  followed the exhibition of them in
many cases where  this secretion appeared to
be impeded or interrupted.  Even those very
writers who have argued for this mode of oper-
ation of  these medicines, have employed them
most inconsistently with their  own views ;
even for acute inflammations ofthe liver, where,
according to these  views, they must  have ag-
gravated or perpetuated  the  morbid  action
which they  were given to subdue.
   163. Mercurials,  like most other medicines,
 when employed in  small doses, exert a stimu-
lant influence for a short time upon living tis-
sues ; but, in large doses, this effect is either
 rapidly exhausted, or hardly produced, and a
 sedative operation results, which is the chief or
 the  only effect usually observed. In doses either
 small or moderately large, they also exert a
 qualitative or alterative influence, relatively to the
 state of vital energy and vascular action, that
becomes more and  more  manifest  the more
frequently they are prescribed, and the shorter
the intervals between the doses.  All the mild-
er preparations, and  the more acrid  ones in  a
state of dilution, produce upon the capillaries
ofthe parts to which they are directly applied,
somewhat  of  an astringent effect, resulting
most probably from  the influences already as-
signed to them ;  these preparations diminish-
ing for  a time the vascularity  of the surface,
and modifying its vital actions.  This is shown
by inflamed or vascular surfaces becoming less
inflamed and less vascular soon after calomel
and the other milder preparations of mercury
are applied to  them.   Such, then, appear to be
the changes produced by the usual  medicinal
doses of mercurials upon the states of vital en-
ergy and vascular action of parts to which they
are more immediately applied; such, I infer,
are their topical effects upon living structures in
health and in disease ; provided, however, that
the vitality of the part be  not  remarkably de-
pressed, or capillary action not altogether sup-
pressed.  Vital agents cannot  influence dead
structures, or structures  approaching  to this
state, unless in as far as they may exert a chem-
ical  action, and  then this  action is confined
chiefly to their antiseptic or septic agency, by
combining with the  tissues  or with the fluids
they contain.
   164. The consecutive or constitutional effects
of mercurials are equally important,  and ought
always  to be considered in connexion with the
topical effects ; for the former, in some cases,
rapidly  follow the latter, while in others they
are  produced with  difficulty.    The  circum-
stances connected with this uncertainty of the
consecutive operation of mercurials  will be at-
tended to hereafter.  Having produced, or while
producing their topical changes, mercurials are
absorbed and  carried into the circulation from
the external surface of the body, by means of
the absorbents, and from the digestive canal,
either by the lacteal  absorbents or by the veins:
if by the last, they will necessarily pass al-
most directly into the portal circulation.  When
carried  into the blood, their effects  are mani-
fested with greater  or less  rapidity  and inten-
sity, according to existing states of vascular
action and vital  power;  but,  in ordinary cir-
cumstances, and in  a time which bears some
relation to the frequency and largeness of the
dose, they effect these states; increasing the
frequency and impairing the tone of the former,
and depressing the latter ; and, ultimately, they
weaken or otherwise change the crasis or coag-
ulability of the blood, and even the vital cohe-
sion of the several tissues.
   165.  Owing partly  to their  local  influence,
and the sympathetic extension of that influence,
and partly to  their absorption,  mercurials soon
increase the exhalations and secretions from the
cutaneous and mucous surfaces, and the secre-
tions of glandular structures, while they dimin-
 ish exhalation  into serous or shut cavities.
 Those  secretions in which are excreted effete
 or injurious materials from the  blood, as the
 bile, the  salivary  and pancreatic  fluids, the
 menstrual discharge, &c, are especially aug-
 mented by large or repeated doses of mercuri-
 als ; nutrition, however,  being impaired, and
 absorption increased, especially of  interstitial
 or imperfectly organized deposites.   If the ex- 
LIVER—Inflammation of—Treatment.
857
hibition of these medicines, in frequent or large
doses,  he persisted  in, these effects become
more manifest; secretion and excretion, more
especially salivary secretion, are greatly aug-
mented ;  the crasis, or  coagulability of the
blood, that is often increased at first by them,
is afterward either  weakened  or  altogether
lost; vital cohesion  is remarkably impaired in
some tissues, so much so as to amount to gan-
grenous  softening and sphacelation; the flow
of the saliva becomes excessive ;  absorption
and  vital exhaustion are rapidly augmented;
and low, irritative fever, consequent upon these
latter conditions, and the transit of morbid or
effete elements into the circulation, during the
rapidity of absorption, exhausts and ultimately
sinks the patient, either with or without certain
local effects of a still more remarkable nature,
as sloughing of the gums and cheeks, caries
of bones, &c.
  166. These being the local, consecutive, and
progressive  effects of mercurials, their influ-
ence upon diseases,  particularly those of glan-
dular organs and serous  membranes, may be
more accurately inferred.  From these effects
we  may explain  their beneficial influence in
many instances of inflammatory irritation or
action  in the villous coat of the stomach and
small intestines, when taken  internally ; and
their good  effects,  when given in repeated
doses for the removal of inflammation of serous
membranes  and its consequences.
  167. In the acute and sub-acute disease of the
membranes or surface of the liver (y 113), large
and  repeated doses of mercury are often most
beneficial, not only in equalizing and lowering
excited vascular action, but also in diminishing
or preventing the exudation of lymph on the
inflamed surface, especially after vascular de-
pletions  have been  duly resorted to.   When
the substance ofthe  liver is inflamed, a similar
recourse to  mercurials is not  so generally ad-
vantageous, unless the inflammation be conse-
quent upon or attended by active congestion of
the organ, or accumulations of bile in the bil-
iary ducts, and blood-letting has been largely
premised.  When the pulse is quick, soft, and
irritable, and the bowels  much relaxed or dys-
enteric, mercurials are frequently more injuri-
ous  than beneficial; and attempts then  made
to produce their usual effects  upon  the  mouth
and  salivary glands  are  either unavailing, or
productive of injury  by accelerating the acces-
sion or progress of suppuration.
  168. The propriety of having recourse to
mercurials in the  more acute inflammations of
the liver depending thus  upon the peculiarities
of individual cases ofthe disease, general rules
as to the employment of them cannot be stated
with sufficient precision.   Much should depend
upon the pathological deductions formed by the
physician as to each case which comes before
him.  Authorities on the  subject are contradic-
tory, and are more calculated to perplex than
to guide the inexperienced.
  169.  Formerly mercury was employed in hep-
atitis, by Indian practitioners, as a substitute
for blood-letting.  The injurious effects of this
practice were first exposed by  Dr. Ballingall.
About the same time, or soon after he wrote, I
endeavoured to show that mercurials should be
employed only to aid, not to supersede blood-
letting, to remove accumulations of bile in the
     II.              108
 biliary passages and liver, and to restore the
 secreting functions of the organ.  Many of the
 writers on hepatitis, during the latter part ofthe
 last century and the early part of this, relied
 solely or chiefly upon the use of mercury for
 the cure  of hepatitis, and yet had no  precise
 ideas  as to its operation, beyond the produc-
 tion of its specific  effects;  and the majority
 of them, moreover,  never discovered, notwith-
 standing the extent  of their unfortunate experi-
 ence,  that it  was  difficult to  produce these
 effects while inflammatory reaction continued,
 and almost impossible when suppuration had
 commenced.   Still,  believing or being told that
 mercury  was  the cure  for the disease, they
 continued to dose their victims with it in every
 instance and in all circumstances, actually pro-
 ducing thereby most of the unfavourable conse-
| quences ofthe malady, and other serious affec-
 tions of related organs.  The rectum-operators
 of the present day  have been  under no small
 obligations to the calomel and mercury halluci-
 nation of the last half century, for the extensive
 field of practice with which it has furnished
 them.  Nor have they alone experienced the
 bliss of the practice, for both East Indian and
 British practitioners have in some way or other
 reaped the advantages accruing from  it, and
 from the happy ignorance which frequently, if
 not generally, prompted it.  The slightest dys-
 peptic, often denominated hepatic disorder, was
 a sufficient indication, with the great mass of
 the profession, for the exhibition of five or six
 grains of calomel every night, or every other
 night, in  this  country, and of  twenty grains
 every night in India ;  and the tenesmus and
 other  consequences of irritation of the  rectum
 thereby produced were rarely  recognised as
 the necessary results  of the  practice, but
 viewed as a part of the disease, requiring only
 a repetition of the same means for its removal,
 until fatal dysentery, abscess  of the liver, or
 other disorganizing  lesions were produced, and
 the fatal issue, which ultimately supervened,
 was most innocently and complacently  viewed
 as the uncontrollable course and consequence
 of the malady, instead  of the common result
 of a treatment prescribed with complete igno-
 rance of the nature of the disease and of the
 operation of the means used to cure it.  This
 is no  over - charged statement.   Numerous
 proofs of it have fallen under my observation
 in this country.  I have seen still more numer-
 ous proofs of it in the hospital books kept at an
 East  Indian  presidency,  and  some of  these
 books I can still  refer to and  even produce.
 There is,  perhaps, no other disease that more
 fully proves how very little mere experience—
 the blind experience of exclusive practitioners,
 incapable  of close observation  and legitimate
 deduction — serves the advancement  of real
 knowledge, than the history of the treatment
 of hepatitis during the last seventy years.  The
 following  abstract of the opinions of a few of
 the many writers on diseases of the liver—of
 those more especially enlightened by  Indian
 practice and extensive experience—shows the
 amount of obligation which is still their due.
    170.  Mr.  Annesley recommends  twenty
 grains of calomel to be given  at bedtime, and
 a purgative in the morning, daily.  In  some
 cases, and especially in those where the  mem-
 branes are chiefly  affected, or where bilious 
858
LIVER—Inflammation of—Treatment.
engorgement of the liver exists, two or three,
or even more of such doses may be of service ;
but  there  are  other cases, equally numerous
with the foregoing, where this practice, contin-
ued  as Mr. Annesley advises it,  until salivation
is produced, would  be more injurious than ben-
eficial, or even most dangerous or fatal.  Dr.
Chapman, on the other hand, in advising small
doses of calomel, considers, with  considerable
truth, very large  doses to be productive of de-
bility, irritation, and the irregular febrile move-
ment caused by  irritation.   Mr. Malcolmson,
Mr.  B. Clark,  Dr.  Dick, and others, also con-
sider large doses of calomel to  be injurious  in
a large proportion of acute cases,  and in a still
larger proportion of chronic cases, and are of
opinion that disease of the liver is more apt  to
return when thus treated.  Mr. Twining, also
an Indian  practitioner, believes mercury to be
of no greater efficacy in hepatitis than in other
inflammations,  in most of which it is secondary
and  subsidiary to  blood-letting.   In  answer,
however, to Mr. Twining, Mr. Martin remarks,
that " It is for  the very reason that calomel as-
sists powerfully  both in  ' drawing off' accumu-
lations, and in procuring 'increased secretion,'
that it proves of such value in aid of blood-let-
ting (in hepatitis).   In short, it  is by this very
double action of  purging and increasing secre-
tion at the same time that mercury  relieves
the loaded and inactive vessels ofthe diseased
gland, not to speak of the other acknowledged
influences of this mineral, such as its increase
of all the secretions and excretions of the body ;
its influence on  the capillary circulation ;  its
febrifuge effect;  the peculiar  specific power
ascribed to it by Gooch and other authors as an
antagonist to inflammations, whether general
or local; its power over the absorbent function ;
its power of unloading at the same time that it
gives a new impulse to  the vascular system ;
its peculiar power in removing viscid and tena-
cious intestinal secretions ; its  alterative  and
solvent effect on  the blood : these are the uses
and  actions ascribed to mercury by the ablest
of our physicians and surgeons, and they are
such as place this remedy second only in order
to blood-letting, in all the more acute hepatic
affections of India."  Mr.  Martin has  here
given a  favourable  and  an able view  of the
operation of mercury ; but the practitioner can-
not expect to find it fully realized in more than
a portion ofthe cases in  which he will employ
this  mineral. Still, in those acute  cases where
these effects require to be produced, there is no
other substance that can  be so  well depended
upon as  it,  when  judiciously  administered.
Nevertheless,  while we endeavour to obtain
these effects, we must  not overlook its more
injurious influences, and neglect means orways,
in respect both  of dose, mode of exhibition and
combination, that may prevent or counteract
them.
  171.  Dr. Saunders remarks, that it is a mat-
ter of  dispute  among those who recommend
calomel  as a  specific  in  liver  complaints,
" whether it acts by purging or by exercising
any local operation  on the biliary  ducts, or  by
acting on the general system, and ultimately hy
salivation,  it being a prevailing opinion that,
when the system  is impregnated with mercury,
suppuration of  the liver  seldom takes  place  ;"
but the question is not  as  to  which of these
ways the medicine operates, but as to whether
or  not  it acts in all  these ways,  producing,
moreover, other effects,  such as have been al-
ready particularized, certain of these effects
being more prominently  produced in some cir-
cumstances and cases than in others.
   172. b. The question, then, is not so much
as  to the propriety of exhibiting  mercury  in
acute hepatitis,  after blood-letting  has  been
duly premised, and repeated in cases requiring
its repetition, for that is  very  generally con-
ceded, with the  exception  I have made above
($ 167), but as to the quantity  and  manner  in
which it should be given.   Although the diffi-
culty of answering this question has been al-
ready shown (Y  170), yet sume have attempted
to answer it with more precision and univer-
sality of application than is compatible with the
rational employment  of medicinal agents  to
control  morbid actions.   On the one hand, we
have Mr. Annesley's  twenty-grain doses of
calomel, which  are  sometimes required, but
which have been recommended  by him as the
almost only mode of employing  this medicine;
on the other,  we find  Mr.  Curtis,  another In-
dian practitioner, advising only three grains of
calomel to be  given with four each of soap and
rhubarb, every  night  and morning, in which
combination the calomel  is decomposed, and
the patient  takes only the oxide of mercury.
In many cases, this latter  plan will  be prefera-
ble, especially when it is desired, as in states
of inaction ofthe liver consequent upon inflam-
mation, or connected with congestion, infarc-
tion, or  enlargement, to stimulate the functions
of the organ,  and promote the absorption of
morbid  deposites ; but in other cases, where
the objects are to derive from the seat of dis-
ease, and to arrest with the utmost speed in-
flammatory action and its consequences, scruple
doses of calomel every night, or smaller doses
taken more frequently, will be more efficacious.
Many years ago, I stated, as a reason for ex-
hibiting mercury with decision,  in order to ar-
rest the progress of hepatitis, that the saliva-
tion thereby produced, and the determination
of the fluids to the salivary glands,  acted as a
powerful derivative from the liver, allowing the
morbid action  in this organ to subside, and the
healthy  functions to  be restored.*
   173. c. Another question  suggests  itself,
namely, are there other means which may be
used in  aid  of blood-letting, or  after vascular
depletions have been carried sufficiently far,  in
order to procure  a free discharge of bile, and
prevent suppuration 1  I believe that there are,
although farther experience is required to de-
termine fully the extent of benefit to be deri-
ved from them, and the particular circumstances
in which they are more especially indicated.
Some of these may be employed either as sub-
  * [From considerable experience in the treatment of acute
hepatitis,  we have come to the conclusion that mercury in
it is not only an unnecessary, but a hazardous remedy, when
given to any extent.  We say it is unnecessary, fur we have
seen no case which has not promptly yielded to free, gener-
al, and local blood-letting, with fomentations, blisters, free
catharsis, with cream of tartar and jalap, the neutral salts
and antimony in nauseating doses.  Dr. Dickson, of Charles-
tun, also states (Essays on Pathology, &c, p. 163, vol. i.),
that he has never seen a fatal case of hepatitis when treat-
ed in this manner, without mercury.  In chronic hepatitis,
however,  we believe  small doses of mercurials are highly
useful and necessary.  If suppuration sets in, then the min-
eral tonics, given freely,  are in the highest degree bene-
ficial.] 
LIVER—Inflammation of—Treatment.                      859
stitutes for or in aid of mercury; the mer-
curial being taken at bedtime, and  the  other
remedies in the morning and course of the day.
Among these the bitartrate of potass is  the
most efficacious  in  promoting a discharge of
bile, in removing viscid and tenacious secre-
tions from the intestinal mucous surface,  and
in lowering inflammatory  action.   It should,
however, be prescribed in full doses—from  one
to three or four drachms twice or thrice  daily,
in the form of electuary ; and it is often advan-
tageously conjoined  with small doses of  tar-
tarized antimony, or  with biborate of soda, &c,
according to circumstances.  The sulphate and
bisulphate of potash, the phosphate of potash, the
nitrate of soda, and other neutral salts, are also
of service when given in full or frequent doses,
and judiciously conjoined with appropriate med-
icines.
   174. C. Acute hepatitis affecting Europeans re-
siding in the East Indies or in warm climates re-
quires a similar treatment  to that already ad-
vised; the only difference being the necessity
of greater activity and promptitude  in the use
of the means of cure.  Blood-letting, general or
local, or both, should be freely practised.  A
full dose of calomel, from ten to twenty grains,
may be given at bedtime, as it will not disturb
the rest of the patient by its operation, but will
act upon the secretions until morning, when a
brisk purgative should be taken to carry off ac-
cumulated feces, and those morbid secretions
which the calomel  had prepared  for removal.
The purgative that may be  given in the  morn-
ing may be either  any of the saline solutions
above mentioned, or the compound  jalap pow-
 der, or the Seidlitz powders.
   175. In warm climates,  the rest of the pa-
 tient ought not to be disturbed by the-operation
 of purgatives during the night; and when  it is
 necessary to continue the mercurial without
 disturbing the patient, it may still be given with
 one or two grains of opium, and with one grain
 of ipecacuanha, if the stomach be not irritable.
 In some cases, particularly when the bowels
 are irritated, an anodyne draught, or an ano-
 dyne enema,  may also be administered at  bed-
 time.   These precautions  against  disturbing
 the patient during the night require especial at-
 tention in some localities,  and where there is
 a free ingress of the night air, and where the
 nights are cold, damp, and chilly.
    176. If the calomel at bedtime, and the pur-
 gative in the morning, saline diaphoretics and
 refrigerants being given in the course  of the
 day, be followed by affection of the mouth, as
 usually happens in the course of three, four, or
 five days,  when vascular depletions have been
 duly premised, then it is sometimes necessary
 to induce  ptyalism as quickly as possible, par-
 ticularly in  the  circumstances  and with the
 exceptions above noticed (Y 167).  The  reason
 which influenced me in thus recommending the
 speedy induction of ptyalism for inflammation
 of the substance of the  liver, conjoined  with
 vascular or biliary congestion, was, that where
 the full operation of mercurials on  the system
 and ptyalism are induced speedily, a derivation
 from the  seat of disease  is  effected, and the
 functions ofthe liver are more readily and com-
 pletely restored.  But if these effects are not
 soon produced, the means should be relinquish-
 ed.  If there be any reason to believe that sup-
puration has commenced, symptoms of it hav-
ing appeared, then mercurials ought not to be
prescribed, inasmuch as they will not then pro-
duce these effects upon the salivary apparatus,
but increase the  debility and irritability of the
patient, and accelerate disorganization.
  177. Where much disorder ofthe bowels exists
or appears in the course of the disease, calo-
mel, or even the mildest preparations of mer-
cury, as  the hydrargyrum cum  creta, &c,
should be given with great caution ; and where
it is clearly  indicated,  it should be combined
with opium, ipecacuanha, &c.  And in order to
protect the  mucous surface  of the large intes-
tines from the irritation of the morbid secre-
tions passing over them, emollient enemata
ought to be administered.
  178. When calomel has been given as above
stated, its operation upon the secretions, excre-
tions, and system in  general,  will be induced
with a celerity in proportion to the extent  to
which vascular  depletion  has  been pushed.
But in many cases the symptoms disappear so
quickly after blood-letting, as not to require the
farther exhibition of calomel at bedtime.  When
this is the case, and  the patient is recovering
rapidly, the secretions  and  excretions having
assumed a healthy appearance, there is no far-
ther need of mercurials, although their specific
effects may not have  at all appeared.  If they
have taken  place,  the circumstance may  be
viewed as favourable ; but  to continue  them
after the secretions are healthy and the symp-
toms of the disease have subsided, is most mis-
chievous, by exhausting vital power,  and  by
over-exciting or otherwise disordering the  bil
iary organs.
   179.  If, after the means above advised have
been employed, the secretions and stools con-
tinue still morbid;  if any disorder can be  de-
tected in the seat of the liver or  in the abdo-
men;  if the tongue  be loaded  or furred, and
the countenance be sallow or unhealthy—the
speedy induction of ptyalism will then be often
judicious and beneficial.  If, however, this  ef-
fect be not produced in the course  of four or
five days, it will be  detrimental to make  the
attempt for a  longer period.   The  means  by
which the mercurial action may be speedily  in-
duced are  various ;  but mercurial  inunction,
thrice daily, with mercurial ointment conjoined
 with camphor, the patient  continuing  the  full
dose of calomel  at bedtime with James's pow-
der, or ipecacuanha and opium, is most to be
relied upon.  Combining calomel  with any of
the preparations of antimony tends to hasten
 the specific  effects of the former, particularly
 after  blood-letting.   If irritation  of the large
 bowels supervene, emollient  enemata  should
 be administered; and  a cooling aperient may
 be taken occasionally to evacuate the  morbid
 biliary and intestinal secretions which rapidly
 accumulate  in hepatic diseases, and which, if
 not removed from the bowels, irritate, inflame,
 and ulcerate the parts in which they lodge.   As
 soon as ptyalism is produced mercurials should
 be intermitted, and gentle tonics, refrigerants,
I and alkaline carbonates, saline aperients, and a
 light abstemious diet should be prescribed.  It
 is  not necessary, in  hepatic diseases, to con-
 tinue  this effect upon the  salivary apparatus
 above a  few days; for its  influence upon the
 complaint is produced in a short time. 
860                      LIVER—Inflammation of—Treatment.
  180  In the  sub-acute and less active cases,
particularly those which have been  of some-
what long standing, or which have supervened
on previous disorder  of the liver, deobstruent
and  saline  aperients,  alternated  with mild
mercurials and  alteratives,  and occasionally
with a full dose of calomel at bedtime, is gen-
erally beneficial, particularly after local deple-
tions  have  been duly  prescribed.   If  these
means fail,  then the full  effects of mercury
should be induced as quickly as possible; after
the appearance of which mercurial  medicines
may be laid aside, at least for a time.
  181. When great congestion and enlargement
ofthe liver accompany the inflammatory state,
repeated leeching, or  cupping under the scap-
ula, and deobstruent and chologogue aperients
are requisite.  After  the inflammatory action
is entirely removed, blisters applied to the re-
gion of the  liver are  generally useful;  and in
the more chronic or obstinate cases, the blister
should be kept open, or an  issue made in  the
side.   Laxatives and  aperients act more copi-
ously after vascular depletion, and blisters ap-
plied on the region  ofthe liver promote the se-
cretion and excretion of bile.  In all instances
the evacuations  should be  inspected  by  the
physician, as they furnish the chief part of the
information required as to the state ofthe dis-
ease and the effects of remedies.   The patient's
or the nurse's account of them ought never to
be trusted.
   182. If fulness, swelling, or congestion con-
tinue after inflammatory action is removed, and
after deobstruent aperients have been duly em-
ployed, and  if  the disease thus assumes  a
chronic form, the means hereafter to be recom-
mended become appropriate.  In this state of
disease,  I have  prescribed small doses of the
iodide of potassium, with liquor potasse and de-
coction of taraxacum, and occasionally the spirits
of nitric ether, with marked advantage.  A lini-
ment rubbed on the region of the liver, or an
embrocation, or deobstruent plaster,  in this sit-
uation, is also of service.
   183. After the acute symptoms have yielded,
and the digestive functions appear restored, still
much torpor ofthe  liver often continues, and a
course  of gentle laxatives and  deobstruents,
combined with bitters and mild tonics, is often
required, in order to  assist the vital action of
the organ, and to excite the sluggish bowels.
If any enlargement still exist in these cases,
either the deobstruents just mentioned, or small
doses of Plummer's pill, or of blue pill, should
be given  at night,  and weak solutions of salts
in the morning.   But care  should be taken to
detect any remains or return of inflammatory
action, and to remove it by local depletions and
cooling diaphoretics.   In many of these cases
the treatment advised for chronic hepatitis is
appropriate,  particularly the  nitro-hydrochloric
acid bath or lotion, and the nitric and  hydro-
chloric acids, or either of them singly, taken in
any ofthe simple beverages used by the patient.
When torpor of the liver remains after acute
hepatitis, a course  of these acids promotes the
re-establishment of the biliary secretion  and
the return of strength, particularly when con-
joined with mild tonics and  a suitable regimen.
   184. D. Treatment of the  Complication of acute
Hepatitis.—These complications chiefly result
from the neglect of  treatment of the primary
disease, or of the early stage  of the disease,
and more especially from the neglect of blood-
letting—a. When the concave or posterior part
of the liver is inflamed, the extension of dis-
ease  to the  stomach, gall-bladder, or ducts, is
often  rapid, particularly in warm climates, if an
appropriate treatment be not promptly employ-
ed.  In this complication general and local de-
pletions, and  full or large doses of calomel, with
or without  opium, are especially requisite  ; and
from  having recourse to these,  the state of the
pulse and feelings of the patient should not de-
ter the physician, as the symptoms will all im-
prove after resorting to them.   Subsequently,
external derivation, the semicupium, or  pedi-
luvium, &c, may be prescribed.  Irritating pur-
gatives should not be given by  the mouth ; but
the action  of the bowels should be procured by
means of purgative enemata.  The treatment
of this  complication  is, however, not different
in any respect from that of the  simple disease ;
it requires  only to be more energetic and  more
promptly resorted to.
   185.  Diaphragmitis, pleuritis, pneumonia,  or
even  pericarditis, is  not  unfrequently associated
with  acute hepatitis, particularly when the con-
vex surface of the liver is  affected ; and it is
sometimes  difficult to  determine,  especially
when the patient comes under treatment late
in the disease, which of these was the primary
affection.  In some cases disease commences
in the form of pleuritis  and  extends to the dia-
phragm, or liver, or both ; but  more frequently
it attacks first the superior surface ofthe  liver,
and  subsequently  the  diaphragm, the  pleura,
and lastly  the lungs, or more  rarely the  peri-
cardium.   The respiration,  expectoration, and
physical signs will indicate the  presence of one
or more of these complications, of  which dia-
phragmitis  is the most frequent, as respects the
affection of  either  of its serous  surfaces,  al-
though  it is not that which is  most frequently
detected during life.   (See art.  Diaphragm, y
8, et  seq.)   In  some  cases, however, the liver
rises, in consequence  of the  congestion and
swelling attending  inflammation of it, so high
in the  right thoracic  cavity,  as to simulate
either simple pleuritis, or  pneumonia, or the
complication of hepatitis with these.  When
hepatitis is neglected, or inactively treated, ex-
tension of the  disease  to the  diaphragm, tho-
racic membranes, and lungs is of frequent oc-
currence, both  in warm and in temperate cli-
mates.   In these  complications, active deple-
tions, and the antiphlogistic treatment and regi-
men  in all  their details, are required.  In order
to aid in lowering vascular action, and to pre-
vent  or to  remove the consequences of inflam-
mation, full  doses  of calomel  with  James's
powder, with or without opiates or anodynes,
according  to the circumstances of the  case,
should be prescribed.  Antimonials ought never
to be omitted whenever there is reason to sup-
pose  that disease exists in the  thorax, or is ad-
vancing thence  from the liver.  They may be
given so as to occasion  some degree of nausea ;
but it is doubtful whether or not they should be
prescribed so as to produce full vomiting when
the  liver is  unequivocally  inflamed ;  for,  al-
though vomiting may relieve the affection  of
the lungs,  it may aggravate that of the  liver.
In some cases good has indirectly resulted from
the exhibition of an emetic, in developing and 
LIVER—Inflammation of—Treatment.                     861
 rendering more manifest an obscure disease. |
 and thereby leading to a more  energetic and j
 Buitable treatment than would otherwise have |
 been  employed.  Where  inflammatory action
 is  subdued, these blisters, rubefacients, or the
 tartarized ointment may be applied ;  and if the
 case become chronic, a seton or issue may be
 made in the side.  In this complicated state of
 disease mercurial medicines should be given in
 combination with antimony, camphor, or opium,
 or with  either  or  all, according to circum-
 stances.   If no effusion has taken place into
 the thoracic cavity, vascular depletions having
 been  duly employed, benefit will be derived
 from  a warm terebinthinate embrocation ap-
 plied over the seat  of uneasiness; but if effu-
 sion have taken place, the repeated application
 of blisters, persistence in the use of mercurials
 until  the  mouth is  slightly affected, and the
 continuance of this affection by means of the
 milder preparations every night,  while  small
 doses of the hydriodate of" potash are given  in
 the course of the day with the liquor  potassae,
 will generally remove the disease, if extensive
 disorganization have not taken place.
   186. E. Treatment of Abscess of the Liver.—
 When the symptoms noticed above (y  131, et
 seq.) indicate commencing, or even impending
 suppuration, then mercurials ought not to be
 prescribed ;  for they will only lower the vital
 powers, and extend the local disorganization.
 Moreover, it has been  shown  by Marshall,
 Malcolmson, Graves, Stokes, and others, that i
 it  is  impossible to  affect the salivary glands ]
 with mercury when an abscess has once form-
 ed ; and I have long ago insisted that it is also
 difficult to produce  this effect while  acute in-
 flammatory action exists, or is unsubdued.  Al-
 though matter may be actually forming, the in-
 flammation producing it does not cease upon
 this event.  Suppuration  in parenchymatous
 structures especially is a consequence, but not
 a termination, of inflammation.   In  some ca-
 ses, inflammatory action continues with much
 activity until the abscess makes its way either
 externally or into some viscus or cavity ; while
 in others it subsides considerably,  the circula-
 tion exhibiting  merely the irritable state, and
 the hectic symptoms usually attending the for-
 mation orthe existence of matter in vital organs.
 When, therefore, it  is inferred that an abscess
 is formed, it is  necessary to control, as much
 as possible, the state of vascular action, locally
 and generally, particularly where we find, from
 the existence  of pain, excited state of the
 tongue and character of the pulse, that inflam-
 matory action is considerable.  In these cases,
 small or repeated local depletions, cooling diaph-
 oretics, and  a  refrigerant and  febrifuge regi-
 men, are the most appropriate means.  By these
 the morbid action should be diminished, while
 vital power is preserved by attention to air and
 diet.   While depleting locally and  prescribing
 aperients  in  order to  evacuate  morbid secre-
 tions and faecal accumulations,  which always
 increase disorder when allowed to remain, the
 physician will often see the necessity,  in these
 cases,  of supporting  the vital functions by  a
 gently  nutritious and cooling diet, allowing the
 patient no more food than the digestive organs
can properly dispose of.  When  these func-
tions fail, he will endeavour to rally them by
gentle  tonics conjoined  with refrigerants, as
 the nitrate of potass, the hydrochlorate of am-
 monia, or the mineral acids, knowing well that,
 if these functions  are  allowed to  sink in the
 struggle they have to  endure against the or-
 ganic changes going on in the liver, the puru-
 lent formation becomes the more extensive and
 formidable.
   187. a. When there are general tumefaction
 and throbbing in the region of the  liver, with
 pain, firmness of pulse, and erethismal appear-
 ance of the tongue, but without either rigours,
 cold  sweats, faintings,  or a sense  of sinking,
 anxiety at the scrobiculus cordis, or night per-
 spirations, then local  depletions may still be
 freely employed; but the amount of such de-
 pletions should depend upon the strength of the
 patient, his age, and on what has  previously
 been done.  In this state  it is generally too
 late to have recourse to mercurials, excepting
 as  aperients ; they will merely add irritability
 to  an irritable pulse, and  lower vital power.
 In  general, the  abscess which is forming has
 not yet materially  deteriorated the  circulating
 fluids; and leeches applied over the seat of
 swelling, and followed by a succession of warm
 poultices, may tend both to  lower the local ac-
 tion and to favour the extension of the matter
 to the surface.
   188.  When  formications, rigours, cold, or
 profuse sweats, a sense of  sinking, and other
 signs of change in the circulating fluids, and of
 vital  depression are present, even local deple-
 tions will then be injurious, and mercurials not
 less so.  But the nitro-hydrochloric  acid, or the
 nitric acid, taken frequently, or in the patient's
 usual  drink, is often grateful and restorative,
 especially if it does not disorder the  bowels.
 If it have this latter effect, the tincture of opi-
 um should be used along with it.   Either of
 these  acids may also be taken in gentle tonic
 infusions.  When it becomes still more neces-
 sary to support the  powers of the system, the
 sulphate of quinine  with sulphuric acid, the in-
 fusion, decoction, or other preparations of cin-
 chona, with chloric acid, or  chlorate of potash,
 or with liquor potassae, or the alkaline carbo-
 nates, may be severally prescribed.
  189.  As an hepatic abscess advances exter-
 nally, the diffuse swelling is gradually changed
 to a distinct tumour, which  generally becomes
 softest at  its apex or  most prominent part.
 The tumour  is attended by an expanded and
 firm base.  If adhesions have formed between
 the inflamed  surface of the liver and  the ab-
 dominal parietes, the most  prominent part of
 the swelling  is soon after somewhat red and
 hot.  When an  abscess forms in the concave
 part ofthe  liver, although much general swell-
 ing is evident in the region of the organ, yet a
 distinct tumour  is  rarely detected,  unless the
 abscess be  seated in or  near the anterior edge
 of the viscus.  When  the  symptoms indicate
 the existence of abscess, in  connexion  with
 prominent disorder  of an adjoining viscus, no
 distinct tumour appearing externally, it may be
 concluded that the  abscess  is making  its  way
 towards or into that viscus.  In most of such
 cases, little more can be done than to support
 the  powers of life,  without  exciting vascular
action, and to evacuate  morbid secretions.
  190. b. If the  abscess point upon, or adhere
to the diaphragm,  dyspnoea, thoracic  oppres-
sion, anxiety at the praecordia, cough, hiccough, 
862                      LIVER—Inflammation of—Treatment.
 or a  suffocating  sensation,  are generally pres-
 ent,  and  require  the exhibition  of anodynes,
 antispasmodics, and aperients.  If pain be com-
 plained of, and the pulse has not  become weak
 or irritable, a few leeches may be  applied in the
 direction of the diaphragm or over the sternum.
 If the abscess open into the bronchi, after ad-
 hesions have formed between the  several se-
 rous  surfaces intervening, the chief intentions
 are to palliate the several thoracic symptoms,
 and to support the strength of the patient.  If
 adhesion  of the pleural  surface-does not take
 place, the abscess may break into the thoracic
 cavity, and give  rise to  all  the phenomena of
 Empyema.  (See  Pleura.)  Where an abscess
 of the liver  finds its  way to  the bronchi, the
 sudden irruption of the matter is  often attend-
 ed by signs of impending suffocation.  In order
 to relieve this, the patient  ought to be raised
 up, and warm fomentations should be applied
 to the chest and region of the liver.   When the
 abscess has burst in this situation,  benefit will
 sometimes be derived from nitric  acid solution,
 conjoined with laudanum, hyoscyamus, or co-
 nium.  When the tongue is  moist, the expecto-
 ration easy, copious, and purulent,  and the pa-
 tient  does not complain of much pain, the pulse
 being devoid of hardness or sharpness, the in-
 fusion, or even the decoction of cinchona, may
 be tried, with an  acid and narcotic,  the bowels
 being duly regulated and evacuated.  If night
 perspirations, with loss of strength  and  appe-
 tite, or with other signs  of  exhaustion, super-
 vene, the same means,  in  still more efficient
 forms, or the mistura ferri  composita, may be
 prescribed.   Where it is  requisite to exhibit an
 aperient  in these cases, the decoctum  aloes
 compositum  with the spirit, ammon. arom., or
 the compound infusion of gentian  and senna,
 are the most appropriate.
   191. c.  If abscess of the  liver  is  apparently
 pointing  upon  the stomach,  as  indicated by
 some difficulty in swallowing, by great thirst,
 by vomiting  soon after  substances  are  taken
 into the  stomach, or  by general  irritability of
 this organ,  or a  pumping up of  its contents,
 sometimes by jaundice,  and by the sitting or
 semi-recumbent position of the  patient, little
 can be done beyond palliating the more urgent
 symptoms.   Large or full doses of opium may
 be given,  and the  mineral acids may be taken
 in the patient's beverage.   The compound in-
 fusion of roses, or the infusion of calumba, may
 likewise be tried with laudanum,  or with  other
 narcotics.  Hydrocyanic  acid and  creasote may
 also  be employed.  In one  case  I  prescribed
 the creasote with opium with temporary relief.
 The bowels should be evacuated chiefly by en-
 emata.  When the abscess pointing  on the
 stomach  is large,  considerable tumefaction is
 observed in the region  of the liver ; and when
 it makes its way  into  the stomach,  death gen-
erally follows immediately  afterward.   In a
case to which I was lately called  in Montgom-
 eryshire, this occurred; the swelling and bul-
ging of the right hypochondrium and epigastri-
um being  remarkable, in  addition to the  other
symptoms, and to deep jaundice.  When the
abscess is smaller, death  is less immediate.
   192. d. If the symptoms indicate that hepatic
abscess has opened into  the large bowels, the
indications are to  palliate the urgent symptoms
and to support vital power.   In some cases, the
abscess actually opens in this situation, with-
out the event being detected, the occurrence
being mistaken  for the frequent complication
of chronic diarrhoea, or dysentery, with inflam-
mation  of the substance of the liver.   When,
however, the abscess is large, the change ob-
servable in the  hepatic regions, and the state
of the evacuations,  often indicate the occur-
rence.  In these cases, the chief intentions are,
to support the strength of the patient, to soothe
the irritation in the bowels, and protect their
internal surface, by administering emollient and
demulcent enemata.  The warm  bath, hot or
rubefacient embrocations applied  over the ab-
domen, and the nitric acid or nitro-hydrochlo-
ric acid, in demulcent and gently tonic vehicles,
with laudanum,  or with the compound tincture
of camphor, &c, are also sometimes beneficial.
In these cases, the abscess may refill, and open
again in the same or in  another  part of the
bowel, most commonly in the former; and al-
though  death follows  in the great majority of
cases, recovery  sometimes takes place.
   193. e. It is not improbable that one or more
abscesses may form in the substance ofthe liver,
and that, after having increased to a certain ex-
tent, or remained stationary for a considerable
period, they may either partially* or altogether
be absorbed, without opening either externally
or into  any one part, and the patient  entirely
recover.  Proofs of this occurrence have been
furnished by the history of cases,  and  by post-
mortem examinations, where the liver has pre-
sented extensive  cicatrices, or marks of the
seat of old abscesses, from which the matter
had been  absorbed, and the  internal surfaces
had adhered, as described in another section
(y 212, 213).
   194. This favourable result occurs  chiefly
when the powers of the constitution  are  not
allowed to sink, and when the absorbed matter
is freely eliminated by the kidneys before it
accumulates in  or contaminates the blood, so
as to give rise to the severer forms of hectic
and all its consequences.   It  is very probable
that  the chronic diarrhoea and dysentery at-
tending abscess of the liver  are  owing to the
effect produced  upon the glandular apparatus
and on the villous surface of the intestines by
the purulent matter absorbed into the  circula-
tion,  particularly when it  is  not  sufficiently
eliminated by the kidneys.
  195. /. The diet  and regimen of the patient
should be carefully attended to, and should be
so regulated, during the course of hepatic  ab-
scess, as not to excite or increase febrile  ac-
tion,  or to impair  the powers  of life.   The
farinaceous kinds  of food taken in sufficient
quantity for the wants of the  system and pow-
ers of digestion, as tapioca, arrow-root, sago,
rice, rice-milk, bread and milk, bread-puddings,
stale bread, biscuits, jellies, &c, are generally
most appropriate, although cases occur in which
other  articles of diet, according as they are
relished, digested,  or agree  with the  patient,
may be  permitted.  When  animal food is al-
lowed either to  support the system, or during

  * It is not unlikely, also, that certain deposites, assuming
a  semi-consistent or cheese-like appearance, and varying
from one to several  in number, occasionally found iu the
liver, particularly in  Europeans who  have resided long in
the East Indies, are merely the more consisteut and albu-
minous parts of pus, the aqueous portions of which had been
absorbed. 
LIVER—Inflammation of—Treatment.
863
convalescence, the lightest kinds of fish and
white meats should be preferred, and taken in
small quantity.
   196. g. The  external opening  of  hepatic  ab-
scesses, and the best  modes of  accomplishing
this end, have engaged  the attention of sev-
eral writers,  and very  discordant testimony
has been furnished by them of the success of
the operation.  There are numerous circum-
stances which influence the results  of these
cases :  1st. The age, diathesis,  and  constitu-
tional powers ofthe person.  2d. The size and
pathological associations of the abscess.  3d.
The existence of two or more abscesses.  4th.
The situation, particularly as respects the more
external part of the organ.  5th.  The existence
or  non-existence  of adhesions  between  the
surface ofthe liver and the abdominal parietes.
6th. Redness  and prominence over  the seat of
the abscess ; and, 7th. The states of severe or
advanced hectic and protracted diarrhoea, or
chronic dysentery.  Of these more important
circumstances, external  redness  and  promi-
nence  over the seat  of abscess, as indicating
the existence of adhesions and a  somewhat
external or  superficial position of the purulent
collection, and sufficient constitutional power
to bear the more immediate and the  contingent
effects of the operation,  are the  chief indica-
tions for entering  upon it.  Mr. Bell  states
that Dr. Dick, a physician  of extensive expe-
rience in the diseases of India, found that the
application  of caustic to the part at which an
abscess is pointing externally, with a view of
opening it gradually, is sometimes followed by
absorption of its contents, and by the  recovery
of the patient.  This being the case, he was
led to consider severe external irritation over
the seat of the abscess as a most  efficacious
mode of favouring the absorption  of the con-
tained matter, and to recommend the applica-
tion of caustic as the best means of procuring
its  external discharge.  Dr. Graves advises
an  incision to be  made through the integu-
ments over  the most prominent part ofthe ex-
ternal  swelling, dividing  the more  superficial
muscles, and keeping the wound open  by a plug
of  lint.  Mr. Annesley  recommends the  op-
eration only when external redness, with some
degree of pointing, indicates the adhesion  of
the surface of the abscess to  the  abdominal
parietes, and prefers  the lancet to  the  trocar
in performing it.   He objects to  the latter on
account of  large flakes  or curd-like matters
being contained in some abscesses, which can-
not pass through the  canula, but are retained,
while the more fluid parts only pass  away.
Having made  the external excision large and
with caution, until the peritoneum is exposed,
fluctuation will  be felt.   An  abscess  lancet
should then  be introduced, and the abscess
opened to the full extent  of the external  in-
cision, which ought to be from  two and a half
to three inches in length.   Care ought always
to be taken that the  opening do not extend
beyond the limits of the adhesions which have
been formed.  Being fully evacuated, the cav-
ity is directed to be filled with lint,  in order to
give a mechanical  support to  the  excavated
parts, and the wound  to be dressed with com-
presses and  bandages  in the usual way.
  197. Of these several modes of procuring the
external discharge of  hepatic abscess, that ad-
vised by Dr. Dick, when aided by appropriate
internal  and constitutional  treatment, is  evi-
dently that which is most congruous with path-
ological  conditions, and with an  enlightened
experience.  To  fill the cavity of the abscess
with lint, as  Mr.  Annesley  advises, is merely
to admit the air, and to promote a more co-
pious secretion of pus  from the internal  sur-
face of the abscess : it cannot aid granulation
and contraction of the cavity, but will  increase
the discharge, aggravate the hectic symptoms,
and sink the patient with greater  rapidity, as
in all  other cases where large  internal ab-
scesses have a free external opening, permit-
ting the action ofthe air.  In hospitals, and in
low, damp, crowded, or miasmatous situations,
this mode of procedure  is particularly danger-
ous.  I believe that, in  whatever way the ab-
scess may be opened,  the  orifice  should be
completely shut after the matter is discharged,
so as completely to exclude the air,  even al-
though it may be  necessary to reopen  it often-
er than once, when matter re-collects.  After
the abscess has  been opened, it is necessary
to attend to  the  diet and regimen of the pa-
tient, to  support  the constitutional powers by
means of mild tonics, or tonics conjoined with
refrigerants,  and  to promote and correct the
secretions  and  excretions by  alteratives  and
restoratives.
  [With  respect  to the use of mercurials in
chronic  hepatitis, as  our author has passed
them by,  it  is presumed  that  they do not, in his
opinion, form a necessary part of the modus me-
dendi in this form of the disease.  And yet, if
we mistake not, very minute  doses of mercury,
in some of its forms, especially when combined
with iodine, will be found among the most suc-
cessful remedies  for this obstinate complaint.
Dr. Dickson, of Charleston, S. C, who has had
much experience  in the treatment of this affec-
tion, remarks that mercury holds the first rank
in the treatment of chronic  hepatitis,  after lo-
cal bleeding by cups and leeches, and recom-
mends that it should be introduced into the sys-
tem slowly, and its influence upon the secreto-
ry vessels,  as exhibited by a  slight soreness of
the mouth and gentle ptyalism, kept up for some
length of time,  in the mean  time keeping the
bowels free, and promoting a due determination
to the surface.  For these purposes, Dr. D.  rec-
ommends calomel in small doses, in combina-
tion with pulv. antim., with jalap, or rhubarb in
sufficient quantity to affect the bowels moder-
ately.   This plan is to be  persevered in for
some time, employing, as useful  adjuncts, the
mineral acids, topical bleeding, blisters, exer-
cise in the open air, flannel next the skin, &c.
  We have seen  that Dr. Chapman attributes
the frequency of  chronic hepatic affections in
some parts  of the United States to  the extrav-
agant use of mercury in the treatment of au-
tumnal fevers and other diseases.  The mode
of procedure recommended  by Dr. C. in  this
form of  hepatitis, is moderate and repeated
venaesection, cups and leeches over the liver,
followed by a succession of blisters, or a caus-
tic issue, aided  by occasional purgings.  To
this end calomel is to he freely given every two
or three nights, to be worked offthe next morn-
ing with castor oil, Epsom salts, or magnesia,
alone, or combined with  colchicum, and  this
course  to be continued  for some considerable 
864                      LIVER—Inflammation of—Treatment.
time.  Dr. C. also recommends the taraxacum
as a valuable deobstruent in these cases, pre-
pared  after the following  formula:  R Infus.
Tarax., § iv. ; Extr. Tarax., 31J- ; Carb. Soda,
•ss. ; Tart.  Potass., Tinct.  Rhei., aa, 3iij.  M.
Dose, $j. or more, three  or four times a  day.
The fresh plant should be employed whenever
it is possible to  obtain it.   Should this course
fail in affording relief, Dr. C. next recommends
a resort to a course of mercury, in order to re-
store the organ to its natural state by an altera-
tive operation.   For this  purpose, minute doses
of calomel,  or blue pill with opium,  are to be
given until some constitutional effects are per-
ceived, as shown by an improvement in the state
of the secretions, &c.   This effect is to be kept
up without abatement for several weeks, and in
the more inveterate cases,  with occasional in-
termissions, for  months.   There is,  however,
great need of discrimination in the employment
of mercury, for where it fails  to promote the
biliary discharge, it will  not only prove of no
benefit, but  cause positive  mischief,  such as
general irritation, or positive phlogosis, with an
irregular  febrile movement.  In every  case,
therefore, we must closely watch its  effects,
and immediately suspend its use if it does not
appear to exert a salutary influence over the
secretory functions  generally.  Where  there
are objections to the internal  use of mercury,
it may be employed by inunction until  the de-
sired effect is produced, maintaining  the  same
by repeated applications from time to  time.
"That in these cases," says Dr. O, "reliance
is placed mainly on mercury must be apparent,
and  in recommending  it,   having  previously
mentioned it as  one of the  causes of the dis-
ease, it may seem that I am guilty of an incon-
sistency.  But such an imputation is not just,
and  cannot be sustained.   It is against the
abuse of the article I protest; and do not in-
stances occasionally present where  the  same
agent is the cause and remedy of the disease 1
This, indeed, is so true,  that we have the old
aphorism, ' Similia similibus curentur.'   Take,
for illustrations of it, delirium tremens, the
atonic states of the stomach  from  intemper-
ance, &c.  Do we not frequently resort to that
very stimulant as a cure,  which, improperly
used, had produced the  condition  we  are en-
deavouring  to  redress]    Like the  fabulous
sword, the rust on which healed the wound in-
flicted by its point, mercury here cures the mis-
chief it had occasioned.  Even admitting that
the case  of hepatitis we are  called  to  treat
could be indisputably traced to the undue em-
ployment of that article, it would still be the ap-
propriate means of relief.  The liver being tor-
pid, we should recur to mercury, from its well-
known specific powers of exciting and restoring
its healthy functions.
  " It will not, I trust, be  supposed, from what I
have said, that I mean to lend any support to
homeopathy, the leading feature in the doctrine
of which is, that remedies are curative in propor-
tion as they operate like the cause ofthe disease.
The principle, as I have shown, undoubtedly is
true to a  certain extent; but  what is to be re-
ceived with many qualifications, they make of
universal application, or without any limitation
at all.  False in theory, its disciples are still
more so in practice, from the  entire impotency
of the  means  they  profess to employ.  Ex-
ceedingly absurd and mischievous as are many
of the notions which disfigure the early annals
of our science more especially, none equal in
these respects this recent  phantasmia, or  had
for its votaries such a collection of audacious
charlatans or unmitigated impostors, and who,
unrestrained by law or conscience, are spread-
ing death in every direction.
  " No longer ought it to be concealed that these
mercenary miscreants, perceiving a loss of pub-
lic confidence in the utter inertness of the  ori-
ginal practice, and particularly in the  avowed
infinitesimal doses of medicine,  are whirling
around into the opposite extreme ; now resort-
ing to the most active, and in exorbitant quan-
tities.  The articles to which they are at pres-
ent devoted,  arsenic,  veratria, and aconite,  are
the most deleterious, when incautiously direct-
ed, of the whole Materia Medica.   But
     1 Fools rush in where angels fear to tread.'
   " From too feeble or energetic practice, I have
seen, among other instances of disastrous re-
sults very  lately, two individuals  absolutely
poisoned by the inordinate use of aconite, the
one thrown into violent  tetantoid spasms,  the
other with incessant  vomiting  and  delirious
wanderings, and  both  cold, damp, and nearly
pulseless.  In a few words has been given my
opinion of homoeopathy and its followers, nei-
ther  of which can a wise or good man, and es-
pecially a physician, countenance  in any way
or degree for a moment.  To consult with such
arrant quacks is a degradation.  To encourage
them is to become particeps criminis, and to em-
ploy them is wantonly to hazard life."—(Lecture
on Thoracic and Abdominal Viscera, p. 335.)
   We have derived great benefit, in the treat-
ment of  chronic hepatitis, from the use of the
different  preparations of iodine, and especially
those natural  mineral waters containing it.
The  sulphur  springs of Virginia and of New-
York (as at Avon, Richfield, and Sharon), the
Saratoga waters, all of which contain more or
less of this powerful mineral agent, have proyed
among the most  successful means we have
ever employed for the relief of chronic hepatic
affections of every kind  and degree.  The hy-
dropathic treatment, when  directed by a skilful
and scientific physician, will be found adequate
to the removal of many cases of this disease,
which have resisted all other remedies]
   198. F. Treatment of Chronic Hepatitis.—a.  I
have shown above that  the chronic states of
hepatitis are often similar to the  acute, and
differ chiefly in the activity or duration of the
disease, in the structure chiefly affected, and in
the more frequent association of organic le-
sions with the  former than  with  the latter.
The  nature, however, of these lesions  is sel-
dom manifested through life,  unless in as far
as they may be attended with enlargement of
the organ, and with deficiency of bile, or with
jaundice ; and even these are often equivocal.
Although the bile is generally  in smaller quan-
tity,  more remarkably changed from its healthy
characters,  and  more frequently  obstructed
where the internal structure of the  liver is
chronically inflamed than  when the  surfaces
are the seat of acute disease, yet the excep-
tions to this are so numerous as to forbid great
reliance  being placed upon it as a basis for in-
dications of cure.  The circumstances of chron-
ic hepatitis being generally the cause of a great 
LIVER—Inflammation of—Treatment.
865
.majority ofthe lesions of structure found in the
 liver, and of itself being as frequently a seque-
 la of the acute disease as a primary affection,
 ought to be kept in recollection in determining
 the treatment that should be  pursued.  The
 forms  of chronic  hepatitis which are most
 readily  recognised, and are  most  commonly
 treated  as such, are those which are charac-
 terized  by enlargement, by  a scanty and  de-
 praved state of the bile, dyspepsia, and general
 ill  health, low spirits, a sallow countenance  and
 emaciation, particularly  when they follow  the
 acute disease, or periodic  fevers, and occur in
 warm climates.   In these  cases the treatment
 should depend upon the previous disease, upon
 the antecedent treatment, and upon the dura-
 tion of a residence in a warm climate.  If much
 mercury has  been already  prescribed, if  the
 constitutional powers are  much reduced, mer-
 curials,  vascular depletions,  and drastic  pur-
 gatives  are inappropriate, and  recourse ought
 to  be had to the  nitro-hydrochloric acid bath,
 which  should be  steadily persisted  in for  a
 month or six weeks.   While it is being  em-
 ployed, or previous to a course  of it,  a  vapour
 or  warm bath should  be  taken two  or three
 times, and followed by friction of the general
 surface ; but the occasional recourse to the va-
 pour or warm  bath  is preferable.  At the same
 time,  two or three  drops  of these acids  may
 be  taken in the patient's  usual drink, and  de-
 obstruents with  mild  aperients may be  pre-
 scribed.   It is in this form of the malady that
 the nitro-hydrochloric acid bath or lotion is the
 most beneficial; and in it the chlorides, the ni-
 tric acid, the tartrate, supertartrate, and acetate
 of potass are also beneficial. In the more chron-
 ic  and obstinate  states of the  disease,  I have
 found small doses  of the  iodide of potassium,
 conjoined with  liquor  potassas  and  with  the
 decoction and extract  of taraxacum, of great
 service.
   199. b. When chronic hepatitis is  a  recent
 or  primary affection, or follows the acute  dis-
 ease, owing to neglect or inactive treatment,
 or  when it occurs  in persons who live fully or
 who  have  not been reduced by previous  dis-
 ease, or by long residence in an unhealthy cli-
 mate, then local  vascular  depletions, deob-
 struent  and active purgatives, and mercurials
 are especially indicated.   If this state  of the
 disease be attended by congestion or enlarge-
 ment  of the organ, local depletions may be
 freely prescribed,  and saline or other  purga-
 tives often repeated ; but mercurials should, in
 most forms of chronic hepatitis, be given with
 caution.   They are most beneficial in this par-
 ticular state of the disease, where, however,
 they should be employed chiefly as deobstruent
 purgatives.  In  other circumstances, experi-
 ence has  not demonstrated  their utility,  but
 shown that  a  frequent  recourse to them  only
 perpetuates the  mischief for which they were
 employed.  This  seems to be the opinion of
 Clark,  Dick,  Saunders,  Pembert-on,  Mal-
 colmson, Martin, and others; and it accords
 with my own observation.
  200.  c. The  nitro-hydrochloric  acid bath was
 first recommended by Dr. Helenus Scott, who
 afterward ascertained that sponging  the sur-
 face with  a wash, containing the same acids,
 was  as efficacious  as  the bath.  Since 1796,
 when Dr. Scott published his first paper upon
    II.              109
this subject, Sir James M'Grigor, Dr. Pember-
ton, Mr. Bell, Mr. Annesley, Mr. Martin, and
many others have  shown the great efficacy of
this  treatment in chronic hepatitis ;  and, after
all the acute symptoms have  been removed, in
cases ofthe more active states of the disease.
It is more especially beneficial in cases attend-
ed by enlargement of the viscus, and a depra-
ved state of the biliary and  intestinal secre-
tions.   It should be employed daily for some
time ;  and a trial of from two or three to five
or six weeks may be given it, according to its
effects.  Even after its use has been intermit-
ted for some  time, its good  effects will often
continue to appear.   In obstinate  cases, ad-
vantage from it should not be despaired of, al-
though weeks  may  elapse without benefit being
derived from it; and, although the first course
of it may have  been ineffectual, a second trial
may  be decidedly  beneficial.  A short  time
should elapse  between the use of mercurials
and  a recourse to  this bath, or wash ;*  and
purgatives should be occasionally given during
the course, in  order to  carry off accumulated
secretions  from the liver and intestines.  If
heaviness or drowsiness occur after this treat-
ment has been  pursued  for a few days, purga-
tives  may  be  more actively  prescribed.   Du-
ring the nitro-hydrochloric course, a change of
air, especially to a  temperate, or cool and pure
atmosphere, will be of service.   A feeling of
cold,  however,  should not be  occasioned by
the change, as  some  risk of aggravating the
complaint  may be  thereby  occasioned.   Sea
voyaging, particularly when medical  care may
be enjoyed at the  same time, is  often of  ser-
vice, especially after the patient has resided
long in a warm  climate.  In all cases of change
from  a warm  to  a colder   temperature,  the
clothing ought  to  receive  due attention,  and
the night  air should  be avoided or guarded
against.
  201. The nitrous acid  has been  employed, in
a very dilute state, as a common drink in chron-
ic hepatic affections, in warm climates, chiefly
as an  alterative, and in order to promote the
secretion  and  excretion of  bile.  When ta-
  * Mr. Annesley gives the following directions as to the
preparation uf the nitro-hydrochloric solution, lotion, wash,
or bath:  " Into a common quart bottle put about eight
ounces of pure water, to which add four ounces of the nitric
acid and four of the hydrochloric acid, ofthe strength of the
London Pharmacopoeia. The ' nitro-hydrochloric solution'
is thus formed. If it is used in the form of a bath, from two
to five ounces of it, according to the strength of the patient,
is mixed with from two and a half to three gallons of warm
water, of 96° or 96°, in a  high and narrow vessel, and the
feet and legs kept immersed in it for about twenty minutes
or half an hour every night before retiring to rest.  If the
bath does not occasion a  pricking or itching sensation in
the parts immersed after twenty minutes have elapsed, the
next bath should be increased in strength."  Mr. A., how-
ever, states that, upon the whole, he prefers sponging the
trunk of the  body, and particularly the abdomen, with the
nitro-hydrochloric lotion or wash, which consists of two or
three drachms of the above solution added to a pint of warm
water. With this wash, he advises the trunk of the  body
and the insides of the thighs to be sponged assiduously, for
about a quarter of an hour daily, or occasionally night and
morning.  In torpor, and other chronic affections of the liv-
er, he recommends  this wash  to be used ; also in the form
of fomentation, or to be aided by the  application of warm
poultices.  " Occasionally much benefit will arise," he ob-
serves, "from employing the lotion in the form of fomenta-
tion ;  the water being made as hot as 130° or 140° when
the acid solution is added."  Flannels soaked with the lo-
tion maybe applied  for an  hour or two every night over the
hypochondria and abdomen ; and they may be covered with
warm poultices, both the moistened cloths and the poultices
being renewed from time to time. 
866
LIVER—Structural Changes in.
ken freely, and  continued  for  a  few days, it
sometimes occasions salivation ; but it is often
of service without producing this effect.  Sir
J. M'Grigor considered it equal to mercury in
the cure of hepatitis.   In the chronic states of
the disease it is certainly a safer  remedy than
mercury, which ought not to be employed when
this acid or the nitro-hydrochloric  acids are
being  used.  Issues, setons,  or open blisters, or
even  the  repeated action  of blisters, a  little
below or over the region ofthe liver, are often
beneficial  in the more  protracted cases,  and
when  the  foregoing  means have  proved una-
vailing.   After  a  discharge  from  them  has
been established, poultices applied  directly over
them, and frequently renewed, are sometimes
of service.   Vapour baths, followed by frictions
with a coarse  towel, or by the flesh-brush, or
hair gloves, and  chlorine baths, are occasionally
serviceable, and may be employed in the ob-
stinate cases,  in aid of deobstruents, altera-
tives,  and  aperients.  Of other means, notice
will be taken in the sequel, and  after I  have
exhibited a view ofthe  more chronic structural
lesions of  the organ.
  202. IV. Structural Changes in the Liver.
— Classif. :  IV. Class ;  I.  Order (Author).
These changes  are divisible into two classes,
viz., those which proceed from excited vascu-
lar action, or are inflammatory, and those which
depend upon the state of organic nervous power
and nutrition, or  are  non-inflammatory.  The
former are generally more or less acute  or ac-
tive at their commencement, or are  the conse-
quences of acute or sub-acute disease ; the lat-
ter are always chronic.  Although both classes
of lesions may originate in alterations of the
organic, nervous, or vital condition of the liver,
affecting the circulation and  blood, and ulti-
mately the structures  of the  organ, yet they
depend upon very different  states of the parts
primarily  affected ;  for while the  one  class
seems to arise from an excited or  exalted state
of local nervous power and vascular action,
the other apparently proceeds from a depressed
as well as depraved condition—from very op-
posite states of power and of action ; although
the former may pass into the latter, when neg-
lected, or  in circumstances  favouring the tran-
sition.  Congestions  of the organ, which may
be independent  of, or connected with  either
of these classes of lesions—both  vascular and
biliary congestions — have already been  suffi-
ciently noticed above (I) 59, et seq.), and  need
not,  therefore, be again adverted  to at  this
place.
  203. i.  Changes more strictly inflammatory,
and consequent upon Inflammations.—A. The se-
rous membrane or covering of the liver is liable
to the same changes as are observed in other
serous membranes.  These are chiefly disten-
tion or development of the capillary vessels,
effusion of lymph from the  free surface of the
part, and adhesion, by  means of this lymph, to
contiguous surfaces.  The  lymph thrown out
upon  the  inflamed surface generally excites
inflammatory irritation in the opposite surface,
when brought  in  contact  with it;  and new
capillary vessels are developed from the meshes
ofthe old, and shoot into the coagulable lymph,
and organize it.  The membrane itself becomes
slightly thickened, softened, and less tenacious
than natural   These changes are common on
the convex surface of the organ, are less fre-
quent upon the concave surface, and are gener-
ally observed after acute or sub-acute hepatitis,
affecting chiefly the surface of  the  organ,  or
membranous hepatitis.   In  these cases, con-
gestion of the substance of the liver, and some-
times inflammatory  appearances of  the part
subjacent to that chiefly  affected, are also ob-
served.    In old or chronic cases the serous
membrane is  often thickened,  opaque,  and
dense.   It is sometimes,  also,   more readily
torn,  or  less resistant.   Depositions are also
formed  underneath  this membrane  in  the
chronic forms of  inflammation  of it.  They
consist  of thin plates, presenting a cartilagi-
nous appearance, and of an atheromatous sub-
stance.
  204. B.  The substance or parenchyma of the
liver (a), when inflamed,  is more or less red-
dened, often deeply red, congested,  and soft-
ened.  If the inflammation is general, there is
also great tumefaction from vascular distention.
It is seldom, however, that the earlier ehanges
connected with acute or chronic inflammation
of the liver are observed, as the  consequences
and complications of the disease chiefly cause
death.  These early changes may occur in a
part of, or more or less extensively throughout
the organ.  They may exist alone, or be asso-
ciated with inflammatory appearances in the
serous surface, or with more advanced or other
lesions.
  205. (b.) Softening of the structure of the or-
gan  is  various  in  degree, and   is  commonly
caused by the more acute states of inflamma-
tion, although it may also proceed from other
causes. When produced by inflammation, there
is not only friability, but  also redness more or
less deep.  In some places, the redness is less-
ened  by a sero-puriform  or a puriform infiltra-
tion between  the minute lobules.   In these,
abscess would most likely have been more fully
developed, had  the patient lived longer.  In
other cases, the softening has proceeded still
farther in the centre, or in various parts of the
inflamed  tissue.   In some instances, particu-
larly in warm climates, the softened part is of a
deep or dark colour, owing to associated vas-
cular and biliary congestion (see Congestion
of, y 73).   The most remarkable grade of soft-
ening is that which is sometimes  observed after
death from the more  adynamic or malignant
forms of remittent or  marsh  fever,  and from
scurvy.  In these, the  softening is not the  re-
sult of inflammation,  but of depressed vital
power, causing extreme congestion with alter-
ation of the congested blood.  The congestion
is sometimes so great in  these cases, the blood
so dark,  and the tissues of the  organ so soft-
ened or so much deprived of its  vital cohesion,
that the viscus assumes the  appearance of a
black, friable,  or  pulpy  mass,  which readily
breaks when it is handled.   Softening of the
liver is often conjoined with tumefaction or en-
largement, although not necessarily.  Dr. Bail-
lie has noticed softening of this organ in aged
persons, the consistence  of it approaching that
of the spleen, and its colour being of a brown-
ish red.   Still  more extreme  states  of soften-
ing  have been  observed by  Portal, Bally,
Jackson, Deveze,  Montfalcon, Bailly,  my-
self, and  many others, in fatal cases of malig-
nant  remittent and other fevers,  of scurvy, and 
LIVER—Structural Changes in.                         867
of purpura.   In these the organ had hardly re-
tained its form by means of the cellular frame-
work of Glisson's capsule  and of its vessels.
   206. (e) Suppuration and abscess often follow
softening of a portion or parts ofthe substance
of the liver.   Indeed, the softening may gener-
ally be viewed as the antecedent of suppura-
tion, the sero-puriform matter effused from the
capillaries of the part  breaking down or dis-
solving the vital cohesion of it, especially at
its centre.  If the constitutional powers be not
sunk,  and if  the  blood be not contaminated,
lymph is effused  around the central softened
and infiltrated part, and this lymph, as the infil-
tration and  effusion in the centre proceeds,
forms a cyst enclosing the matter secreted from
its internal  surface.  (See art. Abscess, v 5,
ct seq.)   If, however, the  powers  of life and
state of the circulating fluids are  such as  not
to form coagulable lymph, which may be thus
condensed and  stretched  into a  cyst by the
matter accumulating within it, the  abscess as-
sumes  a diffuse character, is not  surrounded
by any distinct cyst, the purulent matter at the
margins of the  collection  infiltrating the sur-
rounding  lobules  or structure of  the organ.
(See art. Abscess, y 13, et  seq.)
   207. Abscess of the liver may hence be divi-
ded into  the  encysted and  non-encysted, either
of which may be large and  single, or numerous
and small; or one large and several small may
exist in the  same organ;  but it is very rare
to find both the encysted and non-encysted in
the  same viscus.  Abscesses  frequently pro-
ceed  from  acute, and  less  frequently  from
chronic inflammation.  They are much  more
frequently consequences of chronic or sub-acute
inflammation  in  scrofulous persons. — a. Ab-
scess, particularly when single and contained
in a cyst, often attains a very great  size, and
converts the whole ofthe right lobe into avast
sac, stretching and condensing, and ultimately
atrophying or destroying the lobular  structure
of the organ around it, rising high  in the right
thorax, and bulging  the hepatic regions.   The
cyst may be thin or thick, or more or les6
manifestly organized, and capable of containing
from  a few  ounces to several pints.  Louis
and Andral consider that  the internal surface
ofthe cyst is analogous to mucous membrane.
   208. /?.  The non-encysted  kinds of abscess are
rarely very large,  although I  have seen  them
very large in one ease, and others have been
observed  by  Mr. Annesley.   They are rarely
single, several or even many  existing in  the
same case.  They  are  either  in  immediate
contact with the structure ofthe organ, or par-
tially infiltrating or diffused among the sur-
rounding lobules.  In many of these cases, lit-
tle or no inflammatory appearances exist in the
adjoining  substance of the  organ, while in oth-
ers these appearances are either slight or equiv-
ocal, or are merely those of congestion.  These
abscesses are owing chiefly to phlebitis, or to
the passage of puriform matter into the portal
circulation, that is either deposited  in the part,
or excites inflammation in the minute  capil-
laries of the secreting  structure.   They have
been also attributed, as noticed above (v 20,
152, 153), to  inflammatory action  propagated
along the hepatic ducts, according to some ;
and along the  mesenteric and portal veins from
the intestines, according to others.
  209.  The  researches of  M. Cruveilhier
(Nouv. Bibliotk. Med., t. iv., et Anat. Pathol,
liv.  xi.), however, have thrown much light upon
the formation of these abscesses, which I have
denominated consecutive or secondary.  (See art.
Abscess, $ 27.)   He ascertained  that abscess
of the liver from injuries, fractures, wounds,
and surgical operations is always preceded or
accompanied by  purulent  collections in the
lungs, and always results from the same cause,
namely, from capillary phlebitis in the neigh-
bourhood of the injury or wound ; the globules
of pus, which thus pass into the circulation,
occasioning inflammatory irritation in the capil-
laries of these organs, in which the secondary
suppuration is developed.  When purulent, or
other morbid secretions are carried into the
general circulation, the lungs,  and frequently
also the liver, become  the  seat of secondary
abscesses, particularly when the powers of life
are reduced, and the morbid matter is not ex-
creted by the active functions of depurating
organs.  When these secretions pass into the
blood of the portal  system, consecutive ab-
scesses or purulent collections generally take
place in the liver.  Hence, when ulceration
occurs in the follicles or mucous surface of the
bowels, in chronic diarrhoea  and dysentery,
capillary phlebitis in the vicinity of the ulcer-
ated parts sometimes supervenes, and the pus
being carried into the portal circulation, excites
inflammatory action of the capillaries of various
parts of the liver.  In like  manner, secondary
abscesses in the liver follow, as noticed above
(y 20), operations for haemorrhoids,  fistula in
ano,  abscess,  or  ulceration near the  anus,
uterus, &.c.
  210. The changes which take  place in the
liver in these cases are stated by M.  Cruveil-
hier  to be, in  the first  instance, effusion of
bloody lymph and induration around the con-
secutively inflamed capillary vein ; secondly, a
secretion of yellow concrete pus into the minute
veins, and among the lobules, giving the part a
granite-like appearance ; and,  thirdly, collec-
tions of pus, or small abscesses lodged in ir-
regular cells, which increase in size by the
continued secretion and extension into other
cells.   These  purulent collections  are  sur-
rounded by a narrow congested circle or mar-
gin,  imparting  to them a  peculiar character.
After they have  existed a considerable timo,
their watery parts are absorbed,  leaving con-
crete, whitish, and cheese-like masses, often
resembling the matter of scrofulous tubercles.
  211. (d) Gangrene ofthe  liver has been very
rarely observed, and then chiefly in connexion
with  non-encysted  or diffuse abscess.  I  have
seen only one instance  of it;  and it has like-
wise been noticed by Forestus, Steidele, Dr
Carswell, and Mr. Annesley.
  212.  (e) Enlargement or  hypertrophy of the
liver is commonly consequent upon chronic in-
flammation, or upon  the acute,  after it has
lapsed into the chronic state.  It  maybe  inde-
pendent of any existing inflammation, and of
vascular or biliary congestion, although either
or all of these, in some grade or other, may
have  preceded or may accompany it.   The en-
largement may be partial, or limited to any part
or lobe of the organ, or it may  he general.
Mr. E.  Wilson considers that it  arises  from
irritation  of  the  mucous  membrane  of the 
868                         LIVER—Structural Changes in.
 ducts, occasioning,  in  the  first  instance, re-
 tarded circulation and venous congestion;  or
 from impediment  either  in  the  circulation
 through the heart, or through the  rest of the
 venous system ; or, again, from impairment of
 the  general powers of the systetrff as in the
 scrofulous constitution.  Without, however,
 disputing these sources of the lesion in some
 cases, I believe that it  as frequently proceeds
 from an exudation of lymph between  the mi-
 nute lobules,  or in the distributions of Glis-
 son's capsule,  that becomes  more fine and
 dense, or more organized, the longer the period
 which has elapsed from its  effusion ; and that
 this lymph is the result of a sub-acute or chronic
 state of inflammatory action.  Mr.  E. Wilson
 states that the  lobules  are always in  a state
 of  partial  congestion, resembling  the second
 stage of hepatic venous congestion  (y 67); the
 congested portion  presents a deep red tint, and
 the uncongested part is ramose or  convoluted
 in appearance,  of a dirty white, grayish, yel-
 lowish, or greenish hue, according  to the con-
 dition of the  biliary ducts and apparatus, and
 to the quantity and colour of the bile contained
 in the liver.   Sometimes the organ  is pale, and
 seems deficient in blood ;  at other times it has
 a generally diffused redness, or the congestion
 may be  greater in  one part than in  others.
 The consistence of an enlarged liver is equally
 variable with  its colour : sometimes it  is hard-
 er, firmer, or  denser than common, and even
 apparently granulated ;  the uncongested and
 granulated or denser parts projecting occasion-
 ally above the surface,  and the conjested por-
 tion sinking below the level  ofthe former.  As
 frequently, however, the organ is more or less
 softened, although often partially or unequally
 so.   The enlargement  of the liver may take
 place to a very great extent, the organ weigh-
 ing  twenty, thirty, or even forty pounds ; its
 enormous  bulk displacing  more or less the
 other abdominal viscera.   Hypertrophy is often
 associated with lesions of other organs, partic-
 ularly of the lungs, spleen, mesenteric glands,
 pancreas,  <kc.; and with other maladies, as
 scrofula, rickets, dropsical effusions, &c.
  [One prominent cause, undoubtedly,  of en-
 largement  of the liver is the  separation from
 the blood by the hepatic cells of some abnormal
 matter, which, instead of passing freely out of
 the liver in the bile, is  retained  there, adding
 to the size of the liver, and more or less  chan-
 ging its texture and appearance. To  understand
 how these changes are produced, we must bear
 in mind the intimate structure of the organ—
 that the lobules ofthe liver are spaces mapped
 out by the ultimate twigs of the portal vein,
 which, as Budd remarks, are hairy,  as it  were,
 with  capillaries springing  immediately  from
 them on every side, and forming a close and
 continous net-work, and that the insterstices of
 these capillaries are filled with nucleated cells,
 in which the vital chemistry of secretion goes
 on   We discover by the microscope that these
 cells vary in  size  in different livers;  that  in
 some they are almost transparent, in  others
 opaque, and apparently more solid; that in some
 they contain but a few very small oil globules,
 while in others they are  distended almost to
bursting with globules of oil; that in some they
 are colourless, or nearly so,  and in others, yel-
low with bile ;  and that in some instances they
are broken down and destroyed.  It is probable,
too, that in some cases the cells are only slow-
ly reproduced;  that without complete destruc-
tion they become less productive of new cells,
so that at length the number of active cells is
much diminished.   Now, corresponding differ-
ences in the size,  colour,  and texture of the
liver are produced by these differences in the
condition  of the cells; sometimes these  cells
are completely  broken down  and destroyed,
and this may result from long retention of the
secreted bile from closure of the common dnct,
causing an enormous dilatation of the hepatic
gall-ducts, and  occasioning the whole organ to
assume a  deep  olive colour.  Its tissue is flab-
by in  these cases, but not readily broken down
by  the finger, and presents no appearance  of
lobules.  Every part of the liver is  affected
alike, and exhibits  under the microscope no-
thing but free oil globules, and irregular patches
of solid biliary  matter; the liver  contains but
little  blood, and partly from this, but chiefly
from  loss of the cells, it may be smaller than
in  health, and  its  surface wrinkled, notwith-
standing the biliary matter accumulates in it.
But destruction of  the hepatic cells may take
place rapidly without  any obstruction of the
gall-ducts, and  instead of being consequent on
jaundice,  may  be the  cause of jaundice that
proves rapidly  fatal, apparently from disorder
ofthe functions ofthe brain.
  Several writers have  described what  they
call scrofulous enlargement of the liver, which is
generally found connected with scrofulous dis-
ease  of the glands or of the bones.   Portal
supposes that it is an albuminous obstruction of
the liver.  Rokitansky calls it the  " lardaceous
liver," and describes it  as follows: " Its an-
atomical characters  are, considerable increase
of volume, with striking development in breadth
and accompanying  flattening; very consider-
able gain in weight; a smooth, tight, stretched
peritoneal coat;  a  doughy  consistence,  com-
bined with a certain degree of resistance and
elasticity; anemia ; watery, pale-red  appear-
ance  of the portal blood  ;  grayish-white or
grayish-red  (mingled with   yellow or  brown)
colour of the  organ ;  smooth,  homogeneous,
lardaceous-looking section  ; scarce any fat on
the knife-blade."  The morbid appearances, he
adds,  depend on  infiltration of the liver,  with
" a compact, grayish, often transparent, albu-
minous, lardaceous, or lardaceous-gelatinous
substance."   Dr. Budd, as already  stated, con-
siders that, as in the fatty liver, the substance
to which the liver owes its increased size and
its  other peculiarities  is a product  of secre-
tion, which, instead of passing off in the bile,
is retained in the liver.   This affection, like the
fatty enlargement, comes on without any pain,
or even tenderness of the liver, which is sup-
posed to be owing to the very gradual manner
in which the  foreign matter accumulates, and
from  its having no  tendency to cause  inflam-
mation  of the  capsule of  the  liver  or of the
veins.  It is worthy of note, that  the passage
of blood through the liver  is much more im-
peded than in the fatty liver, probably from the
foreign  matter  being firmer  and less yielding
than oil globules.—(Budd.)  The secretion of
bile, however, may  go on as in the fatty liver,
at least the colouring matters of the  bile ; the
complexion often remaining  clear, but not so 
LIVER—Structural Changes in.
869
often as in the  fatty liver,  as  the matter  de-
posited in its substance is firmer and more  apt
to interrupt the secretion, or the  flow of  the
bile, and render the complexion  sallow.   Scrof-
ulous enlargement of the liver is  met with in
persons  much emaciated, and in a state of
scrofulous cachexia; sometimes also in persons
whose health  has been broken by the conjoined
effects of mercury  and syphilis, or who have
suffered  from protracted intermittents.—(Ro-
kitansky.)  Dr. Budd, however (p.  249), thinks
that the liver is seldom much enlarged from
ague, and states that he has examined a large
number of  bodies in  which the  spleen was
much enlarged from  ague,  but that in no  in-
stance did he find  much enlargement  of  the
liver.  In this disease, as Dr. Graves  has  re-
marked, the stools are variously coloured with
bile, "one part of them will  be  bilious, another
part clay-coloured ;  they will be yellow to-day
and pale  to-morrow."—(Clinical  Medicine,  p.
566.)  He infers from this that  the office of the
liver is performed intermittingly.   Regarding
this affection,  then, as consisting of faulty  nu-
trition of the hepatic cells,  leading to  the  de-
posite of some  peculiar matters, and unattended
with pain, the diagnosis is,  for the most part,
obscure, but we shall  be aided by  the circum-
stances in which  it  commonly occurs, as in
scrofulous affections  of the glands, or of  the
bones, or in individuals who  have suffered from
the combined effects of syphilis and mercury.]
  213. (f) Induration is occasionally attendant
upon enlargement, and also upon atrophy ofthe
substance  of  the liver; but it sometimes is
met with  independently of these alterations, or
with a  normal size  of the  organ ;  the colour
ofthe indurated portion varying with the grade
of  vascular or biliary congestion, from yellow
to green, brown* or brownish red.   The degree
of density varies from a somewhat firmer state
ofthe structure up to a cartilaginous condition.
The highest grade of induration  is generally
observed in cases of atrophy. Occasionally the
induration occurs in parts only  of the organ, or
is greater in some portions than in others.   In
rare instances it presents the distinct character
of a fibrous or fibro-cartilaginous cicatrix, form-
ed  after the adhesion of the opposite sides of
an  abscess, the contents of which had been  ab-
sorbed.   The  most hardened and  granulated-
like parts  are also most deficient of blood.
  214. (g) Atrophy of the substance of the liver
is, like induration, one ofthe more remote con-
sequences of inflammatory action.  It may suc-
ceed congestion, or even hypertrophy ; and, as
shown by Portal, is a much more rare occur-
rence than  enlargement.  As  the viscus  di-
minishes in  bulk, the lobules become indistinct
and variously congested, and appear intermin-
gled and  pressed upon by  the cellular tissue
with which they are surrounded.  Mr. E. Wil-
son says  that the proper lobular structure is
sometimes entirely  removed, and  replaced by
a loose or condensed cellular tissue.  At other
times the  entire substance ofthe organ  appears
to have been absorbed by the pressure of a very
large abscess, which has discharged  its con-
tents into  the intestinal canal, and  the parietes
have afterward  contracted  into an atrophied
mass.  In rare cases, the atrophy is connected
with a complete or incomplete cicatrix, remain-
ing  after absorption of the contents of an  ab-
scess, as noticed above (y 213).   These cases
have been detected chiefly in India.  Lieutaud
found a liver  that was  shrivelled into a mass
not larger than  his closed hand.  Portal met
with this viscus, in a case of ascites, not larger
than an ordinarily-sized apple.  Atrophy of the
liver may be general or partial.  The latter, con-
joined with  hepatic venous  congestion, is not
an infrequent  consequence of the practice of
tight lacing, as  Mr. E. Wilson has justly ob-
served.   The  surface of the liver, in some of
these cases, is marked by deep fissures into ir-
regular polygonal divisions, resembling the lob-
ulated appearance ofthe foetal kidney.
  215.  The  Cirrosis of Laennec is the  most
important form  of atrophy of the liver.  In it
the organ is diminished to  one half, or even
one third of its  natural bulk; the relative size
of the  right and left lobes is destroyed ;  and
the surface  is rendered  shapeless by the pro-
jection of a number of ridges or granular points.
The entire organ is wrinkled and shrivelled,  is
of a yellowish  or greenish colour, varying from
a bright yellow to  a yellowish  or greenish
brown.  Upon dividing its substance, it is found
denser than natural; and the divided surface
presents a number of patches of various sizes,
but of a roundish form, resembling granules;
and hence this  state has  been denominated
granular by  French  writers. This alteration
has been variously described by Laennec, Bou-
illaud,  Andral, and  Cruveilhier.  Mr.  E.
Wilson remarks, that Mr. Kiernan first dis-
tinguished the true  nature  of cirrosis,  which
he called  atrophy of the liver.   In a case  of
granulated cirrosis, the  liver being diminished
to one half its natural size, Mr. Kiernan dis-
covered, on  injecting it, " that a collateral ve-
nous circulation had been established by way
ofthe diaphragm."  In another case, of a wom-
an who had been tapped ninety times, he found,
upon injecting the liver, that the same kind  of
collateral venous circulation had been formed.
" The circulation through the  liver had been
impeded by the development of condensed cel-
lular tissue ; and the greater part of the blood
of the portal vein had made its way through di-
lated vessels upon the  surface of the organ to
the diaphragm, and from thence into the general
venous  circulation.  In the latter case, there
were numerous bands of adhesion between the
liver and  diaphragm, and between the intes-
tines and the walls of the abdomen, and these
also were traversed by large veins conveying
blood from the portal vein into the general ve-
nous current.
  216.  M. Laennec believed that the mottled
and granular appearance of a section of the liv-
ei in a state of cirrosis arose  from a morbid
deposite, or from a special accidental  tissue
existing in the two states of crudity and soft-
ening.  But somewhat more correct views were
successively formed by Bouillaud, Andral, and
Cruveilhier, until Mr. Kiernan demonstrated
that cirrosis is a partial atrophy of the liver—
atrophy of the lobules with hypertrophy of the
cellular tissue ;  complete atrophy of some of
the lobules, partial atrophy of others, and bilia-
ry congestion  without  atrophy or hypertrophy
ofthe rest.  The small yellow grains, varying
in size from a millet seed to a pea or hazelnut,
are not distinct  lobules, in a variable slate of
hypertrophy, but small, uncongested  patches, 
870                         LIVER—Structural Changes in.
composed of parts of several adjoining lobules,
and having a single or several interlobular spa-
ces for a centre.
  217. Cirrosis may follow enlargement ofthe
organ ; and it is  manifestly the more remote
consequence of chronic inflammatory action or
irritation, during  which the coagulable  lymph
exuded into the cellular tissue  connecting the
lobules becomes  organized, adds to the  bulk
and density of the cellular element of the or-
gan, and thus hypertrophies it; the  pressure
thereby occasioned, together with imperfect nu-
trition of the lobules, producing more or less
complete atrophy of  them ;  while the varying
states of vascular and biliary congestion, or of
deficiency of blood and of bile  in the vessels
and ducts, occasion various tints of colour in
different  parts of the organ.   When this lesion
is far advanced, it produces ascites and jaun-
dice,  generally of that kind which proceeds
from  the accumulation of the elements of bile
in the circulation. It is also sometimes prece-
ded and  attended by disease of the  lungs or
heart.
  [Dr. Budd supposes that the ordinary appear-
ances in cirrosis  are the consequences of ad-
hesive inflammation in the areolar tissue about
the small twigs of the portal vein, by which
serum and  coagulable lymph are poured out.
The  serous part of the effusion is absorbed,
and the fibrin contracts and becomes converted
into dense fibrous tissue, which  divides the lob-
ular substance of the liver  into well-defined
masses, giving great density and toughness to
the organ, and by compressing the small twigs
ofthe portal vein and the small gall-ducts, and
thus impeding the flow of blood and the escape
of bile, causes the pale yellowish colour of the
masses of lobules.  The most  frequent cause
of this affection in this country, as  perhaps in
any other, is spirit drinking.  The alcohol  is
absorbed by the portal veins, and  carried di-
rectly to the organ, every fibre of which it per-
meates, and thus causes a change throughout
its entire texture.]
  218. ii. The second class of lesions of the liver,
or those which seem more especially to depend upon
impaired vital power and depravation  of the blood
sent to the organ, differ from the  foregoing in
presenting no inflammatory character;  in de-
pending chiefly upon a constitutional vice, or
proceeding from a diseased disposition inherent
in the system ;  and in consisting chiefly of mor-
bid deposites and of malignant formations. As
most  of these have separate articles demoted
to the consideration of their  nature and treat-
ment, a brief notice will therefore be  taken of
them  as they appear in the liver.
  219. A. A deposite of fatty or oily matter is not
infrequently observed throughout the liver. A
certain portion  of oily or fatty matter is one of
the chemical constituents of the liver ; but this
may be so greatly increased, appearing  in dif-
ferent forms in the substance of the organ, as
to constitute more than one half of its weight.
M. Vauquelin analyzed a fatty liver which fur-
nished 45 parts of oil out of 100 parts  of the
organ.  This lesion is characterized by appear-
ances resembling those exhibited by the  livers
of those  fishes  which furnish a large quantity
of oil.  The organ is of a cream or pale yellow
colour, sometimes presenting deep orange or
brownish spots on the surface.   Internally, its
appearance is nearly the same  as that of its
surface.  It is generally enlarged, and some-
times softened ;  but it is occasionally firmer or
much harder than natural.  The  fatty matter
is  commonly distributed  equally  through its
structure, or infiltrated in the connecting  cel-
lular tissue.  Sometimes, however, it is depos-
ited in a mass, or forms  several collections in
various parts of the  organ.   This  change is
readily recognised by  the greasy feeling it oc-
casions.  A section of it appears  like that of
yellow soap.  " The vessels seem pressed upon,
and are scarcely perceptible; and the greasy
deposite is divided into  angular masses  by a
coarse and compressed  cellular tissue."—(E.
Wilson.)  The quantity of fat deposited in the
organ is sometimes very great, and it may ex-
ist even in  a fluid state.
  220. Portal found  the liver quite white, and
softened almost to the fluidity  of melted fat,
where no hepatic symptoms existed during life.
He also met with this state of the organ in a
female  suffering a severe  form  of syphilis.
Fatty deposite in the liver is similar to other
morbid  deposites.   The  fat  is not owing to a
degeneration ofthe structure ofthe organ, but
to an undue secretion or deposite of the oily
substance  into the cellular connecting tissue
of the organ, whereby its vessels and lobules
are pressed upon,  atrophied, or  removed, in
proportion  to  the amount of deposite.   This
lesion is found most frequently in persons who
have died of scrofulous tubercles  in the lungs,
and of cancerous maladies.  It  has also  been
observed in connexion with hepatic and  vari-
ous chronic eruptions on the skin.
  221. Andral thinks that it may be owing to
insufficient arterialization of the blood in the
lungs,  and  diminished pulmonary exhalation ;
and he inquires  if it can arise from an imper-
fect  separation  of hydrogen from the lungs,
this element combining with the other element
of fat, and  being deposited in the  parenchyma
of the liver.  This is not improbable, particu-
larly during the  low  grades of vital power in
which this  change occurs, and in which nutri-
tion is imperfectly accomplished.
  [It  was  discovered by Mr. Bowman (1841),
and since this  article was  written,  that this
form of hepatic disease originates in an accu-
mulation of oil  globules in  the  hepatic cells.
Dr. Budd informs us that there is some uncom-
bined oil or fat  in every human liver, though
small in quantity, and that it may be extracted
from the liver  by boiling, and  may be  seen
through the microscope in the hepatic cells, in
the form of very small globules of various sizes,
having a dark outline.  In the fatty liver, the
quantity of oil in these cells is enormously in-
creased, they being distended with very large
globules, which obscure their nuclei.  In some
instances, the quantity of oil thus accumulated
may equal in weight,  and more  than equal in
bulk, all the other elements of liver put togeth-
er.   (For a minute description of this patholo-
gical  condition,  see Budd on Diseases of the
Liver, p. 227.)]
  222. B. Deposites of true tubercle in the  liver
are rarely observed, and  still more rarely inde-
pendently of the presence of similar formations
in the lungs or other organs ; or of general in-
dications of the scrofulous diathesis.   They are
met  with in the liver of various sizes, from 
LIVER—Structural Changes in.                         871
that of a  millet seed to that  of a hazelnut.
The tubercles are of a soft, cheesy consistence,
and have a tendency to a brownish tint.  They
are deposited or infiltrated, according to Mr. E
Wilson, in the tissue .of the lobules, which are
compressed and  congested by them.  The ob-
struction to the circulation in the organ occa-
sioned by them gives rise to more or less con-
gestion.
   223. C.  Scirrus, carcinoma, or  cancer of the
liver, appears in  several forms, but most fre-
quently in  that of tubercles, tumours, or tubera
of different size and consistence.  They gen-
erally accompany manifestations ofthe malady
in other parts ofthe body.* At  the commence-
ment of their development in the  liver, they re-
semble small,  whitish, semi-opaque  patches,
occupying  the  tissue of one or several of the
lobules.  As they increase in size, they put on
different appearances, and  hence  they have
been divided  into  species and varieties.—(a)
The simplest of these has been  termed  scir-
rous tubercle, and is well  described by Mr. E.
Wilson. It commences in a semi-opaque patch,
and the outline of the lobules is for some time
distinctly perceptible through its  area ; but at
a later period the centre of the  patch becomes
quite opaque, and presents a cartilaginous hard-
ness.  The circumference is gradually diffused
in the surrounding textures ;  and the progress-
ive increase ofthe  tumour seems  to take place
by the secretion  of a milky,  albuminous fluid
into the meshes of the lobular venous plexuses.
As the secretion  increases, and  becomes more
consistent, the circulation in these plexuses is
arrested, and the vessels obliterated.  The ob-
literated vessels,  according to Mr. Wilson, give
rise to the  appearance of small  cells, in which
the  carcinomatous matter is  deposited, and
the larger  areas are produced by the tissue of
the capsules of the lobules variously distorted
from their  original  form by the increased depo-
sition.   As the tumours become  larger, white
lines, formed by compressed cellular tissue, ra-
diate from  the centre to the  circumference.
Upon the surface of the liver, the scirrous tu-
bercle appears flat,  or slightly depressed in the
centre.
  224.  (b)  In a second variety,  these carcinoma-
tous tubercles, or tubera, are small and  numer-
ous, of a  yellowish or brownish colour, and
more rapid  in their  growth than  those  just de-
scribed. The cells in which the  carcinomatous
matter is contained  seem thicker, of larger size,
and the contained  matter or  secretion is less
  * [The laws which regulate the dissemination of cancer,
•ays Budd, have not been fully made out; but there is clear
proof that the dissemination may take  place in two ways:
1st, by inoculation, or by the mere contact of a sound part
with a part affected with cancer, without any vascular con-
nexion between them;  2d, by cancerous matter conveyed
by lymphatics and veins to other parts ofthe body.  Ofthe
former we have an  example where gelatiuiform cancer of
the stomach or intestines becomes extended to other organs
in the cavity of the  belly ; and of the latter, where cancer
of the  breast is communicated by the veins to the lungs,
liver, and  other organs.  When cancer originates in  the
stomach, secondary cancerous tumours  are known to form
in the liver before they form in the lungs, which latter, in-
deed, rarely become affected at all, while cancer originating
in the kidney is more often propagated to the lungs than to
the liver.  Moreover, cancer may be propagated by inocula-
tion ; for Professor Langenbeck injected into the veins of
a dog some pulp taken from a cancer which had just been
removed from a living body.  At the end of some weeks,
the dog begun to waste rapidly, when it was  killed, and
several cancerous tumours were found in its lungs.]
 firm than  in the above variety.  Occasionally
 they are reddened in the centres by an effusion
 of blood, or by the congestion of unobliterated
 vessels, or by the passage of large or dilated
 nutritious  vessels.  When the latter variety of
 carcinomatous tubercles  enlarge,  they often
 coalesce, forming an irregular compound mass,
 divided into compartments, marking its original
 multiple form by septa of condensed Glisson's
 capsule supporting dilated vessels.  This form
 of tubercle or tumour appears  to be identical
 with the first variety of the tubera diffusa of Dr.
 Farre, and which he states to be " elevated at
 the surface of the organ, but not uniform in their
 figure, some rising with a regular swell into a
 round form, others acquiring a margin by being
 gradually depressed towards  the  centre, form-
 ing tumours without cysts, almost pulpy in their
 consistence, cellular in their structure, and con-
 taining an  opaque white fluid."
   225. (c)  A  third variety of the albuminous
 carcinomatous tumours, the "large white tuber-
 cle" of Baillie, the " tubera circumscripta" of
 Dr. Farre, is  well described by the latter phy-
 sician.  These tumours are of a yellowish white
 colour, and their  projecting  surfaces, slightly
 variegated with red vessels, deviate from a reg-
 ular swell  by a peculiar indentation at or near
 their  centres,  which  are  perfectly white and
 opaque.  They vary much in size, according to
 their age or duration ; for each tuber at its com-
 mencement is very minute,  but  during  its
 growth it assumes the above character, and at
 its maturity exceeds  an inch   in  diameter.
 These  tumours commonly are distinct at  the
 surface of the liver;  but they coalesce  inter-
 nally, and form immense masses pervading  the
 substance  of the  organ.  Their cellular struc-
 ture is so close, that a section of them appears
 solid and inorganic; but a white fluid of the
 consistence of cream is left on  the  knife by
 which  they are divided, and a fresh proportion
 of this fluid adheres to it each time  that it is
 passed over the surface of the section. The
 cellular structure becomes more apparent after
 long maceration.
   226. (d)  A fourth variety of  carcinomatous
 tumour has been named the gelatiuiform cancer,
 from the firm and jelly-like deposite occupying
 the cells of the tumour, instead of the albu-
 minous secretion  in the preceding varieties,
 The liver may contain a considerable  number
 of tumours of  various sizes dispersed through
 its substance.  The smallest resemble the small
 patches in the incipient stage of the other forms
 of carcinoma already noticed.  The largest are
 equal to a  walnut in size.  They are distinctly
 circumscribed, and the lobules immediately sur-
 rounding them are flattened  and compressed.
 In the smaller tumours the form of  the lobules
 is more or less distinct; but  in the larger the
 lobules have yielded to the  characters of the
 disease.  On the  surface, the centre of the tu-
 mour presents an  oval or circularly  indented
 ring, around which it swells abruptly, and then
 subsides to the circumference.   In a section of
one ofthe larger tumours Mr. E. Wilson found
 a  central  area about two lines  in diameter,
transparent, dense, gelatinous, and bounded by
a white marginal line.  The portion of the sec-
 tion surrounding  the central  area formed the
 bulk of the tumour, was elastic, and  rose above
the central area, subsiding gradually to the mar- 
872
LIVER—Structural Changes in.
ginal line and circumference.  The whole sec-
tion bore a striking resemblance to the conjunc-
tiva affected with chemosis, only that it was
paler.  On examining a thin section with a lens
a number of minute parallel injected capillaries
were seen traversing the marginal  portion of
the tumour towards the white boundary line of
the area, but no vessels could be traced through
that line into this area.
  227.  (e) Medullary sarcoma is a fifth form of
malignant disease  occasionally found in the
liver—the encephalosis of several writers.  The
tumours produced by this morbid deposite are
larger  than scrofulous tubercles ;  and fewer,
and  more regular in form,  than the scirrous
variety (y 223).  They are originally developed
the same way as scirrous, by infiltration into
the minute capillaries, or into the tissue of the
lobules, of  a  grayish white  and opaque sub-
stance, which, as it accumulates, obstructs the
circulation in the surrounding lobules. In their
advanced state, the internal structure of these
tumours consists of a loose  cellular base filled
with a soft and brain-like matter, often coloured
with blood, or containing coagula from extrava-
sation, in various stages of softening. As they
increase in size, they become softer and more
pulpy.  This variety of malignant tumour seems
to be identical with the second and third  varie-
ties of the  " tubera diffusa" of Dr. Farre.
   228. (f) Fungus hematodes, or the fungo-ham-
atoid tumour,  is a sixth form of malignant dis-
ease met with in the liver, and is very intimate-
ly allied to the variety last described.  In it there
is a much more remarkable disposition to the
development of new vessels, and to extravasa-
tion of blood, than in any of the preceding. As
 Mr.  Wilson remarks, hard, cartilaginous, and
scirrous tumours may  exist with those  of  a
softer  texture, and of a medullary form ; and
both of these  may be  mingled together  in the
soft, elastic, and bleeding  mass, constituting
fungus haematodes.  Fungo-haematoid tumours
 are often of a large size, and give rise to severe
 symptoms, or  to speedy death, by their frequent
 or copious haemorrhages.  They constitute the
 fourth variety of " tubera diffusa" of Dr. Farre,
 and have been fully described in the article on
 fungo-haematoid disease.
   229.  M.  Cruveilhier considers the venous
 capillary system to be the seat of all these va-
 rieties of malignant disease, more particularly
 of the fifth variety.  He states that he found
 the  ramifications of the vena porta filled with
 the  peculiar matter constituting the principal
 part of the malignant tumour, and that it ad-
 hered  to the parietes of the vessels, which be-
 came in consequence greatly dilated.  The al-
 teration was  confined to the ramifications  of
 the portal vein ; the hepatic veins and their dis-
 tributions were completely sound.—(Anat. Path-
 olog., liv. xii.)
   230.  D.  Melanosis exists in the liver in either
 of the following forms: 1st.  As a secretion
 infiltrating  the cellular structure of the  organ,
 and giving a general blackness to the substance
 of the  lobules.  2d. As a morbid mass, com-
 posed of an areolar cellular net-work, in which
 the black  carbonaceous matter is deposited.
 3d.  As a melanic pigment accompanying tuber-
 cle or carcinomatous tumours, and imbuing the
 morbid structure with  its  colour.  Melanosis
 varies in shade from a deep chocolate brown to
 a rich black.  It rarely, or perhaps never, ex-
 ists in the liver without being met with in other
 organs or parts of the body.   (See art. Mela-
| nosis.)
   231.  E. Simple serous cysts axe sometimes
 found in the liver, and  are mistaken for hyda-
 tids.  These cysts contain a watery fluid ; their
 inner surface is similar to that of serous mem-
 branes ; and  their external surface  is  either
 adherent to the  part in which they are  imbed-
 ded, or is  surrounded  by condensed cellular
 substance.  These cysts are altogether  differ-
 ent from the fibrous cysts, which contain with-
 in themselves a  number  of detached smaller
 cysts or vesicles, and which are next  to be no-
 ticed.
   232. F. Hydatids  or  Acephalocysts are fre-
 quently found in the  liver, enclosed in a fibrous
 cyst, and contained in  a single parent hydatid
 vesicle.  The hydatid  cyst generally occupies
 the right lobe of the liver, and is most frequent-
 ly situated very near the surface.  It  increases
 to a very great size, causing absorption of the
 structure of the organ, and opening into other
 viscera, after adhesions  have been formed be-
 tween them and the external cyst.   Hydatids
 present the same characters in this organ as in
 other viscera.   (See art. Hydatids.)   When
 they are numerous,  or when the cyst reaches
 a great size,  a tumour is perceived or detected
 by  touch in the region of the  liver.   The tu-
 mour is generally without a hardened  base, cir-
 cumscribed, soft, and yielding ; is unaccompa-
 nied by  the symptoms indicative of abscess;
 has not been preceded  by indications of acute
 or sub-acute hepatitis ; and is not attended by
 the constitutional evidences of cancerous dis-
 ease.  The external cyst is sometimes harden-
 ed by deposites of cartilaginous or bony  plates.
 The developing cyst may open : 1st.  External-
 ly  through the  abdominal parietes.  2d. Into
 the cavity of the peritoneum.  3d. Into some
 part of the alimentary canal,  particularly the
 stomach  and  colon.  4th. Through the dia-
 phragm into  the  pleural cavity ; and, 5th. Into
 the bronchi,  whence the small hydatids may be
 expectorated.  Some  small cysts have occa-
 sionally been found in the liver containing a cal-
 careous deposite, mingled with a membranous
 substance resembling fragments of hydatid sacs.
 These  cysts are supposed to result  from the
 spontaneous cure of hydatids.
    [Some physiologists regard acephalocysts as
 true parasites, having independent vitality, and
 propagated by germs from without, while oth-
 ers suppose  them to result from depraved nu-
  trition of one ofthe normal constituents ofthe
  body.   The celebrated comparative anatomist,
  Mr. Owen (Led. on the  Comp. Anatomy and Phys.
  ofthe Invertebrate Animals), has advanced the lat-
  ter opinion, and  supposes them to result from
  unnatural development of the  nucleated cells.
  A French physician, M. Livois, has lately dis-
  covered that acephalocysts are  the  dwelling-
  place of those microscopic animalcules to which
  Rudolphi gave the name echinococcus.  It has
  long been known that echinococci occasionally
  exist in countless number in acephalocysts, but
  such instances have been considered exception-
  al, and the echinococci have been regarded as
  parasites ofthe hydatids. The researches of M.
 j Livois, however, have led him to the conclusion
 [ that echinococci exist in all acephalocysts.  He 
LIVER—Diagnosis of Organic Lesions  of.                     87<T
states that among more than 800 hydatids from
man and other animals, he did not meet with a
single one without them.  Dr. Budd also con-
firms this  statement by his  own observations
(p. 332).]
  233. G. Intestinal worms have, in rare instan-
ces, been  found in the  hepatic  ducts, having
passed from the duodenum along the common
duct.  It is  very probable, however, that  the
worms  have passed into the ducts after  the
death ofthe patient.
  234. iii.  Diagnosis of  Organic  Lesions  of
the Liver. — The symptoms of most of  the
structural changes of the liver are very equiv-
ocal, as  many of them are common to several
of these changes, as well as to  certain states
of functional and acute diseases  of the organ.
I shall  therefore endeavour  to determine  the
dependance which may be placed upon each of
these symptoms, or signs,  in estimating  the
seat and nature ofthe malady which occasions
them.
  235. A. Pain or uneasiness in any part of the
region ofthe liver may arise not  only from dis-
ease of this viscus, but  also from diaphragm-
atic or costal pleuritis, or from partial perito-
nitis in the vicinity ofthe organ ; from disease
of the pylorus or duodenum, or of the pancreas ;
from flatulence  affecting the  duodenum or the
right arch of the colon ; from faeculent accumu-
lations in the colon ; or  from disease of the
substance or pelvis of the right kidney.  Pain
in its most severe states has been  attributed
above (y 62), either to neuralgia  of the nerves
supplying, or connected with  the liver, or to  the
irritation of gall-stones in the biliary passages.
It should, moreover, be recollected that, during
the progress of structural changes  of the liver,
little or  no pain, or merely uneasiness may be
felt in it, while symptomatic  pains may exist in
distant  parts, chiefly, however, on the right
side ; the organic lesion  not materially disturb-
ing the sensibility of the nerves of the organ
themselves, but exciting, through their medium,
the sensibility of some  portion  of the spinal
nerves of sensation.  Next  to the pain occa-
sioned by gall-stones, neuralgia, and acute in-
flammation,  that produced  by malignant  dis-
ease of the liver is the most severe.   Hydatids,
fatty deposites,  hypertrophy, cirrosis, granu-
lations, indurations, and small secondary  ab-
scesses, are attended by little or  no pain, espe-
cially in  the hepatic region.   The  pain varies
as respects its seat and extent.   It may be lim-
ited to a particular point, or  diffused  over  the
whole hepatic region, affecting  not  only  the
right hypochondrium, but also the  epigastri-
um, the back, the lower part of  the right tho-
rax, the  right shoulder or apex,  the left hypo-
chondrium,  &c.  When it is limited, it may be
seated in either of these parts, or it may change
from one to another.  It varies also in severity
and in its character, as well  as in  its continu-
ance.  It is  commonly more severe at  one
time than at another; or it presents exacerba-
tions and remissions, or even complete inter-
missions.   It may be felt only upon pressure,
or in certain  postures or positions.   It is  im-
possible to state any relation between the  na-
ture of  the malady and the  character of  the
pain or  altered  sensibility caused by it, as  no
such relation has been duly  observed, or even
perhaps exists.   It is chiefly, however, in  the
    II.               no
 more acute inflammations, particularly when
 seated in, or extending to, the surfaces of the
 organ, that pain is most continued as long as
 the inflammation is unsubdued.  In all the oth-
 er  lesions,  unless,  perhaps, the  sarcomatous
 form of carcinoma, the pain is remittent or in-
 termittent, or  developed only by pressure or by
 position.
   236. B. Swelling, or tumour, has been already
 noticed, especially with reference to abscess (§
 140), hydatids (y 132).  In order to  ascertain
 the existence of either, the patient should be
 carefully examined  in  the manner above de-
 scribed (y 99).  He should also be examined
 while standing up,  leaning forward with his
 hands upon the back of a chair.   The abdomi-
 nal muscles will thus be released, and the liver
 will fall  more anteriorly.   The changes  with
 which  enlargement  or tumour of the liver is
 most to be confounded are, distended gall-blad-
 der and tumours connected with other organs,
 as the pylorus, the pancreas, the duodenum, the
 omentum, or stomach.  I have already shown
 (y 145) how effusion into the right pleural cav-
 ity  may so displace the liver as to occasion
 swelling or tumour beneath the  ribs from pro-
 trusion ofthe edge ofthe organ. Tumours in the
 adjoining viscera, just named, are often with
 great difficulty distinguished from those of the
 liver, while these latter are very readily mista-
 ken for the former.  Those which are situated
 in the hepatic region, or which are thus doubt-
 ful as to their seat and connexion, have been
 divided  into two kinds, as they seem to  con-
 tain solid or  fluid matter. This  distinction,
 however, is not very easily made, especially
 when they are deep-seated, or when the patient
 is corpulent.
   237.  a. Tumours containing fluid matters  are
 generally more  or less fluctuating; but  cases
 occasionally occur  in  which the fluctuation
 cannot be detected, as  in  a case  about to  be
 noticed.  Fluctuating tumours are chiefly he-
 patic abscess, hydatid or serous cysts, and dis-
 tended gall-bladder.   1st.  Tumour caused by he-
 patic abscess, as shown more fully above (y 140),
 is at first  hard  and  diffused.   Fluctuation is
 afterward detected  with  great  difficulty ; ap-
 pears gradually,  and only in the centre, ex-
 tending to  the circumference as  it increases,
 the more prominent and fluctuating part being
 surrounded by swelling and hardness.  2d. Hy-
 datidic, or serous cysts (y 231, 232), give  rise, in
 most cases, to a  circumscribed tumour, more
 or less  fluctuating, elastic, but little or not at
 all painful,  and unattended by  diffused swelling
 or hardness at its base, or by redness of the
 surface, unless the cyst has reached the integ-
 uments, or has occasioned inflammation ofthe
 surrounding tissues.*  3d. Distention ofthe gall-

   * A fibrous cyst, or sac, containing fluid or grumous blood,
 was said to have been found connected with the liver in the
 case of a lady whom I saw in consultation with my friend
 Dr. Baikd.  She was advanced in age, was corpulent, and
 had been more corpulent than she was then.  A large tu-
 mour was detected in the abdomen ; it changed its position
 more or less with the change of posture, and often fell be-
 low the umbilicus.  It seemed firm, and it evinced no fluc-
 tuation.   Its mobility, situation, size, and hardness induced
I Dr. Baikd and myself  to view it as a cartilaginous or solid
I tumour developed in the omentum. The patient complained
j of various gastric symptoms, but of little or no pain, until
I shortly before I saw her, and then the pain was referable
I chiefly to the irritation produced by the tumour in the peri-
i toneai surface of  the bowels, and other viscera with which
I it came in contact.  This lady accompanied her husband to 
874                     LIVER—Diagnosis of Organic Lesions or.
 bladder has been described in the article on the
 diseases ofthe Gall-bladder and Ducts;  and
 the diagnosis between it  and hepatic  abscess
 fully stated (see Y 22).
  238. b. Solid tumours, in or near the hepatic
 region, generally are  connected with the liver
 when they partially extend under the cartila-
 ges, and when they retain nearly the same po-
 sition.  Tumours of the omentum, stomach, or
 pylorus generally admit of more  or less mo-
 tion.  The swelling caused by  congestion, or
 by inflammation,  or hypertrophy of the organ,
 is smooth and diffused.  The enlargement, or
 tumours  produced by cancerous  deposites,
 when attended by inequalities ofthe  surface of
 the organ, sometimes may be distinguished by
 these characters, which maybe evinced through
 the abdominal  parietes when  the  patient is
 emaciated, and when  the  liver falls  below  the
 ribs.  The celerity or slowness ofthe develop-
 ment of the enlargement,  or tumour, will also
 assist the diagnosis.   Enlargements produced
 by congestions  both appear  and disappear  the
 most  rapidly, while those caused by hypertro-
 phy and malignant deposites are the  most slow
 and permanent.
  239. C. Jaundice has been so fully  consid-
 ered in the article devoted to that subject, es-
 pecially in respect of its pathological relations,
 that no farther notice need be taken of it as a
 symptom of hepatic diseases.  Intimately con-
 nected with this  state of the cutaneous  sur-
 face is the appearance of the alvine evacuations.
 Generally when there is  jaundice, the stools
 are more or less pale ; and, when organic le-
 sions of  the liver are attended by this state of
 the skin, the evacuations  are often  of a light
 drab  colour, approaching  to  white.  But  in
 chronic alterations ofthe organ, unattended by
 jaundice, the motions are very irregular, both
 as to  frequency, consistency, and colour ; they
 are often very unequal, or very  different in
 colour, even  the same evacuation  exhibiting
 a great variety  of colour, owing  to the une-
 qual discharge, and admixture  of the bile in
 the stools.  They are  generally pale,  offensive;
 often  yeasty,  whitish,  or clayey ;  and very
 rarely natural, either as to odour  or  appear-
 ance.   In the  more chronic cases, discharges
 of blood, of varying quantity, are  observed in
 the motions.
  240. D. The urine presents appearances con-
 nected with the nature of  the hepatic disease,
 and with the degree of obstruction to  the  se-
 cretion and excretion  of bile.   In  some cases
 it assumes a deep yellow  hue before the skin
 itself becomes  discoloured ; and it  often  de-
posites lithate of ammonia of  a  bright pink
colour on cooling.  In most cases where  the
 structural change has existed for  some time,
or is  extensive, and the jaundice is deep,  the
urine  is as dark as porter, and  is  often, also,
 of a greenish tint.  It is often also scanty and
 turbid, especially when  dropsical  effusions,
particularly into  the  peritoneum,  have taken
place.
  241. E. Dropsical effusion is  a frequent  at-

Malta, whither he proceeded to pass the winter,  and there
she died soon afterward. The body was opened by the med-
ical man who attended her there ;  but the  account of the
inspection furnished by him was  so imperfect as to contain
nothing more than that a large  fibrous tumour was found
connected with the anterior edge  ol  the liver, and contained
grunious blood.
tendant on  far-advanced structural lesions of
the liver, and generally commences in the ah-
dominal cavity, extending  to  the lower  ex-
tremities only after the ascites has made con-
siderable  progress.   When dropsy  proceeds
from disease ofthe heart, it generally observes
an opposite course, the effusion commencing
in the extremities, and afterward extending to
the large cavities.   Cirrosis,  or  atrophy of
the liver, induration, and the forms of degen-
eration which implicate the principal part of
the substance of the organ, and impede or ar-
rest the circulation of the portal  system, al-
ways, sooner or later, are followed by dropsy.
Indeed, the  abdominal  effusion  may be  the
first, and even the  chief indication of the  he-
patic malady. (See art. Dropsy, y 90, 96.)
  242. F. Hemorrhages, as has been shown in
the article upon this subject, often attend the
more chronic and extensive organic changes of
the liver.   This circumstance has been fully
insisted upon by  practical writers ; and  the
same  resistance placed in  the way of the por-
tal circulation, which, in one class of persons,
is followed by ascites, in another class is pro-
ductive of haematemesis, haemorrhoids, intes-
tinal haemorrhage, or epistaxis.  In  the  one,
serous effusion takes place from the peritoneal
surface ;  in the other, sanguineous effusion oc-
curs from the  digestive  mucous  surface, the
tendency to  either the one or the other  de-
pending much upon the vital condition of  the
membranes, in connexion with the state ofthe
blood  itself, and the condition  of the viscus
from which the haemorrhage proceeds.  Haem-
orrhage, also, like dropsy, may  be contingent
upon the hepatic lesion either before jaundice
has appeared, or at any period subsequently,
but most frequently after some degree of dis-
coloration has at one time or other occurred.
Occasionally jaundice has  been present and
entirely removed, and at some period more or
less remote from its removal haemorrhage from
some  part of the  intestinal canal has taken
place, proved critical for a time, or has recur-
red from time to time, or even been excessive.
In some cases,  particularly when  it  occurred
at an advanced  stage  of the hepatic disease,
and after jaundice has been deep, it has been
very abundant, and has  hastened  a fatal ter-
mination.
  243. G. Cough frequently attends  enlarge-
ment of the  liver, as well as acute, sub-acute,
and chronic inflammations of the convex  sur-
face of the  organ.   It  is most  frequently ob-
served when  adhesions have been  formed  be-
tween the part of the viscus and the diaphragm,
and when  the enlargement has been  so  great
as to  drag the latter downward, or to irritate
the respiratory nerves.
  244. Besides the above, various other symp-
toms  attend  chronic lesions of the liver, and
which, although  not constantly present, are still
very frequently  observed, and  deserve atten-
tion and  due estimation.  Of these the  most
common are, emaciation, sallowness, or pallor
of the countenance, or  a sickly appearance of
the face and eyes ;  flatulence, and acrid or ran-
cid  eructations,  irritating the pharynx ; slight
acceleration ofthe pulse towards evening, heat
and dryness ofthe  palms ofthe hands, drowsi-
ness,  or pain, or heaviness over the eyes.  Oc-
casionally a  fissured or lobulated appearance 
LIVER—Treatment  of  Structural Lesions of.
875
ofthe tongue, which is sometimes also smooth
and glossy, or loaded and foul, or more rarely
furred in the middle and root, is observed.  An
irregular or  partial  perspiration  often breaks
out, and is frequently greasy and offensive, es-
pecially at  night, or when it is copious.   The
existence of malignant formations in the liver
may occasionally be inferred from the state of
the stools and  urine, in  connexion  with  the
general cachexia and anaemia attendant on the
advanced stages of those  maladies, and some-
times with manifestations of them in most ex-
ternal or superficial parts; but much uncertain-
ty always attends their diagnosis.
  245. iv. Treatment of the Structural Le-
sions of  the Liver.—It is obvious that  the
treatment of these lesions must necessarily be
a matter of difficulty and uncertainty, inasmuch
as  most of them cannot be ascertained with
any degree  of precision during the life of the
patient.  It is chiefly in cases of enlargement
of the organ that admits  of recognition, or of
serous or hydatidic cysts  of considerable size,
that means  of cure can be appropriately or suc-
cessfully employed.   When fluid, semifluid, or
solid matters  are deposited in the liver, so as
to enlarge or obstruct it, a reasonable expecta-
tion may be entertained of removing them, by
the aid either of medicine or of diet  and regi-
men.  Hitherto,  however, the  means which
have been  considered most suitable  for this
purpose have not been such as could admit of
a very successful application. Whatever means
may be  had  recourse to  should be directed
with the following intentions:  1st. To the re-
moval of the  morbid lesion presumed to  exist.
2d. When this object is unattainable, to retard
its progress ;  and, 3d. To alleviate its effects.
   246. A. The first  intention was formerly at-
tempted to be fulfilled by courses of mercury,
followed by mineral waters, &c. ; and subse-
quently, and often less injuriously, by the nitro-
hydrochloric acid baths.  That mercurials were
often injuriously employed in many cases of
this kind, even where they might have  been
advantageously prescribed, if they had been di-
rected with greater  knowledge  of the powers
ofthe various preparations of this mineral, es-
pecially  in  various  modes  of combination, I
have had  sufficient opportunities of observing.
The error which has commonly characterized
the employment of mercurials  in organic  le-
sious ofthe liver, is the exhibition of them, ei-
ther in  doses and forms, or with a  frequency
and continuance which are  calculated to sink
the vital  powers, and  to weaken the resist-
ance opposed by the constitution to the exten-
sion of the local mischief.   Where,  however,
the organic  lesions  are the more immediate
consequence of sub-acute  or chronic inflamma-
tion, a judicious combination of the mild prep-
arations of mercury with diaphoretics or anti-
monials, as Plummer's pill with soap and  tarax-
acum, blue pill with antimonials, or with small
doses of colchicum, &.c, and a recourse  to ex-
ternal derivations,  as issues, setons, &c., are
often of service.
   247. As early as 1823 I had recourse to the
preparations  of iodine, especially to the  iodide
of potassium and iodide of mercury, in  the treat-
ment of those lesions of the organs attended
by enlargement,  or characterized by torpor of
function, absence of fever,  and dropsical effu-
sion from  impeded portal circulation ;  and
since then, as stated in the early part of this
work (see art. Dropsy, y 103), I have contin-
ued to employ this  substance, in some one of
its  forms and combinations, more especially
the iodide  of potassium,  for  the  removal of
these lesions.  Long subsequently to the pe-
riod just named, this  medicine has been re-
sorted to by other physicians in the treatment
of organic changes in the liver ; but the prep-
arations of it employed, or the  doses in which
they have been exhibited, or the modes of com-
bining them, have been such as were little cal-
culated to prove beneficial, particularly  in the
cases for which they were prescribed.  In many
instances they were exhibited in too  large
doses, and were inappropriately combined ; in
others,  they  were  unsuited to the  existing
pathological conditions.  In the first place, the
preparations of iodine may prove  injurious, by
exciting  or developing inflammatory action,
where it already exists in a sub-acute or latent
form, or where a strong tendency to it is pres-
ent, especially when they  are  given  in  large
doses, or when those which are more acrid are
employed.  Where  inflammatory action impli-
cates more  particularly the surface or  mem-
branes ofthe organ, still greater caution in the
use  even of the milder preparations  of this
substance is requisite.   It  is chiefly when en-
largement, obstruction,  or  torpor of the liver
occurs after periodic fevers, or in the scrofu-
lous diathesis, either alone or as  a cause of
dropsy, that  iodine, particularly the iodide of
potassium, employed either  externally or inter-
nally, or both, and  in  conjunction with other
deobstruents, as the liquor  potasse, or alterna-
ted with purgatives, has proved most beneficial
in my practice.  In  these  cases, the iodide of
potassium, conjoined with liquor potassae, may
be given with the preparations of taraxacum, or
of sarsaparilla, or in mild,  bitter, or stomachic
infusions ;  while an ointment containing the
iodide (zb of the latter to f j. of the former) may
be rubbed over the  right hypochondrium, or a
plaster may be kept applied in this situation,
consisting of equal parts of the emplastrum am-
moniaci cum hydrargyro, and the emplast. picis
compositum.
   248. In those cases of  enlargement  of the
liver which are attended  by pain, or by sub-
acute inflammatory action  in some part of the
surface of the organ, as well as in other cases
where the  above means either are inappropri-
ate  or have  failed, the bi-lartrate  of potash  in
conjunction with the bi-borale of soda, in as large
doses as the stomach and bowels will tolerate,
has often  proved remarkably beneficial, espe-
cially where the hepatic  lesion  has superin-
duced either dropsical effusion, or haemorrhage,
or jaundice.  The nitro-hydrochloric bath, or lo-
tion, or a course of these acids internally, or of
the nitric acid alone, may be tried, particularly
in enlargement of  the liver, as advised above,
and aided by deobstruent  purgatives or other
appropriate remedies.  As  regards other means
of removing structural lesions of the liver, it is
unnecessary to add to  what has been fully sta-
ted when treating, in the articles Dropsy, Hem-
orrhage, and Jaundice, of the most frequent
consequences which they produce.
   249. B. The second and third  intentions of
treatment comprise not only the means already 
876
LIVER—Treatment  of  Structural Lesions of.
mentioned, which  can, when they fail in ac-
complishing the fit st indication, sometimes ful-
fil the  second, but  also those remedies which
have been  more especially noticed with refer-
ence to those serious symptoms or consequen-
ces of organic lesions ofthe liver just referred
to.  It is obvious that, when we  fail in remo-
ving these  lesions, some one or more of these
consequences  will  accrue—either dropsy, or
jaundice, or hemorrhage, particularly from the
digestive mucous surface, or any two or more
of them ; and that, either before they may have
appeared, or subsequently, those  means which
I have advised, appropriately not only to either
of these superinduced affections, but also to the
original malady, should be employed.  What
these means are will fully appear on a refer-
ence to these subjects, especially at the places
where they are treated  of in connexion with
hepatic lesions.
  250. In most ofthe more chronic and exten-
sive lesions of the liver, it is necessary, even
while  we  employ  means to  remove them, to
retard their progress  or to alleviate  their con-
sequences, to support the constitutional powers
and improve the general health by medicine, by
diet, and by air and regimen.  In some cases,
restoratives or mild tonics may be  conjoined
with alteratives, deobstruents, and anodynes :
thus the oxides or other preparations of iron
may be given with iodine or some  one  of its
 preparations,  or with the  liquor potassae, and
 with  narcotics or anodynes, according to the
 nature of  the case, especially in the malignant
 alterations ofthe organ, when pain sometimes
 becomes  a prominent feature of the  malady.
 In other chronic cases, water impregnated with
 chlorine, or chlorine fumigation, as advised  by
 Mr. Wallace, may be prescribed with tempo-
 rary advantage, as tending not only to excite
 the functions of the liver, but also to promote
 the constitutional  powers.  With these views,
 certain of the chlorides may be employed, and
 more especially the chlorate of potash.  When
 there  is no tendency to inflammatory action,
 the bisulphate of potash may be given  in the
 infusion of roses, either with or  without small
 doses of quinine.   In cases of enlargement of
 the liver consequent upon obstinate or repeated
 attacks of ague, the bisulphate of potash, pre-
 scribed so as  to act freely  on the  bowels,  is
 often  most serviceable.
    [As Dr. Budd has well remarked (On the Dis-
 eases of the. Liver.  Phil., 1846, p. 252), the treat-
 ment  in cases  of hepatic enlargement should
 have chief reference to the state of the system
 —the peculiar cachexia—on which the faulty
 secretion  and the large  size of the liver depend.
 When it depends on scrofula, our chief reliance
 must  be on warm clothing, sea  air, and bath-
 ing ; a light, nourishing diet, comprising a lib-
 eral  allowance of animal food and wine, and
 the preparations of iodine and iron, separate or
 combined. If the patient has previously labour-
 ed under syphilis  and taken  mercury in consid-
 erable quantities, the appropriate remedies are,
 warm clothing, a tonic regimen, iodide of po-
 tassium,  nitric acid,  sarsaparilla,  and  quail
  We  are  to bear in mind, in  the treatment  of
 these cases, that the original malady is faulty
 assimilation, and that  the matter deposited in
 the liver  does not become  organized like the
 fibrin found out in inflammation, and that, by
the use of proper means, it may all be removed
by absorption, or pass off in the bile.  To this
end, repeated and long-continued frictions with
iodine ointment, powerfully tend ; and Dr. Budd
states (loc. cit.), that he has seen enlarged  liv-
ers reduced to their natural size by iodide of po-
tassium, and  frictions  with iodine,  or  simply
by these frictions  and saline purgatives.   Dr.
Graves,  also, in his "Clinical  Medicine,"  de-
tails several  cases of a  similar kind, success-
fully treated by blue pill and hydriodate of pot-
ash.
   In cases of malignant disease of the liver,
treatment, of course,  can only  be  palliative,
such as  tends to  relieve pain and any inflam-
mation that may be caused by the  cancerous
tumours, and to retard the emaciation and ex-
haustion which they produce.   So  far as we
have observed, mercury, arsenic, or iodine in-
variably do harm  in these cases ;  morphia, co-
nium, and hyoscyamus will frequently be found
useful in relieving pain and  irritation, and a
mustard cataplasm will often aid  in producing
the same effect, but all powerful agents should
be avoided.   We  should here, as  ever, bear in
mind the remark of Dr. Farre, that "the per-
fection  of medicine consists,  not in  vain at-
tempts to do more than nature permits, but in
promptly and effectually applying its  healing
powers to those  diseases which are curable,
and in soothing those which are incurable."]
   251. C. The Diet, in all diseases ofthe liver,
should  receive  the strictest  attention.  The
chief rules  to be observed are, 1st. To allow
only the most  antiphlogistic diet  and regimen
when  any inflammatory action or  any febrile
symptoms are present;  2d. To recommend the
most digestible food in small, or at least very
moderate quantity, in all other cases ;  and, 3d.
To  advise the  adoption principally of farina-
ceous articles of food, and to allow only a small
 quantity of  the  lighter kinds of animal food
 once in  the day, even in the more chronic and
 least severe cases.  A milk  diet is generally
 of use, especially when the milk is taken with
 the addition of a  small quantity of lime-water,
 or liquor potassae, or  Seltzer water.  A  diet
 consisting of milk and the farinacea is very
 generally  appropriate,  especially when it  is
 found to agree with the patient.
   252. Regular exercise, particularly on foot or
 on  horseback, sea-voyaging, and warm cloth-
 ing, the  general  surface  being covered with
 flannel, are also requisite aids  to medical treat-
 ment.   Change of air, especially to a cool, tem-
 perate, and  healthy locality, and  to  a  dry and
 elevated situation, is also of much importance.
 When  such a  change  can be conjoined with
 the use of deobstruent saline springs, additional
 benefit will accrue.  In torpid states ofthe liv-
 er, after a long residence in  a warm  climate,
 or  in chronic affections of the organ, particu-
 larly those connected with congestion, enlarge-
 ment, or infarction, the deobstruent and purga-
 tive mineral waters  are  generally of service.
 The waters of Cheltenham, Leamington, Harrow-
 gate, or those  of Carlsbad, Kissengen, Marien-
 bad, Homburg,  of Pulna,  Seidschutz, [Avon,
 Richfield,  Sharon, Saratoga, Western Virginia],
 &c, and the artificial mineral waters  prepared
 at Brighton, are severally productive of benefit,
 when  employed  appropriately to the varying
 features of the case, or even of the same case, 
LIVER—Bibliography and References.                           877
at different periods of its progress.   It is very
manifest that the more purgative waters, and
those  which are most refrigerant  and  deob-
struent, are  most suited to  cases characterized
by enlargement,  congestion,  or  infarction,  or
attended by  febrile  commotion ; but,  in  other
circumstances, especially where  loss  of appe-
tite, nausea, debility, rancid evacuations, heart-
burn, torpor of the  liver, &c., are present, and
particularly  if these symptoms  are aggravated
or appear during a course of these waters, those
which possess restorative  in  conjunction with
deobstruent  powers, are the most appropriate,
and  should  at  least  be tried.   In many cases
the good effects  of the waters will be promoted
by a  recourse  to the same waters,  as tepid  or
warm baths, or  at a  temperature prescribed ac-
cording to the peculiarities  of the case.
  Bibliog. and Refer.—Hippocrates, Xltpi rwv tvOoc ra-
6W, p. 574.—Celsus, L. ii., c. i.;  et L. iv., c. 8.—Aretaus,
Chronic, 1. i., c. 13 ;  et Acut., 1. ii., c. 7.—Galenas, De Arte
Cur. ad Glauc, 1.  ii., c. 5.—Aitius, Zetrabib., iii., s.  ii., c.
4, 5.—Paulas ^Egineta, L. iii., c.  46. — Alexander Trallia-
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1, 10; et  fen. 14, tr. 2, c. 4.— G. Piso, Historia Naturalis
utriusque India;, fol.  Amst., 1648.—Bontius, De Med. In-
dor., c. 7.— Willis, Pharmac.  Rat., p. ii., acet. ii.,c. 2.—P.
Alpinus, De Med. JEgypt., 1. iii., c. 4.—F. Glisson, Anatomia
Hepatis, 8vo.  Lond., 1654.—Sylvius de la Boe, De Bile et
Hepatis V%a.   Lugd. Bat., 1666. — Bartholinus, Epist. ii.,
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ii., hist. 85.—Zacutus Lusilanus,  Med. Pr. Hist., I. ii., No.
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—M. Stoll, Rat. Medendi, &c, vol. v., p. 214.—/. Crawford,
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p. 19.—A. D. Stone, A Treatise  on  Dis.  of the Stomach,
Liver, <fec, 8vo.  Lond., 1806.—Monro,  in Edin. Med. and
Surg. Journ., 1805, p. 397.—Firth,  in Lond. Med. and Phys.
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Treat, on Inflammat. and other Dis. of the Liver, 8vo. Bath,
1808.—/. Curry,  Examination of the  Prejudices against
Mercury in Liver Complaints,  8vo.   Lond , 1809. — W.
Saunders, Observat. on the Hepatitis of India, 8vo.   Lond.,
1809.—H. Campbell, Objections to the Opinions, <fcc,of Dr.
Saunders, in  Bilious  and Liver Complaints. 8vo.  Lond.,
1809.—T. Mills, Observ. on Dis. of the Liver, 8vo.  Lond.,
1811.—Spangenberg, in Horn, Archiv. fur  Medicin. Erfuh-
rung. May, 1812, p. 472 (Hepatitis complicated with  Car-
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and ii., 4to.  Lond., 1812-15.-^4.  Portal, Observat. sur  la
Nature  et le Traitement des Mai.  du  Foie, 8vo.  Paris,
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Diag. of Dis. of Liver).—J. Faithorne, Facts and Observat.
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Essay on the  Common Cause and Prevention of Hepatitis,
8vo.  Lond., 1816.— Larrey, in Diet, des Sciences Med., t.
xvi.  Paris, 1817.—Tourdan, in Ibid., t. xxi.  Paris, 1818.—
G. Balltngal, Pract. Observ. on Fever, Dysentery,  and Liv-
er Complaints among European Troops in India, Svo, ed.
1818.—H. Marshall, On the Med.  Topography and Dis. of
Ceylon, 8vo.  Lond., 1821, p. 145. — T.  Mills, Inquiry into
the Effects on  the Brain, &c, by Dis.  of the  Liver, 8vo.
Lond.,  1819.—J. Johnson, A Treatise  on Derangements of
the Liver, &c, 3d ed., 8vo.   Lond.,  1820.—Schmidtmann,
Observat. Med., t. ii., p. 188-258.—/. B. Regnault,  Memoire
sur les Alterations et l'lnfluences du Foie,  &c, 8vo. Paris,
1820.—/. Ayre, Pratt. Observat. on Dis. of the Liver and
Bilious Complaints, 8vo.  London, 1821. — C. Chisholm, A
Manual ofthe Climate and Dis. of Tropical Countries, 8vo.
Lond.,  1822.— W. Wallace, Researches respecting the Pow-
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Kinglake, in Lond. Med. and Phys. Journ., vol. xl., p. 463.
—Pascal, in Nouveau Journ. de Med., t. iii., p. 121.— Fer-
rus, Diet,  de Med., t. ix.   Paris, 1824.—Bouillaud, in M£-
moires  de la  Soc. Med. d'Emulation, t. ix., p.  170.—Mes-
soger,  in  Journ.  Univers. des Sc. Med., t. xxxi.,  p. 367.—
Nacquart, in Ibid., t. xxvii., p. 244.—Bodson, Rev. Med., t.
i., 1825, p. 481 (Hydatids of Liver).—A. Bonnet, Traite des
Maladies du Foie, 8vo.  Paris, 1828.—Hesse, Journ. Com-
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Repertoire Gener. de Anat. et Phys., t. i.,  p. 322.—Cruveil-
hier, Diet, de Med. Pratique,  t. viii.; et Roche, in Ibid., t.
ix.  Paris, 1833.—G. H. Bell, Treatise on Dis. ofthe Liver,
8vo.  Edin., 1833.—Kiernan, On the Anat. and Phys. of the
Liver, in Philos. Trans, for 1833. — Andral, Anat. Patholo-
gique, t. ii., p. 585.— B. Voisin, Nouvel Apercu sur la Phys-
iol, du Foie et les Usages de la Bile, <fcc, 8vo.  Paris, 1633.
— W. Twining, Clinical Illustrations of the  most import.
Dis. of Bengal, with Results of an Inquiry into their Nature
and Treatment, 2d edit., 2 vols., vol. i., p. 227.  Calcutta,
1835. — C. Morehead,  in Edin. Med. and Surg. Journ., vol.
xxxvii., p. 308.— W. Stokes, Cyclop, of Pract. Med., vol. iii.,
p. 44; and Venables, in Ibid., vol. iv., p. 604.—Cruveilhier,
Anatom. Pathologique du Corps Humain, <fec, fol., liv. xi.
et xii. — Bouillaud, in Archives Gener. de Med., t. ix., p.
542.—Andral, in Ibid., t. xii.,  p. 456.—Bricre de Boismont,
in Ibid., t. xvi., p. 5, 381.—Ripault, Quelques Proposit. sur
les Functions  du Foie  et de la  Veine  Porte, &c, 8vo.
Paris, 1839. —M. Reynaud, in Journ. Hebdomad, de Med.,
t. iv., p. 137 (On Obstr. ofthe  Portal Circulal.)—Martinet,
Journ. de  Prog, des Sciences Med., t. xi., p. 248 (Hyd. Cyst.
Recovery). — Pierquin, in Ibid , t.  xiv.,  p.  252 ;  Ibid., t. v.,
p. 249 (Abscess of Liver communicating with Pericardium).
— W. E. Conwell, Treat, on the Funct. and Struct. Dis. of
the Liver, <fec,  8vo.  Lond., 1835.—R. Bright, Guy's Hos-
pital Reports, vol. i., p. 638.—Addison, in  Ibid., vol. i.,476.
—Stewart, Lancet, Jan. 13, 1838, p. 566. — /. G. Malcolm-
son, in Trans, of Roy.  Med. and Cljirurg. Soc, vol. xxi., p.
91 ; et  Med. and Chirurg. Rev., vol. xxix., p. 360. — W.  J.
Cox, in Trans, of Roy. Med. and Chirujg.  Soc, vol. xxi., p.
331.—Graves, Dublin Med. Journ., Jan., 1839.— IV. Geddes,
Trans, of Med. and Phys. Soc. of Calcutta,  vol. vi., p. 284.—
/. Gordon, in Ibid., vol. viii., part i., append. 2.—Mouat,  in
Ibid., vol.  vi., p. 1 ; and in Med. Chirurg.  Rev., July, 1838,
p. 306.—VV. /. Cox, in Ibid., vol. xxix., p.  368.—/. Johnson
and /. R.  Martin, The Infl. of Tropical Climates on Eu-
ropean Constitutions, 6lh ed., 8vo.   Lond., 1841.—Erasmus
Wilson, in Cyclop, of Anat. and Physiol., art. Liver, Anor-
mal Anatomy.
  [Ad. Bibliog. and Refer.— George  Budd, On  Diseases
of the Liver, Am. ed.  Phil., 1846, 8vo,  p.  392. —N. Chap- 
878
LUNGS—Inflammation of the.
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racic and Abdominal Viscera.  Phil., 1844, 8vo. — S. H.
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ton, S. C, 1845, 8vo, 2 vols.—Robley Dunglison, The Prac-
tice of Medicine, &c, 2d ed., 2 vols., 8vo.  Phil., 1844—C.
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George Todd, in Lond. Lancet, vol. iii., Jan., 1846.—George
Johnson, in Lond. Lancet, vol. iii., p. 84, Am. ed.—R. Allan,
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of Med. Science, May, 1842.—F. Bouisson, De la Bile, de
les Varietes Physiologiques, <fcc, 8vo.  Paris, 1843—Wm.
B. Carpenter, Human Physiology ; Gen. and Comp. Phys.
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vols., 8vo, 1840. — W, P. Dewees, Practice of Physic, 8vo.
Phil.,  1833.—R. Dick, Derangements of the Organs of Di-
gestion, 8vo.  Phil., 1842.—/. Eberle, Practice of Medicine,
5th  ed., 2 vols.   Phil., 1836.—/. Elliotson, Am. ed. of Princ.
and Pract.  of Med., by Stewardson.—/. Fletcher, Elements
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Traite. Phil, de Medicine Pratique. 3 vols., 8vo.  Paris,
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Principles  of Diagnosis; Am.  ed., by /.  A. Swett, 8vo.
New-York, 1840.—D. Hosack, Lectures on the Theory and
Practice of Physic, edited by Dr. Ducachet, 8vo. Philad.,
1838. —/.  Hope, Morbid Anatomy; Am. ed., by Lawson.
Cincinnati, 1645.—/. Liebig, Animai Chemistry, dtc, 12mo.
New-York, 1842.—/. Mackintosh, Am. ed. of Princ. of Path.
and Pract. of Med.,  by 5'. G. Morton.  Phil., 1844.—F. S.
Mosgrove, Practical Treatise on Congestion and Inactivity
of the  Liver, <fcc, 12mo.  Lond., 1843.—/. Muller, Elements
of Phvsiology, by Baly,  2 vols.  Lond., 1842; Am. ed., by
/. Bell.  Phil., 1843.—L. Parker, The Stomach in its Mor-
bid States, dec.  Phil., 1841.— W. Prout, On Stomach and
Urinary Diseases. Lond., 1843.— W. Stokes and John Bell,
Lectures on the Theory  and Prac. of Physic, 2 vols., 2d ed.
Phil.,  1845.—Todd and Bowman, The Physiological Anato-
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Surg.  Journ., vol. xvii., p. 55.—E. Alexander, in  Bost. Med.
and Surg. Journal, vol.  xviii., p. 36 (Remarkable case of
hydatids in liver, in which an external incision was made
into the liver, and 200 hydatids, from the size of a pea to an
orange, discharged, besides six pints of pus and bloody se-
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Surg.  Journ., vol. xxvi., p. 80 (Case  of tuberculated  liver
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798.— D. J. Corrigan, On Cirrosis of the Liver, in Lond.
Med. Times, Jan., 1845;  On Jaundice, in Lond. Med. Times,
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Hepatitis,  in Lond. and  Edin. Monthly Jour, of Med. Sci.,
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W. Heustis, in Am. Jour. Med. Sci., vol. vi., p. 73.: Inquiry
into the Functions and Pathology of Liver and Spleen.]

LUMBAGO.  See Rheumatism.
LUMBRICI.   See Worms.
LUNGS—Diseases of. — Syn.  Hvevpuv, ovoc..
   Pulmo, Lat.   Poumon,  Fr.   Lunge, Germ.
   Polmone,  Ital.   Lung.
   1.  I shall confine myself at this place to the
consideration of those diseases which  are seat-
ed  in, or affect chiefly, the substance, or proper
structure of the lungs, and which are independ-
ent of constitutional peculiarity or  affection,
and  of the  diseases of their  investing  mem-
brane, and of  those of the air passages  and
tubes, with which, however, diseases of the sub-
stance of the lungs are very often associated.
Under  the  heads  Bronchi, Croup,  Hooping-
cough, Larynx, and Trachea, &c, the  mala-
dies of the air passages and tubes are fully dis-
cussed;  while under Pleura, Tubercular Cow-
sumption, Asthma, Hemorrhage-pulmonary,
&c, those affecting the  investing membrane
of the organ, as well as those which,  although
seated chiefly or  even  primarily in the lungs,
depend  upon diathesis, and  extend  to  other
parts and organs, are severally treated of.   In
thus confining  myself to the diseases which are
more  intimately connected with, or are proper
to, the substance  or parenchyma of the  lungs,
I shall first consider inflammations of the  lungs,
and, subsequently, emphysema, edema, and struc-
tural changes of the organ.   The other maladies
seated in or implicating the lungs and air pass-
ages are, as just hinted  at, discussed  either
under their  usual  names, or under the head
Bronchi and Pleura.
I. Inflammation  of the Lungs.—Syn.  Tlvev-
   uovta, Uepnrvevuovia (from 7rv£i^wv, the lung).
   TLepinvevfioviKn  Noaof,  Dioscorides.   Pneu-
   monia,  Cullen,  Parr.  Peripneumonia,  Auct.
   var.  Pulmonia, Pulmonaria, Auct.  Peripneu-
   monia  vera,  Sauvages.   Febris, Pneumonica,
   Hoffmann. Pneumo-pleuritis, Dolaeus.  Cauma
   Peripneumonia, Young.  Empresma pneumoni-
   tis,  Good.  Pneumonitis, Swediaur and  Hil-
   denbrand.   Inflammation des  Poumons Peri-
   pneumonii, Fr.   Lungenentzundung, Enlzun-
   dung  der  Lungen, Germ.  Pulmonia, inflam-
   mazion del Petto, Ital.  Peripneumony.
     Classif.—1. Class, 2. Order (Cullen).  2
        Class, 3. Order (Good).   III.  Class, I.
       Order (Author in Preface).
   2.  Defin.—Rapid,  short, and sometimes  op-
pressed  respiration;  cough  and  expectoration;
general feverishness,  and uneasiness referable to
the lungs.
   3. Pathol. Defin.—Inflammation and its usual
consequences  in the parenchyma of the lungs, often
implicating the small bronchi and air cells on the
one hand, or the pleura on the other, or either, more
particularly or exclusively.
   4.  Of  the numerous  symptoms  attending
pneumonia there  are, perhaps,  none which are
present in all cases excepting the above.  The
auscultatory signs vary with  the stage and in-
tensity or extent of the disease, and therefore
are  not comprised in the  above definition.   It
was shown  by me, in the article Bronchi ($ 41,
42), and subsequently by  Dr. Stokes, that, al-
though pneumonitis may originate in the cellu-
lar tissue or parenchyma  of the  lungs, yet it
very frequently arises from an extension  of the
inflammatory action from  the  small bronchi to
the  air cells and substance of the  organ : a
mode of origin which had  been generally over-
looked until  I  insisted  upon it,  and contended
that the inflammation, when thus orrginating,
may not be  confined to the parenchyma ofthe
lungs and the minute bronchi and air cells, but
be extended even to the pleura, producing the
usual consequences of pleuritis, as will be more
fully  shown hereafter.  It will  be preferable
first  to  consider  the primary and simple form
of pneumonia, and afterward to notice its prin- 
LUNGS—Inflammation of the.
879
fipal varieties  or  modifications  and  complica-
tions.
i.  Primary Acute  Pneumonia.—Syn.  Pure
  Pneumonia;  Sthenic Pneumonia; Pneumonia
  vera; Simple  Pneumonitis;  Primary  Pneu-
  monitis.
  5. A. The primary Ttat of pneumonia has not
been determined with due precision, but has
been a subject  of some discussion.  Several
writers have believed it to commence in the
plexus of vessels and sub-mucous tissue uniting
the  minute extremities of the bronchi and  air
cells ;  others state, in general terms, that it is
seated in the connecting filamentous or cellu-
lar tissue constituting the  parenchyma of the
organ.  Dr. Williams considers " the capillary
ramifications of the pulmonary artery and veins
to be the proper seat of pneumonia, and that
these may involve more or less of the tissues
through  and around which they  pass."  Dr.
Stokes describes pneumonia as  " inflammation
of the cells and minute tubes, and believes that
it differs from bronchitis, in the  ordinary accep-
tation of the term, merely in the occurrence of
the  phenomena of a parenchymatous  inflam-
mation, such as solidification, suppuration, and
abscess :  phenomena not proceeding from any
inherent difference in the disease,  but a result
of  anatomical  structure."   This,  however, is
all that  is  contended  for; the  structure  in
which the inflammation  is seated being such as
gives rise to those phenomena  when inflamed,
other phenomena resulting from inflammation
of the bronchial tubes.  There can be no doubt,
however, that inflammation of the air cells and
minute bronchi will so fill up and  obliterate
them with the usual products of  this state of
morbid action,  as to give rise  to appearances
similar to those consequent upon an infiltration
of the same products in cellular  or  parenchy-
matous structures; and that, when the inflam-
matory action  originates in the latter, it will
give rise to changes similar to  those produced
by it when commencing in the minute tubes
and cells; inflammation of these latter being
rarely confined  to them, but extending to  the
parenchyma or filamentous tissue ofthe organ ;
or, in other words, that the morbid action may
originate  and  predominate in either series of
structures, but that it rarely continues  without
implicating both.
   6. The French pathologists,  and after them
some recent English writers, have distinguish-
ed the disease  into lobar, lobular,  and vesicular,
according  as it extends to the whole or con-
tinuous parts of lobes,  or is limited to certain
polygonal  subdivisions  of these, or to single
bunches of vesicles.—a. Of these the  lobar is
the  most common ;  it  may be confined to an
irregular portion of a lobe, or may extend to a
whole lung, or  to a great  part of both lungs.
When the inflammation is very extensive,  it
commonly exists in different  degrees  of  ad-
vancement, as  will  more  fully appear in  the
sequel.
   7. As  to the  parts of the lungs most fre-
quently attacked, Morgagni, Frank, Broussais,
&c, judging from the post-mortem inspections,
inferred that the upper lobes were oftener affect-
ed  than  the lower ; while Laennec, Andral,
Chomel,  and  others, comprising  the  slighter
oases and those of  recovery, considered that
the lower lobes  were most frequently inflamed.
M. Chomel found, out of 59 inspections, that
the apex was attacked in 13,  the base  in 11,
and the whole or central parts in the others.
In general, the upper lobes are more  frequently
affected than the lower in the most  dangerous
cases, and when the disease assumes a low or
adynamic form.  M. Andral found, in 80 cases,
57 ofthe lower lobe, 30 ofthe upper, and 11 of
the whole lung.   The proportion, however, in
which the upper lobe is affected appears greater,
according to this calculation, than  obtains in
this country.
  8. b.  In the lobular state of pneumonia, the
inflammation is confined to a few isolated lob-
ules, being limited by the interlobular cellular
tissue, and appearing as lozenge-shaped  or po-
lygonal patches of red, engorged, or hepatized
tissue.  This form seems to commence at the
same time  in  several distinct  parts, and is
most frequently observed in cachetic persons,
or subsequently to  phlebitis, accidents, opera-
tions, &c.
  9. c. The vesicular form of pneumonitis has
been distinguished  by M. Andral.   He sup-
poses it to be confined to the air cells or vesi-
cles.  It appears as little red spots,  varying in
size from that of a pin's head to that  of a  hemp-
seed, and in colour from a blood to  a livid red.
It is not often observed, at least in a distinct
form, unless the  colour of the  lung be light.
The tissue of the organ surrounding these red
spots are sometimes healthy, and  they often
contain the miliary granulations  of Bayle.
  10. d. As to the lung most frequently attack-
ed, Dr.  Forbes has shown, from the observa-
tions of Andral, Chomel,  and Lombard,  that
out of 1131 cases, the right lung was affected
in 562 cases, the left in 333, and both the right
and left  in 236 ; in every ten five being  in the
right, three in  the  left, and two in  both.  Dr.
Stokes remarks, that this very nearly  agrees
with his experience ; but that double pneu-
monia is more frequent than appears from this
statement; for it commonly happens, that al-
though disease greatly preponderates in one
lung, more or less  of it may be detected,  by  a
careful physical examination, in the  other, even
when pain or uneasiness is not referred to it.
He farther observes, that inflammation of the
right lung is oftener of the sthenic, and that of
the left  of  the nervous or typhoid character.
According to my own experience, it  is undoubt-
ed  that double pneumonia most  frequently oc-
curs in the previously diseased or cachectic, in
the nervous or debilitated, in  states of  the air
causing vital depression, and  during epidemic
constitutions, or in the course of epidemic dis-
eases, characterized by impaired tone and low-
ered vital resistance.
   11.  B. Usual Course of simple Sthenic Pneu-
monia.—a. Certain premonitory  symptoms are
often  observed,  unless the  dis°ase proceeds
from the more violent causes, or from wounds
or  accidents.  These consist  of oppression in
the chest; a slight, short cough ; quickness and
shortness  of breathing,  especially  in motion,
speaking aloud, or on ascending an eminence ;
languor, and occasional  sighing.  These  usu-
ally continue a day or two, and are  followed
by those characterizing,
   12. b. The invasion ofthe disease.  This event
 is  indicated by marked rigours  or  chills, con-
 tinuing from half an hour to one, two, or more 
880
LUNGS—Inflammation of the—Symptoms.
hours.   These are not,  however, observed in
all cases, or are so slight in some as to escape
notice.  Attending this state of febrile exordi-
um, and in addition to the usual concomitants
of it, anxiety, difficulty of breathing, oppression
in the chest; short, dry, or suppressed cough  ;
general uneasiness, loss of appetite,  &c, are
usually complained of.
  13. c. The increment  or  development of the
disease follows the disappearance of chills or
rigours.  Animal heat gradually increases until
it assumes a marked character ;  and with it are
developed vascular reaction, vital turgescence,
and  general orgasm of  the circulation.  The
symptoms especially referrihle to the  inflamed
organ  now more particularly manifest them-
selves.
  14.  Respiration  becomes  short,  frequent,
anxious, and difficult; is attended with unusual
expansion and elevation of the chest; with  a
frequent small cough, and increased warmth
and  moisture of the expired air; and as the
disease advances,  is performed chiefly by the
diaphragm and abdominal  muscles, the chest
apparently remaining unmoved, especially on
the side chiefly affected.   The patient is un-
able to take a deep inspiration, the turgid and
inflamed lung being incapable of farther expan-
sion ; nor is he able to expire freely, the organ
being  equally incapable of collapsing ; and he
lies, in preference, on the  affected side, or, if
both lungs are diseased, in the  supine posture
There is a constant feeling of uneasiness rather
than of pain complained of in  the chest, with
anxiety, a sense of constriction, fulness, inter-
nal heat, and of weight.  There are  constant
restlessness, inquietude, and  tossing,  with fre-
quent  attempts to  elevate the chest and shoul-
ders, proceeding from the great vascular tur-
gescence of the lungs, and  obstacle to their
farther expansion, to attempt  which, the  pa-
tient feels irresistibly called.  The cough at the
commencement is dry, troublesome, and short,
accompanying  almost each  expiration,  espe-
cially  after a full inspiration, and  constant:  it
afterward becomes more  moist, and is attend-
ed with a scanty mucous, crude, or albuminous
expectoration,  of a saffron  hue, or streaked
with blood.  Still the dyspnoea is slight, respira-
tion being quick,  short, and  frequent, but not
 difficult.
   15.   Sometimes  a lancinating pain  darts
 through either side of  the chest, indicating ir-
 ritation of the pleura, proceeding either from
 coeval and consecutive inflammation of a por-
 tion of pleura, or merely  from the unusual degree
 of tension experienced  by  this  membrane, ow-
 ing  to the turgid or expanded state ofthe lung
 enveloped by it.  In the former case the pleu-
 ritic pain is  sharp, acrid, continued,  and fixed
 to one part, forming the very  frequent compli-
 cation of inflammation  of the substance of the
 lungs with inflammation of its investing mem-
 brane, or  pleuro-pneumonilis,  which will  be
 more  fully noticed hereafter.  In the latter case
 it is less fixed or continued,  and disappears  as
 the  vascular turgidity diminishes,  and upon the
 first approaches towards  a  resolution of the
 disease.
   16. The symptoms which have a sympathetic
  relation to the disease are less constant, and
  are less to be depended on than the above and
  the physical signs (Y 48) •. they have generally
more reference to the  degree of symptomatic
fever than to the extent of local disease.   They
chiefly consist of turgidity of the countenance,
with flushing ofthe cheeks, sometimes circum-
scribed, particularly towards  the period of the
evening ; febrile exacerbation ; gravative head-
ache, vertigo, suffusifm  and watering of  the
eyes;  a humid tongue, covered by a thick mu-
cous coating ; constant thirst; anorexia ; ten-
sion ofthe abdomen, with increased action du-
ring respiration, and peculiar uneasiness about
the insertion of the diaphragm ; costiveness ;
scanty, high-coloured,  reddish, crude, or  turbid
urine,  with scalding upon voiding it;  palpita-
tion ofthe heart; great action ofthe arteries ;
a quick, full, and hard pulse—in  children so
quick as scarcely to be counted.   The pulse is
also sharp ; but the  hardness generally ceases
early in the disease, and it often becomes soft,
weak, or small.  In some cases it is soft and
small  from the commencement.   As the dis-
ease advances, lethargy or symptomatic  deliri-
um sometimes occurs  ; or more rarely,  and in
still more unfavourable  cases, sopor or coma,
more  or  less profound, supervenes.    Blood
taken  from a vein is more thick and dense than
usual, and exhibits a  thick tenacious crust on
its  crassamentum, with little serum, or the co-
agulum is  very firm and large.
  17.  The more severe the disease, and the
more  extended its seat, the more intense are
all the symptoms, both  local and general.  They
are  always exacerbated towards  evening and
ameliorated in the morning.  When both lungs
are  inflamed, all the foregoing symptoms are
particularly marked, and vital power more pros-
trated or more readily exhausted, the constitu-
tional symptoms assuming more  of the  ady-
namic character; but  even when  both  are af-
fected, the inflammation is generally limited to
portions of them only.
   18.  Wrhen  one lung  only is inflamed, the
sense of heat,  tension, weight, &c, is  chiefly
confined to the same side as it, and on this side
the patient lies  with  most ease,  reclining on
the affected  side producing  great anxiety and
 uneasiness.   Respiration,  also, is  performed
 unequally, or only by one side of the chest, that
containing the inflamed lung being nearly in-
 active during inspiration, but considerably ele-
 vated.
   19.  Circumscribed  redness of the cheek of
 the same side is often  observed, and frequently,
 particularly in children, the  hand  and wrist of
 the affected  side are red and turgid, apparently
 owing chiefly to the pressure on the upper part
 of the arm, from constantly lying on the affect-
 ed side.
   20. d. The period of fully-developed disease oc-
 curs in from three to five days, according to the
 severity ofthe attack.  The symptoms continue
 for some time afterward, generally for three,
 but seldom beyond five days, with slight exa-
 cerbations and remissions, especially when left
 to nature or inefficiently treated,  and  with oc-
 casional signs of a disposition to crisis.  The
 dyspnoea is then more urgent, and the  respira-
 tion short and rapid.  The head and shoulders
 require to be raised.   In the worst cases, in-
 spirations are short, forced, and as frequent as
 from 40 to  50, or even 60, in a minute.  The
 expectoration  is then  very viscid, tenacious,
 streaked  with blood,  or more deeply and inti- 
LUNGS—Inflammation of the—Lesions.
881
mately tinged by it.  The pulse is quicker, weak-
er, and  smaller;  the strength more depressed,
and the tongue is more loaded,  and sometimes
dry.   In a few cases, where temporary ameli-
orations and exacerbations occur, the disease
is protracted several days  beyond the period
just mentioned.
  21. e. The disease may continue, or even in-
crease,  notwithstanding the treatment.  In such
very unfavourable or fatal cases, the thorax re-
mains expanded, or scarcely acts, during res-
piration, which is chiefly diaphragmatic, or acts
suddenly, forcibly, or convulsively;  the patient
is oppressed with the utmost anxiety, harassed
by continued  cough, dosing occasionally,  or
lapsing into a dreamy delirium, until the lungs
having  become nearly unfit  for the office of res-
piration., or nearly impermeable to  the air,  he
is entirely suffocated.  This event is generally
preceded by a bloated,  pallid,  or cadaverous
countenance,  which is bedewed with  a cold
sweat; by livid lips, dark or livid tongue, great
difficulty and quickness of respiration ; by sup-
pression or change ofthe appearance ofthe spu-
ta, which become greenish, dirty-red, rusty,  or
like prune-juice, and foetid;  by a rapid, thready,
irregular, or intermittent pulse ;  and by a gasp-
ing, convulsive, and rattling respiration.  This
unfavourable change often  happens during the
evening exacerbations, or perturbating efforts
of nature to establish a critical  evacuation.
  22. A favourable result is sometimes preceded
by a gradual disposition to a crisis, which  is
occasionally decided, and sometimes interrupt-
ed or abortive.  This issue generally is ob-
served  to occur  in the  morning on the fifth,
seventh, ninth, eleventh, or fourteenth day of
the disease—very rarely so  late as the  twenty-
first day.  The evacuations which are most
beneficial are, copious and general perspira-
tion, hypostatic urine, a free mucous expecto-
ration,  epistaxis, and the catamenial and hem-
orrhoidal fluxes.
  23. In  93  cases, M. Andral  observed that
the recoveries on critical and non-critical days
were as 14 to 3.
  24. /. The decrement of  the  disease always
follows the subsidence ofthe morbid condition
of the organ, whether brought about by the con-
servative influence of  the  vital energies or  by
art.   The vascular turgidity, infiltration, and
condensation of the parenchyma of the lungs
gradually diminish, the functional disturbance
decreases, and all the symptoms at first sub-
side, and afterward some of them entirely dis-
appear ; but those which were first to manifest
themselves, as cough  and  oppression  at the
chest, are the last to depart. Some degree  of
quickness of pulse  and of  breathing generally
continues for some time.   When these are re-
moved,  convalescence has commenced ; but con-
valescence can never be  confided in until these
symptoms have entirely disappeared.
  25. Acute pneumonitis, marked by no anom-
aly, complicated with no other malady, and oc-
curring  under favourable circumstances, gener-
ally proceeds as now described, and most fre-
quently  to a favourable issue.   But it does not
always  observe this course. It is sometimes
of much longer duration.   In some cases it as-
sumes, from the commencement, a more ady-
namic, or a complicated,  or an otherwise unfa-
vourable  character.   Occasionally,  unwonted
    II.              Ill
and accidental symptoms manifest themselves
in its  progress, owing to various contingent
causes operating during its continuance ;  and
in other cases the whole tendency and charac-
ter of the disease becomes changed, owing ei-
ther to causes proper to the individual affected,
or to a peculiarity of the nature and combina-
tion of the external agents which produced it,
or to the state of the  season or of the atmo-
sphere, or to  the epidemic constitution upon
which  it may supervene.
  26. g.  Relapses of pneumonia  are not infre-
quent  during  some period of convalescence.
They are indicated by a recurrence of the char-
acteristic symptoms—chiefly by slight dyspnoea,
short,  frequent respiration, oppression in the
chest,  cough, viscid or sanguinolent expecto-
ration,  and by increased  frequency and weakness
of pulse.   In cases of relapse, the lungs often
become more extensively affected, and the at-
tendant fever assumes a less sthenic form than
the first attack—even an adynamic character.
This is owing to the reduction of nervous pow-
er, and to the imperfect change effected in the
state of the blood.   Hence relapses are always
more dangerous than a first  seizure,  and are
more rarely attended by critical evacuations.
  27. ii.  Structural  Changes  marking  the
Stages of  Pneumonia. — Laennec described
three stages, with their corresponding symp-
toms and signs.  In his first stage, the lung is
engorged with blood, and a crepitating rale is
heard.  In the second, solidification takes place,
and gives  rise to its  characteristic  physical
signs.  In the third stage, interstitial suppura-
tion occurs ; or a state of softening preceding
the formation of abscess.  I agree with Dr.
Stokes, who contends  for a stage antecedent
to that which M. Laennec has called the  first.
He observes, that the existence  of crepitation
indicates that secretion has taken place in the
cells and minute tubes, so that Laennec's  first
is, in reality, the secretive stage  ofthe inflam-
mation, and every analogy favours the opinion
that a  stage of irritation  has  existed previous
to the secretion which  caused the crepitus. It
is obvious that this first stage of irritation and
capillary  injection can be but very rarely seen,
unless  death has proceeded from  other causes;
but in these circumstances I have observed, as
remarked by Dr. Stokes, portions of the  sub-
stance  of the lungs of a bright vermilion colour,
and even drier than usual.  It  is sometimes
met with in parts of the  lungs where the first
and second stages  of  Laennec  exist; and  I
have seen it  in portions of the organ,  after
death from haemoptysis and acute phthisis, with
which, as I shall show  in the sequel, pneumon-
itis is not infrequently  complicated.
  28.  The stages of pneumonia, therefore, are,
1st. Intense capillary  injection — no  effusion
into the  cells ; 2d. The cells  and parenchyma
engorged with blood, without actual disorgani-
zation—sanguineous engorgement:  first stage
of Laennec ; 3d. Solidification, with some de-
gree of softening—red hepatization—the red
softening of Andral:  second stage of Laen-
nec ; 4th. Interstitial suppuration—yellow he-
patization : the third stage of Laennec   Ab-
scess and gangrene  are contingencies  of com-
paratively rare occurrence.
  29. A. In the stage  of sanguineous  engorge-
ment, the substance  of  the organ is red, but of 
882                     LUNGS—Inflammation of the—Lesions.
different shades, is heavier than usual, and is
still crepitant.  The cells are not yet filled by
effused  fluid ;  or, if any infiltration into them
or into the interstices ofthe filamentous tissue
has taken  place,  it is only  slight, unless, in-
deed, in cases of asthenic or cachectic pneu-
monia, or when the disease  follows inhalation
of noxious gases,  or  occurs in the course of
low fevers or exanthematous maladies ; and
then this state of engorgement may pass very
rapidly, and without  any appreciable crepita-
tion, into the stages of suppuration, or into a
half-suppurative and half-gangrenous state.  In
the usual sthenic form ofthe disease, however,
with capillary engorgement, there are some de-
grees of thickening of the membranes between
the cells, and slight effusion of lymph, to which
the apparent thickening probably is chiefly ow-
ing.
  30.  B. The stage of solidification and soften-
ing, or of hepatization, presents the former stage
in a more advanced state—in a state of more
or less rapid progression to the next.   In this
stage the effusion of lymph, often more or less
coloured by red  particles  of blood, has taken
place  into the parenchyma and air cells of the
part  affected.   The density thus produced is
generally so great that this part sinks in water.
It is also more friable, from  the interstitial in-
filtration of lymph having weakened the vital
cohesion of the tissues, as shown  in  the art.
Inflammation.
  31.  Dr. Stokes agrees  with Andral  in sup-
posing that this solidification arises, not from
any deposition of lymph,  but merely from ex-
cessive congestion of blood ;  and  in proof of
this he argues that the rapid appearance of this
stage, and the rapid  subsidence of the symp-
toms  attending it,  are evidences of no farther
change than congestion.  But this is to assume
that  excessive congestion is  attended by the
same phenomena as accompany infiltration of
lymph ; and these occurrences are no disproofs
even of effusion of lymph having occurred ; for
it is well known that absorption in the lungs
is sometimes remarkably rapid.
  32. The colour  of  the solidified portion of
lung varies, according to  the quantity of blood
injecting the capillaries, from a red to  a pink-
ish brown or reddish gray;  but it  is modified
by the quantity of lymph infiltrating the  part,
and by the presence of black pulmonary matter.
Frequently, when  a portion of hepatized lung
is divided, numerous little granulated points,
the size of pins' heads, and of a lighter colour
than  the  surrounding tissue, appear.  Laen-
nec considered these to  be  the  air cells con-
verted into solid grains by thickening of their
parietes, and by the obliteration  of their cavi-
ties by a concrete fluid.   Andral viewed them
>s single air cells or terminations of the bron-
 hi distended by a viscid mucus from their mu-
jous linings.  If this be  the case, and if it be
not coagulated lymph, the mucus  must have
become concrete during  its  retention.  It is,
however, most probable that  these granules are
produced by an infiltration of lymph into the
cells or minute tubes, as well as into the con-
necting cellular tissue.
  33.  In some cases the solidified lungs are
devoid of the granular appearance just noticed,
and are of a more uniform and deeper red than
the foregoing.   M. Andral attributes this state
to a more uniform and complete obliteration of
the cells; but if such is the  case, there must
have been also more intense capillary injection.
Dr. Williams thinks  that this non-granular
form of hepatization  may be ascribed  to the
circumstance of the inflammation having been
confined chiefly to the intervesicular  tissue.
MM. Hourmann and Dechambre have also dis-
tinguished the granular from the  non-granular
form of solidification,  and have designated the
former  vesicular pneumonia, and the latter in-
terlobular.  Dr. Williams's appellation  of  in-
tervesicular is, however, more appropriate.
  34. C. The stage of interstitial suppuration,
or of puriform infiltration—of yellow hepatization
—is merely the conversion of the affused lymph
and red particles of the previous stage into an
opaque, pale yellow, soft, and semi-fluid mat-
ter, and ultimately into a purulent liquid, which
infiltrates the inflamed part.  This conversion
takes place in the manner shown in the articles
Abscess and  Inflammation ; but the matter
rarely is confined in the form of a defined ab-
scess, but is more or less diffused, owing to the
structure of the organ, through the part  affect-
ed.  Owing to the organization of the lungs, a
distinct abscess is rarely formed, because the
lymph thrown out can rarely confine the mat-
ter, or  prevent its infiltration of surrounding
parts, by completely  obstructing  the minute
tubes, cells, and pores permeating the inflamed
part.
  35. a. Abscess, therefore, cannot be consid-
ered as a stage of pneumonitis, but merely a
contingency of comparatively rare occurrence,
but not so rare as Laennec  and  some  others
have supposed.   I agree with Dr. Stokes in
believing that the rarity of  pneumonic abscess
has been much overrated ; and it is most prob-
able that Laennec was partly  deceived by trust-
ing too  implicitly to the physical signs, to the
neglect of the rational symptoms, in his obser-
vations.  Attention to the whole course ofthe
case, and to the  succession of both rational
and  physical  signs throughout it, will alone
guide the observer aright. The actual existing
phenomena derive the chief part of their value,
in forming a diagnosis, from  a recognition of
those which preceded  them.   Dr. Stokes states
that  abscess  occurs  more  frequently  in the
lower than in the upper lobes, and that  he has
met with  instances of its cure by cicatrization.
It may  result from localized  phlegmonous  in-
flammation, or from the extensive and complete
solidification above described.  I  have seen it
chiefly  after phlebitis,  injuries, wounds, and
operations, and in connexion with erysipelas;
but in  these the  inflammation or  solidification
around  the abscess, of which there  were often
several, was neither intense nor extensive.
  36. Without reference to those purulent col-
lections in the lungs which result from venous
absorption, Dr. Stokes has seen acute pneu-
monic  abscess under  three forms :  1st.  As an
encysted abscess, with all the characters of true
phlegmon; 2d. As purulent cavities communi-
cating with the bronchi, and without any cyst,
the walls of the  abscess being formed  of the
solidified lung; 3d. The abscess is seated under
the pleura, and external to the pulmonary tis-
sue,  dissecting the latter from the  former, so
as to show the structure of the lung.
  37. b. Gangrene is another  contingent result 
LUNGS—Inflammation of the—Diagnosis.                    883
 of inflammation of the lungs.  It is rarely ob-
 served unconnected with suppuration ; but it
 may be rapidly caused by the inhalation of nox-
 ious gases, which may so impair the vitality of
 portions of the lungs as to  favour the occur-
 rence of gangrene before the suppurative stage
 can be developed.  In other cases, it has not
 been determined whether or not  this change
 depends upon the intensity and suddenness of
 the congestion, or upon the cachectic state of
 the patient—most probably upon both.  It has
 also been attributed to inflammation of a prin-
 cipal vessel supplying one or more lobules. In
 the interesting cases adduced by Dr. Stokes,
 the patients  were long addicted to the use of
 spirits, a cause which operates upon the vas-
 cular system in a more direct manner than has
 been generally supposed;  and likewise in all
 were evidence of extreme congestion, and ty-
 phoid, or, more correctly, asthenic pneumonia.
   38.  c. The state of the tissues adjoining the
 vascular plexus of the pulmonic parenchyma is
 deserving  some notice.  Dr. Williams states
 that the interlobular cellular texture  is some-
 times red,  and sometimes singularly free from
 redness, or partakes  of it in a much less de-
 gree.  In the  latter  case, the hepatized  lung
 presents somewhat of a marbled  appearance.
 The interlobular septa retain their cohesion,
 and, in more  chronic cases, are  thicker and
 denser than usual.   The mucous  membrane
 of the large and middle-sized bronchi  is gener-
 ally more or less  inflamed, presenting the same
 6triated appearances  seen in acute bronchitis.
 The smaller bronchi  is commonly of  a deeper
 red  than in that  disease.  The bronchi in the
 inflamed part often partakes of the softening
 of the parenchyma.  In some  instances,  they
 are  plugged up with an albuminous exudation ;
 but  this arises from  the extension or associa-
 tion of inflammation of one series of tissues to
 that intimately connected with it.  More com-
 monly the air  tubes, as far as they can be
 traced, contain more or less of the rusty mucus
 or muco-puriform matter which has been ex-
 pectorated.  The pleura is very frequently in-
 flamed.  It may, however,  be  free from  red-
 ness, or from  lymph  or  liquid effusion, even
 when  covering a hepatized  portion of lungs
 (v 30).
   39. iii. Diagnosis of Simple Pneumonitis.—
 A. By the  aid  of certain  rational Symptoms.—
 There is hardly one of the symptoms described
 above that may  not  be  present in other dis-
 eases, or be absent  in pneumonia.  When it is
 considered that pneumonitis is associated, in
 the very great majority of cases,  either with
 pleuritis or with bronchitis, or with both ;  that
 it may  be  consequent upon, as well as  give
 rise  to either, it becomes the more difficult to
 determine what are the phenomena which dis-
 tinguish  the  simpler states of the  disease.
 Generally,  local symptoms, especially fulness,
 soreness, oppression, or uneasiness  in some
 part of the chest, smallness and increased fre-
 quency of pulse, are complained of before chills
 or rigours occur,  and  before the constitutional
 symptoms are fully developed.
  40. a. The cough in pneumonia varies  re-
 markably.  It is often slight, short, and occa-
sional, and  not  such as gives  much uneasiness
to the patient.   In other  cases,  particularly
where the bronchi are affected, and in propor-
 tion to the extent of their affection, the cough
 is severe ;  at  first dry,  and subsequently at-
 tended by expectoration.  If the pleura be  at
 all affected, the cough is generally short,  sup-
 pressed, sometimes infrequent, but it varies
 much  according to the extension and  amount
 of disease.  The cough presents more  diversi-
 fied and more prominent features  in the com-
 plications of pneumonia than in the simple
 disease.
   41.  b.  The expectoration may furnish very de-
 cided evidence of pneumonia in some cases,
 while in others it can in no way assist the diag-
 nosis.   In children, especially, among whom
 pneumonia is a most frequent and dangerous
 malady,  the expectoration  furnishes no diag-
 nostic  aid.  The viscid, muco-puriform, and  san-
 guinolent character of the  sputum, although
 observed in many cases, is by no  means con-
 stant.  The disease may present all the kinds
 of expectoration, particularly during its early
 stages, and it may be even  unattended  by  any
 until its most advanced stages, or until shortly
 before  a fatal issue.  The rusty sputum is gen-
 erally  found in the most acute cases,  and in
 robust  persons ; but in feeble constitutions, or
 where  the disease occurs as a complication of,
 or during convalescence from continued or ex-
 anthematous fevers, it is not often observed ;
 indeed, in these circumstances, the   sputum
 furnishes comparatively  little information, or
 it  may be altogether wanting or very  scanty.
 Although it is  generally true that the viscid
 and red sputum occurs only at the height of the
 disease,  yet it may continue for some days
 after the subsidence of the more acute symp-
 toms, or even after all signs of pneumonia have
 disappeared.  Instances  of this latter occur-
 rence  have been  furnished  by Andral  and
 Stokes, but in  these cases it is evident that
 the inflammation continued  to proceed in the
 bronchi after that of the parenchyma of the
 lungs had subsided.
   42. In the suppurative stages,  the  sputum
 assumes a more characteristic form than in the
 preceding, and  is either a purplish red muco-
 puriform fluid, or a homogeneous purulent mat-
 ter, of a light yellow colour, and  of the con-
 sistence of cream.  These kinds of expectora-
 tion occur only in the far advanced or suppura-
 tive stage of interstitial suppuration and soft-
 ening ($  34).   Dr. Stokes remarks that there
 are no  differences in the local changes between
 the  cases with prune-juice-like sputum  and
 those in which  there is a secretion of healthy
 pus; but he admits, with all  other observing
 physicians, that in the  former the disease ex-
 ists  in  a lower, or more asthenic type, or in
 broken-down constitutions,  while the latter is
 seen in the more sthenic cases, occurring in
 young  or robust persons.
  43. In pulmonic abscess, and as long as  the
 matter continues pent up, or before it has found
 its way into the bronchi, the  sputum presents
 no characteristic appearances.  In many cases,
 nothing is  expectorated  but  a little mucus ;
 while in others it is muco-puriform, as in chron-
 ic  bronchitis,  and either devoid of smell or
more or  less foetid.  If,  however, an  abscess
form and burst into the bronchi, the expectora-
tion becomes suddenly abundant and distinctly
puriform.
  44. Gangrene is attended by an expectoration 
884
LUNGS—Inflammation of the—Diagnosis.
 of a dirty greenish, or brownish, or sanious
 matter, mixed with a muco-puriform  matter;
 the whole being of a putrid and very offensive
 odour,  and occasionally  mixed  with  sloughy
 portions of tissue.
   45. As the powers of life sink, the expecto-
 ration in  the advanced stages becomes scanty,
 or is altogether suppressed.  The suppression,
 however, does not proceed from any diminution
 of the  secretion,  but from the failure of the
 respiratory acts, and of the vital manifestations
 of the organ, both of which are insufficient to
 procure its expulsion.  Thus, in fatal cases, the
 mucous  rhonchus  increases  and extends  as
 death approaches, until the accumulated secre-
 tion mounts  to the large bronchi and trachea,
 when the rhonchus  becomes tracheal, and as-
  nmes the character to which the appellation
 death-rattle has been given.
   46. c. Dyspnea, as remarked above ($ 14), is
 more urgent in bronchitis, or even in pleuritis,
 than in pure pneumonia; and, generally, the
 amount of dyspnoea indicates in some measure
 the extent to which the  latter is associated
 with the  former, particularly with bronchitis.
 However, extensive or double pneumonia will
 increase the  dyspnoea, but it will increase the
 frequency and  shortness  of respiration  more
 than any  actual sense of difficulty.  This latter
 often depends more upon an  attendant irrita-
 tion or spasm of the bronchi than upon actual
 inflammation of them.
   47. d. Pain is often but little felt.   Uneasy
 sensation is  generally present, but  it seldom
 amounts  to  pain, unless  the  pleura becomes
 implicated in some way or another.  The  mere
 tension of this membrane consequent upon in-
 flammatory turgescence ofthe parts underneath
 can hardly develop this symptom to any perma-
 nent or marked degree.  In the last stage of the
 disease, the functions ofthe lungs, or arteriali-
 zation of  the blood, is interfered with,  but  not
 so early or so rapidly as in bronchitis, unless
 when associated with it; an association which
 will often mask pneumonitis  without  the  aid
 of physical diagnosis.
   48. B.  The Physical Diagnosis of Pneumonia.
 —It is chiefly upon the physical signs that  reli-
 ance is  to be placed in  determining the exist-
 ence of pneumonitis.  Dr. Stokes has enumer-
 ated the following as the most important rela-
 tions of these signs :  1st.  Evidences of a local
 excitation ; 2d. Proofs of sanguineous conges-
 tion ; 3d.  Evidences of a  diminished quantity
 of air in the affected lung; 4th.  Signs of in-
 creased solidity of the lung ;  5th. Phenomena
 of the voice;  6th. Phenomena referrible to the
circulating system;  7th. Evidence of accom-
panying lesion of the pleura ;  8th. The dimin-
ished volume ofthe lung.
   49. a. In the first stage of pneumonia, or that
of inflammatory irritation ($ 27),  the physical
signs have not been observed with due preci-
sion.  Dr. Stokes  believes that it may be in-
ferred, by  the occurrence of a local puerility of
respiration, combined with an excitement ofthe
respiratory system.  It is evident that this sign,
namely, an unusually loud sound of respiration
in a part ofthe lung, in connexion with inflam-
mation of it, can be present only for a short
time, and often before the patient comes under
treatment; and that its chief  value is  in con-
nexion with  disorder of the  respiratory  and
 circulating  actions, and with  the succeeding
 phenomena.
   50.  b. In the second, or LAEHNEc'n first, stage
 (v 29), the crepitating rhonchus, and  the grad
 ually diminishing vesicular  murmur, are the
 characteristic signs.  Still, these  signs derive
 their value chiefly from their combination, and
 partly from the accompanying, the preceding,
 and the consequent phenomena.
   51.  Crepitation, which has been most accu-
 rately compared by Dr. Williams to the sound
 produced by rubbing a lock of hair close to the
 ear, is not so invariable and  positive  a sign of
 pneumonia  as Laennec supposed.  It is to be
 relied on only when attended by increasing
 dulness, and by  the gradual cessation of the
 respiratory  murmur.  If the disease be so ex-
 tensive as to impede greatly the functions of the
 lungs, the energy and frequency of the respira-
 tory  movements  will be  increased,  and  the
 respiratory  murmur in the sound side may be
 thereby rendered louder than usual.   The in-
 creasing density of the congested and inflamed
 lung will deaden  the sound emitted by percus-
 sion, so that the affected side  will give  out a
 sound somewhat duller than that of the oppo-
 site side; although not so dull  as will be emit
 ted at a more advanced stage, as there is suffi-
 cient air still contained  in the affected lung to
 prevent complete dulness on percussion.   The
 increasing density of the diseased lung renders
 it also a better conductor  of sound; so that,
 during this stage of extensive pneumonitis, and
 while crepitation is still  present,  some degree
 ofthe bronchial respiration and vocal resonance,
 present in the following stage,  may be heard.
  52. c.  In the third stage (<J 30), the cells being
 obliterated,  crepitation  and  vesicular respira-
 tion cease ;  and, as the large tubes remain per-
 vious, " dulness of sound, bronchial respiration,
 and a loud resonance ofthe voice are produced;
 and within certain limits, the extension or inten-
 sity of these signs furnishes an  accurate meas-
 ure of the extent or intensity of the disease."
 The bronchial respiration requires for its pro-
 duction not  only increased density ofthe lung,
 but also a certain expansion  of the side during
 respiration ; for when the whole lung becomes
 solid, the side is fixed, and the  bronchial respi-
 ration ceases.  In this latter case, the signs are
 universal  dulness, absence of respiration, and
 resonance of the voice.  If, however, the upper
portion begins to  resolve, or even  if an abscess
 be formed, in either of which cases the  bron-
chjal  tubes  admit again  a portion of air, the
bronchial respiration returns, it not being ne-
cessary that the  permeable portion  of lung
should be of great extent to reproduce this state
of respiration.
  53.  In cases of universal solidification of a
lung, the disease  may be confounded  with ex-
tensive empyema, if the history  of the  case and
succession of the  signs be not attended to ; but
there are generally the signs of visceral dis-
placement attending the latter, with absence of
vocal vibration or  fremitus, characterizing solid-
ification of the lung.  When this change is com-
plete, particularly in the central  parts ofthe or-
gan, the voice may be heard  over a considera-
ble space in  the mammary, axillary, and scapu-
lar regions.   The bronchophony,  or vocal re-
sonance of the tubes, may  be so loud  as  to be
mistaken for the pectoriloquy of a cavity ; but 
LUNGS—Inflammation of the—Diagnosis.
835
it is distinguished from this latter by its diffu-
sion over a large space, and by its being much
diminished by  using  the  stethoscope with  its
stopper.   Dulness on percussion is generally
complete when a whole lung is hepatized ;  but
still it is seldom so uniform and general in the
lower and middle portions of the chest as in
cases  of pleuritic effusion;  for  some  of the
lobules still continue to retain air, and the large
tubes furnish some degree of resonance in the
parts nearest to  them.   In proportion  as  the
lung is solidified,  so does  it become inexpansi-
ble, and the corresponding parietes ofthe chest
motionless, without their being  distended  or
contracted, and without displacement of adjoin-
ing viscera or fulness  of the intercostal spaces.
When the left lung is  solidified, it transmits the
sounds and impulse ofthe heart to an unusual-
ly wide extent.
   54.  In the  usual sthenic pneumonia, dulness
of sound and bronchial respiration are preceded
by crepitation; but in some cases of asthenic
pneumonia solidification takes place so  rapidly
as not to be preceded by these signs, in a very
appreciable form, or for a  time sufficient to ad-
mit of their detection. In these cases the dis-
ease  proceeds  with great rapidity, and it be-
comes difficult to distinguish it from pleuritic
effusion, unless the phenomena above alluded
to be carefully observed ;  namely, the absence
of displacement of viscera, and of fulness of the
intercostal muscles, the resonance of the voice,
the greater frequency of bronchial respiration,
and the occasional occurrence of a rhonchus in
parts of the chest.  The disease  rarely proves
fatal  in this stage, unless it be extensive, and
both lungs are more or less affected.
   55.  d. In the fourth stage, or that of suppura-
tive infiltration (y  34),  the physical signs  are not
materially altered until the effused matter accu-
mulates in the bronchi, so  as to occasion a sharp
and peculiar  muco-crepitating  rhonchus,  the
bronchial respiration still continuing,  and the
dulness of sound  on percussion increasing ; but
these phenomena should  be viewed in connex-
ion with the previous  history and existing state
of the case.   When, however,  this peculiar
rhonchus occurs  in the circumstances  descri-
bed, and is connected with signs indicating an
extension of disease  in the  lungs, it  may be
considered as truly the  result of suppurative
infiltration of the lung.   Still, there are some
cases  in which this stage may be with more
certainty inferred from the duration ofthe dis-
ease and from the rational symptoms than from
the physical signs ;  in it the prune-juice expec-
toration sometimes  occurs, or  the  purulent
sputum;  but either may  be absent, and little
or nothing may  be expectorated  excepting a
mucous or muco-puriform fluid from the larger
bronchi, and that only in small quantity.   In
this  stage, however,  the  attendant fever as-
sumes an adynamic form ; and rigours, follow-
ed by sweats; a small, quick, weak pulse ; a
short, frequent respiration, with a sense of want
of breath ; a pallid,  waxy countenance,  with
incipient lividity ofthe lips, anxiety, low delir-
ium, &.c, indicate  the local extent of lesion,
and the consequent effect produced by  it upon
the pulmonary functions, and the vital manifes-
tations generally.  It is chiefly in  this stage,
particularly when the disease is limited, that a
fatal issue takes place.
  56. When  an abscess forms in this stage, a
favourable result may take place nevertheless,
and even  more frequently than in the state of
suppurative infiltration just noticed, inasmuch
as the former change  indicates  more sthenic
action and greater constitutional energy than
characterize the latter.   The signs of abscess
are nearly the same as those of a tuberculous
cavity communicating  with a  bronchus.   The
diagnosis  is to be inferred chiefly from the his-
tory of the case, a cavity from tuberculous ex-
cavation being of much slower progress, and
preceded  by much  less acute  symptoms than
that from abscess.   Nor is it attended by so
great an  extent of dulness as is observed  in
pneumonia.   A cavity  from an abscess occurs
most frequently at the inferior portion, or about
the root of the lung ; and, owing to the quan-
tity of fluid contained in it, upon  its first com-
munication with a  bronchus, it gives rise,  at
that time, to a gurgling or bubbling sound upon
a deep inspiration or coughing; and in  some
cases there is a putrid  or foetid odour with the
expectoration and  breath of the  patient, but
chiefly when  some degree of grangrene occurs
or accompanies the abscess.
  57. e. As to the more circumstantial diagnosis
of true pneumonitis,  it may  be noticed  that
crepitation heard throughout the greater part
or the whole  of a  lung shows extensive dis-
ease ; if it be  heard at the apex or root of the
lung, or in the infra-clavicular and scapular re-
gions, it evinces a more intense form of disease
than if it  were seated  in the middle or lower
lobes.  The extension of crepitation to  parts
not previously affected by it shows the increase
of inflammation ;  its cessation and the substi-
tution of bronchial respiration  and perfect dul-
ness on percussion, are proofs of solidification;
and  the return of  crepitation and  resonance,
where they had been replaced by bronchial res-
piration and  dulness, indicates  absorption of
the effused lymph and the admission of air into
the cells,  and consequently a progress towards
recovery ; but a change from complete dulness
and  bronchial respiration to clearness and re-
turn of the respiratory murmur, without any
crepitus of resolution,  may take place; and
when this sound is heard, it is of a looser and
less even  character than before—a sub-crepita-
tion merely.   If  solidification have advanced
far and approached to  suppurative infiltration,
the restoration of the natural structure  of the
lung becomes  proportionately difficult and pro-
longed to  the extent of lesion.   The cure may
be eventually complete, but more frequently
permanent alteration is produced, more  espe-
cially obliteration of some of the cells and small
bronchi, and dilatation of others.   Bronchophony
is most evident when  dulness  on  percussion
and  bronchial respiration coexist, and it is al-
ways most evident in the superior and posterior
parts of the chest.  It  is readily distinguished
from pectoriloquy by its greater extent, and by
the absence of gurgling or  cavernous respira-
tion.   It sometimes approaches the aegophonic
character, when the pneumonia has passed into
the fourth stage, and when resolution from the
third is taking place.
  58. When pneumonitis is  limited to a central
or deep-seated part, especially near the base of
the lung, without extending to the surface, the
physical signs may be  very obscure, and the 
886
LUNGS—Inflammation of the—Asthenic.
rational symptoms  thus become  more  impor-
tant.   When the inflammation is very circum-
scribed, even although it may affect a more su-
perficial portion of the lung, it  is  detected by
the physical signs with some difficulty, particu-
larly when it is seated in the posterior and lat-
eral parts  ofthe organ.
  59.  /. Pneumonia may be  distinguished from
bronchitis by the crepitation being finer and more
equal  than  that of the latter; by the  blood-
streaked or rusty appearance of the sputa ; by
the dulness on percussion as the disease pro-
ceeds, and the bronchophony and bronchial res-
piration.   In pneumonia, also, the skin  is hot-
ter and less livid than  in  severe bronchitis;
while the cough and dyspnoea are generally less
urgent, and the former less paroxysmal.
  60.  g. From pleurisy pneumonia is to  be dis-
tinguished,  in the first  stage,  chiefly by the
crepitation and sputa ; and  in the second and
third  stages, by the bronchophony and vocal
vibration sensible to the hand ;  by the absence
of the signs of displacement of the adjoining
organs and of bulging of the  walls of the  chest;
and by change of posture causing no alteration
of the sound on percussion.
  61.  h. Pneumonia is sometimes not readily
distinguished from the hemorrhagic congestion,
or  from pulmonary  apoplexy, with  both  which,
however,  as will be noticed  hereafter, pneumo-
nia is occasionally associated.   It is chiefly the
presence of febrile symptoms, the character of
the sputum, the absence of any real haemor-
rhage, the existence of crepitation, the progress-
ive dulness on percussion,  and  the  course of
the disease, which distinguish pneumonia from
these.
   62.  iv.  Varieties and   Complications  of
Pneumonia.—A. Asthenic  Pneumonitis—Con-
gestive Pneumonia—Typhoid Pneumonia of va-
rious authors—Nervous Pneumonia of others.—
In this variety of the disease, the inflammatory
action assumes an asthenic form, and  the at-
tendant fever the adynamic type, owing either
to  original  weakness of conformation,  to  ex-
haustion,  or a cachectic habit of body, or to the
nature of the exciting causes.  Hence it is met
with  chiefly in persons who are weakened by
exhausting influences,  by   insufficient  or  un-
wholesome food, or by  residence  in  unwhole-
some localities and in an  impure air [except
when it prevails epidemically, when it attacks
all classes].  Owing to  these  circumstances,
and to certain associated disorders, it has re-
ceived from modern authors not only the names
mentioned above, but also  those  of malignant,
putrid, erysipelatous, or bilious pneumonia.
   63. The general character of this form of the
disease is its occurrence during previous disor-
der or ill  health ; during a general morbid con-
dition ; in a more or less latent form, and with
marked prostration of the vital energies  When
pneumonia  appears in the course of,  or in con-
nexion with, continued or adynamic  fever, in-
fluenza, erysipelas, diffuse inflammation ofthe
cellular tissue, or phlebitis,  it always assumes
this form.  In these circumstances, however,
it appears more frequently  complicated either
with  bronchitis or with pleuritis, or with both,
than as a  simple disease.
   64. a.  The rational symptoms of this state of
pneumonia  are rarely well marked.   There are
generally, however, a dusky hue ofthe counte-
nance, slight dyspnoea, quick and short respira-
tion, slight cough, either  with  or  without  ex-
pectoration ; oppression or weight at the chest,
but rarely pain, although  the disease  may  be
most extensive and dangerous,  or even extend
to the  pleura.   The constitutional affection is
severe.   The pulse is rapid, weak, and small.
The skin is hot  and dry, or covered with a
clammy sweat,  particularly at the extremities;
the tongue is  furred  and  brown ; the bowels
are costive, and the evacuations offensive ; the
urine high-coloured, turbid, scanty, sometimes
ammoniacal; and, as the disease proceeds, low
muttering delirium, coma, lividity of the lips,
cold, clammy extremities,  &c,  supervene, and
the patient sinks from interruption to the func-
tions of the lungs.
  65.  In this form of pneumonia the inflamma-
tory action is characterized by  the asthenic or
diffusive characters pointed out in the article
Inflammation  ($ 54, et seq.), and it possesses
many of the characters of active congestion.
When  it occurs during continued fevers, par-
ticularly at a far-advanced period of their course,
it generally affects the posterior parts of the
organ, and extends to both lungs.   In the ca-
chectic, and in most other complications, it is
similarly extensive.  The  parts affected are not
only engorged  or hepatized, but also soft and
friable, readily  breaking down  on pressure or
exuding a dark grumous blood.   The hepatiza-
tion, however, is seldom as complete as it is in
the sthenic form of the disease ; but is irregu-
larly disseminated or extended through the pos-
terior  and central parts  of  the organ, or in
points only, with marks of softening approxi-
mating the suppurative infiltration of the fourth
stage,  already noticed, and with films of lymph
exuded upon the pleura.   This partial or in-
complete state of hepatization may, however,
occur  in any part of the lung, but is more dif-
fused  or extended than in the sthenic form;
and although one lung is generally more affect-
ed than the other, it  is much  less  frequently
limited to one lung only than in that form.  It
is commonly also much more rapid in its prog-
ress ;  and, particularly when complicated, has
often advanced to an irremediable state before
it has been detected.
   66. b. The  physical signs  of this form  of
pneumonia are more deceptive  than  in the pre-
ceding.  For as both lungs are generally affect-
ed, and as the disease occurs in previously de-
bilitated or diseased persons, the patient lies on
his back, either altogether in the supine posture.
or with his head and shoulders much elevated,
this latter  position being  usually  preserved
when the bronchi are also much affected  This
posture favours the congestion  of the more de-
pending portions and the inflammatory reaction
in these parts,  while the anterior, or more ele-
vated  portion of the organ, remains compara-
tively  unaffected.  Hence, the anterior parts
of the chest do not evince the extent of exist-
ing mischief.   In this situation but little dul-
ness on percussion is detected, and the breath-
ing is often distinct, although attended by  sib-
ilant or sonorous rhonchi. In the posterior,
and in some degree in  the lateral portions of
the chest, dulness on percussion, and  absence
of the respiratory murmur, are always found,
occasionally with a whiffing or sibilous sound.
As Dr. Stokes has shown, crepitation does not 
LUNGS—Inflammation of the—Complications.
887
always attend the early stage of this form of
pneumonia, or, if it occur, it is of very short du-
ration, the structural change of the part caus-
ing obstruction to the passage of air through it
soon becoming complete.
  67. c. The terminations of asthenic pneumo-
nitis are :  1st. In recovery, or restoration ofthe
healthy state of the organ.  This is, however,
much less frequent than in the sthenic form;
and, although the disease is formed and pro-
gresses with rapidity, its resolution is remark-
ably slow compared with that form ;  chronic
hepatization, with low hectic, or latent or more
manifest  congestion, continuing  for  several
weeks.  Recovery even from these states may
take place under proper treatment;  but more
frequently atrophy of the lungs,  with or with-
out ulceration, or other fatal changes, supervene.
2d. Fatal  hepatization or splenification—irreg-
ular, diffused, or incomplete,  but more or less
extensive in both lungs—takes place more fre-
quently than any other  lesion, and with great
rapidity, and arrests the pulmonary functions.
3d. A sloughing or gangrenous abscess some-
times forms, and generally destroys the patient
in a very short period.  4th.  Chronic solidifica-
tion of portions of the lung occasionally occurs,
and commonly passes into a tubercular state.
  68. Dr.  Stokes observes that  months may
elapse before the respiratory murmur is re-
stored, and in many cases it is never complete-
ly re-established; and, even when recovery
takes place, the contraction of the chest, which
usually is observed,  shows the slowness with
which the disease is removed.   However, a
more rapid recovery may occur when an acute
disease of another  and distant  organ super-
venes.
   [The typhoid pneumonia prevailed very exten-
sively in this country in the years 1812-13-14,
and was called by different names in different
places; as, pneumonia notha, pneumonia typhoides,
malignant pleurisy, bilious pneumonia, malignant
bilious fever, &.c.  For a particular account of
the epidemic, and for various opinions  relative
to its nature, the reader is referred to the differ-
ent volumes ofthe " Medical Repository," Mann's
" Medical  Sketches," and Gallup's " Epidemics
of Vermont."  The disease appears to have as-
sumed somewhat different forms and types  in
different parts of the country, whence, undoubt-
edly, originated  the various opinions as to its
nature which were  held by  medical men,  as
well as the various modes of treatment which
were adopted by practitioners.   On our north-
ern frontier, among the United States troops,
Dr. Mann states that it assumed a highly  in-
flammatory form, accompanied with strong ar-
terial action, and requiring free depletion with
the lancet.   In  this city and vicinity the  dis-
ease had  less of a  sthenic diathesis,  and  at
Washington city it was regarded as typhus fe-
ver.  The disease  generally came on with
great languor and lassitude,  numbness in the
muscles, lancinating pains in the limbs, to which
succeeded chills, pain in the  side, head, stom-
ach, or region ofthe heart; pain in one side or
other of the  thorax was, with few exceptions,
characteristic of the disease.  The respiration
was short and difficult; frequent cough, attend-
ed with bloody mucous expectoration ;  or there
was an absence of  cough and  expectoration,
the disease  invading the  serous membranes;
pulse weak  and frequent, or small and hard ;
the heat of the body and extremities generally
below the standard of health.   In most cases
the tongue was coated in the  commencement
with a short, white fur,  which  grew darker as
the disease advanced ; diarrhoea was frequently
present; in  short,  the  symptoms partook  of
fever in general, connected with membranous
inflammation of the internal organs, diversified
according to the degree of  irritability of the
subject, the particular organs attacked, and the
duration of the disease.   According to Gallup,
the local inflammation was not strictly phleg-
monic, but of a membranous erythematic kind,
not apt to end  in suppuration, though sero-pur-
ulent depositions  containing flakes of lymph
were often met with in the large cavities. The
disease often  terminated fatally within a few
hours, reaction never taking  place, while, as a
general rule, it was protracted for many days,
and  recovery  slow and  tedious.  In the most
malignant cases the symptoms  were somewhat
modified, the temperature being much  below
the natural standard, respiration  extremely la-
borious, and  accompanied by a distressing sense
of suffocation  and oppression about the chest.
On dissection the lungs were found excessively
gorged with blood and  hepatized, with much
sanguinolent, frothy mucus in  the bronchi, ad-
hesions of the pleura to the ribs, and conges-
tion of the cerebral vessels.  Dr. Gallup esti-
mates  the number of deaths  by the typhoid
pneumonia in the State of Vermont (population
218,000), during the autumn of  1812 and winter
of 1813, including  five  months, at 6400,  750
of which were among the United States troops.
An equal mortality, at least, prevailed over the
whole of New-England and portions ofthe Mid-
dle States.]
   69. B.  Complications  of Pneumonia.—These
are more common than its pure or unassociated
form, and are  met with in both the sthenic and
asthenic types of the disease;  the latter, how-
ever, more generally presenting the complicated
state.—a. The association of the bronchitis with
pneumonia—broncho-pneumonitis—is most com-
mon.  Indeed, from what has been advanced
above (Y 5), it  will appear evident that pneumo-
nia, especially its most asthenic form, can hardly
exist without the small bronchi becoming more
or less  implicated.  It is, however, when the
disease extends to the larger branches that this
complication should  be considered as existing.
It is sometimes material to mark the procession
of morbid phenomena in order to ascertain the
primary affection.   In the great majority of in-
stances, the bronchi are primarily affected, the
morbid action  extending thence to the paren-
chyma of the lungs, owing either to the nature
of the causes, to the constitution and existing
state of the patient, or to the treatment adopt-
ed at the commencement.  I have observed in
numerous cases, particularly among the children
of the poor, living in low, damp, and close sit-
uations and rooms, sleeping in  over-crowded
apartments, and insufficiently or unwholesomely
fed and clothed, that the disease has commenced
in the bronchi, extended to the  air cells and
substance of the lungs,  and thence to the pleu-
ra, with great rapidity.   In this complication
the quantity of mucus in the bronchi may mask
the crepitation of pneumonia.  Still, crepitation
will generally  be heard  in the  inferior and pos- 
888
LUNGS—Inflammation of the—Complication*.
 terior regions of the chest, while the mucous
 rhonchi will be  evident in the more  superior
 parts.  The rusty or tinged appearance of the
 sputa, as the disease proceeds,  the dulness on
 percussion, the increased dyspnoea, the greater
 severity and more paroxysmal character of the
 cough,  will also mark this association.
   70. Broncho-pneumonia very frequently su-
 pervenes in the course of influenza.  It was
 common  and  fatal in the influenza  of 1837,
 particularly when it implicated, as it very often
 did, both lungs.  In this epidemic the pulmona-
 ry affection generally  assumed the  asthenic
 form, the pulse being weak, quick, and small,
 the cough being severe, puriform expectoration
 abundant, and dyspnoea  distressing;  and  in
 proportion to the vital depression the most en-
 ergetic means were required to rouse  the  vital
 resistance to the extension and  fatal tendency
 of the  disease.  Broncho-pneumonitis is also
 frequent in  the course of hooping-cough, and in
 the  more unfavourable  forms of croup; but in
 these it assumes a more sthenic character than
 in influenza.  It  also occurs in  the course of
 cardiac  disease, particularly when  the valves
 are affected, and  in connexion with hamoptysis;
 but  in  these circumstances it presents much
 of the congestive form.
   71. The bronchitis which so  very generally
 complicates measles passes very  frequently into
 broncho-pneumonia, although the  pneumonia
 may be the chief affection.   In all cases of this
 association, the pulmonary disease partakes of
 the  constitutional  malady, being  sthenic, as-
 thenic,  or malignant,  as this  latter  may be.
 When the local disease is severe, it is readily
 recognised, as  it is commonly attended by an
 imperfect evolution of the eruption, or it fol-
 lows immediately upon either the premature or
 the  regular disappearance of it; the  fever or
 constitutional disturbance being unabated or
 increased.
   72. The peripneumonia nolha of several  wri-
 ters was  frequently a broncho-pneumonia, oc-
 curring in aged,  cachectic, or debilitated  per-
 sons, in whom the disease assumed, from these
 circumstances, more or  less of an  asthenic
 form, and extended to  both  lungs ;   but the
 same term was often also applied to other states
 of bronchitis, and even to asthenic pneumonia,
 with extension  of disease to the  pulmonary
 pleura.
   73. b. Pleuro-pneumonia — Pleuro-pneumonilis
 —-Peripneumonia—Peripneumony—or the asso-
 ciation of inflammation ofthe substance ofthe
 lungs with that of its investing pleura, very fre-
 quently takes place.  The supervention of pleu-
 ritis upon pneumonitis,  or  the coetaneous oc-
 currence  of both,  is attended  by additional
 changes and phenomena  to those  mentioned
 above.  Several of the  alterations and symp-
 toms described in the article Pleura  are ob-
 served  when the inflammation  implicates the
 serous membrane ; but when the substance of
 the lungs has been for some time, or is exten-
 sively affected before the pleura is invaded, this
 latter is .very rarely so remarkably altered as in
 primary pleuritis, and effusion of lymph, espe-
 cially from  it,  very rarely takes place to so
 great.an extent.  M. Laennec has  shown  that
 when,the  inflammation has been nearly equal-
 ly severe in the substance  of the lung and in
She .pleura,, Hie-effusion from the ipieura, by its
 pressure, modifies the effects of the inflamma-
 tion in the lung; this latter  being often found
 after death more consolidated, and tougher and
 redder than  in  ordinary hepatization, and de-
 void of the granular texture.  Its resemblance
 in such  cases to  the muscular substance in-
 duced M. Laennec to call this state that of car-
 nification.  In this complication, the effusion of
 lymph into the air cells is probably prevented ;
 hence the granular appearance is not produced,
 the lymph being effused external to the cells,
 or in  the connecting cellular  tissue.  In many,
 at least, of these cases wherein the carnification
 is most complete, I believe that the inflamma-
 tion originates in the pleura, or in its subjacent
 cellular tissue, and extends through the medium
 of this latter tissue  to the subjacent structure
 of the lung;  and this is rendered the more
 probable by the  amount of the  effusion, which
 is generally  great where  the  carnification is
 complete.  In such  cases the  progress of in-
 flammation is much less rapid, and the lesion
 of the lung rarely proceeds so far as the fourth
 stage, or that of suppurative infiltration or soft-
 ening.  If the pleura  is covered with  a false
 membrane, the  contraction  and  solidification
 of this, as the disease continues or  becomes
 chronic, binds down and  compresses the sub-
 jacent pulmonic structure,  rendering  it  still
 more dense, and obliterating, more  or less per-
 manently, the air cells of the part.  The con-
 sequence  of this change  is,  as somewhat  too
 strongly  insisted upon by Dr. Williams, that
 the chest  remains to a certain degree contract-
 ed, as after pleurisy, when the liquid  effusion
 is removed by absorption, the obliterated air
 cells no longer admitting the  air.   But in some
 of these  cases the lymph obstructing the cells
 is gradually absorbed, and the parts are partial-
 ly restored to their former  state.  When, how-
 ever,  such restoration is not effected, the air,
 not reaching the cells, often dilates the bronchi,
 this dilatation taking place in various grades;
 dilatation of the bronchi thus following pleuro-
 pneumonia in its more chronic states.
  74.  As respects the pleura in these cases, the
 changes which take  place consist  chiefly, 1st.
 Of effusion ef lymph ;  2d.  Of effusion of a se-
 ro-puriform fluid ;  and, 3d. Of the effusion of
 air, or gaseous fluid.   The first is  almost con-
 stant,  although it may occur to a  very slight
 extent, when the substance of  the lung is ex-
 tensively, deeply, and primarily affected. The
second is comparatively rare in pleuro-pneumo-
 nia, and the third is very rare indeed, although
it may take place in this complication of pneu-
monia, as in primary pleuritis, especially in the
more  asthenic cases.
  75.  The symptoms of pleuro-pneumonia are
not materially different from those of  simple
pneumonia, unless much effusion  takes place
from  the  affected pleura.  When  this mem-
brane is consecutively or slightly affected, pain
may not be severely  felt.   Indeed, this compli-
cation is generally not so severe  or acute as
either simple  pneumonitis or primary pleuritis;
and the symptoms are very often more obscure
than those of either.   WThen lymph is effused
 on the pleura, it does not necessarily  induce
 corresponding physioal signs; hence the frot-
 tcment of Laennec is  not  a  common sign of
 pleuro-pneumonia, and is rarely observed in the
 advanced stages, or at the resolution of the dis- 
LUNGS—Inflammation of the—Complications.                  883
 ease.  It is observed chiefly in the early stages
 of some  cases of extensive pleuro-pneumonia.
 At first  crepitation may be heard;  but  it be-
 comes indistinct as effusion from the pleura
 takes place and is considerable.  Dulness on
 percussion is greater than in pneumonia, espe-
 cially in the lower parts of the affected  side.
 As Dr. Williams  states, bronchial respiration
 and bronchophony are soon produced, in the
 central regions of the  chest, by the condensed
 lung being pushed against the walls; and if a
 thin layer of liquid intervene, the bronchophony
 acquires a buzzing accompaniment, the sound
 seeming to consist of two voices ; this probably
 arising from the vibrations being modified into
 a buzzing or bleating  by passing through the
 thin layer of liquid.  The vocal resonance is
 generally louder in pleuro-pneumonia than in
 either simple pneumonia or pleurisy, owing to
 the greater condensation of the vesicular struc-
 ture, and to the closer application  of the in-
 flamed lung to the walls of the chest, circum-
 stances,  also, which explain the occasional ap-
 pearance ofthe  tracheal or amphoric sound on
 percussion in the mammary  region,  while oth-
 er parts  are dull.  In cases inefficiently treated
 at  their  commencement, and become chronic,
 solidification of a portion  of the lung having
 become  permanent, and the fluid effused  from
 the surface of the pleura having been  in great
 measure absorbed, respiration  is often  quite
 tracheal  in this region, and  resonance of the
 voice as loud as that of cavities, especially if
 dilatation of the bronchi have  taken place, as
 frequently occurs in these circumstances.
   76. c. During the course  of tubercular disease
 of the lungs pneumonia often occurs, and is
 either partial or limited, or more or less extend-
 ed, especially in one lung.   Inattention to this
 fact, and the consequent non-detection of the
 superinduced  inflammation  in such  cases, are
 often the  causes  of their more rapidly unfa-
 vourable termination.  Either simple pneumoni-
 tis,  or pleuro-pneumonitis, or  even  still more
 frequently broncho-pneumonitis, may thus su-
 pervene  ; and the  great frequency of their oc-
 currence should induce the physician to watch
 for them, and to combat them on their first ap-
 pearance.
   77. d.  When treating of hemorrhage from the
 lungs (y  114), I remarked  upon the frequent
 connexion of this  pathological  condition  with
 inflammation of some portion ofthe organ.  It
 is not unusual  for active congestion of the
 lungs to give rise to  slight, or even  copious
 haemorrhage, and then pass on either to simple
 pneumonia, or  to broncho-pneumonia.  Gen-
 erally this occurrence is connected with tuber-
 cles, this latter being the primary  malady ;
 but, in many, the  consequent inflammation is
 more immediately dependant upon the haem-
 orrhage and congestion than upon the tuber-
 cular disease ; and this is more especially the
 case when haemorrhage takes place in the form
 of pulmonary apoplexy.   Whenever, therefore,
 haemoptysis occurs, partial or  more  general
 pneumonia or broncho-pneumonia  should be
 suspected, and its  existence  or  non-existence
ascertained by a careful examination.
  78. e. The absorption of purif orm or other mor-
bid  secretions into  the  blood, and phlebitis oc-
curring either after parturition, or after surgi-
cal  operations, or  injuries  or wounds, are not
    II.              112
infrequent  causes of pneumonia of a peculiar,
insidious, and  latent kind,  which sometimes
does  not manifest  itself until shortly before
death, and then chiefly  by oppressed, quick,
and  short  breathing, and mucous rattle.  In
some of these cases, portions only ofthe lungs
are found inflamed in the first and second sta-1
ges ;  in  others, there  are numerous circum-
scribed hepatizations, varying  somewhat in
their  characters ; and in several, purulent de-
posites are met with in the parenchyma ofthe
organ; these  deposites  being circumscribed,
and the tissue surrounding them either inflamed
or almost healthy.   These are, however,  to be
viewed as  infiltrations  of puriform  or other
morbid secretions into  the pulmonary tissue,
inducing asthenic  inflammatory action in the
parts with which  they come in contact and
contaminate ; and, perhaps, in some situations,
as asthenic inflammation of the more extreme
capillaries through which these secretions cir-
culate,  the capillaries of mucous and cellular
parts  being most prone to be affected by them.
Those small abscesses, or deposites, which are
more obviously instances of puriform infiltra-
tion, present  the matter in contact with, and
infiltrating  the margins ofthe  surrounding tis-
sue, which is hardly or  not at all inflamed  ;
while those which  are manifestly connected
with inflammatory action present a red or liv-
id margin, with a more or less distinct coat of
lymph in some  instances, but only in those in
which this action  approached the nearest to
the sthenic form.  These consecutive abscess-
es or  deposites  are more particularly noticed in
the art. Abscess (§ 27, et seq.) and Liver (§ 208,
et seq.).
   79. /. A  complicated  and congestive form of
pneumonia,  complicated most frequently with
bronchitis,  is often  consequent upon eruptive
fevers, upon  cholera asphyxia, or pestilential
cholera, and  upon  asphyxia  from  whatever
cause, and  especially when produced by foql
exhalations.  It sometimes also occurs in the
course  of continued endemic,  remittent,  and
intermittent fevers.  In ail these circumstan-
ces, the pneumonia is  generally more or less
asthenic and obscure, or even latent, some-
times not manifesting itself until shortly before
death, or before the lungs had become exten-
sively impervious to the  air, or even  not  until
it is detected  after death.
  [Pneumonia  may also  be complicated  with
pericarditis, which is supposed to coincide more
frequently with inflammation of the  left  lung.
The  heart  should  frequently be  examined in
cases of severe pneumonia of the left lung, in
order to detect this complication, if it  exists.
It is  not an  uncommon  occurrence to meet
with  fibrinous  concretions in  the heart  and
large  vessels   after  death  from  pneumonia,
which are supposed to be indicated during life
by dull, obscure, and  veiled  sounds of the
heart, with intermittent pulse.  Icterus is also
a frequent  complication  of pneumonia,  hav-
ing occurred  in 27  out of 70 cases reported
by Grisolle.    Its occurrence  has been attrib-
uted by some writers to the extension of the
inflammation  to the convex  surface of the
liver.
  g.  Bilious  pneumonia  is a  not unfreqtient
form  of the disease in this country, and occa-
sionally takes on an endemic, or even epidemic 
890
LUNGS—Inflammation of the—Causes.
character.   It is that form  of pneumonia un-
der which the late  President  of the United
States,  Gen  Harrison, sunk, and  it prevails
every winter, to a considerable extent, in some
portionsof our country, under the name of'bilious
pleurisy.  It  generally attacks  adults, coming
on  suddenly, with nausea and much derange-
ment of  the  digestive organs ;  a  soft, feeble
pulse; hot  and dry skin ; severe pain in the
head, particularly  the frontal region, and very
great prostration of strength.  The gastric and
biliary  derangement  are indicated by a foul
tongue, it being covered  by a thick, yellowish
fur" a  bitter taste in the mouth, nausea, and
vomiting; variable thirst, constipation, yellow-
ness  of skin,  and tenderness at  the  epigas-
trium, &c.   It is  very apt  to assume the  ty-
phoid type  if improperly treated, under which
there is great danger that the patient may sink,
 especially if the  epidemic form  of the disease
 prevails]
   80. v. Causes of Pneumonia.—Inflammation
 of the  substance of the lungs, in some one of
 its forms or states—in a sthenic, asthenic, con-
 gestive,  malignant,  or complicated form, ac-
 cording to the nature and association of the
 exciting causes,  and the state ofconstitution
 and predisposition of the individual—is a  fre-
 quent  disease, especially in cold and temper-
 ate  or variable  climates.—A.  Childhood  and
 far-advanced age; the sanguine temperament,
 and the weak or  scrofulous diathesis, are most
 predisposed to pneumonia.  Infants  and chil-
 dren* are especially predisposed  to  this disease,
 which, in its  several forms and complications,
 destroys more of them  than all other inflam-
 matory diseases.  Debility from whatever cause,
 whether original or from previous disease, re-
 markably  predisposes  to  pneumonitis.    The
 eruptive  fevers,  especially measles, hooping-
 cough, and previous attacks of  either pneumo-
 nia, bronchitis, or pleuritis, exert  a similar in-
  fluence, as I have  shown under  these heads.
  The greater disposition  of pneumonia to occur
  during gastric and bilious disorder, especially at
  certain seasons, as the autumnal, and in  ca-
  chectic states ofthe frame, have induced some
  authors to notice varieties  of pneumonia by
  these appellations.   But these are not varie-
  ties, but merely contingent associations of the
  disease with, or  appearances of it during these
  states of previous disorder.
    81.  B. Cold, or whatever favours or produ-
  ces congestion of the lungs, excites an attack of
  pneumonia;  and the readiness with which it
  operates is generally in proportion to the sus-
  ceptibility and  excitability of the individual,
  and to the impairment  of vital resistance.  If
  exposure to cold be so long continued, or if the
  degree  of cold  be so great, relatively to the
  state  of vital energy and resistance, as to cause
    * The remarkable prevalence and fatality of pneumonia
  among infants and children are shown by the returns to the
  registrar-general.
    ]. In Manchester, in 1839, of 501 deaths from pneumonia,
  213 were infants in the first year, 156 in the second year,
  and 44 in the third year of age.
    2. In Liverpool, of 657 deaths from  pneumonia in 1839,
  216 were infants in  the first year, 212 in the second year,
  and 68 in the third year of age.
    3. In Birmingham, of 395 deaths from pneumonia in 1839,
  160 were in the first year, 136 in the second year, and 26 in
  the third year of age.
    In persons far advanced in age, asthenic and complicated
  pneumonia becomes somewhat more prevalent than at mid-
  dle age, and very much more fatal.
vital depression and congestion of the lungs,
reaction  will generally follow, unless the de-
pression  be so great as to overcome or alto-
gether annihilate the powers of vital resistance
and vascular reaction.  All noxious agents af-
fect  the  lungs more severely and certainly
when the constitutional powers are  weakened,
or the spirits depressed, and when the body is
in a state of repose  or asleep, than in  other
circumstances  ; and this is especially the case
in respect ofthe influence  of cold.   When suf-
ficient exercise can be taken  to preserve the
circulation in a state of activity, cold is seldom
injurious ; but as  soon as repose or  sleep takes
place congestion supervenes, particularly in the
lungs, and the congestion may go  on to  as-
phyxia, or vital extinction, if the cause contin-
ue to  operate  or to increase ;  while it may be
converted into inflammation  if the cause  be
suddenly  removed,  or if exciting or  other
 agents be brought into operation, which tend
 to develop vital reaction.   Owing to this and
 other causes, pneumonia  is  most  frequent in
 winter,  autumn, and spring, and most common
 in those classes  of the community which are
 most  exposed to  cold in any form, or to vicis-
 situdes  of climate, season, weather, and tem-
 perature, especially sailors and soldiers, coach-
 men  and grooms, day-labourers, firemen,  &c.
 It is more prevalent in males than in females,
 owing to these  circumstances ;  but, accord-
 ing to the returns to the registrar-general, &c ,
 not so much more so than is generally stated,
 the  deaths of males from  pneumonia, com-
 pared with those of females, being as  ten to
 eight.
    [The  late Dr.  Forrv has shown, in his re-
 cent work on the  " Climate of the United States,"
 that  the average  number of cases of pleuritis
 and pneumonia is much lower in the cold and
 variable  climate  of our Northern and Eastern
 States than in the middle and southwestern re-
 gions of the United States ; at the southwest-
 ern parts the annual ratio being 92, while on
 the coast of  New-England it is only 41.   Dr.
  Forry  first laid down the important law, which
 he seems  to have  established by numerous
 facts, that, in proportion  as  the high tempera-
 ture  of summer  makes an impression  on  the
 system, do the lungs become susceptible to the
  morbid  agency of  the opposite  seasons.   In
  our Northern States, for  example, as cold pre-
  dominates, and no decided impression is made
  upon the animal  economy by the short summer,
  the annual ratio of pleuritis and pneumonia is
  not only low, but there  is little difference in
  the ratios of the seasons ; on the  other hand,
  in  the  Southern  States, which are remarkable
  for high and long-continued summer heats, the
  annual  ratio  is about twice as high  as in the
  Northern States, while  the  difference in  the
  seasons is very considerable, the ratio of the
  third quarter  being less  than one  ninth of the
  annual  average.  The statistics of the United
  States army, then, show that pneumonia, pleu-
  ritis, and phthisis pulmonalis are  most preva-
  lent  in the middle districts of the United States,
  and  these diseases are of a more fatal tendency
  in the  southern than in  the northern regions.
  In the latter, the ratio of mortality from phthisis
  pulmonalis is 32, and in the former 42  per 100
  cases;  and, as regards pleuritis and pneumonia,
  the difference is  much greater, the average mor- 
LUNGS--1NFLAMMATI0N OF THE—CAUSES.
891
 tality in the northern being 9, and in the south-
 ern 26 per 100 cases.  Much credit, we believe,
 is due to  the lamented Forrv for first devel-
 oping the  important fact above mentioned, and
 calling the  attention of the profession to the
 predisposition to pulmonary diseases, induced
 by the high  temperature of summer, contrasted
 with the low temperature of winter.—(Loc. cit.,
 p. 246-7.)]
   82.  Inhalations of acrid, chemical, and other
 noxious gases ; public speaking, and all exer-
 tions of the voice; the use of wind instruments ;
 concussions ofthe chest; prolonged swimming,
 or immersion  in water; and removal into a
 very warm air after prolonged exposure to cold,
 and particularly to atmospheric cold, are pow-
 erful exciting  causes  of the disease.  Other
 maladies not only predispose to,  but often ex-
 cite an  attack of simple or complicated pneu-
 monia, but more frequently the latter, in either
 a sthenic  or asthenic form, and  either during
 their  progress  or   upon convalescence  from
 them.  This is especially the  case in  respect
 of eruptive  and continued fevers ; of hooping-
 cough, bronchitis, and pleuritis; of diseases of
 the heart; and  of  croup and  laryngitis.  The
 greater liability of  pneumonia to occur after
 the disappearance of cutaneous  eruptions, or
 upon the sudden cessation of an attack  of gout
 or of rheumatism, has  been  noticed  by most
 writers; but much more importance has been
 attached to this cause than  it deserves, for
 pneumonia is very rarely produced by it.
   83.  The incautious exposure to cold or wet,
 and to the night air, after breathing  for some
 time the foul  and depressing air  of a confined
 or crowded  apartment, or ill-ventilated quarter,
 bedroom, or barrack-room, is perhaps the most
 productive cause of pneumonia, particularly in
 large towns, and in armies and fleets, and ex-
 plains the greater prevalence and mortality of
 the disease in these circumstances than in open,
 healthy localities.
   84. C. The endemic  and epidemic prevalence
 of pneumonia has been admitted by most wri-
 ters.—a. It  is sometimes endemic in  elevated,
 cold, and dry localities, either in its simple form
 or in connexion with pleurisy, as a pleuro-pneu-
 monia.   It is also prevalent  in low, cold, and
 humid situations, but less so than in the fore-
 going places, and is most commonly associated
 with bronchitis, as a broncho-pneumonia.  Al-
 though pneumonia prevails chiefly in cold coun-
 tries, yet it is often observed in the more tem-
 perate climates  of  the  south of Europe, espe-
 cially where cold northerly winds blow from
 high ranges  of mountains.   In both Milan and
 Madrid pneumonia  is very prevalent.   Acerbi
 states that,  in the hospital  of the former city,
 there were 142 cases of it out of 175 patients.
 It is also said to be  prevalent in the vicinity of
 Vesuvius, probably owing to acrid or otherwise
 noxious exhalations or gases from that volca-
 no.  Mr. Farr has shown, in his tables of mor-
 tality, drawn up from  the returns made to the
 registrar-general, that the deaths from pneu-
 monia in cities and large towns  in England are
 much more numerous than in the  same amount
 of population in country districts—are so much
 so as to indicate both a greater prevalence of
the disease, and a greater rate of mortality from
it, in the former than in the latter*
  * 1. The deaths from pneumonia, registered in the me-
   85. b. Epidemic pneumonia has been described
by many authors ;  as  a complication of influ-
enza,  pneumonia  of  an asthenic  form,  and
broncho-pneumonia, may be said  to have been
epidemic at the commencement of 1837.  When
this disease is epidemic, it is most frequently
asthenic.  It is not infrequently, also, epidemic
among horses and cattle.   Laennec  attributed
the epidemic occurrence of pneumonia to dele-
terious miasms in the  atmosphere;  and others
have imputed it to swarms of minute insects in
the  air — a subject of much  importance,  and
most ably considered  by Dr. Holland, in the
chapter " On the Hypothesis of Insect Life as
a  Cause of Disease."   (Medical Notes and Re-
flections,  p.  560.)   Although changes  in the
temperature, in the hygrometrical state, in the
weight or  density, and in the electricity of the
atmosphere, may account for the  increased prev-
alence  and varied forms of this  and of many
other  diseases,  still they  are  insufficient  of
themselves to cause the more devastating epi-
demics sometimes  observed,  and, as respects
this disease, most remarkably among some of
the lower animals.   Even when occurring epi-
demically, situation, weather, and  seasons* ma-
terially influence its characters and prevalence.
Thus, Huxham states,  that  during an epidemic
it  assumed more of the bronchitic character in
low and humid places, and most of the pleu-
ritic form in dry and elevated situations.   (See
articles Endemic and Epidemic Influences.)

tropolis for 1838 and 1839, were 3954 males  and 3477 fe-
males : total, 7431.
  The deaths from this  disease in about the same amount
of  population in the counties of Cornwall, Devonshire, Dor-
setshire, Somersetshire, and Wiltshire, during these two
years, were 1888 males and 1558 females : total, 3446, or less
than one half the deaths from pneumonia in the metropolis.
  2. The deaths from pneumonia in 1838 and 1839, in twen-
ty-four town districts, including the metropolis, were 8188
males and 6874 females : total, 15,062.
  The deaths from this disease in the same  two years in
twelve country districts, containing about the same amount
of  population as the town districts, were 3392 males and
2826 females : total, 6218, or in the proportion of about 3
to  7J.
  3. The deaths from pneumonia in the  metropolis, in 1839,
was 1949 males and 1738 females: total, 3687.
  The number of deaths in 1839, in England and Wales,
were 10,000 males and 8151  females:  total, 18,151.
  * Number of deaths from pneumonia registered in the
metropolis during the/our quarters of 1838,1839, and 1840 :
  1. During  January,  February,  and  March, 271 days,
3326.
  2. During April, May, and June, 273  days, 2454.
  3. During July, August, and September, 275 days, 1827.
  4. During October, November, and  December, 275 days,
3600.  The greatest number, and nearly double that of the
preceding three months, in which the number is least.
  From these data, pneumonia appears to be most prevalent
and fatal during the cold and humid weather following the
third three months of the year.  This agrees with my ob-
servation in respect of children.
  [From 1819 to 1834 inclusive (16 years), there were 63,783
deaths in the city of New-York, of which 19,084 were by
diseases of the lungs, 4696 being acute affections, and 14,388
were from pulmonary phthisis. Besides these, there were
2243 cases of death  from croup, 1400 from hcoping-cough, .
and 183 from asthma, all of which might, with propriety, be
added to the list.  In some years the mortality among the
aged, from the  prevalence of epidemic influenza, has been
extensive ; in others a general catarrhal influence has ren-
dered children peculiarly subject to inflammation of the
thoracic organs from exposure to atmospheric vicissitudes.__
(Statistics of the City of New-York, by  the Editor, in Am.
Jour. Med. Sci., vol. xix.)  Of 8715 deaths which occurred in
Massachusetts during the year ending April 30th, 1845 (4th
Report relating to the Registry and Returns of Births, Mar-
riages, and Deaths inMass.,hyJ. G. Palfrey, 1845), 2542
were of the respiratory organs, 9 of asthma, 12 of bronchitis,
2072 of consumption, 49 of hydrothorax, 5 of laryngitis, 20 of
pleurisy, 350 of pneumonia, 11 of quinsy,  14 disease of lungs.
From diseases of the nervous system there were 794 deaths;
from diseases of the organs  of circulation, 136 ; of the di- 
893
LUNGS—Inflammation of the—Prognosis.
   86.  vi. Terminations, Duration, and Prog-
 nosis.—A. The chief terminations of  pneu-
 monia have been noticed when describing the
 usual  course of the disease.   But in  addition
 to these it may be stated, that the superven-
 tion of pleuritis with very copious effusion may
 supersede or resolve the inflammation of the
 substance of the organ, that of the pleura  and
 its consequences becoming the chief or only
 lesion.  This is, however, comparatively rare.
 Much  more  frequently  the acute  attack  of
 pneumonia subsides or is subdued, and the pa-
 tient  continues short-breathed and feverish.
 The pulse remains quick, and  dulness or crepi-
 tation is still detected in parts ofthe chest, with
 more or less uneasiness.   Chronic hepatization
 of portions of the lungs thus  not infrequently
 follows  neglected or improperly treated pneu-
 monia, or premature exposure  or neglect during
 convalescence,  especially among  soldiers  and
 saibrs, or the poor, who are exposed to vicissi-
 tudes  of weather.   It is not  improbable that
 tubercular disease of the lungs may originate
 in these states of chronic pneumonia, especially
 after repeated attacks, or exacerbations of the
 local changes, as supposed by MM. Broussais
 and Andral ; and when occurring  in scrofulous
 constitutions.   It is not unlikely, however, that
 many  of the cases in  which the inflammation
 has been  supposed  to lapse  into the chronic
 state,  and to give rise to tubercles, have been
 tubercular from the commencement, the pneu-
 monia being  merely an  intercurrent  disease,
 which has more rapidly developed the  tuber-
 cular  formations;  and these  have tended to
 keep up a state of chronic inflammatory action,
 with more or less engorgement or  solidification
 ofthe lung;  for pneumonia very rarely degen-
 erates into a chronic state, unless  in connexion
 with tubercles or haemoptysis, a circumstance
 which probably induced Bouillaud to infer that
 tubercular formations in the lungs is merely a
 chronic form of inflammation of them.
   87.  B. The duration of pneumonia is very in-
 definite, and varies with the age of the patient,
 with the state of vital action characterizing the
 inflammation, with  the complications  and the
 treatment adopted.   In  general,  the  asthenic
 states are more rapid in their progress than the
 sthenic ;  and the complications of the disease
 with exanthematous or other fevers, or the oc-
 currence of it during early convalescence from
 these, not only accelerates the progress, but in-
 creases  the danger  from it.   Debility and ad-
 vanced age also accelerate its course.   In some
 instances  of its occurrence in these  circum-
 stances it may run its course in from thirty-six
 to  forty-eight hours, or even  in a somewhat
 shorter period.  M. Laennec attempted to as-
 sign periods to the  different stages of the dis-
#ease ;  but these can be viewed as approxima-
 tions only to  the truth, which numerous causes
 may vary, more particularly the violence ofthe
 attack, and the circumstances just adverted to.
 He states that the  average duration of  the
 stage  of engorgement is from  twelve hours to
 three days ; of  the stage of hepatization, from
 one to three days ;  and of the  stage of suppu-

 gegtive organs, 517 ; of the urinary organs, 32; of zimotic, or
 epidemic, endemic, and contagious diseases, 2208; of diseases
 of uncertain seat, 889 ; of diseases of organs of generation,
 95 ; of organs Of locomotion, 34 ; of the integumentary sys-
 tem, 17.]                                '
rative infiltration, from  two to six.  Remedied
which retard the progress of the disease may,
however, prolong the duration of the  first two
stages beyond the periods here assigned ; these
varying most remarkably with  the treatment
and peculiarities of the case ; and, as contend-
ed for above, the stage  previous to hepatization
is more important, and  of longer duration, espe-
cially in children and young subjects, than M.
Laennec appears to think.
  88. C. The prognosis is, equally with the du-
ration of the disease, dependant upon numer-
ous circumstances, and more particularly upon
those just named ($ 87).   Pneumonia in all its
forms, but more particularly its asthenic and
complicated  states,  and  when epidemic, is  a
very serious malady, requiring a cautious prog-
nosis even in the  more favourable cases; for
these may superinduce a most dangerous pleu-
ritis, or become otherwise aggravated in their
progress ; or a relapse  of a most dangerous
kind  may  occur  during  early  convalescence
from them.   The  " numerical method" of esti-
mating the danger has been extended to pneu-
monia as well as to  other diseases  by sev-
eral French pathologists, as well as by a few
British writers.  But  it  must  be obvious, on
reflection, that  the danger and rate of mortality
must necessarily  vary with the  situation and
climate ; with  the prevailing epidemic ;  with
the age, constitution, and other circumstances
of the patient; and with  the  severity, stage,
and complications of the  malady.  Hence the
mortality from  this disease has been  different-
ly estimated ; and, among soldiers during set-
vice, among the poor, the ill-fed, and ill-clothed,
among persons engaged in crowded  or over-
heated or ill-ventilated factories, and in other
unfavourable circumstances,  it  is  generally
high.  Dr. Mann states, that during the last
war in the  United States of North  America,
pneumonia was both very prevalent  and very
fatal.  Sir J. MacGrigor  states  that  the dis-
ease was prevalent among the troops in Spain
during the last  war,  and that it often assumed
an insidious, latent, or low form.  The disease,
however,  does  not appear to have been  very
violent or fatal; for of 4027 cases entered as
pneumonia,  only 285 died, or rather less  than
1 in 14.  The treatment of it appears to have
been energetic, early, and judicious.  In some
of the hospitals in  Paris the  mortality has
varied from two fifths  to one tenth.   The loss
is still greater than the highest of these rates
among the aged.
  89. The danger  from an attack of pneumonia
is  remarkably increased by previous ill health,
or attacks of pulmonary disease ; by preceding
eruptive fevers  ; and by original debility of con-
stitution.  Although  recovery may take  place
from any stage  of  the disease, the chances di-
minish rapidly with the supervention ofthe ad-
vanced stages, and become very few after sup-
purative infiltration takes place.   The very rare
occurrence of gangrene or abscess is a most
dangerous, but  not hopeless event.   A violent
attack, a great  extent of the disease, and par-
ticularly the  implication of both lungs, and its
complications with double  bronchitis ; the af-
fection of the upper lobes  and roots of the'or-
gan ; the operation of  causes of a depressing
and contaminating nature, as foul air, and par-
tial asphyxia from  foul  exhalations ; the occur- 
LUNGS—Inflammation of
renceof the disease during influenza and erup-
tive fevers,  during the puerperal states, and
after prolonged suckling;  all the more severe
complications noticed above, and the progress-
ive  advance of the disease, notwithstanding
early and judicious treatment,  are extremely
unfavourable circumstances.
   90. The symptoms more particularly evin-
cing danger  are those indicating the progress
ofthe disease to suppurative infiltration ofthe
lungs, or even to extensive hepatization ; very
quick and short breathing ; frequent dilatations
or a working of the  alae  nasi;  a feeling of a
want of breath rather than of difficulty of
breathing; delirium or restlessness ; a rusty
or prune-juice  appearance of the  sputa; cold
sweats ; anxiety, and sharpened, pale features,
with lividity of the lips and tongue, and  the
other symptoms noticed above ($ 21, 55),
   91. vii. Treatment.—The treatment of pneu-
monia should be conducted with strict refer-
ence, 1st.  To  its stages ; 2d.  To the states
of vital action  and power;  and, 3d. To  the
complications and   peculiarities  of each case,
To each of these circumstances the indications
of cure should be individually appropriate.
   92. A.  Treatment of Sthenic Pneumonia.—a.
In the first and  second stages, or those of incip-
ient inflammatory  action  and engorgement—
the first stage  of Laennec (§ 49-51)—the dis-
ease may be much  shortened, if not altogether
arrested by energetic means.  This,  therefore,
should be the first and chief intention.—a. If, at
this period, the  local and  constitutional symp-
toms and appearance of  the patient indicate
sthenic reaction either commencing or estab-
lished, a large blood-letting ought to  be  imme-
diately practised; and the blood should be ab-
stracted in a full stream,  and until  a marked
impression is made upon  the pulse,  while  the
patient is in a sitting or semi-recumbent posture,
as directed in the article Blood (y 64); but, for
the reasons there stated, and since adopted by
the  ablest writers  and practitioners, it should
not be carried so far as to produce full syncope.
In the young and robust,  and where there is
evidence of  unimpaired constitutional power,
blood-letting may be resorted to as early as any
signs of inflammatory action can be detected,
if it be performed  in  the  way I  have advised.
This having been performed with the effect just
mentioned, means should be prescribed to pre-
vent the return or increase of the vascular re-
action ; and  with this view I have  for many
years directed, immediately after the blood-let-
ting, from 5 to 15 or 20 grains of calomel, with
from 3 to 5 of James's powder, and from 1 to 3
of opium, to be taken at one dose : saline diaph-
oretics, with antimony, more particularly  the
liquor ammonia? acetatis and liq. antimonii tart.,
in full doses, with  the  spiritus aetheris nitrici,
in camphor water,  being given  every three or
four hours.   In many cases this prompt and
large blood-letting will arrest  the farther prog-
ress of the disease, and  in  all tend remark-
ably to shorten it.
   93. The  patient ought to be  seen  again in
about eight or ten hours, or twelve at the far-
thest ; and if the symptoms are not abated, or
if they have  become exacerbated, and if vas-
cular reaction  from the state to which it had
been reduced by the blood-letting have taken
place, the pulse having increased in strength,
he—Treatment of Sthenic.              893

venaesection must again be resorted to, if the
patient be robust or plethoric, and blood ab-
stracted, so as to affect the  pulse  and system
as before, and in the  manner already  advised,
and it should be instantly followed by the ex-
hibition of the same medicines  which I have
recommended above (Y 92) after the first bleed-
ing.   In many cases, as in the less robust or
plethoric, or where the increase or return of
the vascular action is slight or hardly manifest,
or where  there  is merely a persistence of the
morbid action, either in the  same or in a de-
creasing degree, local depletion  by cupping or
leeches,  or by  cupping over  the  leech-bites,
will be adopted with advantage ;  the  amount
of local depletion having reference to the cir-
cumstances of each  case.  The chief advan-
tages of this plan, which I have long pursued
in this and in other sthenic  inflammations, is,
that the means  employed  immediately after a
full blood-letting are  such as will  promote all
the effects which it  is  calculated  to produce,
and as will prevent  a  return of the vascular
excitement, which is prone  to return  as long
as the local morbid action continues, and even
after it is subdued, when the blood-letting has
been copious.
  94.  The practice of prompt and copious vas-
cular  depletions, so very generally and long ob-
served in  this country, has been recently adopt-
ed by M. Bouillaud and a few others in France,
and with the success which  has followed it in
this country, although it  has been decried by
M. Louis, who  has  adduced his  " numerical
method" in proof of the little benefit produced
by it.   But,  as  I have elsewhere contended,
this method is a delusion, unsupported by that
best of all tests of medical  doctrine,  common
sense ; for it must be manifest, that if a mode
of treatment be  empirically followed in  all
cases  said to be nosologically the same, al-
though different or even opposite  as  respects
vital power, complication, and stage of advance-
ment, it must be injurious almost as frequently
as beneficial.*   The quantity of blood abstract-
ed by M. Bouillaud is certainly  large, but not
larger than has usually  been  taken in  this dis-
ease by public and private practitioners.
  95.  It  is unprofitable  to follow  the  French
physicians in their arguments on this question,
as some of our recent philo-Gallic writers have
done;  as their lucubrations tend only to over-
lay a plain, common-sense view of the subject
with a load of flat, stale, and inapplicable nu-
merical, vainly called statistical, details. From
what  I have advanced, it may be inferred, that
nothing can  be  said  with  propriety as to the
precise amount to which  blood-letting should
be carried in this more than in any other in-
flammation.  It should be practised so as to

  * fThe numerical system of M. Louts has never obtained
many advocates among the enlightened members of the pro-
fession in this country.  Its fallacy, indeed, is too obvious
to need pointing out; but we may allude to one well-known
fact, which  must render it entirely nugatory in the estima-
tion of all who are governed by truth and positive observa-
tions.  The fact to which  we refer  is, the great difference
in the  diathesis of diseases in different years, in some re-
quiring  active antiphlogistic means, while in  others the
same diseases will  not bear a similar course.   This has
been particularly noticed in the treatment of typhoid fever
in the  Massachusetts General Hospital; and we may, for
additional examples, allude to the pneumonia of 1812 and
that of recent years, the former being of a low typhoid type,
and not bearing the use of the lancet, while  the latter is in-
variably benefited by the abstraction of blood.] 
894
LUNGS—Inflammation of the—Treatment of Sthenic.
make a full impression upon the pulse and sys-
tem, and with but little reference to the quan-
tity.  I have taken as much as fifty-four ounces
at one time, in the manner I have advised,
from a strong,  plethoric man, the early stage
having been fully developed, and vascular re-
action  being energetic ; and, having had re-
course to the additional means above mention-
ed ($ 92), no farther blood-letting was required.
In  similar circumstances,  I have not unfre-
quently had from forty to fifty ounces taken at
the first venaesection, and with the same result.
In this, as well as in other  inflammations, al-
though vascular depletion is the  chief remedy,
it ought not to be the  only one.   It should be
aided by other means.   What these means are
I have  already partly indicated; but they re-
quire to be noticed more in detail, for the chief
of them have been individually lauded with all
the zeal which partisanship generates, and with
all  the  exclusiveness which a one-sided  view
or an adopted doctrine  never fails to produce.
  96.  b. Tartarized antimony has  been long em-
ployed in  emetic and nauseating doses in the
treatment of pneumonia ;  and,  independently
of these effects,  by  Dr. Marryatt, and more
recently by Dr. Balfour.  Rassori of  Genoa,
however, first demonstrated the great extent to
which  this substance might  be  prescribed for
inflammatory diseases ;  and Laennec, more es-
pecially, elucidates its effects in  the treatment
of pneumonia, but, in estimating it above blood-
letting in this disease, rated it much too highly.
He gave this medicine in doses of from one to
two and a half grains in three ounces of sweet-
ened weak infusion of orange leaves, withhold-
ing it after the  sixth dose, or persevering in it
according to the violence  of the attack.   It
was chiefly  to  this remedy  that he attributed
the great  success of his treatment, which he
rated  as high as  2 deaths  only in 57 cases: a
success, however, which has not  been attained
by other practitioners who have  used this sub-
stance. Since 1819  I have given it an exten-
sive trial  in pneumonia, chiefly  in dispensary
practice ;  and, although I do not think so high-
ly of its efficacy as Laennec, I believe it to be
a valuable remedy, but subsidiary only to blood-
letting, and appropriate chiefly to theirs* stage
of the disease.  It is by no means a safe med-
icine for young children or infants; for I  have
seen large doses of it, particularly when too
often  repeated  or continued too  long, produce
most dangerous and  even fatal collapse, which
was sometimes mistaken for the unfavourable
course of the disease.  In this class of patients,
therefore,  it should be given with caution, and
its effects  ought to be carefully watched.   For
adults  it  may  be prescribed, after sufficient
blood-letting, in doses of from half a grain to
two grains in any agreeable vehicle, and repeat-
ed every two, three, four, or five hours, accord-
ing to  the severity of the disease ; but I  have
found  it equally  beneficial  in smaller  doses,
when  conjoined with the other medicines no-
ticed above in  connexion with it (§ 92).  The
first doses usually cause vomiting, which ceas-
es after the second, third, or fourth, and which
should be  arrested if it continue  after the sec-
ond or third, by one  or two  doses of hydrocy-
anic acid.  If it produce purging, a few drops
of laudanum or the sirup of poppies should be
given  with it.  Tartar emetic, when given in
large and repeated doses, operates chiefly upon
the organic nervous energy and  the  vascular
action,  lowering  both, or the  latter chiefly
through the medium of the former, in a very
remarkable manner, when neither of them ia
much excited, but much less manifestly when
either or both are greatly increased.
  97. c. Mercury with opium, in large doses, has
been much employed, both with and after blood-
letting ; and calomel, in doses of from 5 to 20
grains, is  the preparation which is most to be
preferred.   If the bowels have not been suffi-
ciently evacuated, the  first dose of it may be
given without the opium, with four or five of
James's powder, or with  one or two of the  ex-
tract of colchicum,  or even  with  both ;  but
when the  bowels  are free from faecal accumu-
lations, from one to three grains of opium should
be combined with these, and given immediately
after the  first blood-letting, as noticed above
(§ 92).  The doses of these, and frequency of
exhibiting them, should be regulated according
to the severity and progress of the attack and
the circumstances of individual cases ; but they
should be  persisted in until the gums are affect-
ed or the disease  is arrested.   In children very
generally, and in adults  not  infrequently,  the
disease will be either much mitigated or alto-
gether arrested before the effect upon the mouth
is produced by the mercury.   The application
of the mercurial  ointment to  a blistered sur-
face, and rubbing it on  the insides of the thighs
and arm pits, have been likewise recommended;
but the exhibition of calomel internally, partic-
ularly with the remedies  here advised, is much
more efficacious,  these remedies accelerating
the operation, and securing or promoting the
beneficial  effects of the calomel upon the local
disease as well as upon the constitutional dis-
turbances.   In  some cases, the  hydrargyrum
cum creta may be given, particularly when the
bowels are irritable, with opium  and ipecacu-
anha ;  but it is not so  entirely to be depended
upon as the calomel.
  98. The good  effects of calomel, prescribed
as now advised, are less immediate than those
of tartarized antimony, but more certain and
permanent; it should,  therefore, be preferred,
particularly when  the disease is advancing to,
or has far advanced in, the stage of hepatiza-
tion.  It is also a much safer treatment  for
children than that by antimony in aid of blood-
letting ; but for them, James's powder or ipe-
cacuanha should be given with it, in preference
to other medicines, and opium should be omit-
ted, unless the child is several years of age.
The great advantages of this treatment are  its
influence in lowering local and  general vascu-
lar excitement; in relaxing the cutaneous sur-
face, and  equalizing the  circulation ;  in pre-
venting the effusion of lymph,  and in promo-
ting the absorption of whatever may have been
already effused.
  99. d. In the early stages of pneumonia, ven-
aesection, as above advised, local bleeding  ac-
cording to  circumstances, tartar  emetic, mer-
cury, &c,  are the means which ought to be de-
pended upon.  Other remedies may, however,
be employed, either  in aid of these or with a
view of preventing a return of the inflamma-
tion. Blisters and  other external derivants should
be employed  only after the treatment advised
above has  been carried sufficiently far, when 
LUNGS—Inflammation of the—Treatment of Sthenic.
895
they will aid in removing existing congestion.
Purgatives  are not of much service;  still, the
biliary and other secretions should be promo-
ted,  and  the bowels  duly evacuated:  ends
which the means already recommended will
seldom fail to accomplish. ' Diaphoretics and di-
uretics should be  viewed as adjuvants merely,
and are but little required where either the tar-
tar emetic or the mercurial treatment  has been
prescribed  with due activity.  Of these  medi-
cines, the liquor ammoniac acetatis, ofthe spirit-
us aeth. nitrici, and ipecacuanha are the most
beneficial, and are generally valuable adjuncts to
the more energetic means previously  mention-
ed.  Expectorants  are  seldom required in the
earlier stages of sthenic pneumonia,  not even
after the inflammatory action is  removed, un-
less in old  persons, or  when the treatment has
occasioned considerable exhaustion, and  is fol-
lowed by a difficult expectoration.  They should
be employed with caution, or they may favour
a  relapse.   The  decoctum senega?, camphor,
and  ipecacuanha should  be preferred; squills
and ammoniacum should be prescribed only in
small  doses.  In this  stage too  much should
not be attempted by expectorants.   Nature will
generally perform her own work the best  when
not impatiently driven.   If she require aid, the
means just named, blisters, or the embrocations
hereafter to be noticed ($  110), will be sufficient.
A recourse to other  sedatives than the opium,
in the manner above advised (§ 97), is seldom
either required or beneficial.
   100. e. In the third stage—the  second of La-
ennec—when solidification has taken  place,  or
is far advanced or extensive, the chief  inten-
tions are, to procure the absorption ofthe effu-
sed  matter, to remove the attendant  engorge-
ment, and  prevent the extension of  irritation
or inflammatory action  around the  hepatized
part.  Blood-letting is now no longer of ser-
vice, unless it has been previously neglected or
very insufficiently practised, and the patient is
still plethoric, the veins  evincing considerable
fulness and the pulse much power.  A general
or local bleeding, or  both,  may be cautiously
employed in these latter  circumstances, partic-
ularly if crepitation be  still heard  in any part of
the lung ; but the chief  dependance should  be
placed upon calomel  and opium, which may be
conjoined with colchicum  or James's  powder,
or with digitalis, according to the peculiarities
ofthe case.  When this stage becomes advan-
ced, or has continued for some time, blisters,
rubefacient embrocations (§ 110), and salines,
with mild expectorants, digitalis, camphor, die,
according  to the  state  of the pulse  and  the
presence of fever, are often beneficial. In this
stage  of the disease, the decoction of senega,
in small or moderate doses, with  orange-flower
water, and full doses of the liquor potassa, or
the liquor ammoniae acetatis, with  the ammo-
nia in excess, or with camphor, and  spirits of
nitric  aether, or  either of  these  with digitalis
and  small doses of squills, are the most  appro-
priate medicines.  When there is much  cough
or irritation, alkalies, particularly the liquor po-
tassae, should be given  freely with  sedatives,
especially opium or henbane ; or the hydrocyan-
ic acid may be prescribed with demulcents and
diaphoretics.  When  fever is removed, but the
lung still remains partially hepatized or much
engorged, I have found small doses of the iodide
of potassium, with the liquor potassae, in a weak
decoction of senega,  or with sarsaparilla, of
great service, frequent recourse being also had
to blisters, or  to  rubefacient embrocations on
the chest.  If the vital energies become much
depressed in the course of this stage, our chief
reliance  should be  placed  upon full doses of
camphor or of ammonia, with the decoction of
senega, upon  stimulant  embrocations on  the
chest, and the  other means advised for the next
stage.
  101. /. In the fourth stage—the third of Laen-
nec—or that of suppurative infiltration (y 55)—
the chief indication is to support the powers of
life, in order to enable them to resist the exten-
sion of mischief  and to repair that which has
been done.  This, however, cannot frequently
be accomplished,  but it ought always to be at-
tempted ;  for  well-directed  efforts will  some-
times succeed in procuring the expectoration
of whatever puriform matter may pass into the
small bronchi, or in limiting the extension of
the suppurative infiltration, and subsequently
in  procuring its  absorption and the repair of
the lesions which have  been produced.  The
means with which these efforts should be made
must be varied with circumstances ; but cam-
phor, asafcetida,  ammoniacum, squills  (pilula
scillae comp.),  senega, ammonia, musk, myrrh,
sarsaparilla, iodide  of potassium, the mistura
ferri composita, liquor potassae, may severally
be prescribed, in various forms or combinations,
according to the peculiarities of the case, and
aided by stimulating  embrocations applied to
the chest ($ 110).
  102. g. If abscess occur  in this stage,  the
treatment need hardly be varied from that just
advised ; but the state of the pulse, the expec-
toration, the state of vital power, and the phys-
ical signs should guide the physician.  When
the symptoms of gangrene (§ 44, 56) appear,
the treatment should depend much upon  the
state of vascular  action and vital power attend-
ing it.  In most  cases, quinine, with camphor
and opium or henbane, or the decoction of bark
with soda and ammonia, and inhalation  of  the
vapour of creasote, are more or less servicea-
ble.  If vascular  action still continue much ex-
cited, and vital power not materially impaired,
local depletions, especially by cupping, may be
prescribed, even while the tonic and antiseptic
means  just  mentioned  are being  employed.
Dr. Stokes prescribed, in these cases, the chlo-
ride of lime with opium, as an antiseptic ; and
Dr. Williams, the nitro-muriatic  acid.  I pre-
fer camphor in full or large doses, conjoined
with the  other substances just mentioned, or
with expectorants and  alkaline  carbonates.
Laennec advised quinine or cinchona, either of
which may be given with the camphor, as above.
   103. h. There are various circumstances, some
of  them only of  occasional occurrence, which
require attention during the treatment of pneu-
monia.—a. A female may be seized with pneu-
monia without the catamenia disappearing, or
they may appear early in the attack; but this
occurrence is not to paralyze the treatment;
for, unless this discharge occur at an advanced
stage, or after active means have been employ-
ed, and unless it be attended by marked abate-
ment of the disease, blood-letting, general or
local, or both, should be adopted, according to
the circumstances of the case. 
896             LUNGS—Inflammation of the—Treatmf.nt of Asthenic
  104. b. The occurrence of  delirium during
pneumonia, a circumstance long and justly con-
sidered as very unfavourable, and as generally
precluding  blood-letting, ought not always lo
forbid a recourse to this treatment, particularly
if the delirium occur only in the night.   In sev-
eral  instances I have prescribed  venaesection
with marked benefit,  although this symptom
was  present, the other symptoms indicating
the propriety of it.  Two  of these were per-
sons between seventy and eighty years of age,
and in one of them venaesection was twice per-
formed.  They both quickly and  perfectly re-
covered.
  105. c. In persons  far advanced in  age, in
those addicted to the excessive use of spiritu-
ous liquors, in the ill fed and badly clothed, in
females during the puerperal states, blood-let-
ting  is often but ill tolerated ; and it  should,
therefore, be  resorted  to with  caution.   In
many of these cases, even a moderate sanguin-
eous depletion is fallowed by increased oppres-
sion, collapse, and extended congestion and in-
filtration of the lungs.  For these, the treat-
ment recommended for  the  asthenic disease (§
109) should be immediately adopted ; and cam-
phor, the balsams, senega,  asafoetida,  musk,
ammoniacum, squills,  &c, ought to be prescri-
bed in such forms and combinations as the pe-
culiarities of the case  may suggest, and be aid-
ed by rubefacient embrocations,  blisters,  &c.
In the cases of persons addicted to drunkenness
or to the excessive use of spirituous liquors,
due regard to these habits should be had during
the treatment, especially in the  advanced stages
ofthe disease.
  106. Calomel  and opium  were first  recom-
mended by Dr. Hamilton, of Lyme Regis, and
subsequently by Reil, Thomann, Wright, "Vo-
gel,  Hufeland, Schmidtmann, and several con-
temporary writers.  In severe sthenic cases, it
will  be often preferable  to combine them with
the tartarized antimony, or to give them in
much larger doses and at  longer periods,  and
the tartar  emetic during the  intervals, com-
mencing with them immediately after the first
bleeding, as advised above (§ 92).
 No. 287.  R Hydrarg. Chloridi, 3ss.;  Antimonii Potassio-
tart., gr. iij. ; Pulveris Opii puri., gr. v.; Confect. Ross,
q. s. M. Fiant PiluUe, viij.; quarum capiat duas 4tis, 5tis,
vel 6tis horis.

  107. No dependance can be  placed upon the
plan  of giving a large dose of opium alone after
the first blood-letting, as recommended by Tm-
lenius,  Kortum, Horn, and  Michaelis,  and
more recently advised by  Dr.  Armstrong.
Other preparations of opium, as the acetate or
muriate of morphia,  the bi-meconate  of mor-
phia, or the liquor opii sedativus,  may be used
instead of the pure opium, or the watery ex-
tract ;  but they should be given either with
calomel, or with antimony, or  ipecacuanha, in
order to secure a beneficial effect in this disease.
  108. As long as the pulse  continues hard or
sharp,  the  tongue dry,  and  the  skin  hot  and
unperspirable, the heating expectorants ought
not to be prescribed, nor should blisters be ap-
plied.  These symptoms, however, do not pre-
clude having recourse to the turpentine embro-
cation, which may be applied over the  chest in
the manner about to be described ($ 110), and
which generally, especially when  employed in
aid of the treatment by calomel and opium, or
by antimony, or by both conjoined, reduces the
frequency and  force of the heart's action, and
promotes a copious perspiration.
  109. B.  Treatment of  Asthenic Pneumonia
($ 62).—This form of the disease seldom ad-
mits of more than local vascular depletions, and
even these  should be prescribed with caution.
Where they cannot be  applied, dry cupping on
the chest or between  the shoulders, as sug-
gested by Celsus, may be substituted for them.
Camphor  is one of the most valuable remedies
that can  be given in this form of pneumonia.
It  was much employed  by Thomann, Reil,
Bayler,  Horn,  Schmidtmann, and  Willich,
and has been frequently prescribed by the au-
thor in this state of the  disease.  It may be
taken  in doses  of from  two  to  six or eight
grains, every four, five, or six hours, and con-
joined with calomel and opium, or with anti-
mony and henbane, according  to the  character
of the attack.  The latter combination may be
preferred when  the inflammation approaches
the sthenic form,  and  then the camphor may
be given  in the smaller doses ; the quantity of
it  being  increased as  the asthenic  character
predominates.   It  may  be farther  combined
with digitalis,  which is not contra-indicated in
this form ofthe disease.
   110. Embrocations with spirits  of turpentine,
applied over the chest or between the  shoul-
ders,  are the most valuable remedies that can
be used in this form of the disease, and in the
advanced stages of the  sthenic variety (v 30,
et seq.).  The  best mode  of resorting to them
is  by  means of two or three folds of flannel, of
sufficient width to cover the greater part of the
chest. These should be wrung as dry as pos-
sible  out of hot  water, be instantly sprinkled
freely with spirits of turpentine, and  applied to
the surface, taking care  to cover them, when
thus placed on the thorax, with a napkin, oil-
skin,  or other  material which may prevent or
much impede  evaporation.  This embrocation
should be kept applied as long as the patient
will endure it,  or be  renewed from time to
time.   Instead of the spirits of turpentine, an
embrocation consisting of equal  parts  of the
compound camphor liniment, and of the turpen-
tine liniment,  with a  little cajeput  oil, may,
after having been well  shaken, be sprinkled on
the warm flannel, and applied as thus directed.
I believe  that the inhalation ofthe vapour from
this embrocation is partly influential in produ-
cing the  benefit  which accrues  from it, and
which I have witnessed in many cases.
  111. In this form ofthe disease, and particu-
larly in its  advanced stages, the warm expecto-
rants may be severally employed.  The senega,
which was praised by  Thilenius, Hufeland,
Beaime,  Oberteuffer, and others,  is among
the best expectorant remedies in  this state of
the disease, particularly  when aided by other
appropriate  medicines; as the nelhers, hydro-
cyanic acid, the  paregoric elixir, &c.  Arnica
has been also much recommended, particularly
by Fischer, Hufeland, Rau, and other German
physicians.  I have had  no experience of its
effects in this malady.   Cinchona, or the sul-
phate of quinine, is advised  by Williamson,
Laennec, and others.  I have given the quinine
with camphor  and henbane with benefit.  The
infusion or tincture of valerian  is prescribed by
Horn and Thomann.  I have  tried it in a few 
LUNGS—Inflammation of the—Treatment of Asthenic.             897
cases combined with ammonia, and with nar-
cotics  and sedatives, and have found it most
beneficial  in the complication of  pneumonia
with the adynamic states of the eruptive fevers,
or with hooping-cough (T 70).  Ammoniacum,
asafetida,  myrrh, or squills may severally be
advantageously combined with soap, or with
an alkali or an alkaline carbonate, or with other
substances suitable to this state of pneumonia.
Musk was much praised by Reill  and  Horn.
M. Rkcamier has more recently employed it in
very large doses, and has viewed it as almost
specific in this variety of the disease.   Phos-
phorus  was  prescribed  many years ago by
Barchewitz ; but it does not appear to have
had  a sufficient trial, either  then or since, in
this  form of pneumonia, the only  one to which
it is appropriate.
   112.  In  the  typhoid  or  asthenic states of
pneumonia, as  well as in the advanced  stages
of the sthenic, when the disease  has assumed
the former character, and when diffusive infil-
tration ofthe cells and small bronchi has mani-
festly interfered with the functions of the lungs,
benefit sometimes results from prescribing the
decoction of senega in doses so large as to in-
duce vomiting, or from giving along with it the
sulphate of zinc, in sufficient quantity to produce
this  effect. In some  of the  complications of
pneumonia, particularly those with hooping-
cough, croup, and bronchitis, the emetic effect of
these medicines is often very beneficial.
   113. In the more malignant forms  of asthenic
pneumonia, more especially in those compli-
cations of it sometimes met with in adynamic
or putrid  eruptive and continued  fevers,  the
posture of the  patient should  be changed as
often as possible, as justly advised by Mr. Ger-
dy and  Dr. Stokes, in order to prevent  the
more depending portions of the lungs from be-
coming irreparably infiltrated or congested, from
a protracted retention of the same position.
  [Typhoid pneumonia is one of the most fatal
diseases which the American practitioner is
nailed  upon to treat.  This arises from excess-
ive depression  of nervous  energy,  and  a con-
sequent loss of tone in the pulmonary vessels ;
so that, as Dr. Williams  has well observed,
we might  empty the great blood-vessels, and
stop the heart's action, before the  congestion
of the lungs would be relieved, and their ves-
sels  enabled to contract.  In this condition,
the weight of medical  authority is decidedly
opposed to the  abstraction of blood from  the
general system, although local depletion is re-
garded  as  highly  beneficial  and  necessary.
Our  own experience in the treatment  of this
disease leads us to believe that  the local  ab-
straction of blood by cups  and leeches,  while
at the same time the nervous power is roused
by the internal administration of diffusible stim-
ulants  and tonics, and mustard cataplasms to
the external surface, will  be found the most
effectual mode  of relieving that congestion or
engorgement of the pulmonary structure which
is the leading phenomenon  of the disease.  To
this end, wine,  camphor, snakeroot, quinine,
and ammonia should be freely given ; but our
great dependance, after all, .except in the very
malignant form  ofthe disease, must  be on mer-
cury, which, beyond all other agents of the ma-
teria medica, is best calculated to restore tone
to the capillary system, and  arouse the dormant
    II.                113
energy of the cerebro-spinal axis.  This should
be given so as to produce slight swelling ofthe
gums, and its action should be maintained by
small and repeated doses, in combination with
camphor and Dover's powder.  In the typhoid
pneumonia of 1812, general bleeding was prac-
tised to a considerable extent by many physi-
cians, and, according to Drs. Gallup and Mann,
with very satisfactory  success.  The former
states  that  the first  indication  is,  to restore
warmth and activity to  the surface as quickly
as possible; which  he effected by the warm
bath,  or by wrapping the  patient in  several
folds  of blankets  dipped in  warm water, or
warm alcohol. The next remedy, says Dr. G., is
blood-letting, which is to  be practised early, and
in proportion to the pain and distress, without
much regard to the pulse.  Regarding the low
and feeble state of the circulation to be owing
to torpor and congestion, Dr. G. maintains that
bleeding relieves  this condition by unloading
the congested vessels, and thus imparting ner-
vous energy;  and that  it should he  practised
early, and carried to a sufficient extent, and
repeated even to  seven times,  if necessary,
without regard to  apparent debility.   " In my
own case," says this writer, " I was bled four
times, and never gained  ease that was any how
tolerable until the last time, when I perceived
by my feelings instantly that  I had gained the
point of relaxation from pain;  the blood was
stopped, and this was the end of extreme dis-
tress."—(" Epidemics," p. 299.)
  Sudorifics, particularly senega snakeroot, are
also highly recommended as adjuvants in the
treatment of  this  disease.   Emetics, we are
told, were found very useful  when the bronchial
vessels  were  loaded, and  expectoration not
very free.   In other cases, they proved inju-
rious ;  rich animal  broths,  of  an  agreeable
taste, were  beneficial, while cathartics  were
employed cautiously,  but often with benefit.
As a stimulant, Dr. G. speaks highly of a prep-
aration  of Peruvian bark, allspice, sugar, and
alcohol; while calomel, or  mercury  in  any
shape, except  as a cathartic, is ranked last in
the scale of efficacy.   On  this plan of treat-
ment, Dr. G. states that he proceeded in from
150 to 200 cases of typhoid pneumonia, and
lost but two patients (p. 311).   Dr. Mann, in
his "Medical  Sketches  of  1812-13-14," also
speaks highly of small and repeated bleedings
in this  disease, which  he  says proved  more
effectual than all other  remedies in rendering
the pulse fuller and slower, and increasing the
heat of the  body.  Stimulants were found al-
most invariably injurious ]
  114. C. Treatment of complicated Pneumonia.
—The complications of the  disease require not
merely strict attention to their nature, but also
to their characters, as respects the states of vas-
cular  action and  of vital power.  The treat-
ment must be based more especially upon these
latter, upon their sthenic or  asthenic states, and
upon the grades in which either of these char-
acters may be manifested; but also with due
reference to the nature ofthe complication.
  115. a. The association of pneumonia with
bronchitis, or broncho-pneumonia (t) 69),  requires
general or local blood-letting, or both, common-
ly in moderation, and a free recourse to tartar-
ized antimony ; afterward camphor, ipecacuan-
ha, and the milder expectorants, with sedatives 
898
LUNGS—Inflammation of the—Treatment.
and  rubefacient embrocations or blisters ap-
plied on the chest, are generally of service, and
accelerate  or ensure  recovery.  When pneu-
monia  is associated with double bronchitis, it
most commonly assumes an asthenic character,
and requires the remedies advised for that form
ofthe disease (y 109).
  116.  b. Pleuro-pneumonia, or the complication
with pleuritis (y 73), requires a free and prompt
recourse to general and local blood-lettings, in
Ihe manner advised above, and to the exhibi-
tion of calomel and opium, sometimes with col-
chicum or  digitalis.  In this  association calo-
mel and opium, in large or frequent doses, are I
especially beneficial in promoting the effusion
of lymph, and in procuring  the absorption of
what may have been effused ;  and although
the tartarized antimony is useful in addition to
these, it is less so in this complication than in
broncho-pneumonia, for which it is a principal
means  of cure, and to which the calomel and
opium  are  not so appropriate.  If the dulness
on percussion, buzzing, bronchophony, and oth-
er signs  (§ 75), indicate considerable  intersti- I
tial infiltration of lymph, and effusion from the
pleural  surface, calomel  or other mercurials
should  be continued or prescribed so as quick- j
ly to affect the gums ;  and blisters ought to
be repeatedly  applied to the side.   After  in-
flammation is  removed, and pleuritic effusion
only remains,  the hydriodate of potash, with
liquor potassae, may be prescribed internally, a
mercurial being given at bedtime ; and the ter-
ebinthinate embrocation, alternated with blis- j
ters, should be applied to the chest.  If the effu-
sion is so great as to endanger collapse or par- I
tial obliteration of the cellular condition of the J
lungs, paracentesis  thoracis, and the means ad- |
vised for this state in the article Pleura, may
be resorted to.
   117.  c. The complications of pneumonia with
eruptive or continued fevers (y 71) are frequent,
and require close attention, not merely in de-
tecting them, but also in recognising the exact
states  of vascular action and of vital power by
which  they are characterized.   Upon these
states  will depend the treatment which should
be adopted. When the fever, and consequent-
ly the  pulmonary affection complicating it, as-
sumes  much  of the  slhenically  inflammatory
character,  blood-letting, general  or local, but
more frequently the latter, will generally be re-
quired  ; but in large towns, and during the ep-
idemic prevalence of these  maladies,  unless
they assume a decidedly inflammatory or phlo-
gistic diathesis, vascular depletions should be
cautiously  practised ;  calomel and opium, tar-
tarized antimony, camphor and henbane, rube- j
facient  embrocations, blisters,   and  similar |
means  being  more  generally appropriate.  If
these complications, particularly with eruptive j
fevers, assume an asthenic or malignant form, the
means  recommended for the treatment of this
form of the disease (y 109,  et seq.) should be
promptly resorted  to, more particularly cam-
phor in full or large doses, with tonics, stimu-
lants, or antiseptics, or with these  and ano-
dynes,  according to the peculiarities of the case.
In these complications more especially, the as-
siduous application of the warm terebinthinate
embrocation to the chest (y 110) will be found
remarkably beneficial.  The complications of j
pnuumonia with fevers, both continued and erup- \
tive, are fully considered in the articles Fever,
Measles, Scarlatina, and Smallpox, to which
the reader is referred.
  118. d. Ofthe association of pneumonia with
hooping-cough (Y 70), it is unnecessary to say
more  than I have advanced in that article.
The treatment should depend chiefly upon the
character of the disease and  circumstance* of
the patient.   In most instances, however, after
moderate vascular depletion, most frequently
local,  anodynes, anti-spasmodics, emetics, ru-
befacients, and external derivants, will be found
most  beneficial.   During hooping-cough,  pneu-
monia rarely occurs in a pure form, but chiefly
in that of broncho-pneumonia (y 69).   In the ear-
ly stage, when the paroxysms of cough are not
followed by vomiting,  the occasional exhibition
of an ipecacuanha emetic will be of great ser-
vice ;  and, as the disease advances, conium,
hyoscyamus, or hydrocyanic acid, if the patient
be not too young, may be added to  demulcents
or diaphoretics,  in order  to  soothe the cough
and allay local and general irritability.  In the
cases of infants, however, these and other nar-
cotics should be used with  caution.  In this
complication, the terebinthinate embrocation
(Y 110) applied between the shoulders, or the lin-
iment rubbed along the spine, for a few minutes,
night  and morning, will prove very  beneficial.
  119. e. Croup, particularly when it is fatal, is
generally complicated with pneumonia.   After
local  depletions, the means  advised for the
complication with hooping-cough  (y 118) are
most  appropriate, aided by emetics of the de-
coction of senega with ipecacuanha or sulphate
of zinc, and  rubefacient  embrocations or blis-
ters applied  to the chest.   Calomel, antimony,
&c, are also generally requisite.
  120. /. The association of pneumonia with
influenza (Y  70) occurs,  as in hooping-cough,
in the form of broncho-pneumonia, and the treat-
ment  should  depend chiefly upon the character
of the existing epidemic.  In most instances,
both of such epidemics and of individual cases,
vascular depletions should be resorted to with
great caution.  In the many cases of this com-
plication which  I treated in 1837, even local
bleeding was not required ;  and in  a very few
instances, where only a few ounces of blood
were  taken by cupping, no benefit resulted from
its abstraction.   The treatment should not, in
this state of disease, be different from that
which I have advised for  the asthenic form of
pneumonia (§ 109)   See, also,  article Influ-
enza  (y 42).
  121. g. The occurrence  of pneumonia in con-
nexion with tubercles or pulmonary  hemorrhage
((} 76) requires  vascular depletions,  but gen-
erally local,  more especially by cupping.  Tar-
tarized antimony, digitalis, external derivation
by blisters and rubefacient embrocations, issues,
&c, are the chief means which  may  subse-
quently be prescribed.
  122. D. The remarkable prevalence and fatal-
ity of pneumonia  among  infants and children
(see v 80) require a few remarks.  It may be
asked, to what causes are the prevalence and
fatality owing 1    The former is manifestly ow-
ing chiefly, 1st. To the greater susceptibility of
the organs,  in  infancy and  childhood, to the
impression  of external agents, and  to  their
more  marked disposition  to react upon or after
the impression of sedative agents, such as cold, 
LUNGS—Inflammation of  the—Treatment.                    899
 if the  sedative  operation be  not such as  to
 overpower vital  reaction ; and, 2d.—a. To the
 circumstance  of this class  of patients being
 frequently subjected  to  the  depressing influ-
 ence  of cold, without  the  ability  of making
 those exertions  which may enable the circula-
 tion to resist this influence.   A child, before it
 can run about, is often carried out and exposed
 during too long a period to the  cold air in a
 state  of perfect quietude ; and,  although the
 surface ofthe body be warmly clothed, still the
 cold air  paralyzes the organic nervous influ-
 ence of the lungs, and causes congestion and
 engorgement of them, which are soon converted
 into inflammatory action, as  soon as removal
 into a warm air—often rapidly or suddenly ef-
 fected—develops vascular reaction.   A certain
 grade of cold, relatively  to the state of suscep-
 tibility and of vital action, is followed by in-
 flammation ; a greater degree of cold produces
 inflammation, which rapidly passes into disor-
 ganization.
   123. b. The fatality of  this  disease  in young
 children is chiefly ow*ingto the frequently latent
 form it assumes, to the  circumstances of the
 patient being unable to express his feelings,  or
 to convey a satisfactory  idea of his ailments ;
 to the complaint being often mistaken for a
 common eold, and to the  consequent  neglect  of
 a suitable treatment until the disease has ad-
 vanced beyond the reach of remedies.  Hence
 the  importance of an  early attention to pecto-
 ral  symptoms during infancy and  childhood.
 A neglect of these, and  allowing the slighter
 attacks  of pneumonia at this epoch to lapse
 into a chronic  state, or altogether leaving them
 to nature, are frequent  causes of  tubercular
 formations, in their incipient or  early stages,
 which may remain for years latent, or be slow-
 ly developed, to  burst forth in more  open dis-
 ease at some future period.
   124.  c. The  treatment of pneumonia in chil-
 dren is not different from that in adults,  due
 reference  being  had to  the age, constitution,
 nutrition,  and strength  of the child ; to the
 character or form of the disease, and the stage
 to which it has advanced. Very frequently the
 disease has advanced far before  it is seen by
 the physician, and  the period for vascular de-
 pletions has entirely or  wellnigh  elapsed, and
 then mercurials  and  external derivants  are
 chiefly indicated ; and these are very frequent-
 ly unequal to the control or removal ofthe dis-
 ease.  At  an early stage, blood-letting, calo-
 mel, James's powder, or other  antimonials,
 with suitable anodynes, are required ; but tar-
 tar-emetic should be given with great caution
 at an  advanced  stage; calomel,  with extract
 of poppies, the liquor  ammoniae acetatis, with
 vinum ipecacuanhae, and a few  drops of the
 spiritus ammoniae aromaticus, and rubefacient
 embrocations,  particularly the  terebinthinate
 (y 110), are then the  most efficacious reme-
 dies.   If blisters  be applied, they  ought not to
 remain on the part  above four hours, and they
 should lie  replaced by warm bread and water
 poultices, which  may  be  renewed every two
 hours.   Blisters are very apt to be followed by
 severe sores, or by sloughing, when  applied at
 an advanced stage of pneumonia,  if these pre-
cautions be not attended to; and the tartar-
emetic ointment  often produces  no less un-
pleasant  effects.  The embrocations here rec-
 ommended are  never productive  of  injury.
 Pneumonia in children most frequently exists
 as a broncho-pneumonia, but this circumstance
 does not materially modify the treatment now
 advised.   When the bronchitis is double, the
 attendant  pneumonia is generally asthenic, and
 requires the  remedies recommended for that
 variety (v  109, et seq.).
   125.  E.  Although pneumonia generally as-
 sumes  an  asthenic form in  aged persons, still
 this does not  always obtain.   In a few  instan-
 ces,  copious  blood-letting may be  prescribed
 even in  very aged persons.  I have directed it
 in a person aged about eighty years, and have
 mentioned above (y 104)  instances of  a suc-
 cessful recourse to it at nearly as great an age,
 even when delirium had supervened, the symp-
 toms  indicating high  phlogistic  action. In
 most cases, however, it should be  most cau-
 tiously, or only locally, or even  not  at all pre-
 scribed ; and  chiefly  at the very commence-
 ment of the attack, for the period at which it
 is beneficial soon passes  away.   I have, how-
 ever, found tartar-emetic alone, or with calo-
 mel and opium, well borne at a far-advanced
 age ; and expectorants especially beneficial, as
 the disease proceeds.  Blisters,  embrocations,
 and other external derivants are generally use-
 ful ;  and even  at  an  early  stage,  when the
 pneumonia is  complicated  with  bronchitis,
 which is often the case in aged as well as in
 very young patients, they may be prescribed.
   126. F. In the dark races, and particularly
 among individuals belonging to them who have
 recently migrated to cold countries, or to highly-
 elevated regions, and to changeable  climates,
 pneumonia generally assumes an asthenic form.
 In intertropical countries, also, these races do
 not bear copious blood-letting, even when the
 subjects of pneumonia.   It should, therefore,
 be resorted to among  them with  great cau-
 tion, in small quantity, only at  the  very com-
 mencement ofthe disease ; or it should be en-
 tirely omitted, and  the means advised for as-
 thenic pneumonia be had recourse to.  This
 inability to tolerate vascular depletions char-
 acterizing these races depends chiefly upon the
 greater laxity of their soft solids, and the na-
 ture of their diet, habits, and modes of living.
 The individuals of  the negro race born in the
 northern states of America, and much better
 fed than those living within the tropics, and ob-
 taining only poor or scanty vegetable food, bear
 blood-letting better  than they.
   127. G. Diet and Regimen.—The  diet  ought
 to be strictly antiphlogistic in the sthenic states
 of pneumonia  and their complications.  Muci-
 laginous or farinaceous fluids only should be
 taken, and  in  small quantity.  In  the asthenic
 form of the disease, light nutriments may be
 given, at rather short  intervals, and in  very
 small quantity.   Persons  addicted to the ex-
 cessive  use of intoxicating liquors may be al-
 lowed, in this  form of  the disease, and  partic-
 ularly in its advanced stages, certain quanti-
ties of the  beverages to the use  of which they
had become habituated.   Children affected by
the asthenic form  of the  disease may  be al-
lowed asses'  milk,  more or less diluted  ac-
cording to  the circumstances of the case. Ii
the disease in  them be  associated with gastro-
enteric irritation, as is not infrequently observ-
ed, this should be the chief or only diet. 
non of the—Chronic.
 900                    LUNGS—1stLAMMAT

   128. If gangrene  or  extensive  suppuration
 take place, jellies, beef tea, wine, &c , may be
 allowed.  As  convalescence commences and
 advances, weak  veal, or  mutton or  chicken
 broth, may  be given in small quantity, with
 boiled rice or with toast; and subsequently the
 lightest baked puddings, water-souchee flound-
 ers, and the white kinds of fish, &c, may be
 cautiously ventured upon.  Attention should be
 paid,  during convalescence and the  course of
 the disease, to the preservation of a free state
 of all the secretions and excretions.
   129. During the treatment the patient should
 be kept out  of currents of cold air, in a large
 apartment, the temperature  of which should
 not vary much above or below 60°.   In asthen-
 ic, prolonged,  or severe cases, the position of
 the patient ought to receive attention, with the
 view of preventing hypostatic congestion.  Res-
 piration and expectoration will be  favoured,
 particularly  when both  lungs  are  affected, by
 raising the chest by a bed-chair.  During con-
 valescence great care should  be taken at first
 in changing the apartment,  and subsequently in
 exposure to the open air.
   130 viii.  Chronic Pneumonia.—Chronic In-
 flammation of the Lungs.—Primary and consec-
 utive Chronic Pneumonitis.
   131. Dr. Stokes correctly remarks, that it is
 difficult to define  the  exact meaning of  the
 term  chronic pneumonia, or to draw the line of
 distinction between it and that low irritation of
 the lung which is followed by tubercular infil-
 tration ; and he seems to infer that  there  are
 two forms of the disease, the one producing
 the iron-gray and indurated lung, and the oth-
 er  forming,  or ultimately passing  into tuber-
 cular solidity.  The first he calls the simple
 chronic, the second the scrofulous  pneumonia
 Many of the cases of senile  phthisis may be
 referred to the second variety.  These forms
 of disease differ remarkably in their liability to
 produce suppuration.   Dr.  Stokes contends,
 that in  the  scrofulous  affection, suppuration,
 though  slow in its  occurrence, is almost sure
 to supervene; while in  the  simple  form  ab-
 scess is seldom observed, the termination being
 in that  hard and semi-cartilaginous  condition
 termed " induration gris" by M. Andral.
   132. Chronic pneumonia, in  a primary  form,
 is very rare.  It  is  commonly observed as a
 sequel of the acute disease, and as a complica-
 tion of other lesions of  the lungs, and in con-
 nexion  with prolonged  organic lesion of  the
 heart.   The gray  induration constituting  the
 more simple form  of the disease varies in its
 aspect like acute hepatization, according to the
 tissues chiefly affected.   It may thus assume a
 granular or oolitic aspect, owing to the thick-
 ening, as Dr. Williams contends, of individual
 vesicles.  In some  cases it appears  streaked
 and veined, from the hypertrophy of the  inter-
lobular  septa  and  cellular  tissue  around  the
vessels ; in others it is more uniform and of a
darker colour.   In this last  variety, the cellular
tissue between the lobules is sometimes thick-
ened to the extent of several lines, and is of a
light drab or gray colour, like that of miliary
granulations, and,  like  them,  has  almost  the
density of cartilage.
   133. These  changes  are  chiefly consequent
upon  acute pneumonia which has been imper-
 fectly subdued, but  they are  frequently also
found  complicating  tuberculous  states  of the
lungs ; the  solidifications, so  frequently  met
with in these states of the  organ, being en-
tirely identical with the  changes now deaci ibed
as being  a sequela of acute pneumonitis ;  and
hence  it  may  be inferred, as  noticed above
(v 67), either that chronic pneumonia may give
rise to tuberculous formations, or  that tnber-
cles may occasion a state of chronic irritation
of the substance of the lungs  followed by solid-
ification.   Probably both modes  of morbid suc-
cession may obtain in different cases, more
particularly the latter.   These chronic solidifi-
cations of portions of the lung are met with in
connexion, not only  with tubercles, but  also
with irregular dilatation of the air cells ; hence
the organ often presents a knobby surface after
death.
  134. A. The symptoms and signs of chronic
pneumonia are chiefly  the continuance, in a
less severe form, of those attending the acute
disease.   The cough, dyspnoea, or oppression
at the chest,  quickness of respiration, &c, are
still felt,  although less urgently, and are read-
ily induced, even  by slight exertion.   Quick-
ness of pulse and heat  of skin occur towards
night, and the improvement following the acute
attack is  either slow, or,  after  a  time, alto-
gether checked.  Partial dulness  on  percus-
sion, with some bronchial respiration,  and vo-
cal resonance, may be detected near the  seat
of inflammation.
  135. I  agree with Dr. Williams in his  re-
mark, that several cases of  consumption  ap-
pear to originate  in this way, independently of
any distinct tuberculous disease or diathesis ;
and I have at this time  a case of this kind un-
der my care.  In these, the previous health has
been good, and the chest free from any indica-
tion of disorder, before  the attack of acute in-
flammation,  which,  afterward  lapsing  into a
chronic state, has laid the foundation for con-
sumption, which  has ultimately  proved fatal.
This form of disease, however, is  slower and
less intractable than the true tubercular con-
sumption ; it is more local, and less constitu-
tional; and if circumstances do not promote
its extension, nature, aided  by  art, may  ulti-
mately effect partial or complete restoration ol
the organ.
  136. B. The treatment of chronic  pneumonia,
when consequent upon the acute disease, con-
sists of a mild course of mercury aided by ex-
ternal  derivation, by  means  of open  blisters,
or of tartarized antimonial ointment, or of ru-
befacient embrocations  (§ 110), or of issues  or
setons.   Either after the mercurial has very
slightly affected the gums, or soon after com-
mencing  the  use  of it, two or three grains of
the iodide of potassium should  be  given with
from 20  to  30 drops  of the liquor potassae,
three times daily, in any of the preparations
of sarsaparilla.  The doses of these medicines,
and the continuance of them, should, however,
be varied with  their effects,  and with the pe-
culiarities of the case.   Sea air, regulated diet,
and gentle exercise ought also to be recom-
mended.   (See art. Tubercular Consumption.)
II. Emphysema of the Lungs.—Syn. Pulmona-
  ry Emphysema.
    Classif.—IV. Class, II. Order (Author).
  137. Defin.— Constant  shortness of breath,
dyspnea,  $c., depending  upon excessive dilatation 
LUNGS—Emphysema of the.
901
of the air cells, or upon infiltration of air into the
connecting cellular tissue, or upon both.
   138. Previous to the time  of  M. Laennec,
emphysema of the lungs was viewed as an in-
filtration of air into the  cellular tissue of this
organ.  That pathologist, however,  extended
the application of this term so as to embrace
simple dilatation of the air  cells or vesicles,
and divided emphysema of the lungs into two
varieties, namely,  vesicular  emphysema, and
interlobular emphysema ; the former being dila-
tation of the air vesicles, the  latter infiltration
of air into the cellular  tissue which connects
them.  To these, a third variety has been added
by some  French pathologists, particularly M.
Bouillaud, consisting of an  extrication of air
immediately beneath  the pulmonary  pleura,
which is elevated in the form of a cyst, varying
in size.
   139. i. Vesicular Emphysema.—Dilatation of
the Air  Cells.—A. Description.—The lesion de-
scribed by M.  Laennec under this appellation
essentially consists, as I have just stated, of
dilatation of the air vesicles, with some degree
of change as respects their form.   The dilated
air cells vary most commonly from the size of
a millet seed to that of a bean.  Those  of the
largest bulk probably are sometimes formed of
several cells, owing to a rupture of  the parti-
tions which separated them.   Occasionally the
dilated  vesicles are not observable at the sur-
face of the lungs, but sometimes they are con-
siderably in relief upon  it, and even  are, in
some cases, elevated much  above  it.   More
rarely, single vesicles are observed on the sur-
face  of the  lungs  distended  to  the  size of a
cherry-stone, or larger, generally globular, and
apparently pediculated, owing to  a constriction
at the point where the cell begins to rise above
the  surface of the lung.  Cases of this kind
may  he distinguished  from  infiltration  of air
beneath the pleura by the circumstance of the
air not being  displaced,  or caused to pass or
circulate beneath this membrane when the ves-
 icle is pressed upon, as may be done when the
 air is infiltrated in  that situation.
   140.  When the air cells are inordinately dis-
 tended, and when this change takes place sud-
 denly, rupture of them, and a consequent infil-
 tration of air into the cellular tissue connecting
 them, are not infrequent.  This constitutes the
 true  emphysema,  and is nearly  allied  to that
 which takes place from  wounds or  laceration
 ofthe lungs.   In this case, vesicles of an irreg-
 ular form are found on the surface  of the lung,
 which may be displaced  by pressure with the
 finger.   These vesicles vary from the size of a
 hemp seed  to  that of a walnut, or even of an
egg.  M. Laennec remarks, that sometimes the
 air, although truly extravasated under the pleu-
 ra, cannot  be  displaced  by  pressure, as now
 mentioned.  This  is observed when the air is
 infiltrated at the point of reunion of the parti-
 tions which divide the different groups of air
cells.   In this case the  projection  has usually
a triangular form, and is small in size.
   141.  The infiltrated air seldom penetrates to
any considerable extent into  the substance of
these interlobular partitions, nor into the cellu-
lar tissue surrounding the  blood-vessels and
ramifications of the bronchi;  but  the interior
pulmonary  substance  is  sometimes lacerated
by over-distention of the air cells.   When this
is the case, an irregular projection is observed
over the site of laceration, and is proportionate
in size to it.   When the projection is divided
it is found to contain air, and sometimes a mi-
nute quantity of blood, either fluid or coagula-
ted ; and the surrounding air cells, forming the
immediate  walls of the cavity produced by the
rupture, are loose, flabby, and deprived of their
natural globular form.
  142. Accompanying this dilatation and occa-
sional rupture  of  the air cells, the bronchial
tubes, particularly those of a small caliber, are
sometimes, but comparatively rarely, dilated in
those parts of the  lungs where emphysema ex-
ists.  They are more frequently  inflamed and
partially obstructed.
  143. When a lung affected with this kind of
emphysema is dried  and afterward  cut into
slices, the  air cells are generally found  much
more dilated than  they appear externally; and
some of the cells are observed simply dilated,
while others are ruptured, the partitions of sev-
eral being more or less completely destroyed.
  144. This  form  of emphysema may  affect
both lungs at the same time, or one only, or a
part of one or both. When vesicles of a con-
siderable size exist not on the surface of the
organ, the  disease may be  overlooked during
post-mortem examinations.  M. Laennec con-
siders that the lungs of persons who have long
suffered from  dyspnoea, from whatever cause,
always present, upon  accurate  examination,
dilatation of the air cells, to a  greater or less
extent.
  145. When the  lesion exists in a very high
degree, and occupies one or both lungs, the
appearance is very striking.  When  exposed,
the lungs  seem  confined in the thorax, and
instead of collapsing, as usual,  often project
beyond the  margin  of its  divided  parietes.
They feel at the  same time firmer than natu-
ral, and are flattened or depressed with greater
difficulty.  They are also less crepitous than
in health, and the air escapes from them more
slowly upon pressure,  and with a sound re-
sembling that produced by the slow escape of
air from a pair of bellows.  When the lung is
detached, crepitation is  still less perceptible;
and when pressed, it produces a sensation sim-
ilar to that occasioned by handling a pillow  of
down ; probably owing to increased  difficulty
of communication between  the air in the cells
and that in the bronchia, together with dimin-
ished elasticity of the structure of the lung it-
self.   When a portion of emphysematous lung
is placed in water, it is observed to float more
lightly than a part which is healthy.   It is also
drier even at its roots, and less  moistened by
the sero-sanguineous infiltration often observed
after death.  When a single lung is affected, it
becomes much more voluminous than the oth-
er ;  sometimes so much  so as to press aside
the heart and mediastinum, and even  to occa-
sion an increase of the size of that side of the
chest.
   146. Emphysema of the lungs, which con-
sists of dilatation  of the air cells, is, therefore,
often consecutively accompanied with infiltra-
tion of air from  rupture of some of the cells,
but not always nor necessarily.   M. Laennec
considers the latter lesion to be of less conse-
quence than dilatation  of the  cells, inasmuch
as  the air  will be  absorbed and the rupture oc- 
902                              LUNGS'—Emphysema of the.
casionally be cicatrized, while the dilatation is '
a permanent change.
  147.  B. Causes.—This  kind of emphysema
ofthe lungs is generally produced by extensive
or severe bronchitis,  and particularly by those j
modifications of it termed by Laennec dry, suf-
focative,  and  latent  catarrhs.   He conceives
that,  in the dry catarrh, the smaller  bronchial
ramifications are  obstructed either by pearly
sputa, or  by tumefaction of the membrane li-
ning them; and that, as the muscles of inspi-
ration are much more powerful than those of
expiration, air will be  drawn into  the  cells
through the obstructed bronchi, without being
expelled,   succeeding  inspirations, which  are
forcible or energetic, introducing a fresh supply
of air into the cells, occasioning their disten-
tion ; and, when the obstruction ofthe bronchi
is of  considerable duration, rendering the dila-
tation permanent.  There can be no doubt that
one of the most  common antecedents of  this
form  of emphysema is  chronic bronchitis, par-
ticularly when it  is seated in the smaller rami-
fications  of the bronchi.  The obstruction of
these vessels, as  well as the share the air cells
themselves have in the inflammatory state,  will
so far injure their elasticity as to render them
more  susceptible  of dilatation  than  in  the
healthy condition.
  148.  Other causes may  also conspire to pro-
duce  this lesion  of the  air cells, such as long
retention of the breath, as in the case of play-
ers on wind instruments, and reading or speak-
ing aloud for  an unusually long  period.  Vio-
lent exertions  of any kind, which require  the
long-continued retention of the breath, are also
causes of this kind  of emphysema, although
more frequently of the kind next to be consid-
ered.   In rarer instances, this lesion may be
produced  by tumours obstructing  or pressing
upon the bronchi, whether those developed in
the lungs themselves, as cysts, tubercles, polypi
of the bronchi, &c, or those  produced exteri-
orly to this organ, as aneurisms of the aorta,
enlargements of  the bronchial glands, tumours
in the mediastinum, &c.  It may be also con-
sequent upon the spasmodic affections of the
large bronchi  sometimes attendant upon asth-
ma, bronchitis, croup, and hooping-cough,  and
upon tuberculous formations, and the solidifica-
tions attending chronic pneumonia.
  [Rokitansky believes that emphysema usu-
ally  results from  the forced  inspirations in
croup, hooping-cough,* &c, &c.  Louis denies

  * ["LaENNEC's views," says this pathologist," hold par-
tially true,  in emphysema from catarrh.  Still, we do not
believe that it is the long retention of the air which causes
the forcible expansion ofthe air cells, but, much rather, the
very deep and powerful inspirations which finally follow the
retarded expiration;  this  view gathers confirmation  from
the  effects  of the laboured inspirations in croup, bronchial
catarrh of children, and hooping-cough.  Besides the for-
cible dilatation, they may also cause  paralysis of the con-
tractility of the lungs, and consequent stagnation of air in
the dilated  cells.
  " Still, emphysema  undoubtedly develops itself in  some
cases in which such injurious influences have never been
present, and, in fact, slowly in persons who lead a sedenta-
ry life.  In these, the less frequent, but so much the deep-
er, inspirations are the more to be regarded, because they
take place  without the aid of the diaphragm, as the occu-
pation of these persons generally requires a bent position,
by which the abdominal cavity is compressed.  The para-
lytic and atrophied condition of the  diaphragm is of the
greatest importance here, for the prevented abdominal res-
piration is compensated by the laboured activity ofthe oth-
er great respiratory muscles ; and hence we find an evident
d.latation of the superior portions of the chest, while em-
the explanation offered by Laennec, and state*
that in nearly all  his observations the dyspnera
was not preceded by bronchitis.   In several in-
stances it occurred several years subsequently,
and the dyspnoea did not appear to be augmented
by the occurrence of an intense acute catarrh
It is worthy of note, that the maximum intensity
of emphysema is  at the free border ofthe lung
and its neighbourhood, whereas that of bron-
chitis is posteriorly and  inferiorly.  Grisolle
maintains, also, that pneumonia does not favour
the development of emphysema.   Louis sup-
poses that in vesicular dilatation, as well as in
bronchial,  there  is a force analogous to that
which presides over the development of hollow
organs, in virtue  of which these latter enlarge,
without our  being able  to account  for it by
means  of any obstacle or mechanical obstruc-
tion.   Emphysema has  also  been caused by
moral emotions;  it seems also to be more or
less hereditary.   Jackson found that  ont of 20
emphysematous patients, the parents of 18 were
emphysematous; and out of 50non-emphysema-
tous individuals, 3 only had asthmatic parents.]
   149.  C. Symptoms  and  Diagnosis.—Short-
ness of breath, and dyspnoea  more or less  ur-
gent  and continued,  are the  most remarkable
symptoms of this disease.   In all the cases of
it observed by M. Laennec, there bad been ha-
bitual cough.  Sometimes this  was slight, in-
frequent, and either  dry or  attended with a
scanty expectoration  of  a  viscid, grayish,  and
transparent mucus ; at other times it was more
severe,  occurring in  paroxysms and accompa-
nied by abundant opaque mucous expectoration.
There  is no fever, and the pulse is  generally
regular.  In  slight cases the habit of body and
complexion  aie scarcely altered ;  but in more
severe cases the  countenance assumes a dull,
physema is primarily and most folly developed in the ante-
rior portions of the upper lobes of the lungs.
  " The thickening ofthe walls of the dilated air cells- ari-
ses, doubtless, from the final coalition with them ofthe ad-
jacent tissues, which have become atrophied from the com-
pression exerted upon them.  Notwithstanding this, if the
dilatations increase, atrophy of the contiguous walls of the
cells will ensue, from the persistent pressure which the ad-
jacent cells exert upon one another, and several  of them
will unite to form larger cavities, as is also the case in rare
instances with contiguous bronchial sacs.
  " The dyspnoea in emphysema arises from a complication
of causes:
  "a. The excessive accumulation of air in the lungs pre-
vents the circulation in the capillary vessels which ramify
on the wall* ofthe air cells, by the pressure which  it exerts
upon them, and hence renders the arterialization of a suffi-
cient quantity of blood impossible.
  " 6. In the higher grades  of emphysema numerous capil-
lary vessels become obliterated, not only in the walls of the
air cells, but also in the adjacent atrophied pulmonary pa-
renchyma, and produces the above consequence in a still
greater degree.
  "c. The diminished contractility  of the lungs, and the
frequent  and laboured inspirations to which the lungs are
constantly urged, allow of only a very imperfect evacuation
of the air cells, and occasion a permanent accumulation of
highly carbonized air in them, which in its  turn  prevents
the arterialization ofthe blood.
  *' The impermeability of numerous capillary vessels leads
to an accumulation of blood in the pulmonary arteries, and
gradually effects an active dilatation of the right ventricle,
then of the right auricle and both ven<e cavse, and finally
of the venous system generally.  The predominant venosity
and cyanosis which ensues occasions the immunity of asth-
matic persons from tubercular diseases.
  "The  impermeability of the capillary vascular system
also occasions  the  anaemic condition of emphysematous
lungs, and renders the occurrence of cedema, stasis, haemor-
rhage, and pneumonia in them impossible.
  " It proves fatal by final paralysis of the lungs, by as-
phyxia, from the accumulation of highly carbonized air, by
paralysis of the heart, and vascular apoplexy of the brain."] 
LUNGS—Emphysema of the.
903
earthy hue,  and the lips  become  violet, and
somewhat  tumefied.  The difficulty of breath-
ing is constant, but is increased  by flatulence
of the stomach  and bowels, anxiety, exercise,
ascending heights; by indigestion or a loaded
stomach, catarrh or bronchitis :  it also presents
exacerbations or paroxysms, occurring  at  ir-
regular intervals, and continuing an indefinite
time. The dyspnoea and cough, however, should
be considered as being less the signs of emphy-
sema, than of the disease of which emphysema
is the consequence.
   150. This  form of emphysema of the lungs
sometimes begins in infancy.  It may even con-
tinue, when slight, from that period of existence
through  life, without materially  abridging  it,
if the person so affected live in an easy, regu-
lar,  and  abstemious manner.   It, however,
more frequently tends  to aggravate, modify,
and  induce other diseases, so as  greatly to di-
minish the probabilities of life.  The disordered
state of respiration always attendant on it par-
ticularly affects  the functions of the heart, and
ultimately its organization, giving rise, at last,
to dilatation and hypertrophy of the cavities of
the organs.
   151. When vesicular emphysema is confined
to one lung, or is much greater in one than the
other, the side thus affected is perceptibly larger
than the other, its intercostal spaces are wider
and  fuller, and it yields a clearer sound on per-
cussion.   If both sides are equally affected, the
parietes ofthe thorax are depressed much less
than natural during expiration, while the efforts
to accomplish  the  depression  are  very  much
greater; and the whole  chest, instead  of its
natural compressed form, is more rounded and
globular, swelling out both anteriorly and pos-
teriorly ; and yields a more  hollow or clearer
sound on percussion than usual.   Dr. Stokes
thinks that  the symptoms are  more  severe
when the lower lobes of the lungs are chiefly
affected.
   152. The only diagnostic or pathognomonic
symptoms are, however, furnished from a com-
parison of the indications derived from auscul-
tation and  percussion.   The respiratory sound
is inaudible over the greater part of the chest,
and  is very feeble  where it is audible, a very
clear sound being, at the  same time, produced
by percussion.   At intervals, also, particularly
when the patient coughs, a slight sibillous rat-
tle, or a clicking or cracking sound is heard,
occasioned by the displacement of the mucus
in the bronchi.   These signs, together with the
rational symptoms already enumerated (y 149),
and  the history ofthe case, will generally ena-
ble us to form a diagnosis.  When one lung is
principally  affected, the increased size and so-
norousness of this side will sufficiently discrim-
inate the disease from all others, excepting pneu-
mothorax, from  which, also,  it can readily  be
distinguished, as shown in the  article Pleura.
When vesicular emphysema exists in a very
high degree, Laennec considers that it may  be
accurately ascertained by the presence of what
he calls the crepitous rattle with large bubbles.
In this case,  the sound during inspiration and
coughing is like  that produced by blowing into
half-dried cellular membrane.  It differs from
the common crepitous rattle, in conveying the
idea  of dryness, and of being connected with
bubbles which are at once large  and unequal,
 the other rattle having qualities exactly the re-
 verse.   This phenomenon is, however, not fre-
 quent, nor of long duration, and occurs only in
 points of small extent.  It is more common and
 more permanent in the interlobular emphysema.
 In rare instances the patients are sensible of a
 crackling in the spot where  this rattle is heard.
 Dr. Williams has sometimes observed a sound
 of friction, seemingly produced by  the rubbing
 of lobules or cells against the costal pleura.
    153.  D. Progress and Prognosis.—Dilata-
 tion of the bronchial vesicles takes place only
 in a gradual manner.  When it has reached a
 certain pitch, it may continue stationary for an
 indefinite  period, or  afterward  increase,  or  it
 may even diminish slowly,  and disappear alto-
 gether.  This  last result is, however,  of com-
 paratively rare occurrence, and only takes place
 when the causes of the lesion  have  entirely
 ceased to act.   When the dilatation of the ves-
 icles is extreme and general throughout one or
 both lungs, the obstacle to  respiration is then
 very great and the danger  considerable, inas-
i much as this change indicates the existence of
 an antecedent lesion of great severity and im-
 portance from which it proceeds and with which
 it  subsequently becomes  complicated.    But
 when the vesicular emphysema is moderate,  it
 is  not to be  considered, in  itself, as a danger-
 ous affection.  According to M. Laennec, it is,
 of all the forms of asthma (of which disease he
 considers  it, but too generally and indiscrimi-
 nately, as the proximate cause), that which ad-
 mits the most of expectations of length of life.
| There can be no doubt that it constitutes  one
 of the most frequent pathological states exist-
 ing in cases of continued dyspnoea, particularly
 in the chronic forms ofthe  disease, and in  per-
 sons advancing in years who  have been sub-
 ject to the occasional causes of this kind of em-
 physema.  In general, it may be remarked that
 this affection is a consequence of another dis-
 ease of the respiratory organs, to which even
 more regard should be paid, both  as respects
 prognosis  and  treatment, than  to itself,  and
 more particulary of those noticed above (Y 148);
 and that it often supervenes upon and attends
 tuberculous  formations   and  solidification of
 portions of the substance of the lungs, conse-
 quent upon repeated  attacks of pneumonia, or
 upon the chronic states  consequent upon the
 acute form of that disease.
    154.  Dr. Stokes, among other  conclusions,
 arrives at the following  respecting the vesicu-
 lar form of emphysema :  1st. That the disease
 consists essentially  in an enlargement of the
 air cells ; 2d. That the rupture and coalescence
 of several cells is not a constant occurrence ;
 3d. That the disease increases the volume and
 rarefaction of  the lung  (when it is far ad-
 vanced) ; 4th.  That it may occur uncomplica-
 ted with any other affection except bronchitis,
 or it may exist along with other diseases, which
 are generally chronic ; 5th. That it may coex-
 ist with great dilatation ofthe tubes ; 6th. That
 it may be partial or general; 7th. That percus-
 sion gives a morbidly clear sound when the dis-
 ease has attained a  certain extent; 8th.  But
 that the cells may be so enlarged as to evince
 feebleness of  respiration without  change on
 percussion ;  9th. That the physical signs of
 bronchitis which occur, though indicating  dis-
 ease in the smaller bronchi, are not character- 
904
LUNGS—Emphysema of the.
istic ofthe affection ; 10th. That the stethosco-
pic indication is the want of proportion between
the sound of vesicular expansion, the results
of percussion, and  the efforts  of inspiration ;
11th. That the increased volume ofthe lung is
the source of an important physical sign;  this
increase being ascertained by measurement of
the chest, by displacement of the mediastinum,
by depression ofthe diaphragm, and by the lat-
eral displacement and the depression of the
heart; 12th. That the physical signs from aus-
cultation are much modified by the degree of
yielding of the thoracic parietes ;  the charac-
teristic feebleness of respiration  appearing  to
be directly as the amount of resistance to the
increased volume of the  lung;  13th. That the
intercostal spaces are not protruded in this dis-
ease ; 14th.  That cases  of it may  be divided
into two  classes, viz., those  in  which the dia-
phragm is unaffected, and those in which it is de-
pressed;  15th. That in the first class the abdo-
men is collapsed, and without  tumefaction  in
the epigastric or hypochondriac  regions, the
heau being in its natural position ;  16th. That
in the second class the reverse occurs; the liv-
er is depressed, and the heart so displaced  as
to be found pulsating as low as the ninth inter-
costal space ; the postero-inferior portions of
the chest sounding clear even to the last rib;
17th. That the volume of the lung varies  re-
markably at  different periods ; 18th. That when
it is greatest, all the physical  signs are most
evident; 19th. That the  cause  of its increase
is a return or exacerbation of bronchitis ; 20th.
That under treatment  calculated  to remove
bronchial irritation  the vesicular murmur may
return, and  the volume of the  lung be dimin-
ished.
   155. ii. Interlobular  and Sub-pleural Em-
physema.—The infiltration of air into the interlob-
ular cellular tissue,  or under the  pulmonary pleu-
ra, is the consequence either of a sudden and
immediate laceration of some of the bronchial
vesicles, as  in cases of external  injury, or  of
rupture of these vesicles from previous inordi-
nate dilatation of them (y 140) of some  dura-
tion—a consequence of the emphysema already
described.
   156. A. Anatomical  Characters.—When the
air is infiltrated into the compact cellular tissue
forming the partitions between the pulmonary
lobules, small bubbles or vesicles are formed at
the surface  of the  lungs, and disposed  in the
form of transparent bands, penetrating more or
less deeply  into the opaque  substance of the
organ, and becoming narrower  the more deep-
ly they pass into it.   These small bubbles of air
are occasionally, also, found in  the cellular tis-
sue in the course ofthe pulmonary blood-vessels.
Sometimes the interlobular bands of emphyse-
ma run parallel to each other, with sound por-
tions of  lung  intervening.  More  rarely, they
cross one another in such a manner as almost
to  isolate several  of the pulmonary lobules.
The transparency and want  of  colour of these
bands, by which they are readily distinguished
from the opaque pulmonary structure, are chief-
ly owing to the infiltration of the air, and to the
drier state of the cellular tissue into which the
air is passed.
   157. The  infiltration of air into the  sub-pleu-
ral cellular tissue gives rise to bubbles or vesi-
cles, sometimes of very considerable size, and,
 in rarer cases, the pleura is elevated into very
 remarkable bladders.  Upon pressing the bub-
 bles of air extravasated in this situation, they
 are  readily displaced and  made  to pass along
 the  surface of the lungs.  When interlobular
 emphysema is in the vicinity of the roots of the
 lungs, it frequently extends to the mediastinum,
 and thence to the neck and to the whole sub-
 cutaneous and intermuscular cellular tissue.
   158.  Although this kind of  emphysema ne-
 cessarily  supposes the rupture of certain air
 vesicles, the rupture has seldom or ever been
 satisfactorily demonstrated.  It has, therefore,
 been believed by some that the air is secreted
 in the cellular tissue from the  blood-vessels of
 the  lungs, and not extricated from rupture of
 the cells or smaller bronchi, and others suppose
 that it is exhaled into this tissue from the ob-
 structed cells and minute bronchi.
   159. The different kinds of emphysema now
 described—the  vesicular,  the interlobular, and
 sub-pleural—may coexist  in the same person ;
 but  this is a very infrequent occurrence.  The
 vesicles arising from morbid dilatation of the
 air cells may, in  such cases, be distinguished
 from those occurring from the  infiltration of
 air into the cellular tissue, by  means  of press-
 ure and insufflation, by  which  the air is not
 made to circulate, or pass from one part to an-
 other, in the former as in  the latter.
   160. B. The causes of this kind of emphyse-
 ma  are those of the vesicular emphysema, par-
 ticularly when acting in a very marked manner.
 Infants and children are  more subject to this
J lesion than adults, especially during attacks of
 croup, in the advanced stages  of pertussis, and
 in severe attacks of bronchitis, where there is
 much obstruction of the air tubes ;   and from
 fits of anger, or from struggling and crying,
 owing to the  violent inspirations taken in such
 circumstances.  Forcible retention ofthe breath
 during powerful  or long-continued exertions;
 wounds,  injuries, or laceration  of the  lungs;
 lifting  heavy weights, straining at stool, and
 the advanced state of the acute  suffocative ca-
 tarrh  or bronchitis, are  the most efficient and
 frequent causes of this kind of emphysema  in
 adults.  The spontaneous secretion or exhala-
 tion of air into the cellular tissue of  the lungs
 may possibly be  a cause of the disease; but
 this  has  not  been satisfactorily shown.  M.
 Laennec remarks that interlobular emphysema
 is very seldom consequent upon the  vesicular
 form ofthe disease, owing to the great density
 of the cellular tissue  intervening between the
 air cells and lobules, as shown by Reisseinsen,
 and perhaps to some degree of thickening of
 the parietes of these cells during the continu-
 ance of their dilatation.   Extravasation of air
 into the cellular tissue  connecting  the pleura
 with the lungs is much more frequently met
 with as a consequence of the vesicular species
 of the disease.
   161. C. The symptoms  and  diagnosis of this
 species of emphysema are, dyspnoea and short-
 ness of breathing suddenly following violent ex-
 ertion, or continuing in a marked degree after
 croup, suffocative catarrh, or any other disease
 which may have occasioned obstruction for  a
 time of the bronchi. In some cases the patients
 are sensible of a kind of crepitation in the part
 affected.    On percussion, the  chest  generally
 sounds well over the site of  the emphysema, 
LUNGS—Emphysema of the.                           905
unless an  engorged state  of the lungs from
peripneumony exists with it.   Auscultation de-
tects " the dry crepitous rattle with large bub-
bles," which Laennec considers pathognomonic
of this lesion, particularly when  this sign is
very distinct and continuous.  It is never want-
ing, and is always more marked than in the ve-
sicular emphysema.   Together with this sign,
a sound or sensation as of one or  more bodies
rising and falling, and rubbing against the ribs,
is usually perceived during inspiration and ex-
piration.   The dry crepitous rattle  with bub-
bles, and the friction of ascent during inspira-
tion,  and of descent during  expiration,  with
the occasional production of  the crepitation by
pressing the intercostal spaces over the affected
part, are  the  signs of this lesion most to be
depended upon, and are the least  liable of the
other stethoscopic signs to temporary interrup-
tion from  obstruction of the bronchial tubes.
Should  an external emphysema appear at the
same time with, or  subsequent to, the above
symptoms beginning in the neck, the nature of
the disease then becomes perfectly evident.
   162. iii.  Treatment.—A.  Of  Vesicular Em-
physema.—Care should be taken to avoid the ex-
citing causes,  more especially all exertions of
the voice, and exposure to the  inhalation of dust,
or of particles of any kind which  may float in
the air that is respired,  or of deleterious gases
or vapours.  Violent mental  emotions, and the
influence of cold and humidity, or other causes
of catarrh, coryza, &c., should also be shunned.
Attention ought to be directed to  the state of
the digestive organs ; the secretions and excre-
tions being preserved in a regular state,  and
flatulent distention of the stomach and bowels
being prevented.  These objects  ought to be
kept in view, particularly as respects those who
have had parents affected by the disease, even
although they may not themselves have experi-
enced  an  attack; for it would  appear,  from
what M. Louis has advanced, that the parents
of more than one half the patients  which he
treated had been similarly attacked ;  thus indi-
cating an  hereditary  predisposition to the dis-
ease in a very large proportion of those affected
by it.   In entering  upon the  treatment we
should endeavour to distinguish the cases which
are simple from those which are complicated, or
consequent upon  or  associated with organic
or other affections.   Most of  the means of cure
recommended for chronic  bronchitis  (see  art.
Bronchi, y 91, et seq.) are more or less benefi-
cial in this affection.  The medicines which I
have  found the most serviceable, particularly
when the complaint is exacerbated  by cold, 4c,
are camphor, myrrh, asafoetida,  and the  bal-
sams, with henbane, or extract  of poppy, or
opium ; the decoction of senega  with an aro-
matic water;  the liquor potassae, and small
doses of the iodide of potassium ;  the mixtura
ferri composita, with the alkaline sub-carbon-
ates and anodynes or narcotics ;  the compound
decoction of sarsaparilla, with an alkali and an
anodyne ; the sulphate of zinc, with  the com-
pound  ipecacuanha pill;  and the compound
squill pill, with soap, and the compound galba-
num pill. Rubefacient liniments and embrocations
(y 110), or a blister or warm  plaster applied to
the chest,  or  any of the stimulating liniments
prescribed in the Appendix (F. 296, et seq.), rub-
bed along the  superior parts  of the spine,  will
    II.             114
also materially contribute to the relief of the
patient.  The  inhalation of various balsamic
fumes or terebinthinate vapours, or the vapour
of tar, of creasote, or of iodine, when much
diluted in the steam of warm water, as advised
at another  place (see art. Bronchi, y 100); or
smoking  stramonium, opium,  or tobacco,  or
other narcotics, is generally very beneficial in
the more urgent cases.
   163. It has been supposed that vesicular em-
physema,  when once  established, cannot  be
altogether  removed.   Dr. Osborne and  Dr.
Stokes, however, think that the disease is sus-
ceptible of very great  amelioration, if not of
complete cure.   In this opinion I concur.  As
the disease is a consequence of hooping-cough,
bronchitis,  chronic pneumonia,  and  the  dry
catarrh of Laennec,  much of the treatment
which is appropriate to these maladies is also
suited to it.  When symptoms of congestion in
the lungs still continue, or when the complaint
has recently followed these or other affections
of the lungs, local depletion by means  of cup-
ping, or  even dry-cupping may  prove useful.
If local depletion be adopted, it should be re-
sorted to before expectorants and the means
just mentioned  are  prescribed.   It has  been
suggested by Mr. Martin and Dr. Stokes to try
the effect of strychnia in this disease ;  but the
contractility of the air cells and tubes can hard-
ly be restored  by  other  means than by those
which  will promote  the general tonicity and
health of the frame ; and of these, residing in a
pure,  dry,  and  moderately warm atmosphere,
and attention to all the digestive and assimila-
tive functions, are the most influential.
   164. B. When the disease is complicated with
some other lesion, as congestion, inflammation,
or  obstruction  of the  minute  bronchi, with
chronic  bronchitis or  dry catarrh,  or  with
chronic pneumonia, tubercular infiltration, or
solidification of portions of the lungs, the treat-
ment should be chiefly directed to these in the
first instance, and subsequently to the resto-
ration of the tone of the pulmonary cells, by the
several means  above suggested, and by those
more fully stated  in the articles Asthma and
Bronchi, and more especially by those recom-
mended for the chronic states of bronchitis.  In
some instances I have found a residence in as
dry and mild an  air as the sea-coast can furnish
of great service.  In two  or  three cases re-
moval to Ramsgate, Brighton,  Worthing,  or
Hastings has been advantageous.  The sea air
being invigorating to the lungs, voyaging may
prove of service, particularly  in the cases of
young persons affected with the slighter grades
of the complaint.
   165. C.  The treatment of interlobular and sub-
pleural emphysema requires few remarks.  When
air is  infiltrated in the  cellular tissue of the
lung, it is soon absorbed.  When it continues
or increases, it is  probable that the passage of
the air from the minute  bronchi into the cellu-
lar substance is not interrupted by the closure
of the minute laceration through which the air
passed ;  but the laceration generally closes by
means of the lymph effused, as these cases,
with few exceptions, recover, whatever means
may have been prescribed.
III. 03dema of the Lungs.—Pulmonary (Edema.
     Classif. — IV.  Class,  II.  Order  (Au-
       thor). 
906
LUNGS—-Hypertrophy and Atrophy of the.
  166. Defin.—Infiltration of a serous fluid into
the cellular tissue between the cells of the lungs,
and probably also into  the cells themselves, occa-
sioning dyspnea, cough, and short breathing.
  167. A. The anatomical characters of oedema
are, the pitting of the organ  on pressure, its
greater  gravity and paler colour than in the
healthy  state, its imperfect collapse  or subsi-
dence upon opening the  chest, and a copious
exudation of a frothy serum when it is divided.
C3dema ofthe lungs occurs generally as a con-
sequence of disease of the heart, particularly
ofthe valves  and orifices, occasioning obstruc-
tion to the return of blood from the lungs ; of
the exanthematous fevers ; of other diseases of
the lungs ;  and of obstructions of the kidneys,
liver, &c. ; it  thus arising from the same mala-
dies which occasion other dropsical infiltrations
or effusions,  and being often  associated with
serous effusions in other situations.   This le-
sion, although previously noticed by Albertini
and Barrere, was first correctly described by
M. Laennec ; by whom, as well as by other
writers, it was ascribed to two causes, viz., in-
creased effusion from  interrupted circulation,
and impaired  absorption of the serum poured
out to facilitate the vital functions of the lungs,
owing to excessive vascular plethora, impeded
circulation, or impaired vital power.  Laennec
believed  that a certain degree of cedema  at-
tends the  resolution  of  most cases  of pneu-
monia.  From this it will appear that it can
rarely be a  primary  or idiopathic  affection.
Slighter grades of it not infrequently  occur in
the advanced stages  of adynamic or typhoid
fevers, particularly  in the posterior or more
depending parts of the lungs, but generally in
connexion  with hypostatic congestion in the
same situation ; and are not to be distinguished
from this condition, or from  incipient conges-
tive pneumonia.
  [It is a frequent attendant upon Bright's dis-
ease of the kidney, and very often the imme-
diate  cause of dissolution in this complaint.
In 100 cases  of death  from  albuminous neph-
ritis, cedema of the lungs has been observed in
31 instances.]
  168.  B. The symptoms of oedema of the lungs
are very equivocal, and vary greatly with the
pathological states from which it arises. When
it becomes extensive,  it causes dyspnoea, short
breathing,  cough, and  serous  or thin mucous
expectoration.  The physical signs are a crep-
itant or sub-crepitant rhonchus, with the breath-
ing less fine or even than in pneumonia, and in-
dicating the presence of more fluid in some of
the larger tubes by the mucous rhonchus.  The
natural vesicular rhonchus is rendered indis-
tinct,  particularly at the lower  and  posterior
part ofthe chest; and percussion is followed by
a duller sound, especially in  those situations.
These symptoms  are  not very different from
those ofthe early stage of pneumonia ; but the
absence of fever and of the characteristic ex-
pectoration, and the  presence of cedema  of
other parts, and of other signs of the organic
lesions usually producing oedema of the lungs,
sufficiently distinguish the nature of the dis-
ease.  There can be no doubt of oedema occur-
ring much less frequently in the lungs than the
external  cellular  tissue; and it  probably is
never, or  is very rarely seen, but consecutive-
ly upon anasarca or external cedema.
  169. C. The treatment of oedema of the lungs
should be based entirely upon the  pathological
conditions which occasion it.  That which at-
tends or  follows low eruptive  or continued fe-
vers, particularly scarlatina, should be treated
by dry cupping, frequent change of position, by
diuretics, digitalis, senega, camphor, and the
means above advised for asthenic pneumonia (y
109, et seq.).
IV. Hypertrophy and Atrophy of the Lungs.
    Classif.—(See y 166.)
  170. i. Hypertrophy of this organ is rarely
met with in  a true or unequivocal  form.  A
spurious  form of it arises  in  consequence of
chronic pneumonia and emphysema.  A state
of the organ, which has been described by Dr.
Clendinning in connexion with disease ofthe
heart, and which consists of a denser, heavier,
and more developed condition, without any ap-
parent obliteration of the  vesicular  structure,
and either with or without  congestion, closely
approaches hypertrophy.   It  occurs  chiefly in
consequence  of hypertrophy of the right ven-
tricle  of the  heart,  with difficult circulation
through this organ.   It is evident that this as-
sociated  disease of both lungs and heart will be
attended  by shortness of breathing, more or
less  dyspnoea, particularly  on exertion, and
slight dulness of sound on percussion.
  ["The various  differences," says  Rokitan-
sky, " in  the size of the lungs depend, for the
most part, upon the number of the air cells, and
their capacity.  Enlargement of the lungs may
depend upon the presence of a greater number
than usual of air cells, which  are at the  same
time larger ; under opposite circumstances, the
lungs are reduced  in volume.  The  first  state
is generally connected with  a great develop-
ment  of the muscular and osseous systems,
and a comparative smallness of the abdominal
organs ;  hence it is most frequent in the male
sex.   The second is generally found when the
muscles  are less  large and firm, the  bones
more  slender and delicate, and the abdominal
organs large;  hence  it is most frequent  in fe-
males.
  "The lungs may appear large, either within
or beyond the bounds of normal development,
when any given number of their air cells are
dilated ;  under an opposite  condition of the
cells,  the lungs will seem  small.   The  lungs
may even appear larger with a smaller number
of air cells, than in other examples in which a
large number of air vesicles are crowded into a
small  space.   In the first case, the tissue of the
lungs  is  rarefied; in the second, it  is denser
and compressed.
  " Hence, in forming an opinion of the size
of a lung,  the density of  its  parenchyma re-
quires especial attention.   The two extremes
of excessive  rarefication  and extreme density
of the lungs constitute very important diseases,
of which we will  treat more fully  when we
come  to the consideration of the  alterations of
the texture of these organs.
  " Hypertrophy of the lungs doubtless results
from a remarkable combination of dilatation of
the air cells with simultaneous thickening of
their tissues; it is at times observed in the
vicarious development of one lung, when the
other, from  any given cause, has  become un-
serviceable.   This  variety  does  not depend
upon an increase in the number of the air cells, 
LUNGS—Abscesses perforating the.                       907
  but  in  a dilatation of the  existing ones, the
  walls of which have also become more massive
  and thick, while their capillary vessels are en-
  larged in caliber, or even  increased in number
  by the  addition of vessels  of new formation.
  The tissue of the lung is thus rendered more
  dense, but in particular more firm, and the lung
  itself resists the pressure of the air in a re-
  markable degree; it has, in fact, become larger,
  and its  thoracic cavity wider."—(" A Treatise
  on Path. Anatomy," translated by J. C. Peters,
  N. Y., 1845 )]
    171. ii. Atrophy ofthe lungs, or a state op-
  posite the foregoing, takes  place as  a conse-
  quence  of age ; the cells  becoming larger, ap-
  parently from the absorption or wasting of their
  intermediate parietes or septa ; the substance
  of the lungs being softer, paler, more flaccid,
  and less dense than natural.   A similar change
  is rarely observed in cases of chronic emaci-
  ation and debility.   Partial atrophy is  often ob-
  served as a consequence of bronchitis, tuber-
  cles, pneumonia, and  pleuritis.  Andral and
  Stokes have argued that, when a portion of the
  lungs does not  admit the air, owing to obliter-
  ation or obstruction of the bronchus supplying
  it, atrophy of it is  the  result, the  consequent
  deficient circulation of blood to it, and impair-
  ed nutrition, necessarily causing this ; and it
  has been even farther supposed that an impair-
  ed state of function of the lungs, or any limita-
  tion of the function, may have some effect of
 the same kind as respects the whole organ.
   [Rokitansky  remarks of atrophy ofthe lungs,
 that it " is exactly the opposite of the preceding
 condition ; it occurs in the most marked degree
 in old age, under the form of atrophia senilis
 ofthe lungs ; whenever it is  found at an earlier
 period, it depends upon a premature involution
 of the respiratory  organs,  and comes  more
 properly  within the limits  of pathology.   It
 consists in a dilatation ofthe air cells (emphy-
 sema), with  an alteration of their normal an-
 gulo-concave form to a roundish or elliptical;
 and this  dilatation  is  the consequence of an
 emaciation and thinning of their  walls, the
 vessels of which  finally become obliterated.
 In extreme cases, the walls ofthe air cells are
 atrophied to such a degree that  several of them
 coalesce  and form a larger cavity;  the  inter-
 lobular cellular  layer  has  disappeared,  and
 hence the lobular structure is  destroyed ; the
 parenchyma ofthe lung resembles an irregularly
 perforated net-work, while the lungs themselves
 are blanched, pale-gray  in colour, but spotted
 with  much, black pigment; they are soft and
 downy to the feel,  light in weight,  small in
 size; they collapse  as the thorax is opened ;
 when cut into, the air exudes sluggishly,  with
 a dull, diffused  sound, and their tissue is dry
 and bloodless.
   " This marasmus of the pulmonary organs is
 generally  connected with  an equally  marked
 emaciation of the tracheal  passages, dilatation
 and thinning of their walls, and dryness of their
 mucous membrane,  and the proximate cause
 of both is essentially the same. As a rule, it
 attains its maximum of development  in the
 peripheric  portions of the superior  lobes, and
 hence often occasions a remarkable dislocation
of the interlobular fissure, which gradually as-
sumes a vertical position.—(Hourmann.)
  " The walls ofthe chest sink down upon the
 atrophied lungs, become flattened laterally, and
 take on a conical form ; the spine bends back-
 ward with a bow-shape ;  the sternum is thrust
 forward ;  and the vertical diameter of the chest
 is diminished by the spinal curvature, the con-
 sequent absorption of the intervertebral carti-
 lages,  and even  of the vertebrae themselves.
 The soft parts  of the chest, but especially its
 muscles,  are pale  and emaciated ;  the  dia-
 phragm is thin, lax, and lies in folds ; the heart
 is small.
    " The difficulty of breathing, the greater part
 of the  weakness,  pallor, and lividity of the tis-
 sues, and the general atrophy of aged persons,
 are owing to the above condition of the lungs.
 The small size  of the respiratory muscles ren-
 ders every inspiration imperfect; the loss of
 contractility of the lungs, together  with  the
 above  condition of the muscles, makes each
 expiration  equally  laborious and  imperfect ;
 while so large a portion of the capillary vessels
 of the  lungs are obliterated, that but a small
 quantity of blood is offered for arterialization.
   " If atrophy of the lungs occur at an earlier
 period  of life, and be far advanced, while that
 ofthe rest ofthe body is but little so, then the
 disease will acquire fresh importance from the
 superaddition of active dilatation of the right
 side of the heart.
   "A remarkable enlargement of the  lungs is
 present in emphysema ; lesser degrees, and in
 part only apparent increase in  size, take place
 in  hepatization,  high degrees of tuberculariza-
 tion, and in cancer ofthe lungs, &e.
   " A diminution of the size of the lungs may
 be induced by contractions of the thorax,  but
 in  particular by accumulations  of air or fluid
 within  the chest, as in pneumo-thorax, hydro-
 thorax, empyema, &c, or by obliteration of the
 bronchi."—Loc.  cit.]
   172.  V. Abscesses perforating the Lungs.
 —An abscess may  form,  or purulent matter
 may collect, in any of  the following situations,
 and, by perforating the tissue of the lung, pass
 into the bronchi, whence it may be evacuated,
 1. In the thoracic or abdominal  parietes, per-
 forating successively the  adherent pleura and
 pulmonary tissue; 2. In either of the pleural
 cavities, and thence directly passing into the
 lungs ;  3. In the anterior or posterior medias-
 tinum, through the pleura and lungs (see Medi-
 astinum, Abscess of); and, 4. In the liver, thence
 passing through the diaphragm and pleura, as
 shown in the article Liver (y 141).  The first
 of these rarely  occurs, the second still more
 rarely,  unless the purulent collection in the
 pleura is limited by adhesions of the opposite
 surfaces of this membrane ;  the third also rare-
 ly, but I believe more frequently than generally
 supposed.  In a  case recorded by Dr. Froriep
 (Medicinische Zeitung, July, 1834), an  abscess
 ofthe anterior mediastinum communicated both
 with  the lung and the vena cava.  The fourth
 mode in which abscess may perforate the lung
 is not infrequent; sufficient notice of it and of
 the phenomena  consequent upon it has been
 taken in the article Liver, Abscess of.
  173. VI. Gangrene of the Lungs.—a. Gan-
grene in this organ is always a consequence of
inflammation ; but  whether or not it be always
caused by inflammation seated in the substance
of the lung itself, or  in a large  vessel convey-
ing blood to a portion of the organ, causing ob- _ 
908                            LUNGS—Gangrene of the.
literation of this vessel, and consequent inter-
ruption to the circulation in that portion, has
not been  fully determined.  It  is not improba-
ble that it may arise from either, or from as-
thenic or congestive inflammation of a portion
ofthe substance of the organ extending to the
blood-vessels.  Dr. Stokes  seems  to believe
that it may proceed from the suddenness and
completeness of the congestion occurring in a
morbid state ofthe patient; and the cases which
he has instanced support this view.  In all these
the patients were long addicted  to  the use of
spirits : a cause, however, of artereitis as well
as of phlebitis.  In one case there was chronic
circumscribed gangrene, with an isolated slough
in one lung, followed by acute sphacelus in the
other;  in  another an enormous gangrenous
abscess,  succeeding  to contused injury  of the
chest;  in a third, a  gangrenous cavity  occur-
ring after causes likely to produce intense con-
gestion of the organ ;  and in the fourth, gan-
grenous  abscess supervening upon  asthenic
pneumonia.  Two instances of undoubted gan-
grene of a portion of the lung which  have oc-
curred in  my practice were  observed  in cir-
cumstances altogether  similar to the above ;
both were in persons whose constitutions were
injured by intemperance, and both followed con-
gestive or asthenic pneumonia, which had been
neglected in its  early stages.   One  of these
cases recovered by the aid of means  about to
be noticed.   Drs. Williams and  Hudson have
also recorded cases of recovery after gangrene
of a portion ofthe lungs, in the works referred
to in the Bibliography.
   [According to Rokitansky, who is,  perhaps,
the first living authority on the pathology of the
lungs, gangrene of these organs occurs under two
forms,  viz., diffused gangrene and circumscribed
or gangrenous eschar.  " In diffuse gangrene we
find a larger portion  of the lungs discoloured,
greenish, or brownish,  and filled with a like-
coloured, moderately frothy, flocculent,  turbid
serosity, which renders the affected parts soft,
rotten, and easily converted into a pulpy,  shred-
dy mass.   The whole gives forth the  peculiar
gangrenous odour. Towards the circumference
of the  gangrenous part, the discoloration, in-
filtration, and diminution in the firmness ofthe
lung gradually decreases,  and  imperceptibly
passes over into tissue which exhibits nothing
abnormal except simple, colourless oedema and
anemia.   It corresponds to diffuse gangrene
of the bronchi, and is almost always associated
with it;  it is rare, upon the whole, but always
attains a  considerable degree of extension, as
it commonly inculpates the whole, or, at least,
the greater part of a lobe. It is most frequently
found in  the upper lobes, under circumstances
which have led to the formation of emphysema
and anemia in them, and to passive stasis in
the lower lobes.   It may be  regarded  as so
much the less an essentially independent affec-
tion, as  it is almost always  associated with
gangrenous eschar of the lungs, and  hence may
be readily induced by the exhalation of  gas or
ichorous fluid from it upon  the  bronchial and
pulmonary mucous membranes ;  or  it may fre-
quently arise from a similar affection of a bron-
chus.   The above description of gangrene of
the superior lobes will answer in all  respects
when any other portion of the lungs  is affected.
It is distinguished in particular by the absence
 of all demarcation by means of a surrounding
 reactive inflammation.
   "As has already been remarked,  it should
 be carefully distinguished from softening of the
 lungs.
   " Circumscribed or partial gangrene of the
 lungs occurs in the form of gangrenous eschar,
 and is, beyond all comparison, far more fre-
 quent than the former  variety.   In  any one
 part of the  lungs,  we  may find  a larger or
 smaller portion of the parenchyma converted
 into a blackish or brownish-green, hardish, but
 moist and tough eschar, which adheres to the
 adjacent  tissues,  and gives forth  the  peculiar
 gangrenous odour in a very marked degree ; it
 is, as Laennec truly remarks, very similar in
 appearance to the eschar produced  by the ac-
 tion of lunar caustic upon the  skin.   It is
 sharply circumscribed,  and the  surrounding
 tissues may be in various conditions.
   " The  eschar  gradually separates from the
 adjacent  parts, and is then  found  seated in an
 excavation which corresponds to it in form and
 size ;  its circumference and  edges are soft,
 shreddy,  pulpy, and bathed in an ichorous fluid;
 its centre is a hard, firm, blackish-green plug.
 More frequently, however,  the  whole eschar
 breaks down  into a greenish, brownish, ex-
 tremely foetid, ichorous  fluid, in which are in-
 termixed many  rotten,  shreddy  remnants of
 parenchyma ; no trace of a  plug is left, and the
 whole is  contained within a cavity, to the walls
 of which a shreddy tissue infiltrated with  ichor
 adheres.
   " The  original size of a  gangrenous eschar
 and its cavern varies from  that  of a bean to
 that of a hen's egg; but usually the latter is
 not larger than a hazel,  or English walnut ; its
 shape is, upon the whole, irregular, but gener-
 ally somewhat roundish ; its seat is more fre-
 quently in the superficial than in the deeper
 parts of the lungs, and more frequently  in the
 lower lobes than in the upper.
   " These eschars either occur singly, or else
 several are present simultaneously.
   " Gangrenous  destruction attacks more and
. larger bronchi, the larger the gangrenous cavern
 orginally was  ; they form the passages through
 which the horribly foetid effluvia and sputa are
 exhaled and ejected. It attacks the pleura the
 more quickly, the nearer the eschar was origi-
 nally situated towards the surface of the  lung.
 If the  eschar should then  separate from the
 lungs, it will,  provided no adhesions prevent it,
 fall free into the cavity of the pleura ;  if it have
 already broken  down into  a  thick, ichorous
 fluid, then this will flow into the pleural sac,
 and  pleurisy, with  ichorous  exudation,  and
 pneumothorax will ensue ; either  the foetid gas
 which is accumulated in  the gangrenous cavern
 will alone form the pneumo-thorax, or,  if the
 cavern communicate with  the air passages,
 then both gas and atmospheric air will  be ef-
 fused into the chest.  Such superficial gangre-
 nous caverns may be recognised at a glance,
i after opening the thorax, for the  pleura  above
 them is either converted into a blackish-green
 eschar, the internal surface of which is shrunken
 and hardish,  or, if  the eschar  have already
 broken down  without  perforating the pleura
 then this latter will appear of a blackish-green
 colour, be moist, rotten, and puffed up by the
 gas in the cavern; finally, if the pleura  be la- 
LUNGS—Gangrene of.                              909
cerated in one or several places, or be perfo-
rated, or perfectly destroyed by a spontaneous
dissolution of its tissue, we will find the cavern
either partially, wholly, or not all concealed and
covered  by  the remnants of the  pleura, and
either partially or wholly emptied.
  " The original gangrenous abscess  should be
distinguished,  if possible, from one which has
undergone  a consecutive enlargement;  very
large caverns are rarely of primitive formation,
but have arisen from the extension of circum-
scribed gangrene; they, as will subsequently
be shown, are not circumscribed in  the  same
manner as primitive abscesses.
  " The  pulmonary parenchyma  surrounding a
gangrenous  abscess  is at times in  a normal
condition, with the exception of being the seat
of a serous or sanguineo-serous  infiltration ;
when melting down of the eschar takes place,
diffuse gangrene may ensue in this to various
distances.   More frequently, however, we find
it in a state of reactive inflammation, of various
degrees of intensity and character.  Very fre-
quently,  simple asthenic stasis is  formed, and
gradually changes into inflammatory conges-
tion, in which it remains for a long  time, and
then slowly passes over into imperfect hepati-
zation.   In  consequence of a want  of energy
in this reactive inflammation, the original gan-
grenous destruction may extend into  it in vari-
ous directions  and distances, so as often to at-
tain to the size of a man's fist or child's  head.
In such cases,  the adjacent tissues become dis-
coloured more or less rapidly, without the suc-
cessive extensions being marked  by any dis-
tinct  limitation,  and break down into a  gan-
grenous, ichorous pulp.  In this  way, the gan-
grene may reach the pleura, and there occasion
all the consequences which have been alluded
to ; and if the  pulmonary pleura be adherent to
the costal,  this also may  be  involved in the
destructive process.
  " Frequently we find the surrounding tissues
forced into  a  higher degree  of  inflammation,
viz., that of evident  hepatization,  which  is at
times so extensive as  to include the whole of
the lobe  in which the gangrene is  located.  It
often happens  that the  disease proves  fatal,
mostly in consequence of the severity of this
reactive inflammation.
  " The  most important  process,  however,
takes place in  the tissues immediately  sur-
rounding the cavern, and must be regarded as
a natural curative endeavour.  The reaction
here appears as an inflammation of  the  inter-
stitial cellular  tissue, which, together with the
walls of the cavern, passes over into suppura-
tion, and thus  effects the separation  and ejec-
tion of the sphacelated parts.
  "At the commencement of this  process, the
gangrene still  progresses in  single parts, and
we find the pus, which is secreted from the walls
of the forming purulent abscess, still mixed with
gangrenous  shreds of  tissue,  and with ichor.
In the course  of time, the suppuration  gains
the upper hand, and, after the spachelated parts
are ejected through the bronchi, the cavern is
changed  into  a  simple  suppurating abscess.
The  internal parts of the walls  are  infiltrated
with pus; beyond this, for three, four, or six
lines, the parenchyma  is grayish-red and firm,
and in case  the inflammation ofthe interstitial
tissue is  coupled with croupous exudation into
the air  cells, we find  a scarcely perceptible,
very minute granular texture.  If the suppura-
tive process in the internal layer of the capsule
now abate, a cavity will be  left, with whitish,
cellulo-fibrous, callous  walls, which sooner or
later approximate each other and coalesce in
the manner described when treating of tuber-
culous vomicae, so that nothing but a cicatrix
will remain.  This is the manner in which cir-
cumscribed pulmonary gangrene heals in single,
rare instances.
  " If the softening of the eschar progress very
rapidly,  and none or only very slight reactive
inflammation be developed  in  the adjacent
parts, or if the  primitive cavern enlarge itself
very quickly, then the  gangrenous destruction
may involve large blood-vessels, which have
not yet  become obliterated, and exhausting
haemorrhages ensue into the cavern, bronchi,
and, when the  abscess has opened into the
pleural sac, even into this latter.
  " Partial gangrene  often  arises in healthy
lungs, under the  influence of general depress-
ing causes,  especially  in weak,  decrepit,  and
dyscratic subjects ; it then develops itself out
of circumscribed passive stasis.   Besides,  it
associates itself,  when  aided by similar exci-
ting causes, with pneumonia, in all its stages ;
also  to  pulmonic abscesses, tubercles,  tuber-
culous vomicae,  and to bronchitis,  especially
that which arises in the course of various ex-
anthems.   Finally, it appears in the train of
typhus fever, as a local expression of a spon-
taneous degeneration of it  into putrescency;
or it may be excited by the absorption into the
blood of gangrenous ichor from distant abscess-
es, and  then shows itself in the lungs  in the
form of gangrenous and dissolving deposites,
or as septic capillary phlebitis."—Loc. cit.]
   174. b. The symptoms of gangrene of a por-
tion of this organ are chiefly the appearance of
a most disgusting odour of the breath and ex-
pectoration, rendering the patient loathsome to
those around him, and even to himself; with
general  sinking, or remarkable depression of
the powers of life, and  collapse of the features,
consequent upon a severe attack of asthenic
pneumonia.  The matter expectorated generally
consists of a foetid greenish, or of a dark-colour-
ed sanious matter or  fluid, sometimes  attend-
ed by a discharge of blood.  Dr. Stokes re-
marks, that the  stench is not constant; for,
during the progress of a case, it may disappear
more than once.   In some cases the expecto-
ration is foetid, while the breath is comparative-
ly free from odour ; but the gangrenous stench
is generally perceived when the patient is made
to cough.
   175. c. The  treatment of gangrene  of the
lungs should be based upon the intention of en-
abling the  system to  resist the contaminating
influence of the  septic matter  formed in the
organ, while means are being used to diminish
the septic tendency of the matter—while bark,
the chlorides, and camphor, with opium, are
taken internally; and wine in the intervals be-
tween the exhibition of these, chlorine gas, or
the fumes of creasote and camphor may be
inhaled.  Dr. Stokes  advises  the use of the
chloride of lime  and opium. In  the cases to
which I have alluded (v 173), a somewhat simi-
lar treatment to the above was prescribed.  In
the first, which occurred many years ago in dis- 
910
LUNGS—Malignant Structures in the.
 pensary practice, the decoction of bark with the
 chlorate of potash, and compound tincture of
 bark was  ordered, and  chlorine gas was in-
 haled.  Camphor  and opium were  also taken
 at intervals ; and  the  terebinthinate embroca-
 tion  was  almost constantly applied on  the
 chest.  In the second, which I saw  more re-
 cently in consultation, very nearly the  same
 means were employed, and the fumes of crea-
 sote and camphor were  inhaled.   In  this, the
 unsuccessful case, the remedies appeared for a
 time to arrest the disease.  Laennec recom-
 mends for this state  the sulphate of quinine,
 and Dr. Williams  the  nitro-muriatic  acid,
 which was used in the case which recovered
 under his care ; but the particular means should
 be selected with reference to the previous con-
 dition and the habits of the patient.
   176. VII. Tubercles are the most frequent
 lesions to which the lungs are liable.   They are
 fully considered, with  reference to this organ,
 in the articles Tubercles and Tubercular Con-
 sumption.
   177. VIII. Malignant  Structures in the
 Lungs.—The lesions truly malignant which are
 occasionally met with  in the lungs are, scirrus,
 encephaloid or fungoid disease—the  medullary
 sarcoma  of some writers—and melanosis.—A.
 Scirrus  or  cancer is very rarely observed  in a
 true or  unequivocal  form  in the lungs, and
 then only in the scirrous state, the subsequent
 stages of softening, ulceration, &c, of the in-
 durated mass not having supervened.   Scirrus
 of the lungs occurs only consecutively of can-
 cer in some other part, and most  frequently of
 the  mamma.  It may involve the parietes of
 the  chest, pleura, and  a  portion of the lungs,
 there being  firm adhesions  of the  pleura, a
 shrunk,  dense, and glistening state ofthe lungs,
 and  dilatation of some ofthe bronchi.   In rare
 cases, a portion ofthe  organ is indurated,  glis-
 tening when divided, particularly near  the large
 bronchi, and similar to scirrus ; and yet the ab-
 sence of cancerous disease from all other parts
 renders the malignant nature of this change
 very doubtful.  Dr. Corrigan has denominated
 this, or a very similar change he has observed
 in the organ, cirrosis  of the lungs.   Open or
 ulcerated cancer of the lung is rarely  or never
 seen.  Dr.  Bayle has recorded a case  in which
 this  change was said to  have been observed ;
 but he has not stated whether or not the ulcer-
 ated cavity communicated with the  bronchial
 tubes.
  178. B. Fungo-hematoid disease, or medullary
 sarcoma, is  sometimes  met with in the lungs,
 much more frequently than scirrus, and occurs
 either in separate tumours or infiltrated through
the organ.—a. The medullary tumours vary re-
 markably in this situation.  They are, in some
cases, soft and brain-like;  in  others, tough, j
more dense, or  even fibro-cartilaginous, or
 much softer, and resembling the pancreas in
colour and  consistence.  They are  either en-
cysted or irregular and non-encysted.   In some
they are loose, cellular, and vascular, and con-
tain patches of extravasated blood.  In others,
the texture of the morbid mass partakes of two
or more ofthe above characters.  Indeed, these
malignant formations—cancerous and medulla-
ry—are  modifications of nutrition, depending,
as I have remarked in the article Cancer (y
26), upon a  weakened and otherwise morbid
 state of the system generally, this state occa-
 sioning specific changes in the organic sensi-
 bility, nutrition, and secretions of parts, accord-
 ing to predisposition or concurring causes.
   179. b. When the medullary matter is infil-
 trated through the lungs, it appears as interme-
 diate between tuberculous  disease and chronic
 hepatization or consolidation, and is apt to be
 confounded with  either of those, if medullary
 sarcoma has not been detected also in some
 other organs or parts.
   180. c. While scirrus is, perhaps, never  pri-
 marily developed in the  lungs, medullary sar-
 coma may occur either primarily  or consecu-
 tively in them ^ or it may be coetaneous in this
 and in other organs or parts.   It  is obviously
 a constitutional malady, and depends originally
 upon a depraved state of the vital powers, in
 connexion with alteration ofthe circulating flu-
 ids, the albuminous portion of which is depos-
 ited in certain  parts, in an  exuberant and mod-
 ified form, and subsequently undergoes a low
 and morbid state of organization and nutrition.
 (See art. Fungoid Disease, &c., $  18, et seq.)
   181.  C. Melanosis is the  third form of malig-
 nant disease of the lungs, and is  met with in
 them either in  the form of distinct tumours, or
 as irregular, cellular-like deposites, or  as infil-
 trations of the natural structure, or, indeed, in
 the several states presented to observation in
 other parts of the  body.  It  may  affect  the
 lungs exclusively, but this is extremely rare.
 It is most frequently observed in this organ
 and in other parts of the body in the same case.
 It is occasionally associated  with  carcinoma-
 tous or with fungoid disease.  (See art. Mel-
 anosis.)
   182. D. Symptoms, &c.—The occurrence of
 these malignant diseases in the lungs  is rare,
 and ascertained with difficulty during life, un-
 less pectoral symptoms appear during the exist-
 ence of either of these maladies in some exter-
 nal part.  The symptoms  occasioned by them
 depend much upon the extent to which they in-
 vade the organ ; and the physical signs closely
 resemble those of solidification from hepatiza-
 tion or tuberculation.  The history ofthe case,
 the general symptoms, the  absence ofthe local
 or constitutional signs of tubercles, and the ca-
 chectic state of the system, with or without the
 appearance of anaemia, will serve to direct the
 diagnosis.  In the early stages of these mala-
 dies, however,  the symptoms are very equivo-
 cal,  and consist chiefly of impeded breathing
 and circulation through the lungs, with emaci-
 ation, cachexia,  anaemia,  dropsical effusion,
 dyspnoea, a leaden or livid  hue, &c.  At more
 advanced periods, the expectoration, which was
 previously  scanty or absent, becomes more
 abundant, and is  similar to that of bronchitis
or pneumonia, owing to the supervention of ei-
ther or  both in the course of the  malady, or,
rather, of the  destructive process occasioned
by the morbid  mass on the adjoining tissues.
In some instances the sputum is streaked with
blood, and, in  rare cases  of  melanosis, with
some black matter.
  183. When  these maladies  are developed
chiefly in the  lungs, they occasion death by
compressing or obliterating large vessels and
bronchial tubes, and by ulcerating, or destroy-
ing by their pressure, or otherwise  changing,
by invading, the  adjoining tissues.  Cavities 
LUNGS—Haemorrhage into the.                         911
may be formed in the lungs in consequence of
the pressure or development of fungoid or mel-
anoid tumours ; but this result  is very rarely
observed, unless consecutively upon the fungo-
haematoid tumour.
   184. The treatment of these lesions is alto-
gether hopeless when they implicate the lungs.
   185. IX.  Spurious Melanosis—Anthracosis,
Stratton—-occurs in the lungs in  a peculiar
form, and from a cause affecting only this  or-
gan, namely, from the introduction  of carbona-
ceous matter, or from the infiltration or imbibition
of carbonaceous molecules.  This  alteration of
the  organ was first noticed by Dr. Pearson,
and subsequently by Drs. Gregory  and Thom-
son (Edin. Med. and Surg. Journ., No.  109), and
by  Dr.  Carswell (Patholog. Anatomy,  article
" Melanoma").  This change occurs chiefly in
the lungs of old people, or of those who have
been long engaged in avocations by the light
of smoky lamps, or in mines ; and it has been
observed in various  grades.  When fully pro-
duced, both lungs present  a uniform  black or
carbonaceous  colour, affecting nearly all their
tissues.  The bronchial glands partake, also, of
the same colour.  This change has been shown,
by the experiments  and observations of Drs.
Christison and Gregory, to arise entirely from
the smoke, soot, and minute particles of coal-
dust inhaled during the respiration of air load-
ed with  these carbonaceous matters.  A por-
tion of these seem to be imbibed or absorbed
by the bronchial membrane, until a Considera-
ble accumulation  takes  place.  This may be
greater in certain parts of the pulmonary struc-
ture than in others ; but when it has advanced
far,  it  seems to act as foreign matter, and to
cause  or to favour the  development  of irrita-
tion, or even ulceration, or to render the lungs
more dense and friable, this organ  being even
infiltrated by a black serosity, and also broken
down  in parts into irregular excavations, in
the more extreme cases.  The physical char-
acters of this alteration—the uniform black col-
our of both lungs, the absence of any similar
discoloration of any other organ, its  occurrence
in persons habitually exposed to the inhalation
of the carbonaceous particles contained in the
air of  mines or of smoky apartments, and the
black matter colouring the organ being  shown
by experiment to consist essentially of carbon,
demonstrate clearly the origin and nature of
this change.
   186. X. Haemorrhage into the Lungs.—Pul-
monary Hemorrhage—Hemorrhage of the Sub-
stance  of the Lungs—The Pulmonary  Apoplexy
o/LAENNEcand other French pathologists.—In
the article Haemorrhage (y  96) I very fully con-
sidered the pathology and treatment of " Hem-
orrhage from the respiratory organs," or " He-
moptysis," as the disease has been very gener-
ally denominated.  In it the haemorrhage most
frequently proceeds from the bronchial mem-
brane,  although the blood may also proceed
from the substance ofthe organ, and, owing to
rupture of the vesicular and cellular tissues of
the organ, be poured into the bronchi,  and
thence be  ejected, or  be  carried  along the
smaller bronchial  ramifications.  It  is this lat-
ter, or pulmonary form of haemorrhage, to which
I shall  now briefly allude.
  187.  Hemorrhage from and into the substance
of  the lungs arises from the same  causes as
were  shown to produce haemoptysis, and pre-
sents  similar complications and pathological re-
lations as pointed out in that form of hemorrhage
(Y 108-120).   Pulmonary apoplexy or haemor-
rhage  (1) may be confined to the  vesicular
structure of a portion of lung, the blood being
poured out in the vesicles; (2). or  it may be
seated in the cellular tissue, or, having ruptu-
red the air cells, have passed into this tissue ;
(3)  or it may have  ruptured the pleura,  and
passed into the pleural  cavity.  These varie-
ties are usually preceded by pulmonary conges-
tion of longer or shorter duration.
  188. A. When the effused blood is enclosed
in the air cells, Dr. Carswell describes it as
forming a round,  circumscribed,  solid mass,
surrounded by the natural spongy tissue ofthe
organ.  The cut surface of this mass is of a
very deep red colour, has  a homogeneous as-
pect (excepting the open mouths of the bronchi
and large  blood-vessels, which  are  of a light
red),  and  a granular arrangement, which is
partly effaced by passing the edge of the scal-
pel  over it, thereby removing the coagulated
blood  from many  of the  air cells,  a minute
honey-comb appearance being thereby produ-
ced.  The size of the masses varies from half
an inch to two inches in diameter.
  189. B.  When the blood is poured into  the
cellular tissue, generally owing to laceration of
the  air cells, it spreads to a great extent, some-
times  to the greater part of a lobe, or even of
a whole lung.  In this  case a ragged excava-
tion is  formed, filled partly with  fluid, partly
with coagulated  blood, which penetrates por-
tions of the engorged and lacerated pulmonary
substance.  This form of haemorrhage may co-
exist  in the same portion of the lung with the
preceding.  When this is observed, the round
form,   circumscribed margin,  and  hardness
which accompany  the  first are well marked,
and in the centre of this, when laceration  has
occurred,  there  is  a quantity of coagulated
blood  (Carswell).
  190. C. The third  form is a consequence of
the second, the  effused blood occasioning la-
ceration, not  only of the cellular tissue,  but
also ofthe pleura.
  191. When blood is effused into the vesicu-
lar or cellular structure of the lungs, it may be
retained in these situations, or a part of it may
pass into  the bronchi,  and be expectorated.
The latter occurrence is much more common
than the former, and constitutes  a variety of
haemoptysis which  can rarely be distinguished,
during life, from that variety consisting of haem-
orrhage from the bronchi. The quantity of blood
which finds its way into the bronchi  is general-
ly in proportion to  the  extent or laceration of
the pulmonary tissue.   When  it is great,  it
may not only fill the bronchi of  the affected
lung,  but also those  of the opposite one,  and
thus occasion asphyxia.
  [Diagnosis.—The milder form of haemorrhage
into the lungs, or pulmonary apoplexy, "resem-
bles the severer variety of congestion of the
lungs  in its symptoms : according  to Laennec,
there  is great oppression of the  chest, with
cough, attended by  much  irritation of  the
larynx,  and sometimes  by very acute pain in
the  chest; expectoration of bright and frothy,
or of black and clotted blood, either quite pure,
or mixed with saliva or mucus;  the pulse is 
912                        LUNGS—Bibliography and References.
frequent and full, with a peculiar kind of vibra-
tion, even when soft and weak, as it frequently
is after a day or two ;  the heat of the  skin is
natural,  or nearly so ;  the  heart and arteries
frequently yield a marked bellows sound.  The
diagnosis ofthe disease is obscure, for Laennec
states that, of all the symptoms, the spitting of
blood is  the most constant, commonly copious,
returning by fits, with cough, oppression, anxi-
ety, intense redness,  or extreme paleness of
face, and  coldness  of the  limbs.   But every
pathologist  knows that circumscribed  pulmo-
nary apoplexy is frequently found in the cadav-
er, though there had been no haemoptysis dur-
ing life; again, the almost  invariable depend-
ance of haemoptysis, if at all considerable, upon
tuberculization  of  the lungs,  is  an  admitted
fact.   As about two thirds of all  cases  of  pul-
monary  apoplexy depend upon  disease of the
heart, generally  hypertrophy of the  right ven-
tricle, it is  evident that  if the above train of
symptoms set in, and there be no evidences of
tubercular disease, but marked signs of disease
of the heart, we may  at once  conclude upon
pulmonary apoplexy, the more especially if co-
pious  haemoptysis  be also present.   Laennec
placed great stress upon the presence  of  dul-
ness of percussion over the seat ofthe haemop-
toic infarctus, with absence of respiratory mur-
mur  there, but presence of  crepitant rattle
around the dull part; these signs, however, are
only found when  the  haemoptoic infarctus  is
seated on the very surface of the lungs, which
is not often the case.
   " Severe  apoplexy of the lungs is a more fre-
quent cause of very sudden death, in aged  per-
sons,  than  even cerebral apoplexy.   It may
commence with oppression of the  chest, diffi-
culty  of breathing, great lividity of the  face,
and coldness of the limbs ;  at other times, the
first symptoms are, a sense of extreme weak-
ness and oppression ;  the patient grows  pale,
and totters, or, perhaps, falls down,  yet he gen-
erally retains his consciousness, and may-even
be able  to tell the by-standers that his distress
is  in  his  chest; the face  is  blue, as in  one
strangled, the eyes project from their sockets,
froth  and  blood at limes  collect  before the
mouth,  and slight  gushes of black blood  may
occasionally follow; the breathing is short and
unequal;  there  is rattling in the trachea  and
bronchi; the pulse, from  being full  and strong,
rapidly  becomes small,  weak, and  fluttering;
the limbs are cold ; and, in  a quarter or half an
hour,  a  cold, damp  sweat breaks  out upon the
skin.  It is more dangerous than cerebral  apo-
plexy ;  life  is more speedily extinguished, and
remedial  measures are  altogether less effica-
cious ; the latter generally lasts twelve or more
hours;  this frequently kills  in  a half or one
hour.   The appearance of  the corpse is often
sufficient to indicate the disease :  there  is great
lividity over a  large surface of the body ; the
eyes are open  and projecting, as in drowned
persons; frothy, sanguineous mucus oozes from
the mouth in greater or less quantity,  accord-
ing as the head is  elevated or not; the  body
retains  its heat for a very long time, especially
in the epigastrium."—(Leveille.) — Peters's
translation of Rokitansky.]
   192. D. The  terminations of pulmonary  apo-
plexy are, 1st. Recovery.   This takes place  only
in the  first variety;  and in its  progress the
 granular arrangement  disappears, the margin
 becomes less defined, the deep red passes  into
 a dull purple or  leaden hue, or  into a lighter
 tint ;  the hardness diminishes, and the blood-
 vessels  and  bronchi become permeable.   At
 last the natural structure reappears.  2d. Sup-
 puration  and gangrene rarely supervene.  3d.
 Instead of being  absorbed, the blood has been
 said sometimes to become  organized or enclo-
 sed within  a cyst.  Dr. Carswell adds,  that
 he has not met with an instance of this.   4th.
 When the haemorrhage is excessive, it may be
 fatal either  instantly or in a very short time.
   193. E. The treatment of pulmonary haemor-
 rhage is fully discussed in the part of the arti-
 cle  Haemorrhage  above referred to. (See Haem-
 orrhage from the  Respiratory  Organs, y
 123, et seq.)
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LUPUS—Definition  op.                                   913
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 ticles on the Typhoid Pneumonia of 1812,  13,  14, in the
 New-England Jour, of Medicine, and the New-York Medi-
 cal Repository, edited by Mitchill and Pascalis, Gallup's
 Epidemics of Vermont, &c.)J
 LUPUS.—Syn.   Noli  me tangere;  Herpes ex-
   edens ;  Lupus  vorax ;  Herpes asthiomenes ;
   Formica  corrbsiva, Auct. var.   Cancer lupus,
   Sauvages.  Carkinoma faciei, Swediaur.  Phy-
   matosis lupus,  Young.   Ulcus  tuberculosus,
   Good.   Krebs der wolf,  Germ.   Dartre Ron-
  geante, Loup., Fr.   Canker,  Eating tetter.
     Classif.—IV.  Class,  IV.  Order   (Au-
        thor).
   1. Defin.—A chronic  inflammation of the in-
 teguments,  generally  of the face, commonly ap-
pearing as tubercles of various sizes,  singly or in
clusters, livid and indolent, followed either by ich-
 orous and phagedenic ulcers—Lupus  exedens; or
 by extensive changes in the skin, but without ul-
ceration—Lupus  non exedens;  the disease  being
neither febrile nor contagious.
   2. This disease  is commonly seated in some
part of the face, and has a tendency to destroy
or to  change both the part in which it occurs
and the  adjoining parts.   It is  not  always tu-
bercular, one  variety commencing  in a differ-
ent  form.  Although the disease is usually con-
fined to the face,  or even to one of its parts, it
may attack  at the same time, or successively,
several regions of the body.  Of the divisions
of the disease suggested by authors, that by M.
Biett is to be  preferred.    1  shall,  therefore,
adopt it, with  only a slight modification as to 
914                       LUPUS—Superficialis—Phagedenic^.
 its sub-division :  1st. Lupus with extension of
 the disease superficially.  2d. Lupus with pha-
 gedenic destruction of parts, or with extension
 in  depth; and, 3d. Lupus with thickening or
 hypertrophy of the affected part.
   3. I. Description.—i. Lupus Superficialis.
 —Lupus with superficial extension of Lesion.—
 This species may be divided into two varieties,
 that without tubercles,  and  that with them.
   4. A. Lupus superficialis non-tuberculosus, the
 superficial lupus without tubercles.   This va-
 riety attacks continuous surfaces of various
 extent, and destroys or alters the  superficial
 layers of skin.   It occurs  principally in the
 cheeks, and is not attended  either by tubercles
 or by incrustations.  The skin acquires a  yel-
 lowish-red tint, and is slightly elevated, par-
 ticularly at  the  margins of the affected part.
 A slight epidermic exfoliation takes place on
 its surface, which is smooth, red, or yellowish-
 red, and shining; and the exfoliation proceeds
 slowly and  without interruption.  It is unat-
 tended by pain,  but the part is somewhat ten-
 der when  touched, the redness disappearing
 nearly or altogether on pressure. After the dis-
 ease has continued for a very considerable time, j
 the skin appears to be much reduced in thick-
 ness, the  parts more recently invaded appear-
 ing red and slightly elevated.  As the disease
 subsides the epidermic  exfoliation ceases, the
 redness  declines, but the skin remains thin,
 atrophied, shining as if  seared by a hot iron, or
 resembling a cicatrix after  a superficial burn,
 and allowing the subjacent vessels  to  appear
 through it, as if they were imperfectly covered.
 The above  description  of this variety is taken
 from a case at present under my care, which
 commenced nearly  twenty years ago, in a spot
 about the size  of a bean, at which time I first
 saw it.   M. Rayer  believes this variety  to
 commence in a solitary  tubercle, and to spread
 by  the formation  of fresh tubercles  around
 those which already exist.   MM. Biett, Sche-
 del, and  Cazenave, however, admit  the  ab-
 sence  of tubercles in this variety.
  5. B. Lupus  Superficialis  Tuberculosus—Su-
perficial Tubercular Lupus.—This variety differs
from the former chiefly in the more or  less
manifest presence  of tubercles in its early as
well as in its advanced progress.   These tu-
bercles are small, soft, dusky, or yellowish-red,
and cover a space  of various extent.  They
may remain stationary for a  time, varying from
a few weeks only to several months, or even
years,  when  they may  suddenly become  the
seat of irritation.  Their numberthen  increases,
the  intervening  spaces appear swollen  and
cedematous, they coalesce by their bases, their
summits ulcerate, and they form a continuous
ulcerated  surface of irregular shape and  va-
rious extent.  The  cheek may thus be attack-
ed,  and the disease may slowly extend over
the whole face, destroying the alae of the nose,
and spreading even  lo the front of  the neck.
The tendency of this variety is to  destroy  the
surface of those parts on which it appears.   It
attacks not  only the face, but also, although
less frequently, the  chest, and the anterior  as-
pects of the thighs  and  extremities,  appearing
there in continuous patches.  The crusts cov-
ering the  ulcerated surface are thick, rough,
and blackish ; and when cicatrices form, they
are tender,  thin, and livid.   Tubercles often
 reappear in the midst of the cicatrices, and ul-
 ceration again takes  place in them.   When ul-
 ceration stops, cicatrization assumes the form
 of irregular white bands, stretching from the
 part where the disease began, and are similar
 to the cicatrices after burns.
   6. ii. Lupus  Phagedenicus.—Lupus Exedens
 -~Noli  me  Tangere—Lupus with  Extension in
 Depth.— This species generally begins with the
 appearance of one or more small tubercles oti
 the alae, or tip of the nose.  These tubercles
 are soft, smooth, and dusky, or yellowish-red
 coloured, and  their progress  is usually slow.
 This  species   occasionally commences as  a
 chronic inflammation of the mucous membrane
 of the nasal fossae, with swelling and redness
 of the  nose.   A thin scab then forms at the
 opening of the nostrils, and is succeeded by a
 thicker one ; and ulceration is established, and
 extends to the alae of the nose.   In other ca-
 ses, a livid tint,  with slight swelling of the
 point of the nose, is  the first indication of the
 disease.  The discoloration  increases, and a
 superficial sore is formed, which becomes cov-
 ered by  a scab, and the ulcer extends in depth.
 In some instances the disease begins in a sim-
 ilar manner in one of the alae.   As the ulcera-
 tion proceeds a  foetid  sero-purulent fluid is
 poured out beneath the scab, and  not only the
 integuments, but also the cartilage, are slowly
 and silently destroyed.  The nose  is some-
 times red  on  the  surface only ; and occasion-
 ally it becomes pointed,  sharp, and tapering,
 the nostrils tending to close.  The cartilage at
 the angle uniting  the two lateral  halves supe-
 riorly, seems  then to project, and presents  a
 red tint perceptible through the soft parts.
   7. The extent  of destruction thus produced
 varies  extremely.   In one case  almost  the
 whole nose is destroyed;  while in another
 the point only is  partially  injured, as if a por-
 tion was removed  by  a knife.  After the ulcers
 have been arrested and healed, new tubercles
 occasionally form in or near the cicatrices, the
 work of destruction recommences, and  the
 whole nose and septum ultimately disappear.
   8. The progress  of the  disease may be slow
 or rapid ; after several years a small portion
 only of the nose may be  lost;  and, less fre-
 quently, the whole of it may be destroyed with-
 in thirty or forty days—Lupus vorax.  Some-
 times the  least interference aggravates  and
 accelerates the malady; and after appearing to
 advance towards recovery, it often  suddenly
 assumes a more livid hue, and ulceration either
 recommences  or is extended.
  9. In rare cases, the septum  is destroyed
 before the  outer surface of the nose is impli-
 cated.   When  the  ulceration commences in
the skin of the organ, the mucous membrane
of the  nasal fossae  is generally chronically in-
 flamed,  and ultimately ulceration  takes place
in it also, and spreads along it,  being occa-
 sionally reflected to the arch of the palate and
to the gums, which are then deeply furrowed.
   10. The tubercles of lupus exedens are some-
times formed in the upper lip near the alae nasi,
or near the commissures  of the lips ; and the
consequent  scabbing  and ulceration  occasion
great pain, with destruction of parts.   The con-
sequent cicatrizations also give rise to deform-
ity of the lips and mouth.
  11.  iii. Lupus with Hypertrophy or Thick- 
LUPUS—With Hypertrophy—Diagnosis.
915
 ksiso—Lupus non-exedens serpigenosus, Rayer
 —is generally confined to the face, where it
 appears as an irregular cluster of little tubercles
 of a dingy red colour, soft, slightly prominent,
 and  indolent.  They  implicate often a great
 portion of one or both cheeks or forehead, or
 even of the whole face.   They do not ulcerate
 at their summits; but  their bases appear to ex-
 tend, and accidental sores sometimes appear
 at their circumference.  As their bases enlarge,
 the skin swells slowly, and rises so as to fill up
 the spaces between them.  An epidermic  des-
 quamation generally takes place from the  sur-
 face of the tubercles, and is  usually most re-
 markable around the circumference ofthe clus-
 ters where they  are most prominent.   As the
 disease continues,  the features become much
 enlarged, puffed,  and flabby ; and this irregular
 thickening, with the tubercular swelling  and
 yellowish-red and dingy tint, gives the features
 a hideous appearance, closely  resembling  that
 of the true leprosy, with which it was doubtless
 confounded in the Middle Ages, more especial-
 ly when the ears, as well as the alae nasi  and
 lips, were affected, as they sometimes are.   Ul-
 ceration rarely takes place in this species ; or,
 if it occur, it is accidental, slight, and superfi-
 cial, and  covered by very thin, laminated,  and
 slightly adherent crusts.
   12. This form of lupus sometimes  appears
 on the  extremities in one or more clusters of
 flattened  lenticular tubercles of a yellowish-red
 tint, changing into  patches of an irregular  cir-
 cular shape, covered by thin furfuraceous scales.
 These may continue for a long period station-
 ary and  small;  but they occasionally spread
 even so as to cover the greater part of a limb.
 The disease may also commence beneath the
 ear and on the nucha, whence it may extend
 to the throat or  shoulders, or to the occipital
 region, which then loses its hair.
   13. This disease  continues for an indefinite
 time.  The affected parts  never regain their
 natural appearance, even when the disease  sub-
 sides : the  tumefaction of the  skin and  sub-
 cutaneous cellular  membrane  diminishes,  the
 tubercles  shrink  and ultimately disappear, but
 the  skin continues thin, smooth, and  shining,
 as in the first variety of the disease (y  4).
   14. Either species of lupus may be, from the
 first, a local disease, or unattended by any very
 obvious constitutional disorder ;  but I have ob-
 served it most frequently  in persons of a scrof-
 ulous taint;  in those who suffer from chronic
 disorder of the digestive organs, and in females
 who are hysterical or  subject to derangement
 of the catamenia.
   15. During the progress of lupus, several in-
 tercurrent diseases may appear.   The most com-
 mon of these is erysipelas.  In lupus with  hy-
 pertrophy, the supervention of erysipelas may
 be favourable, the tubercles sometimes disap-
 pearing after the attack of that disease ; but in
 other forms of lupus the occurrence of erysip-
 elas often aggravates the  original malady.
   16. II.  Diagnosis.—Lupus may be mistaken
 for scrofula, cancer, true leprosy, acne rosacea,
 syphilitic  affections, and other tubercular  dis-
 eases.—a. The sores,  tubercles, enlargement
 of glands, and affections  of bones, attending
scrofula, present  certain  characters.   Scrofu-
lous ulcers extend by the detachment  of their
edges from the subjacent tissues and  the  for-
 mation of sinuses, in consequence of the soft-
 ening and suppuration of lymphatic glands, of
 caries of bones, &c. ; but the ulcers of lupus
 are the  effect  of a process that consumes the
 skin and adjoining parts from without inwaru.
   17. b. The red colour, the erythematic areola
 surrounding the indurations left by the pustules
 of acne rosacea, and these pustules themselves,
 usually seen in the vicinity of these indurations,
 sufficiently distinguish rosacea from the indo-
 lent tubercles of lupus.—c. The general tawny
 or lurid  hue of the skin, and the form and ar-
 rangement  of  the tubercles, which  retain the
 tint of the surrounding integuments, distinguish
 the  real  leprosy, or elephantiasis of the Greeks,
 from lupus with hypertrophy.  The tubercles
 of leprosy appear as small, knotty, unequal tu-
 mours, followed by swellings, which deform the
 face, these  tubercles being commonly dissem-
 inated in several parts of the surface  of the
 body.  The tubercles of lupus with hypertrophy
 are, moreover,  arranged in a circular form, ex-
 tending  at their  margins, which are definitely
 limited  and covered with  squamae; circum-
 stances which do not occur in leprosy.—d.  The
 thick incrustations  of  Impetigo  are  yellow,
 rough, and  not very adherent; those of lupus
 are of a  dark brown colour, thick, and very ad-
 herent.
   18. e.  The term " Noli me tangere" has been
 loosely  applied by  Home, Willan,  Bateman,
 and  S. Cooper, both to the tubercular indolent
 ulcerations  of lupus, especially when affecting
 the nose, and to the malignant or virulent ul-
 cers  which sometimes  attack this place,  the
 lower eyelids,  cheeks, or  lips; which  ulcers
 have been described by  Travers, Lawrence,
 Mackenzie, and Muller as cutaneous cancer,
 or malignant disease of the face.   These viru-
 lent  ulcers  of the  integuments of the face, which
 often commence in or near the lower  eyelid,
 or upper part of the cheek, have been confound-
 ed with  lupus by M. Rayer ;  while they have
 been distinguished from that disease by  Biett,
 Jacob, and Byron, and  from true cancer by
 these and by several other writers.  These vir-
 ulent ulcers seem to form a connecting link be-
 tween lupus on the one hand, and cancer on the
 other, as respects both their  local characters
 and  their constitutional relations.   They  re-
 semble the  former in their seat, in their being
 strictly local during the greater part of their
 progress, without affecting the adjoining glands,
 and  in their equally slow destructive course;
 while they nearly approach the latter in the ad-
 vanced period of life at  which they occur, in
 their commencing in a dark pimple or scab, in
 the lancinating  pains felt in  them at an advan-
 ced stage, and in their constant but slow  exten-
 sion ; no spontaneous check or arrest of their
course taking place when  left to themselves,
although, like lupus, they may be completely
cured by powerful escharotics and alteratives.
Dr. Byron, in a very interesting paper on this
kind of ulcer and lupus, has  instanced eight
cases of the former which  occurred  at an age
more advanced than that at which lupus is usu-
ally observed.
   19. /.  Lupus  generally commences in  sever-
al, or in a cluster of tubercles ;  cancer in a sin-
gle tubercle only.  The tubercles of the former
are soft and indolent; the tumour of cancer is
hard and painful,  is surrounded by a firm base, 
916
LUPUS—Treatment of.
and is the seat of occasional lancinating pains.
Cancerous  ulcers are, moreover, everted and
painful;  they present a fungous appearance,
without the dry, thick scabs  characteristic of
lupus.
  20. g. Syphilis affecting the face is often dis-
tinguished from lupus with great difficulty, es-
pecially when the disease is confined to tuber-
cles without ulceration.  The tubercles of syph-
ilis are larger and rounder than those of lupus,
are of a dusky copper colour, have much less
tendency to ulcerate than those of lupus, which
are flatter, softer, and covered by their squamae,
partially detached.   In the  state of  ulceration,
syphilitic tubercles differ from  those of lupus.
The syphilitic ulcer is deep, its edges are swoll-
en, sharply cut, and copper-coloured  ; the ulcer
of lupus is of a dull  red, and appears confined
to the skin.  In this  latter, the skin is first at-
tacked, then the cartilages, and afterward, and
rarely, the bones ;  while in the former the dis-
ease more  frequently begins in the  bones, and
extends to  the skin.   The tubercle of syphilis,
moreover, is  generally attended by pains in the
bones, by nodes, ulcers in the throat, palate,
&c., and by iritis.
  21. III. Prognosis.—Lupus is a most obstinate
disease, months, or even many years, elapsing
before it yields to treatment.   Lupus exedens
is seldom subdued until parts have been  exten-
sively destroyed.  It is, however,  less obsti-
nate,  and its  consequences less severe,if a ju-
dicious treatment has been adopted at an ear-
ly period, especially when its progress is slow.
Soft, bluish, or livid  cicatrices, surrounded by
tubercles of  various  sizes,  indicate  a renewal
of the disease in its most obstinate form.  The
establishment ofthe catamenia, which common-
ly produces a favourable change in most chron-
ic eruptions in females, has no beneficial influ-
ence on this.
   22. IV. Causes.—Lupus is a somewhat rare
disease.  It generally commences between the
seventh and twenty-fifth years of age, and very
rarely after forty.  It attacks women more fre-
quently than  men, and is more common in coun-
try places than in towns.  Although it  occurs
in all constitutions and diatheses—the robust
and the delicate—yet it is most frequently met
with in  scrofulous and weakly lymphatic habits.
Dr. Houghton states, that in Dublin, where the
poor are inured to poverty and want of cleanli-
ness, it  is often met with, although some of the
worst cases come from country places.
  23. V. Treatment.—The treatment of lupus
is internal or  constitutional, and external or local.
—A. Internal ox constitutional means should have
reference to  whatever disorder may manifest
itself in the  digestive or other organs, and to
the form of  cachexia which may be present.
Generally those medicines which exert an al-
terative with a restorative  effect are the most
beneficial; and which improve at the same time
the digestive, the assimilative, and the  excre-
ting processes.  The more superficial forms of
the disease are generally connected with the
scrofulous  diathesis,  and in these especially the
treatment advised for Scrofula is particularly
appropriate.  In these, as well as in  the others,
the preparations of iodine, especially in the com-
binations about to be noticed, are of great ser-
vice.
   24. The  chloride of barytes was recommended
by Bateman for this disease ;  but  its injurious
action on the stomach has prevented its gener-
al use, and the chloride of lime has been there-
fore more commonly adopted.  One drachm of
the solution of this substance may be prescribed
in a pint of water, and half an  ounce may be ta-
ken at first twice,  and subsequently thrice or
oftener in the day, the dose being also increas-
ed gradually.   The preparations of iron  have
also been used.  The tincture of the sesqui-
chloride and the  iodide  of iron are the most
beneficial.  The sulphate of iron and chalybeate
mineral waters, particularly those which con-
tain carbonic acid gas, are also of service.
  25.  The  animal oil o/Dippel has been  much
employed on the  Continent, commencing with
doses of five or six drops, and gradually increas-
ing them to twenty or twenty-five drops.   The
decoction of Fellz has also been advised;  but
these, as well as most other constitutional rem-
edies, generally fail unless aided by local means,
by light, nutritious diet and pure air.  The prep-
arations of arsenic, especially Fowler's solu-
tion, and the Asiatic Pills (each containing one
thirteenth of a grain of the white oxide of arse-
nic and two thirds of a grain  of black pepper)
have  been found influential  in arresting  the
progress of the disease.   The arsenical prepa-
rations  have likewise been employed in  con-
junction with alkalies, narcotics, especially co-
nium, and bitter tonics.  Small doses of the bi-
chloride  of mercury given until  the gums are af-
fected, or the same substance dissolved in the
compound  tincture  of cinchona, have also been
recommended by some physicians.   More re-
cently the combinations of iodine with mercu-
ry, or iodides of mercury, have been resorted to
with considerable success ; but the most deci-
ded benefit has been  found by Dr. Byron  and
others to have been derived from the internal
as well as  external use of the " liquor hydrio-
datis arscnici et hydrargyri" of a Dublin chemist,
generally commencing with  five drops,  given
three times  a day in distilled water, and  in-
creasing the  dose to  ten, fifteen,  or twenty
drops :  this  medicine being  diluted with  an
equal part  of pure water for  external applica-
tion.  The great efficacy of  this medicine in
lupus has been proved by Drs. Graves,  Hick-
son, Stokes,  Byron, and White, and by Mr.
Carmichael and  other surgeons ; and generally
in cases which had withstood iodine, arsenic,
and mercury, when separately or otherwise em-
ployed, than in the form of an iodide of arse-
nic and mercury.
  26. In all cases of this disease, a pure, mild,
and dry air;  the use of the  warm or vapour
bath,  or of the  vapour douche, and strict atten-
tion to diet and to the states  of the digestive,
assimilating, and  excreting functions, are requi-
site.  Excess in  the use of animal food, or of
fermented or distilled liquors, must be avoided
during the treatment; and the patient ought to
be restricted chiefly to farinaceous and mucila-
ginous articles of diet; and to the use of whey,
or of fresh milk with soda or Seltzer  water.
During a course  of internal medicine, external
or local means should  be carefully and constant-
ly applied ; and where there is much irritability
of the digestive  mucous surface,  and particu-
larly  when the internal  remedies above men-
tioned increase  or induce disorder  of the di-
gestive organs, these external means  should 
LUPUS—Treatment of.
917
 be  chiefly confided  in, while gastric irritation
 should be allayed by bland and digestible food,
 taken in moderate quantity.
   27. M. Lisfranc  advises  the  treatment  of
 lupus to be commenced with small or revulsive
 venisections,  three or four ounces of blood
 being taken  at as remote a  point as possible
 from the seat of disease ; and, when the irrita-
 tion is great, or the patient plethoric,  he rec-
 ommends a recourse to depletory bleeding.   Dr.
 Bateman states that, in three or four cases of
 lupous tubercles in the face, the muriate of ba-
 rytes, taken internally, proved of service.
   28. B. The local or external means  advised for
 lupus have been as  numerous as the  disease
 has been obstinate.  Before ulceration has com-
 menced  in the tubercles, particularly in cases
 of  lupus with  hypertrophy, local applications
 which  favour absorption should be preferred.
 Dr. Davies, of Hertford, M. Biett, and myself
 were among the first to employ iodine  and its
 combinations with this view, more especially
 the iodides of mercury and the iodide  of sulphur,
 in the  form  of ointments.   The development
 of erythema, or even of erysipelas, by these sub-
 stauces, should  not be dreaded, as either rath-
 er mitigates than aggravates the future  course
 of the  disease.  In  some instances, the appli-
 cation of the tincture of iodine more or less di-
 luted, or of the ioduretted solution of the iodide
 of potassium, may be premised.
   29. When  the application of these, or fric-
 tions with ointments containing either of these
 iodides, are inefficacious, or when  ulceration
 has  commenced,  recourse  should  be  had  to
 caustics.  Of these,  the most commonly rec-
 ommended are  lunar caustic, caustic  potass,
 the butter of antimony, the bis-nitrate of mer-
 cury, nitric acid, the animal oil of Dippel, and
 the preparations recommended by Frere Come
 and Dupuytren.  But these appear to be infe-
 rior in efficacy to the chlorate of zinc, and the
 liquor hydriodatis arsenici et hydrargyri, intro-
 duced by Mr. Donovan, of Dublin.
   30. When the disease is extensive the appli-
 cation of the more energetic caustics should be
 limited to a portion  only of the surface, each
 portion of it being touched in  succession.   If
 the  ulcerated surface be moist and  clean, the
 caustic may be applied to it at once ; but if it
 be covered by scabs, these should be previous-
 ly removed by poultices.  In  the indolent and
 hypertrophied variety, blisters may  be applied
 previously to  caustics.  The animal  oil of Dip-
 pel  has been  much used by Continental  physi-
 cians as a local irritant, in order to modify the
 morbid action, particularly when the nose is the
 seat of the disease.   It should be applied  by
 means of a small brush passed repeatedly over
 the whole of  the surface.  Dupuytren's pow-
 der  (consisting  of eight or  twelve  grains  of
 arsenious acid, and an ounce of calomel) is a safe
 caustic, and has been found  efficacious  in the
 slighter cases of the disease.   It should not be
 applied at once to a too large surface.
  31. Frere  Gome's arsenical powder or paste
 (consisting of  white  oxide  of  arsenic,  ten
 grains;  sulphuret of  mercury, two  scruples ;
 animal charcoal, powdered, ten grains) is a pow-
erful remedy,  and is most suited to old and ob-
stinate cases ; but it should not be  applied at
once to a surface of greater extent than that
of a shilling.   It is followed by an eresipelatous
 inflammation of the surrounding parts.  The
 bis-nitrate of mercury, prepared from one, two,
 or three  drachms of the proto-nitrate of mer-
 cury, and an ounce of nitric acid, is much em-
 ployed by M. Biett.   It excites erysipelatous
 inflammation.   It  may be applied over the ul-
 cers, tubercles, and scars,  which are soft, or
 purple, or are  on  the point  of breaking out
 afresh, by means of a small  brush dipped in the
 acid;  but it should not be  passed over  a sur-
 face of greater extent  than  a  crown  piece.
 Some scraped lint may then be placed over the
 cauterized surface,  and moistened with the
 acid.  Mr. Plumbe  states, he applied the nitric
 acid freely, and. produced a healthy sore  which
 readily healed.
   32. According to the observations of Dr. By-
 ron and  others above  referred to, these appli-
 cations may be superseded  by the chlorate or
 chloride of zinc,* and the liquor hydriodatis ar-
 senici et hydrargyri.   The former may be ap-
 plied in its solid form,  or, rather, the diseased
 surface should be touched with it, as frequent-
 ly as the state of parts, and as the effects pro-
 duced, may suggest.  The latter remedy may
 be  applied locally, from time to time, while it
 is being exhibited  internally.   It may be ap-
 plied in a wash or lotion, with  an equal  quan-
 tity, or more or less of water.
  33. During the treatment of this disease, care
 should be taken to prevent occlusion of the nos-
 trils by the contraction  of the scars.  This may
 be done by the introduction of apiece of sponge,
 duly prepared, which should be  persisted  in for
 a considerable time  after the cicatrices have
 formed.   Both during the local treatment, and
 after a cure has been effected, benefit will ac-
 crue from vapour or warm baths, and particu-
 larly from the vapour douche.  In such circum-
 stances, the douches and baths  of the Dauphin
 attached to the Thermes de Maria Therese at
 Bagneres  de Bigorre,  or a recourse to the
 douches and baths at Aix-la-Chapelle, or  other
 places, conjoined with the advantages derivable
 from changes of air, of climate, of regimen and
 diet, will  generally prove of advantage.   It is
 not  improbable that, in these cases, the regi-
 men and  diet—the  use of pure water and of
 vegetable and farinaceous food exclusively—so
 eloquently and argumentatively insisted  upon
 by Dr. Lambe, aided by  pure air and regular ex-
 ercise, may prove of essential service ; but as
 to this I am unable  to  speak from experience.
 In all cases, change of air,  particularly to the
 seaside, and the use of the means most suited
 to promote the  general health, or to remove
 associated visceral  disorder, ought not  to be
 overlooked.
  Bibliog.  and Refer.—Hippocrates, Predict., 1. ii., ed.

  * [The chloride of zinc should be mixed with two or three
 parts of flour, and moistened with as little water as possible.
 It is a caustic of great power, and requires delicate manage-
 ment. It should not be  applied thicker than one  or two
 lines, nor left on longer than six to ten hours; an applica-
 tion of one  line in thickness, for ten hours, will, in some
 cases, form an eschar of nearly a quarter of an inch in depth.
 The pain is of a very durable  character, compared with that
 of the arsenical paste or the nitric  acid; it is undoubtedly
 one of the best applications, in the doubtful-looking  ulcera-
 tions met with ou different parts of the body. Pure crea-
sote is a useful application in many mild cases ofthe ulcer-
ating form, freely pencilled over the surface with a brush.
The chloride of antimony and the proto-nitrate of mercury
have both been used with success by Philips (Lond. Med.
 Gazette, March 20,1840). Donovan's solution, with sarsa-
parilla, we have found the best internal remedy.] 
919
LYMPHATIC AND
LACTEAL SYSTEM.
Fasius, p. 98 (cp-irnra codiSucvoi, eating ulcers).—Celsus, L.
v. (Therioma).—Avicenna, fen. iii., 1. iv., tr. i., c. vi.—Ama-
tus Lusitanus, Curat.  Med., cent, ii., cur.  37.—Forestus,
Observ. Chir., 1. ii., obs. 9.—Bachelet de Lindry, sur la Dartre
Rongeante,  8vo.  Paris, 1803.—Patrix, L'Art  d'Appliquer
le Caustique Arsenical, 8vo.  Paris, 1807.—Lemasson, Nouv.
Biblioth. Med., 1826.—Jacob, in Dublin Hosp. Reports, vol.
iv., p. 282.—Plumbe, On  Dis. of the Skin,  8vo. London,
1827.—T. Bateman, Pract. Synopsis of Cutaneous Diseases,
edit, by Thomson, 8vo.  London, 1829, p. 408.—P. Rayer,
Traite Theor.  et Prat, des Mai. de la Peau, translated by
Willis, 8vo. London, 1835,  p. 671.—/. Green,  A Practical
Compend. of the Dis. of the Skin, <fec, 8vo.  Lond., 1835, p.
241.—H. Houghton, Cyclop, of Pract. Med., vol. iii., p. 169.
—R.  Willis, Illustrations  of Cutaneous Diseases,  folio.
London, 1841, pi. 50.— Cazenave et Schedel, Abreg6  Prat.
sur la Mai. de la Peau, 3d edit., 8vo.  Paris, 1838.—L. By-
ron, in Dubl. Journ. of Medical Science, vol. xxii., p. 57.
  [Am. Bibliog. and Refer.—Am. ed. of Cazenave and
Schedel, by  H. D. Bulkley.  New-York, 1846 ; of Rayer, by
John Bell.  Phil., 1846.—Worcester, On Diseases of the
Skin.  Phil., 1845.—Am. ed. of Plumbe, &c]
LYMPHATIC AND LACTEAL SYSTEM—
  Absorbent System.   Vasa Lymphatica;  Vasa
  Lymphifera; Systeme Absorbant,  Fr.   Die
  Saugadern, Germ.
  1.  Pathologist's  have very generally attribu-
ted not only  several  organic changes to  the
lymphatic system, but  also various functional
disorders.  That this  system is capable of an
increased  activity of its functions is probable;
but we have  no  proofs of the circumstance.
We merely infer it from the rapidity with which
fluids, or even morbid growths, are removed
during certain states of the frame,  or from the
operation of various substances on the body.
But  this  result may proceed from diminished
activity ofthe vessels  concerned in the produc-
tion of  those fluids  or growths, or from a re-
tardation or arrest of  the morbid action which
occasioned them, as well as from increased ac-
tivity of the absorbent  system.  Without, how-
ever, pursuing this subject at this place, I  may
remark, that it appears extremely probable that
the functions of the absorbent system are  con-
trolled by the vital energies of the frame  in a
similar manner to the  other vascular systems ;
that they may be  diminished, augmented, or
even  otherwise changed, by the varying states
of these energies ;  and that as the healthy are
opposed to  the morbid functions of  a part, so
the restoration of the latter to the former state
will necessarily be followed by a return also to
its original condition and form.
  2. It  was  acutely contended by Mr. Hun-
ter, that an  increased  state of vascular ac-
tion always coexisted  with diminished absorb-
ing function  in the parts where  the former
state  prevailed ; and that, as vascular action
was  lowered, the absorbent  function became
augmented.  There are many phenomena which
occur during disease, and in  the course of va-
rious  plans of treatment, which seem  to favour
this opinion.   But these may be explained in a
different manner ;  and by simply referring them
to  the different states  of  vascular action  and
conditions of the secerning apparatus merely,
of the existence of which  states we have  pos-
itive proofs, without calling to our aid an oppo-
site condition of a different series of vessels,
of which  condition we have no evidence.  In
order to illustrate this point, let us suppose that
we wish to remove  an effused fluid or a  mor-
bid growth—an ascites or  a  bronchocele—and
we  succeed in our  efforts.  The question is,
whether the means employed have  produced
the desired effect by changing the state of ac-
tion  of  the  vessels whence  the effusion  and
morbid formation proceeded, bringing hack this
action to the healthy condition, the absorbent
functions remaining unchanged ; or by exciting
or rousing the absorbing vessels which had be-
come impaired, particularly in the place affect-
ed.  It  is obvious that the  former of  those
effects merely would be sufficient to account
for the change  produced, without having re-
course to the latter ;  for we can scarcely sup-
pose that the means which would diminish ac-
tion in one series  of vessels would increase it
in another.   It is. however, extremely probable
that morbid  depositions and growths depend
not only on a diseased state of the vital actions
of a  part, manifested chiefly in its  capillary,
nutritive, and secreting  vessels, but  also upon
certain conditions of the circulating fluids ; and
that the same means which remove these  states
will seem to have  restored the healthy condi-
tion ofthe absorbing vessels, although the func-
tions of these vessels may have been but little
affected by them.
   3. The following case will illustrate this view.
A professional gentleman, well known to sever-
al of my medical friends, called upon me, com-
plaining of rheumatic pains in various parts of
the body, and of disorder of the urinary organs.
But his chief complaint was a tumour, as large
as  his head, on  the  right side.   It  was firm,
doughy,  and apparently fatty.   I  prescribed
the iodide of potassium with liquor potassae in
full  doses.  In the course of a few days the
rheumatic pains  had ceased, and  the  tumour
was very much diminished in size;  and after
a few weeks not  a vestige of the tumour re-
mained.   In this case the medicinal agents evi-
dently operated by passing into the circulation,
and thereby affecting the state of vascular ac-
tion and nutrition  in the tumour, and partly also
the  chemical condition of  the fatty deposite
in the cells, thereby rendering it more capable
of being absorbed.
   4. The influence of the lymphatics in pro-
ducing disease has evidently been greatly over-
rated by many pathologists, and particularly by
Hewson, Cruickshank, Isenflamm, Johnstone,
Soemmering, and Alard.  That the  functions
of this system may be disordered, and that they
may, owing to the properties of the fluids and
matters which they convey into the circulation,
be frequently instrumental in the production of
disease, cannot  be denied.  But that they are
often the seat of disease  seems disproved by
the rarity of their organic  lesions.  M. Andral
states that he has examined the thoracic duct
and principal lymphatic  vessels in upward of
600 cases, and found  but in very few instances
any appreciable changes in the parietes of these
vessels.
I.  Lymphatics, Inflammation of.—Syn.  Lym-
  phangeitis ; Lymphangitis ; Lymphatitis; An-
  gioleucitis; Lymphangioitis ; Inflammatio vaso-
  rum Lymphaticorum.  Entziindung des Sauga-
  dersystemes; E. der Lymphgef'asse, Germ.
  Inflammation des  Vaisseaux Lymphatiques, Fr.
     Classif.—III. Class,  I. Order (Author in
      Preface).
   1.  Defin. — Sharp, burning pain;  diffused
swelling, tenderness, and heat; red lines manifest
in the course of the absorbent vessels, when  exter-
nal parts are affected; symptomatic fever, <f-c.
  2. Inflammation ofthe absorbents or lymphat-
ics may be readily confounded with inflamma- 
LYMPHATIC  SYSTEM—Inflammation of  Lymphatics.               919
tion ofthe organ in which the inflamed vessels
are seated; and there is every reason to sup-
pose that both kinds  of inflammation may co-
exist, or the  one  supervene upon  the other.
There is no  doubt that lymphangeitis some-
times coexists with phlebitis, and that either,
especially the  former,  may give  rise  to the oth-
er ; in such cases, one of the diseases, partic-
ularly the phlebitis, may mask the other, ac-
cording  to the degree in  which  either is  af-
fected.
   3. Lymphangeitis occurs  chiefly  in  superfi-
cial parts, and is most frequently seen in the
extremities.   It much more rarely is observed
in large  absorbent  trunks, and in deeply seated
or internal organs.  M. Andral  found in up-
ward  of 600 dissections the parietes of the tho-
racic  duct inflamed in three cases only.  The
lymphatics proceeding from the mamma are not
infrequently inflamed, particularly in connexion
with lactation, or consecutively upon inflamma-
tion or organic lesions of the organ.  Those of
the lower extremities are also often affected,
either consequently upon abrasions, punctures,
&c, or  during the puerperal states;  but the
lymphatics of the  upper  extremities  are the
most  frequently inflamed, owing to the liability
of the fingers and hand to be injured  or con-
taminated during the discharge  of their numer-
ous offices.
   4. Lymphangeitis is rarely observed in the
internal  viscera, probably owing  partly, to the
difficulty of detecting this lesion in these  or-
gans, particularly  when they are the  seat of
other changes, or to the readiness with which
it may be overlooked.  However, I have seen
the lacteals inflamed and structurally changed
consecutively upon ulceration of the intestines,
and  in  connexion with enlarged  mesenteric
glands ;  and those of the uterus inflamed  in
examination of fatal puerperal  cases.  Similar
facts have been recorded by MM. Monod, Ton-
nklle,   Duplay, Lee, Oi.livier, and others.
MM.  Gendrin and Tonnelle observed in two
cases of metro-peritonitis, complicated with
lymphangeitis, the inflammation  extending to
the thoracic  duct.  M. Andral  observed  the
superficial lymphatics of the lungs  inflamed in
a patient who died of tubercal  consumption.
There can be no  doubt of the not infrequent
occurrence of lymphangeitis of internal viscera
when they are the seat of ulceration, or when
morbid matters are absorbed from them by the
lymphatics.   In these circumstances, either
these vessels, or their glands,  or both vessels
and glands, and even the veins also are liable
to inflammatory action, which may assume ei-
ther an acute or chronic form, according to  the
constitution of the patient and the nature ofthe
causes.
   5.  i. Causes.—A. The predisposing causes of
inflammation of this class of vessels are nearly
the same as those  which  dispose to inflamma-
tion of other vessels.  A sanguine and irrita-
ble constitution and  scrofulous diathesis ;  a
weak  and delicate conformation ; a  lowered
state of  the vital energies of the frame, and the
puerperal states, especially the  period imme-
diately consequent upon parturition; great loss-
es of blood ;  previous disease, as scrofula, fe-
vers,  syphilis, and a cachectic  state of  the
frame ;  unwholesome states of  the air;  con-
fined and ill-ventilated apartments, &c.
  6.  B. The exciting causes are  mechanical
or chemical  irritants,  especially  punctured
wounds ; the inoculation of noxious, morbid,
or putrid animal matters, or acrid substances ;
the absorption of malignant, ichorous, sanious,
or purulent fluids from foul, cancerous, or ma-
lignant  formations, sores, or from caries and
scrofulous  or syphilitic ulcers, &c.  ; the ab-
sorption  of matter from whitloes, tubercles,
anthrax, variolous  pustules, and  abscesses;
the bites and stings of reptiles  and insects ;
abrasions of the cuticle ;  acrid applications,
burns,  and  scalds ; the protracted or incau-
tious inunction of mercurial or other prepara-
tions ;  and the bites of animals.   I have seen
it caused by the bite of a rat, in a very interest-
ing case attended by Mr.  Ryan of Farningham
and myself, and by the bites of the cod and
ling when taking the hook  from their throats,
and by the  accidental punctures produced  by
their teeth.   In  two cases  of this kind, which
I saw many years ago, the symptoms assumed
a very dangerous  form.  The most common
causes are  punctured and abrased wounds, and
the inoculation of putrid and noxious animal
matters. I have seen many instances  of it in
cooks and  poulterers,  who had  injured  their
fingers in preparing game for cooking.   Punc-
tures or cuts during dissections  are also fre-
quent causes.
  7. ii. Description.—A. Symptoms of Acute In-
flammation  of the  Lymphatics—Lymphangeitis
Aculus.—The attack may or not  be preceded
by chills or rigours ; and it may  be character-
ized by  signs either of phlogistic action,  or of
great depression of the vital powers ; by local
action and  fever either of a sthenic form, or of
an asthenic, adynamic, or ataxic kind ;  the for-
mer, however, being generally ushered in  by
rigours, the latter seldom presenting this symp-
tom.  The form ofthe accompanying fever de-
pends entirely on the nature and combination
of the causes and state of the patient's consti-
tution and  habit of body ; those  causes which
consist chiefly of mechanical and chemical ir-
ritation being generally accompanied by sthen-
ic action, while the  inoculation of deleterious
or poisonous substances, or the  absorption  of
ichorous or  morbid  matters, especially  when
occurring  during a lowered state  of the vital
energies and marked predisposition,  are  al-
ways characterized by asthenic, adynamic, or
ataxic symptoms.
   8. a. The diagnostic signs of the disease are
tensitive, stinging, and burning superficial pain,
and tenderness  in the course of the lymphatic
trunks, accompanied generally with  increased
heat and appearances of  reddened lines  be-
neath the skin,  commencing in the seat of in-
jury,  or in an ulcerated or suppurated part,
and disappearing about the situation of the ad-
joining glands, which generally  become pain-
ful, swollen, or inflamed.  These reddened lines
or striae are extremely sensible to the touch,
and seem like thin, knotted  chords placed under
the skin.  The parts from  which the inflamed
lymphatics originate, or through  which they
 pass, are generally swollen, tense, and moved
 with pain and difficulty.
   9. b. The constitutional  symptoms are gen-
 erally  those of irritative  fever, with  various
 grades  of vital power, according to the nature
 of the exciting causes, and the circumstances 
920              LYMPHATIC SYSTEM—Inflammation of Lymphatic*.
peculiar to the patient at the time of their op-
eration.  They most commonly, however, as-
sume an adynamic form, or are characterized
by greatly increased or irritated vascular ac-
tion, and  depressed vital  energy.   When in-
ternal and deep-seated lymphatics are inflamed,
or the principal trunks, as the thoracic duct,
&c, the case is extremely obscure.  The con-
stitutional affection is generally similar to that
now noticed ;  and the  phenomena  altogether
differ but  little from those characterizing in-
flammation of internal veins, or from asthenic
inflammation of the internal organs whose lym-
phatics are affected.
  10. B. Chronic lymphangeitis is rarely met
with, excepting  in scrofulous habits,  and du-
ring the course of syphilitic and malignant dis-
eases,  when it  is generally associated  with
chronic inflammation and  obstruction of the
lymphatic glands.  Unless the superficial lym-
phatics are affected, the diagnosis of this form
of the disease is extremely difficult.   Its ex-
istence in many  cases even of this description
is often merely a matter of inference, and the
symptoms  accompanying  it  are seldom dis-
tinctly marked.  When  the  lymphatic vessels
have presented the appearances on dissection
usually resulting from  a state of chronic in-
flammation, the  existence  of some other or-
ganic lesion, particularly of parts whence the
diseased vessels proceeded, has generally been
ascertained, as of scrofulous tubercles and ul-
cers, syphilitic  or cancerous ulcerations, ca- I
ries, elephantiasis,  and malignant  diseases.
Sir A.  Cooper found the lymphatic vessels  of
the  chord  enlarged,  their parietes  thickened,
with induration of their  valves, in a patient
who died  with chronic  disease  of the testicle.
Indications of chronic inflammation were ob-
served in  the thoracic  duct of another patient
by  the  same  surgeon ;  and M. Andral has
found  similar appearances  in  both the lym-
phatic and lacteal absorbents.
  11. iii. Terminations and Prognosis.—The
disease terminates, 1st. In resolution ; 2d.  In
organic changes, chiefly limited to the vessels
affected without occasioning death ;  and, 3d.
By indirectly occasioning death.—A.  The de-
gree of danger  is to be inferred entirely from
the  nature  of the exciting causes, from the
condition  of the patient's frame anterior to the
attack, and from the character of the constitu-
tional  symptoms.   Unless  when  extremely
slight, and when attended with but little feb-
rile  disturbance, it ought always to be viewed
as  a serious disease ;  and when the  vital en-
ergies are evidently depressed, when the dis-
ease proceeds from the inoculation or absorp-
tion of noxious matters, particularly morbid  or
poisonous  animal secretions, when the  pulse
becomes very quick, with a dark-brown tongue,
or with low delirium, offensive secretions* &c.;
when  these and other symptoms of adynamic
or  ataxic fever  supervene, the danger should
be  considered great.   An increase or diminu-
tion of these unfavourable symptoms will  of
course indicate  a similarly modified degree  of
danger.   On the other hand, when all the more
violent local or constitutional symptoms abate,
owing to  the treatment  employed ;  or  when
the causes are  not of  a very noxious  descrip-
tion, nor  the system of the patient much  in-
jured previously, or  the vital energies impair-
ed, a favourable termination may be  anticipa-
ted.
  12. B. A fatal result is commonly occasioned
either  by the extension of the  inflammation
along the vessels to the large trunks or into the
veins,  or by  the  introduction of the noxious
cause, whatever it may be, into the circulation,
and the general contamination of the fluids and
soft  solids of the body which it  thereby pro-
duces,  or by the combination of the  above ef-
fects.  These results, although occasionally ob-
served in weakened and irritable  states of the
frame, occur  not  so  frequently as in phlebitis,
but  still they  occasionally  take place;  and,
therefore, our prognosis should be guarded, and
the disease considered as one of much  impor-
tance.   It is generally observed that the dispo-
sition of the inflammation to extend to  the in-
ternal lymphatics and veins, and the liability of
the morbid matter to be carried  into the sys-
tem, or to contaminate the frame, are great in
proportion to the depression of the powers of
life  characterizing the  progress of  the com-
plaint.   When  these powers  are sufficient to
the production of coagulable  lymph, by which
the extension of the inflammation may be pre-
vented, and the injurious effects of the cause
of the disease thereby limited, recovery gener-
ally  takes place, either by resolution, or by a
limitation of these effects to the lymphatics and
their glands merely.
   13. C. Appearances after Death.—These are
chiefly increased redness, thickening, an easily
lacerated state, the presence  of purulent  mat-
ter in  the  vessel, and,  in rarer instances, ul-
ceration.  In most cases, redness of the vessel
had  given place to  the  other lesions before
death  had occurred, and thickening,  a dull
pearly white state of the coats of the  vessel,
obliteration of the canal of the vessel,  and its
conversion into an impermeable fibrous chord,
are the chief changes.  In more chronic cases,
these  latter  changes, or  a  dilated, knotted,
thickened, and indurated state, with remarkable
whiteness, are generally remarked.
   14. The appearances consequent on  inflam-
mation of the thoracic duct, in two cases record-
ed by M. Andral (Archives Gin. de Med., t. vi.,
p. 502), consisted of intense inflammatory red-
ness of the internal  surface of the canal, with
thickening of its parietes in both instances. In
one  of them  the duct was filled with purulent
matter, one  of the kidneys having been con-
verted into a purulent sac, and surrounded by
large collections of matter.   In  the other case
no purulent matter was found in the duct, but
all the adjoining lymphatic glands were  infla-
med.  A similar  instance is described by M.
Gendrin.  M. Andral  states that he has ob-
served, in  other lymphatic vessels, similar le-
sions to those found in the thoracic duct in the
above cases.  He instances a patient who had
died of phthisis, with ulceration ofthe internal
surface  of the small intestines, and  in whom
the  lymphatic vessels proceeding  from this part
ofthe alimentary canal were  similarly altered.
   15.  Thickening of the coats of the vessel may
proceed so far as to occasion obliteration of the
canal.   M. Andral states that the walls of th«
thoracic duct may be so thickened as to oause
a partial or even total obliteration of its cavity.
   16.  Obliteration of considerable  lymphatic
trunks is  occasionally observed  as  a conse- 
LYMPHATIC SYSTEM—Alterations of Structure  of.
931
quence  of inflammation.   In many  of these  '
cases the obliteration proceeds from inordinate
thickening of the coats of the vessel as now
stated, but in others the vessel  is simply con-
stricted,  or  reduced to a  fibrous chord.   M.
Andral  has  recorded  a  case  in  which  the
thoracic duct was altogether obliterated, and a
collateral circulation established by a consider-
able branch, which came off from the duct a few
lines below the point where it was obliterated,
and re-entered it a short distance after it again
became permeable.  (Arch. Gen. de Med., t. vi.,
p. 504.)
   17. iv. Treatment.—The indications of cure
in this disease are :  1st. To diminish local in-
flammation and irritation ;  2d. To prevent their
extension along the vessels to the larger trunks
and internal parts, and to fortify  the powers
of life  against the  introduction of the morbid
cause into the system, or of the secretions from
the internal  surface  of the inflamed vessels.
The first indication  is best fulfilled by local
blood-letting when the inflammation  is very
considerable.  General blood-letting is rarely
requisite, unless the  patient be very plethoric
or robust.   I have, however,  treated several
cases without even local depletion, and the pa-
tients have recovered  rapidly.  The constant
 application of cloths, kept  wet with cold water
 or with evaporating lotions, has been tried by
 Velpeau and others.  I  have believed  that
 these have increased the pain, and favoured the
 extension of the disease.   More advantage ap-
 peared  to accrue  from warm,  emollient,  and
 anodyne applications  and fomentations.   In
 two or three cases the local affection was al-
 most immediately arrested by means of a strong
 turpentine embrocation applied to it, and of the
 internal medicines about  to be recommended.
 M. Velpeau advises mercurial frictions to the
 part; but  these are not  only  painful, but of
 doubtful advantage.  A similar remark applies
 to vesicatories,  rubefacients, and compression,
 also tried by this physician.
    18. When suppuration  has occurred, or  is
 about to take place,  around the inflamed lym-
 phatics or glands, even local depletion may be
 dispensed with ; poultices and emollient appli-
 cations are then most beneficial; and, as soon
 as matter forms, a free exit should be given to
 it, in order to prevent its absorption, and a per-
 petuation or increase ofthe mischief.
    19. The  constitutional  treatment, whereby
 the second indication of cure (y 17) may be ful-
 filled,  is of much importance.   After having
 evacuated, by chologogue and  stomachic  pur-
 gatives, faecal accumulations  and  disordered
 secretions,  tonics with alteratives will gener-
 ally arrest  the  progress  of the disease, when
 judiciously prescribed, and with due regard to
 the state of the  stomach.  I have generally giv-
 en the decoction of bark, with the compound
 tincture of bark and an alkaline  carbonate, or
 with ammonia  or  camphor, or capsicum,  with
 this intention,  and with  the utmost benefit;
 but the remedies have been varied according
 to circumstances ; still, the principle of prac-
 tice has been adhered to.   Indeed, the  same
 means  as  are  fully  noticed in respect of the
 treatment of diffusive inflammation of the cel-
 lular tissue  and of phlebitis are altogether ap-
 propriate to this disease.*  (See art. Cellular
   * I recently saw, in some respects, a singular case of
      II.               116
Tissue,  v  34,  et seq., and Veins — Inflamma-
tion of.)
  20. II. Alterations  of Structure  of the
Lymphatic System.
     Classif.—IV. Class, II. Order (Author).
  21. Otto and others believe that organic le-
sions are met with in the lymphatic  system,
more frequently in the young than in  the old.
This opinion, however, applies only to certain
lesions, as those connected with scrofula, rick-
ets,  and syphilis, and not to those consequent
upon malignant or cancerous maladies.
  22. i.  The changes more immediately connected
with inflammation have been described above (§
13);  but it is  not improbable that several of
those about to be noticed proceed  more or less
remotely from changes  produced by acute or
chronic inflammatory action.
  23. ii. The  lesions affecting chiefly the canal or
caliber of the lymphatics are analogous to those
found in other circulating vessels.
  24. a. Varicose Dilatation.—This change of
the lymphatics has been  noticed by Schreger,
Tilesius, Mascagni, Soemmering, Attenhofer,
Bichat, [Carswell,] and Meckel, in persons
who have died of pulmonary  diseases, hernia,
and  dropsical  effusions.  It  seems  probable
that, as in varicose veins, this state of the lym-
phatics  proceeds from pressure on the trunks
in which the  dilated lymphatics  terminate, or
from obstructions to the course of the  lymph
through them.  M. Amussat mentions a case
in which the lymphatics of the pelvis and those
coming from the groins were varicose, and fill-
ed with pus.   This state of the lymphatics ex-
tended to  the  thoracic canal.  The patient had
encysted  abscesses  in   both  groins,  and died
from pneumonia, complicated with cerebral af-
 fection.  (Arch. Gen. de  Med., t. xxi., p. 608.)
   25. b. Dilatation of the lymphatics  has been
 supposed  to give rise to rupture  of them, and
 various consecutive  changes, by Morton, Van
 Swieten, Haase, A8salini, Soemmering, Bram-
 billa, and others.  That rupture  may occur on
 some rare occasions is  probable,  but it  is cer-
 tainly not so common, nor the cause of so many
 diseases, as these authors believe.  It has not
 been demonstrated satisfactorily by any of them,

 lymphangeitis with Mr. Ryan  of Farningham, that will il-
 lustrate the treatment here recommended. A gentleman,
 about thirty years of age, was bit by a rat in the second
 joint of the  right fore-finger.  Inflammation of the absorb-
 ents, extending from the bite up the arm to the axilla, took
 place. I saw him a few days afterward (the 6th of October);
 the arm was then swollen and  hard, but the course of some
 of the inflamed lymphatics could still be traced.  What ap-
 peared the most singular was,  that there was a hard, firm,
 and almost elastic swelling of  the arm of  the opposite side,
 much more marked and general over the whole arm than in
 the  arm ofthe injured finger, with some swelling, stiffness,
 and pain of the lower limbs and joints.  Tongue loaded, the
 pulse quick and soft. The following were prescribed :
   No. 288.  ft Infusi Gentianas Comp.; Inf. Sennas Comp.,
 aa, 3vj.; Magnesias sulphatis, 3j.; Tinct. Cardamom. Comp.,
 3jss. M.  Fiat Haustus omni nocte sumendus.
   No. 289.  R Potassae Hydriodatis, gr.  ij.;  Liquoris Po-
 tassae, m. xx.;  Decocti Cinchonas, 3xj.; Tinct. Cinchonae
 Comp.; Tinct. Cardamom. Co., aa, 3j.; M. Fiat Haustus
 ter quotidie sumendus.
   On the 23d. Mr. Ryan informed me that " he continued
 to improve very much from the 7th until the 17th, when he
 got cold, which brought on a  return of enlargement of the
 arms and stiffness in the legs."  His tongue was loaded,
 and brown in the centre and towards the  root.  A full dose
 of calomel  and  compound extract of colocynth were pre-
 scribed, and directed to be repeated, if necessary. The do-
 ses of iodide of potassium and of liquor potassae in the cin-
 chona draughts were increased, and tincture of capsicum
 added to them.   The stomachic aperient  was to be contin-
 ued. These means produced the desired effect. 
922
LYMPHATIC SYSTEM—Alterations of Structure op.
 although Guiffart says that he had seen it in
 one instance.  I agree, however, with Dr. Bail-
 lie, in  admitting  the possibility of rupture of
 the thoracic duct.
   26. c. Constriction and obliteration of the lym-
 phatics have been believed to occur by Halle
 and Ollivier, and  may take place, as  in oth-
 er circulating canals, as a remote consequence
 of inflammation, or of pressure, or of obstruc-
 tion of their canals, by organic or other changes.
   27. The thoracic duct has already been shown
 to have been occasionally obliterated by thick-
 ening or other morbid alteration of its coats.
 Its canal may likewise be obstructed by a vari-
 ety of morbid productions either formed in its
 interior or conveyed there  by absorption.   It
 may also be obstructed by pressure made on it
 by tumours external to it.   When this  duct is
 obstructed or obliterated, the circulation of the
 lymph is generally kept up by a variety  of sup-
 plementary passages, as by, 1st. The great lym-
 phatic trunk ofthe right side ; 2d.  By collater-
 al branches arising from the duct below the ob-
 literated part, and entering it above this part;
 3d. By a second duct arising from the  recep-
 taculum chyli, and ascending to near the sub-
 clavian vein, where it unites with the other,
 entering the vein either along with it or singly ;
 4th. By large lymphatic trunks opening directly
 into different parts of the venous system, par-
 ticularly into the vena azygos, the vena cava,
 the common iliac, splenic, mesenteric, and oth-
 er veins,  and into  the vena porta?; and, 5th.
 By lymphatics  communicating with veins in
 the interior of their glands.
   28. iii. Vices of texture, of a  spurious and ma-
 lignant nature, may occur in the lymphatic sys-
 tem.  Besides induration, thickening, and conse-
 quent obstruction or adhesion of these vessels,
 arising  from  inflammatory action,  and already
 alluded to, other  changes may implicate  the
 parietes of the lymphatics.
   29. a. Fungous productions have  been devel-
 oped in these vessels.   Sir A. Cooper  has re-
 corded instances in which these were found in
 the thoracic duct.
   30. b. Cartilaginous  and osseous formations
 are rarely found  in the coats of the lymphatics,
 although instances are recorded by Mascagni,
 Cruickshank, Walter, Cheston, Portal, At-
 tenhofer, &c, in  which  these changes were
 observed.
   31.  c. Tubercular degeneration may take place
 as a consecutive disease in the parietes  of the
 lymphatics, and has been described by MM.
 Cruveilhier and Andral as occurring in these
 vessels  in the course of tubercular consump-
 tion.  In these circumstances, the coats ofthe
lymphatics proceeding from tubercular ulcera-
tions were opaque, of a whitish yellow, harden-
ed, and thickened, their canals containing  tu-
bercular matter.   In these instances, however,
the tubercular change was very equivocal; for,
although the contents of the vessels were of"
this nature, yet the changes in the parietes of
the vessels were similar to those generally con-
 sequent upon prolonged irritation or chronic in-
 flammation.
  32.  d. Cancerous, carcinomatous, fungo-hema-
toid, and melanoid degenerations sometimes im-
plicate the lymphatics consecutively, although
it is doubtful whether either of these varieties
 of malignant disease occurs in these vessels
primarily, or otherwise than as a consequence
of its advanced progress in some part of the
body, especially cancer uteri.  M. Andral has
detailed an interesting case of this description,
in which this disease had affected the thoracic
duct in  the  following manner:  this duct was
considerably enlarged, of a  dead white colour,
and  filled with a whitish,  puriform fluid.  Its
internal surface was studded with a great num-
ber of round, whitish bodies, about the size of
pease, which were  continuous with the tissue
of the parietes of the vessel, and perfectly anal-
ogous to the cancerous masses  developed in
the abdomen and pelvis.  In the intervals be-
tween these bodies, the parietes of  the  duct
were much  thickened, and presented a dead
white colour, traversed here and there by red-
dish lines, and in other points were reduced to
a soft pulp of a dirty reddish white.   The left
sub-clavian vein in  which the duct opened free-
ly, was distended by a number  of dense clots
of blood, adhering intimately to the coats ofthe
vein, the inner surface of which was wrinkled,
and of a dark brown colour.
  33. iv. Morbid Contents of the Lymphatics and
Lacteals.—The  alterations  presented by  the
contents of these vessels are various, and arise
either from a morbid state of the vessels them-
selves, or from disease in a part in which they
originate; the matters which they contain ei-
ther having been formed in them, or merely in-
troduced by absorption.—a. Blood has been very
rarely found  in the absorbents in a pure state.
Professor Lippi (Journ. des Prog, des Scien. Med.,
t. iii., p. 102), however, states that he has fre-
quently observed, in cases  of pneumonia and
hepatitis,  blood  in  the  lymphatics proceeding
from these viscera ; and he conceives that the
presence of this fluid in the lymphatics to any
considerable  extent is  incompatible with the
continuance  of life.  M. Sanson has  recorded
the case of fatal erysipelas, in which the great-
er number of lymphatics seated in the pelvis
and in front  of  the spine,  as well as the  tho-
racic duct, were distended  by blood, which, on
being analyzed by M. Barruel, was found per-
fectly pure (Archives Gin. de Mid., t. xxi., p. 628).
Mascagni relates several cases of sanguineous
effusion from the pleura and peritoneum, where
the lymphatics ramifying on these membranes
were distended with blood.  This is confirma-
tive of the remarks of Professor Lippi.  The
lymph contained in the thoracic duct in the
healthy  state frequently presents a rose tint,
and M. Magendie states that it presents  this
tint in a marked manner after an animal has
been kept long fasting.
  34. b. Pus  has been found in the lymphatics
by Dupuytren,  Velpeau, Soemmering, Dumas,
and others.   M. Andral has seen the thoracic
duct filled with pus in a woman  who had. sup-
puration of one  of the veins ; the coats of the
duct being red and friable.   M. Velpeau found
pus in the lymphatics of the lower extremities
in a case of phlegmasia dolens ; and M. Dupuy-
tren observed  it in a case of abscess in the
leg.  Soemmering, Gendrin, and Andral have
found pus in the lymphatics, arising  from ul-
cers  of  the  intestines; and Mascagni in the
lymphatics of the lungs in  phthisical subjects.
Dr. Lauth states that the lymphatics up to the
thoracic duct were filled with a sanious matter
in  a  case  of gangrene of the lower extremi- 
LYMPHATIC GLANI
ties, similar to that existing in the gangrened
part.
  35. c.  Tubercular matter of a  curdy appear-
ance  has been not infrequently found in  the
lymphatic vessels proceeding from the ulcera-
ted intestines of phthisical patients.  M. An-
dral,  M. Cruveilhier,  Gendrin,  Otto, and
others have  adduced numerous cases of this
description.  In these cases the lymphatics ap-
peared like so many knotted white chords pass-
ing from the  intestines towards the mesentery.
This  matter also has been found in the in-
guinal, pelvic, and superficial pulmonary lym-
phatics, and in the thoracic duct.  M.  Andral
refers to a case wherein it existed in all those
vessels.
  36. d.  Bile has been stated to have been de-
tected in the lymphatics of the  liver by Mas-
cagni and Saunders.  M.  Andral has not ob-
served this ; but he has seen a remarkably yel-
low tinge in  the  lymph  contained in the tho-
racic  duct  of icteric patients.  Milk has also
been  found in the lymphatics by Soemmering
and Assalini, in females who have died in  the
puerperal states.
  37. e.  Calcareous matter has been found in
the lymphatics by Poncy,  Assalini, Cheston,
Scherl, Attenhofer, Soemmering, and Lauth,
The last-named physician states that, in a case
of caries of the iliac bones, he found the lym-
phatics of  the pelvis  filled with osseous mat-
ter.
  38. /. The  molecules of cancerous, medullary,
and melanoid productions have been found in
the lymphatics proceeding from the  seat of
these malignant  diseases  by most of the  au-
thors mentioned above, as well as by others.
  39. III. LYMPHATIC GLANDS—Diseases
of.—Lymphatic ganglions are composed of, 1st.
Lymphatic vessels  variously convoluted ;  2d.
Fine cellular  tissue uniting those convolutions ;
3d. Of a  fibro-cellular membrane or capsule en-
closing the foregoing ; and, 4th. Of blood-ves-
sels supplying the gland, both entering it along
with the lymphatics and ramifying  in  its cap-
sule.   The nerves cannot be distinctly traced,
and consist chiefly of such as accompany  the
distributions of the arteries.
  [These glands  vary in size from two to  ten
lines; they have an average diameter of one
third of an inch, are of a light pink colour, and
situated  in such  places  as abound in  cellular
tissue, particularly at the bends  of the joints.
They occur in great numbers at the groins, as
well as at the armpit, the side of the neck, the
posterior mediastinal cavity, and in the cellular
tissue of the  pelvis  and mesentery.  In sever-
al of these places they are  connected in chains
or clusters.—(Gross.)]
  40.  The  lymphatic glands are more  suscep
tible of disease than the lymphatic vessels, and
hence are more frequently the seat of it.  This
is owing to their organization and functions,
morbid matters  which fail of making an  im-
pression  upon the trunks  or ramifications of
these vessels not infrequently inducing inflam-
matory or  other changes in their glands.   I
shall first notice inflammation ofthe lymphatic
glands, and afterward the chief organic lesions
to which they are liable.
i. Inflammation of  Lymphatic Glands.—Syn.
  Lymphadenitis, Hildenbrande. Adenitis Lym-
  phatica; Adinite Lymphalique, Ollivier.
)S—Inflammation of.                     923

     Classif.—III. Class, I. Order (Author in
       Preface).
   41. Defin.—Swelling, hardness, pain, and ten-
 derness in the seat of some lymphatic gland, fre-
 quently attended by chills and followed by heat, by
 increased pain on  motion, by febrile reaction, often
 by redness of the surface, when superficial glands
 are affected, and suppuration.
   42. The lymphatic glands are often the seat
 of inflammation,  and, although those which are
 more superficial, or have more or less intimate
 anatomical relations to superficial  parts or to
 the  extremities,  are most frequently affected,
 those which are  more  deeply seated, or which
 are  altogether internal, are also occasionally
 inflamed;  the disease, however, seldom  ad-
 mitting of recognition in the latter situations
 during the life  of the patient.
   43. A. Symptoms.—When a lymphatic  gland
 becomes acutely  inflamed—Lymphadenitis acuta
 —it is swollen, hard, painful, and tender to the
 touch. Chills, or even rigours, may be felt at the
 onset, and there  is generally symptomatic fe-
 ver, varying in type or character with the con-
 stitutional powers and the cause of the  affec-
 tion.   The surface of the seat of the disease is
 usually warmer than natural; sometimes it is
 reddened and a tumour is observable, particu-
 larly as the inflammation advances and  when
 the gland is not deeply seated.   The pain usu-
 ally increases or becomes sharp, and the inflam-
 matory action extends  to the surrounding cel-
 lular tissue, rendering the swelling less circum-
 scribed, as well as greatly  increasing it.  As
 the skin is more distended, it is more reddened,
 or even livid.   In the course of a few days the
 tumefied part becomes softer in one or  more
 points, and a more or less distinct,  superficial,
 or deep-seated, but circumscribed  fluctuation
 may at last be detected, the pain having even
 become more pulsating.  A  spontaneous  open-
 ing at this part, as described in the article Ab-
 scess, or puncture of it, gives issue to purulent
 matter, varying, in quantity and character, with
 the size and maturity of the abscess, and with
 the  constitutional  affection.   After  the dis-
 charge  of matter, the infiltration of the sur-
 rounding  cellular tissue is  removed, the san-
 guineous engorgement and inflammatory action
 in the gland subside, and the aperture closes.
   44. The terminations of acute lymphadenitis
 are resolution, suppuration,  and chronic indu-
 ration or enlargement.—a. Resolution is not in-
 frequent, and may be expected when the disease
 remains for a  few days stationary, or does not
 extend to the  surrounding  cellular tissue, the
 tumour remaining circumscribed and moveable.
 When the adjacent cellular  tissue  is affected,
 resolution very rarely occurs ; and, when the
 skin covering the part  is red and the subjacent
 cellular tissue much engorged, it is not  to be
 expected.—b.  Suppuration follows the  circum-
 stances just mentioned, especially when  the
 surrounding cellular tissue  is much infiltrated
 from extension of inflammation to it.  If sup-
 puration be limited to the gland, the tumour is
 circumscribed, moveable, and feels elastic  or
 fungous ; and  when the integument covering
 the gland is divided, the tumour formed by it
 partially protrudes from the opening, and con-
 sists ofthe inflamed, friable, reddened gland in-
 filtrated with purulent  matter, which, with the
 increased injection of  its  vessels and  infiltra- 
924               LYMPHATIC GLANDS-

tion of serum, occasions its enlargement.  In
many instances, the surrounding cellular tissue
is chiefly inflamed, and the suppuration is lim-
ited to it—one or more points, particularly ex-
ternally or around the affected gland, without,
however, assuming a very regular or circum-
scribed form.  The gland itself is then not so
swollen as in the former case, and presents,
upon  being  cut into, a more regular red, or
grayish-red tint, and is firmer and not so fria-
ble or soft.   In  other instances suppuration
takes place  both in  the  gland and in the sur-
rounding cellular  tissue, at one or more points.
—c. Induration and enlargement  are chiefly ob-
served when the acute has passed into the chron-
ic state of the disease.  The lymphatic glands,
during inflammation and its several consequen-
ces, present the same changes and the  same
post-mortem lesions as have been fully described
in the articles Inflammation and Abscess.
  45.  B.  Chronic Inflammation  of Lymphatic
Glands—Lymphadenitis Chronica—is as  com-
mon a disease as the acute.  It often follows
this latter, and frequently supervenes in the
course of chronic diseases, or of irritation of
parts from which lymphatic vessels passing
through glands arise, as  ulcers, chronic  cuta-
neous eruptions, &c.  It is, however, most com-
mon in scrofulous constitutions, wherein it may
occur  either as  a primary affection, or as a
symptomatic or consecutive  malady of  other
antecedent changes or lesions. (See art. Scrof-
ula.)
  46. WThen the chronic follows the acute dis-
ease, the  acute  symptoms subside  gradually,
either  before suppuration has commenced, or
after it has taken place to a small extent, or in
a limited portion only; and slight pain and heat,
with swelling and hardness of the gland, con-
tinue until ultimately the  latter only remain.
When chronic lymphadenitis  occurs primarily,
the gland  swells gradually, becomes hardened,
and slightly  painful, particularly on pressure
and exertion.  The skin retains its colour, and
the surrounding cellular  tissue  is either  unaf-
fected  or  slightly affected, the enlarged  gland
being moveable.  Symptomatic  fever is  rarely
present, or, if present, in a very slight degree.
No change may occur, locally, for an indefinite
period, unless some local  or constitutional  in-
fluence affect the engorged gland.
  47. The consequences or terminations of chron-
ic lymphadenitis are, resolution, the acute state,
and suppuration.—a.  Resolution takes   place
slowly or imperfectly ; and, although inflamma-
tory engorgement may be more rapidly  remo-
ved, the infiltrated lymph, or deposite in the
gland,  is very slowly removed.—b. An  acute
state of vascular action may be induced by ex-
ternal injury, by  increased irritation affecting
the related lymphatics, or by too great exertion
of the neighbouring muscles or parts.  When
this change occurs, the usual phenomena  of an
acute attack ($ 43) are observed.—c.  Suppura-
tion is generally  a consequence of  the   acute
state  of the disease following the chronic.
When  suppuration is about to take place, the
surrounding cellular tissue becomes infiltrated
and swollen, and the gland more tumefied, less
hard, and  less moveable, the formation of mat-
ter in these  cases taking place around, and
rarely within the  gland.
  48. C.  Specific Inflammation  of  Lymphatic
■Inflammation of—Causes.

 Glands—Lymphadenitis spccialis.—Lymphade-
 nitis may occur in the course of various malig-
 nant and constitutional maladies, and present,
 in  these circumstances,  either  an  acute  or
 chronic  form.—a. It  may  appear in an acute
 form in  the course of malignant or putrid con-
 tinued fever; and it is always  distinctive  of
 plague or pestilential fever.  In these circum-
 stances the affection of the glands is of an ex-
 tremely  asthenic or disorganizing nature.  It
 also occurs consequent upon the inoculation or
 absorption of various contaminating and septic
 poisons, and of putrid animal matter or fluids,
 where it assumes  more or less of the same
 asthenic characters.—b. It generally assumes
 or passes from the  acute into the chronic form,
 when produced by syphilitic ulceration or ab-
 sorption.  The continuance of carcinomatous or
 other local malignant disease induces a chronic
 form of enlargement and alteration ofthe lym-
 phatic glands, which can  hardly be  attributed
 to inflammation, but either to the deposite  of
 morbid matter in the substance of the gland, or
 to the accumulation of it in the extreme rami-
 fications of its vessels, this matter being identi-
 cal with, or similar to that present in the pri-
 mary seat of disease, and altering the size,
 functions, and  appearances of the gland.  Of
 other changes and  more remote consequences
 of diseases of lymphatic glands, farther notice
 will be taken in the sequel.
  49. D. Causes.—The causes of lymphadenitis
 are diversified.—a. They generally operate ei-
 ther through the medium of the constitution,
 or locally ; and in many cases the local causes
 are  enabled  to produce  their effects on  the
 gland, owing to a state of the constitution predis-
 posing it to the affection.  In most ofthe symp-
 tomatic and specific forms of lymphadenitis, the
 disease is chiefly owing to antecedent changes
 in the state of the circulating fluids and of the
 vital cohesion of the soft solids generally.   In
 such  circumstances, the local agents, whether
 merely irritant  or  also contaminating, readily
 produce disease of glands corresponding to the
 primary seat of irritation or of inoculation.
  50. b. The local causes are those, 1st. Which
 act directly on the gland, as contusions, wounds,
 and other  injuries  ; and, 2d. Those which act
 through the medium  of related absorbent ves-
 sels.   Numerous causes act in  this latter way  ;
 punctures, abrasions, injuries, &c, may inflame
 the absorbents, and the inflammation  may ex-
 tend to the nearest glands to which these ves-
 sels proceed ;  or the  local injury may  be so
 slight  as hardly to be remarked,  and yet  the
 gland corresponding  to the  part may become
 inflamed, the vessels communicating with the
 one and the other being apparently unaffected.
 Various morbid matters may even be inoculated
 in this way, and the matters may inflame these
 glands either after the vessels have been affect-
 ed, or  without having sensibly involved  the
 lymphatics communicating between the seat of
 injury and the gland.   Thus putrid  or morbid
 animal matter may be introduced without pro-
 ducing  any  obvious local disease  until  the
 glands  are affected.   Certain  maladies, also,
 which commence  locally, do not produce  in-
 flammation ofthe lymphatic vessels conveying
 the morbid matter, while they generally affect
 these glands to which the vessels proceed, the
 absorbed matters inflaming these glands,  but 
LYMPHATIC GLANDS—Structural Chawois of.                 925
not the trunks of these vessels.  This is illus- ]
trated by the phenomena of syphilis and cancer.
  51.  E.  Treatment.—a.  The treatment  of
acute lymphadenitis  should  depend very much
upon the  state  of  the  constitutional powers.
When  the  disease assumes  a purely  sthenic
character, local  blood-letting freely prescribed,
promoted by the usual means, is always neces-
sary ;  but, in order to  procure the resolution of
the disease, it should be resorted to early, and
before  the integuments have become red,  or
other indications of suppuration have appeared.
M. Velpeau has  advised the application of blis-
ters to the surface of the part, in order  to pro-
cure resolution; and subsequently poultices or
mercurial ointment.  In  strong  or  plethoric
persons these means  should  follow copious
local depletion.  If the disease appears in a ca-
chectic state  of ihe system, or with  signs  of
asthenia, local depletions are rarely of service.
In these cases particularly, as I have  frequent-
ly seen them consecutively upon scarlet and
other  fevers,  alteratives in  conjunction with
tonics have  proved most beneficial, tending to
limit both the extension of the disease and the
consequent  amount of  suppuration, which,  in
these circumstances, can rarely be prevented ;
but even in  these the amount of disease and  its
duration will be  greatly  lessened by the exhibi-
tion of the liquor potassae, or Brandish's alka-
line solution, with or without the iodide of po-
tassium, in the decoction of cinchona and tonic
tinctures, or  the  preparations of sarsa.   At
the same time,  the secretions and excretions
should be promoted by means of alterative and
chologogue aperients, and stomachic purgatives.
  62.  If suppuration appear  inevitable, poul-
tices should  be  applied, and as soon as any
fluctuation can be detected, an opening should
be made, and  the discharge of matter promoted
by a continuance of the poultices ; the  consti-
tutional means being prescribed with strict ref-
erence to the state of general and local action,
and to the functions of the abdominal viscera.
In these cases, as well  as in many others, the
principles of treatment fully developed  and  il-
lustrated  in the articles Abscess and Inflam-
mation should be adopted.
  53.  b. The  treatment of chronic lymphadenitis
consists chiefly of the application of leeches in
some cases, and the  occasional  repetition  of
them, ofthe exhibition of alteratives and  tonics,
as liquor potassium, iodide of potassae,  the  io-
dide of iron, sarsa, cinchona, &c. ; of frictions
with resolvent or deobstruent ointments and
liniments, and of salt-water bathing, &c.   In
all cases ofthe chronic  disease, particularly in
scrofulous persons, and of  the acute,  after the
active symptoms have been subdued,  a change
of air, alterative mineral waters, a cautious use
of the iodides in small  doses, or the  combina-
tion of certain of them with the liquor potassae,
sea-bathing, and sea-voyaging, change  of cli-
mate, the  tepid shower  bath or douche, a mod-
erate or limited  use of animal food, with a suf-
ficient amount of vegetables  and farinaceous
diet, and a very  liberal use of new milk, whey,
or fresh buttermilk, as a  common beverage,
will generally secure  recovery and prevent fu-
ture attacks.
  54.  c. The specific states of lymphadenitis re-
quire few remarks.  When the disease assumes
an asthenic or malignant nature  in connexion
| with similar constitutional maladies, the pow-
 ers of the system should be promoted, and en-
 ergetic general and local means should be em-
 ployed in order to  resist the progress  of the
 local  mischief.  Powerful tonics,  antiseptics,
 and alteratives should be employed, according
 to the symptomatic relations of the disease ;
 but it is unnecessary to particularize these rem-
 edies at this place,  as they are fully noticed in
 the articles Abscess (y 62), Inflammation (§
 238, et seq.), Pestilence, Scrofula, and Syphi-
 litic Cachexia.
 ii. Structural Changes of Lymphatic Glands.
     Classif.—IV. Class, II. Order (Author).
   55. These changes are chiefly seated, 1st, in
 the cellular tissue uniting the convolutions of
 the lymphatics ;  and, 2d, in the lymphatics
 themselves ; and occur most frequently in in-
 fancy and  childhood, when these glands are
 most developed, and their functions most act-
 ive.   Dr. Boeker considers that,  in  diseases
 of these glands, the cellular tissue uniting the
 convolutions of the lymphatics are most fre-
 quently affected, and that there is seldom ob-
 struction of their canals, as he has found injec-
 tions to pass freely  through them.
   56.  A.  Simple enlargement of these glands is
 often observed. It generally arises from causes
 not originally seated in the glands, but from ir-
 ritation at the  origin of the lymphatics passing
 through them,  or from the irritating nature of
 the fluids which they contain.  Thus we  per-
 ceive  painful  swellings of the glands of the
 groin or armpit follow punctures or lacerations
 of an extremity, or  the inunction of mercury;
 and a similar effect is produced on the glands
 under the jaw, on those adjoining the trachea,
 and on the mesenteric glands, from sores in the
 mouth, inflammation of the bronchial lining, and
 from irritation of the digestive mucous surface
 respectively.   When the irritating cause is not
 of a specific or poisonous  nature, the effect
 upon the glands is merely that of irritative en-
 largement, or of healthy acute inflammation, or
 the latter following the  former change.  But
 when a specific cause of a noxious or poison-
 ous nature has affected the absorbents or been
 dbnveyed into  the lymphatic circulation, a spe-
 cific and more  noxious effect is the result.  On
 each of these I shall offer a few remarks.
   57.  B. Inflammation  is frequently met with
 in these  glands, in the acute, the chronic, or
 intermediate states.  (See Y 42, et seq.)   When
 thus affected, they are more or less red, tume-
 fied, and readily broken down.  In the more
 chronic state of inflammation they are consid-
 erably enlarged, hardened, and either become
 colourless or acquire a darker tint.   Inflamma-
 tion, in its more active forms, is often followed
 by  the  formation  of purulent matter,  which
 either infiltrates the tissue of the gland,  giving
 it a  dirty gray colour,  or is  disseminated in
 small distinct drops, or is collected into  an ab-
 scess.  When this last occurrence takes place,
 it often occupies the whole of this gland, de-
 stroying its parenchymatous structure, its en-
 velope alone remaining and forming the  cyst
 to the abscess  (y 45).
   58.  C. Scrofulous enlargement and inflamma-
 tion are generally of a chronic kind ; the gland
 swells and softens, and occasionally becomes
 redder; and, although the suppuration does not
 rapidly supervene, yet this termination is fre- 
926                 LYMPHATIC GLANDS—Structural Changes op.
 quent, is peculiar in its nature, and takes place,
 in many cases, without any signs of inflamma-
 tion of the gland itself, although  the surround-
 ing cellular tissue and the skin become subse-
 quently inflamed and softened, followed by per-
 forations, through which the scrofulous secre-
 tion from the gland is evacuated.  This form
 of disease is  generally unattended by pain or
 tenderness, and the cellular tissue and skin are
 affected.  As  the gland softens,  a  particular
 part or parts, generally about its centre,  are
 converted  into a  sero-albuminous fluid ; and
 this  change invades more or less of the gland,
 extending to the surrounding texture, occasion-
 ing perforation, and the discharge of a  serous
 fluid containing curd-like matter.   On exami-
 nation, the gland  presents the appearances de-
 scribed in the following paragraph (v 59); and
 sometimes merely a more friable state of its
 structure, with cells or cavities  containing  a
 partly serous  and partly puriform fluid, and  a
 white, albuminous, or curdled matter (see arti-
 cle Scrofula).  In some rare cases, scrofulous
 glands, when  inflamed, become rapidly disor-
 ganized, ; sloughing of the cellular  texture sur-
 rounding them and ofthe skin takes place; the
 gland assumes an unhealthy ash colour, and is
 at last expelled either  in shreds and pieces, or
 in a sphacelated mass.  This change has been
 noticed by Cruickshank and Craigie to occur
 in scrofulous persons, generally about the bend
 ofthe arm, and is evidently dependant on a de-
 bilitated and cachectic state of body.
  59. D.  Tubercular matter is found very fre-
 quently in the lymphatic glands, and generally
 either infiltrated and disseminated through their
 tissue, or collected into one or more masses of
 various sizes.   In respect of the production of
 this matter, the question is, whether it is, or is
 not, the result of inflammation.  The develop-
 ment of tubercle subsequently to  inflammation
 is, as remarked  by M. Andral,  undoubtedly
 exhibited  in lymphatic glands; but though in
 many cases the  tuberculated  gland  presents
 unequivocal marks of antecedent congestion or
 inflammation, it is not the less true that in sev-
 eral  instances there exists no evidence what-
 ever of the formation of the tubercular matter
 having been preceded or accompanied by any
 vascular injection.
  60. Tubercular matter,  as found in  the lym-
 phatic glands, has generally been viewed as the
 product of secretion, not necessarily of inflam-
 matory secretion, but rather itself occasioning
 the inflammatory  appearances frequently asso-
 ciated with it.  M. Andral observes respect-
 ing this point,  perhaps it may yet be consider-
 ed as simply the result of an alteration of the
 lymph itself, either spontaneous, or caused by
 a morbid condition ofthe lymphatic vessels, or
perhaps resulting simply  from its stagnation,
caused by some mechanical obstacle to its cir-
culation through the lymphatic plexus.   I am
 disposed to adopt a part  of this  explanation,
 and to infer that the tubercular matter proceeds
 simply from diminished  vital  energy of the
glands affected, occasioning stagnation of the
circulation through the convolution of lymphat-
 ics ;  and, consequently, a  morbid  state of the
lymph and all the other phenomena attendant on
tubercular formations, as inflammation, scrofu-
lous suppuration, &c., alternately supervene.
  [In children, tubercular  matter  is most  fre-
 quently deposited in the bronchial glands.   Dr.
 Lombard found  them thus affected  in 87  out
 of 100 children labouring under lymphatic  en-
 largement.   In adults  the mesenteric glands
 are mo6t liable to this deposite.   In 100 phthis-
 ical subjects, Louis found their bodies tubercu-
 lized in 23, or nearly in the proportion of one
 to  four.   When  suffering under this disease,
 the glands exhibit different appearances, accord-
 ing to the progress it may have made.   Gen-
 erally speaking, they are enlarged in size, of a
 dense grizzly texture, white externally, and of a
 light rosy tint internally, either uniformly,  in
 streaks, or in patches.  The tubercular matter
 itself is of a singularly yellowish colour, espe-
 cially if it has existed for some length of time,
 and often  contains  particles  of  curdy pus.
 (Gross.)]                             «
   61. E.  Pestilential  Disease  of Lymphatic
 Glands (y 47).—From the first twelve hours to
 the seventh or eighth day of plague, the glands
 in the armpits and groins become enlarged, and
 give rise  to an open sore,  accompanied  with
 sloughing, and the discharge of a foul, dirty-
 coloured fluid.  The texture of the gland seems
 softened,  of a dark  gray,  grayish-brown,  or
 brownish-red colour, becoming  rapidly disor-
 ganized and wholly destroyed, especially in the
 fatal cases.  This state of the glands is often
 associated with  carbuncles, to  the  irritation
 occasioned by which it has been imputed. But
 this is evidently not the case, as the lesion of
 the glands  often commences  as early as the
 formation of carbuncles, or  even precedes it.
 Both lesions evidently depend upon the same
 cause, namely, to a certain change of the vital
 condition of the parts  affected, deranging the
 capillary circulation in  the one, and the lym-
 phatic circulation through  the glands in the
 other, and changing the states ofthe fluids cir-
 culating through each system of vessels respect-
 ively, and inducing the  ulterior changes char-
 acterizing both.
   62. F. Disease ofthe glands from the absorp-
 tion of noxious matters is not infrequent.  The
 effect produced by these matters on the glands
 varies very  considerably,  owing, 1st. To the
 nature ofthe injurious cause ; and, 2d. To the
 constitution  and state of the vital energies of
 the patient at the time.   Phagedenic bubo is one
 of the most common effects  proceeding  from
 this source.  It is occasioned by the  syphilitic
 poison, or  by repeated or  too long continued
 courses of mercurial inunction, especially when
 acting on an unhealthy state ofthe body. Hence
 these noxious matters excite inflammatory ac-
 tion of an  asthenic or  diffusive kind in  the
 gland, extending to the capsule and surround-
 ing cellular structure ; and these parts become
 painful, hard, somewhat hot, and of a brownish
 red.  The skin passes from  this tint to a dirty
 grayish brown,  loses its  vitality, and, with the
 cellular  tissue  underneath, alternately ulcer-
 ates and sloughs.  The  glands, however, still
 remain undestroyed, generally enlarged, and of
 a brownish-red or purple colour, and  evincing
 a very low grade of" vitality, until the destruc-
 tion of the  surrounding  tissues isolates  them
 more or less completely, when they are thrown
 off in the state of slough.
  63. G.  Enlargement and  destruction of the
glands sometimes follow the inoculation and ab-
sorption  of putrid or poisonous animal secre- 
LYMPHATIC  GLANDS—Lesions occasioned by.
927
 lions or fluids, as  in wounds from dissection,
 and the bites  of poisonous reptiles.  [Also in
 epidemic erysipelas, plague, and low malignant
 fevers from the same cause]  In cases of this
 kind,  the noxious matters  contaminate  the
 lymph circulating through the gland, the vital-
 ity and circulation of which become greatly in-
 jured, and rapid disorganization is thereby oc-
 casioned,  extending to  the  adjoining struc-
 tures, and in the course  of the lymphatics de-
 parting from thence.  In cases of this descrip
 tion the gland rapidly softens and enlarges, lo-
 ses its healthy colour, and assumes a dark and
 foul appearance, and ultimately sphacelates ei-
 ther in part or altogether.*
   64.  H. Induration of the lymphatic  glands is
 frequently met with in  consequence  either of
 repeated attacks of chronic inflammation alter-
 nating with partial resolution, or ofthe contin-
 ued irritation in a  part whence the lymphatics
 passing through  the gland  originate.   This
 disease  is not infrequent in  strumous habits,
 and is characterized by a very slight  or entire
 absence of pain in  the gland.   When examined
 with the scalpel the gland is enlarged, harden-
 ed, so as often to grate when divided, and pre-
 senting a  whitish  tissue, with a very few red
 vessels, the remains of its natural vascularity.
   65. /.  Scirrous induration may proceed from
 the same causes as simple induration, particu-
 larly in persons advanced in life ;  or from  scir-
 rous disease  in the part  in which the absorb-
 ents of  the  gland originate.   When  divided,
 the gland  is observed to be very slightly vas-
 cular—less so than natural;  very much hard-
 ened, of a bluish gray,  or grayish white col-
 our, somewhat elastic, and consisting of gelat-
 inous and amorphous matter traversed in every
 direction by dense cellular or fibro-cellular tis-
 sue, of a lighter colour  than  the matter trav-
 ersed by it.  This  lesion  is often  accompanied
 with a dull pain, which is sometimes  exasper-
 ated, in the substance of the gland.   (See art.
 Cancer.)
   66. K.  Cancer is met with in the lymphatic
 glands, but it very rarely occurs primarily ; it
 is commonly consecutive of this malady in ad-
 joining or related structures.  It assumes in the
 glands similar forms to those presented by it in
 other parts.   It  is characterized by exacerba-
 tions of pain  in the enlarged and hardened
 gland, by the  absence of tenderness,  the very
 chronic state of the disease, an unhealthy or
 cachectic habit of body, and mature or advan-
 ced age.  The gland, when divided, is vascular,
 indurated, of a reddish brown hue, and its tis-
 sue  is  converted  into a  dense  fibro-cellular
 substance, with  cells containing  a  granular
 amorphous matter.   When the  gland  passes
 generally or partially from this state to that of
 softening and ulceration, with an acrid, foul se-
 cretion, irregular fungous excrescences spring-
 ing from the disorganized surfaces, carcinoma
 ofthe gland has taken place.  (See Cancer.)
  67. L. Fungus hematodes of the lymphatic
glands is rare.  Mr. Wardrop observed  this
change in the mesenteric glands.   I met with
one case of it in the absorbent glands in the
 groin, in a boy of about thirteen years of age,
 who had a  number of haematoidal tumours  in
 different parts of his body.  The structure  of
 these  glands was similar to that described un-
 der the article Fungo-hematoid Disease.
   68.  M. Melanotic depositions sometimes take
 place in the lymphatic glands.   But this lesion
 should be distinguished from the dark discol-
 oration which is  occasionally met with, with-
 out any organic change.  (See Melanosis.)
   69.  JV.  Calcareous and osseous deposites in the
 lymphatic   glands have  been  described by
 Cruickshank, Baillie, Goodlad, Dupuy, Ray-
 er, and Andral, and are stated to occur most
 frequently in the tracheo-bronchial glands, and
 in persons advanced in life.  I have, however,
 met with this change previous to puberty, both
 in the bronchial and mesenteric glands ; and
 M. Andral  mentions a similar  case.   This
 pathologist  refers to  cases which occurred to
 him and  to M. Reynaud, in  which  the pres-
 ence of bony and calcareous  deposites  in the
 glands was coincident with destruction of some
 of the bones,  leading to  the inference that the
 calcareous phosphate which had been absorbed
 from the seat of disease in the bones had been
 deposited in the lymphatic glands.  In cases of
 this  description the  calcareous deposites are
 frequently not limited  to  the glands, but are
 found  also in the lungs.*
 iii. Lesions  occasioned by Diseased Lymphat-
  ic Glands.
  70. These glands, when enlarged or otherwise
 diseased, may derange the functions or struc-
 ture of adjoining parts, either communicating ir-
 ritation or occasioning mechanical pressure, or
 interrupting the  circulation of lymph in the
 lymphatics,  and causing swelling of the  parts
 whence they arise. The bronchial glands have
 been found enlarged, so as to impede the pass-
 age  of air  into the  lungs, and even to give
 rise  to atrophy of the portion of lungs the func-
 tions of which had been  obstructed.  They may
 also occasion  inflammatory irritation of the
 part of the bronchus pressed upon, leading to
 perforation ; and,  if the enlarged  gland con-
 tain  pus or tubercular  matter, these may be
 evacuated into the bronchial tube and excre-
 ted ; and even recovery may take place, more
 rarely, however, if the gland contain tubercu-
 lar matter, inasmuch as the glands seldom con-
 tain  this matter unless it exists also in the sub-
 stance of the lungs.
  71. Enlarged lymphatic glands in the vicinity
 of the pylorus may compress the passage  so as
 to occasion a great  proportion  of the  symp-
 toms attendant  on scirrous of this  part; or
they may compress the hepatic duct and occa-
sion  jaundice; and  they may similarly affect
the cystic and common ducts.  A case occur-
 red to me in 1821, in which the common and
pancreatic ducts were so compressed by a clus-
ter of enlarged lymphatic glands as entirely to
obliterate their canals ; the patient died jaun-
diced,  and  the gall-bladder and hepatic ducts
were enormously distended  by dark-coloured
  *  [Enlargement and suppuration of lymphatic glands,
also, sometimes follow in irritable subjects from punctured
wounds, as of a pin or needle, where no poisonous matter is
introduced.  A remarkable case of this kind is recorded in
the 4th vol. of the New- York Journal  of Medicine and the
Collateral Sciences, by Dr. L. Ticknob, of Connecticut.]
  * [We have met with several instances of deposition of
calcareous matter in the mesenteric glands in scrofulous
subjects, although they are more frequently met with in
the conglobate glands at the roots of the lungs.  In a case
of a lady who died of epidemic erysipelas, we found most
extensive deposites of chalky matter in the glands  of the
mesentery; no other portion ofthe lymphatic system  exhib-
ited any marks of disease.  When  young,  she had been
subject to scrofulous enlargement of the glands of the neck.] 
928                              MAMMA—Diseases of this.
bile.   M. Andral has  seen the gall-bladder it-
self obliterated by these glands.  In some ca-
ses, the  ureters have been found obstructed by
pressure sustained from them, and even the
vena  cava  has been so compressed by them,
and its circulation so  impeded, as to occasion
great cedema of the lower extremities.
  72.  Chronic  inflammation  and  induration
may interrupt the circulation of lymph through
them, and hence occasional swelling or oedema
of  the parts  from which  they arise;  but this
does not so frequently occur  from simple in-
duration or scrofulous  inflammation or depos-
ites as from  scirrous  induration or malignant
deposites.
  73. When the glands of the axilla and parts
adjoining become indurated and enlarged con-
secutively upon cancer mammae, they  may be
so  impervious to the transmission,   by the
lymphatics, of lymph and serum from the arm,
as  to  cause  remarkable  swelling and  oedema
of  it.   Enlargement and obstruction  of the
glands of the groin  may  have a similar effect
upon  the lower extremities:  an effect which
I have seen on several occasions, in both the
upper  and the lower limbs.  Some years ago
I was consulted by a medical gentleman on ac-
count of a tumour, seated internally above the
abdominal ring of the right  side, which was
large and painful.  The  testicle on that side
had never descended.   A treatment suitable to
inflammatory enlargement of the gland, name-
ly,  local blood-letting  and antimonials, follow-
ed  by the iodide of potassium, with liquor po-
tassae,  &c, was prescribed,  and he   derived
benefit from it.  A considerable time afterward
I was again  consulted by him.  The  tumour
had returned; the  lymphatic  glands  in the
groin  of the  same side were  greatly enlarged
and inflamed, and the  right thigh and leg were
swollen  and  painful, resembling the  state  of
the limb in phlegmasia alba  dolens.   In this
case  there were  manifestly inflammatory en-
largement of the undescended testes, and  of
the glands in the  groin, with interrupted circu-
lation  through  the latter, occasioning  infiltra-
tion of serum and lymph in the thigh.   The en-
larged testes  and lymphatic  glands probably
also pressed upon the veins, so as to impede
the return  of blood through  them.  (See art.
Scrofula.)

  Bibliog. and Refer.—Russel, (Economia Naturae in
Morbis Acutis et Chronicis Glandularum, 8vo.   London,
1755.—Diedrich, De Morbis Glandularum.  Lips., 1759.—
G. Hewson, Experiment. Inquiries, part ii., containing a
Description of the Lymphatic System, &c, with Observa-
tions on the Lymph and the Changes  it undergoes in some
Diseases, &c.,8vo.  Lond.,  1774.—Soemmering, De Cogni-
tionis subtilioris Systematis Lymphatici in Medicina Usu,
4to. Cassel, 1779; et De Morbis vasorum Absorbentium,
8vo. Francf., 1795.—E. Darwin, Exper. on Mucilag. and
Purulent Matters ; and an Account of the Absorb. Vessels
in some Diseases,  Svo.  Shrews., 1780.—Assalini, Essai
Medical sur les Vaisseaux Lymphatiques, 8vo. Turin, 1787.
—Wrisberg, in Conim. Soc. Reg. Scient. Gotting., t. ix.,
1789.—C.  F. Ludwig, Physiol, et Pathol, de Systemate ab-
sorbente recent, qusedam Decreta, 4to.  Leips., 1789.—Pujol,
Essai sur les Maladies propres a la Lymphe et aux voies
Lymphatiques, in Mem. de  la Societe Roy. de Med., t. vi;.
and viii.,  1791 ; et CEuvres, t. i., p. 224.—Salmade, Precis
d'Observat. pratiques sur les Maladies de la Lymphe, 8vo.
Paris, 1603.—Attenhofer, Lynlphatologia ; oder Abhandl.
uber das  Lymphatische System und  dessen Leiden, 8vo,
Vien., 1808.—A. Ramsay, in Edin. Med. and Surg. Journ.,
vol. viii.—D. Pring, An Essay on the  Absorbents, compri-
sing some Observat. on the relative Pathol, and Functions
of the absorbent and secreting Systems, 8vo.  Bath, 1813.
— W. Goodlad, A Practical Essay on the Diseases of the
 Vessels and Glands of the Absorbent  System, 8vo.  Lond.,
1814.—Howship, Pract. Observat. in Surgery and Morbid
Anatomy, Case 94.—G. Breschet, in Diet des Sc. Med., t.
xx., p. 196.—Allard, Du Siege de la Nature des Maladies,
8vo, 2 vols. Paris, 1821 ; et De I'lnflammation des Vais-
seaux Absorbants, 8vo.  Paris, 1824.—Lippi, Journ. des
Progres de Sciences Medicales, t. i., p. 167 ;  t. ii., p. 27 ; t.
iii., p. 108.—Rossi, in Ibid., t. ii., p. 20.—Lalscrrt, In Journ.
Univers. de Med., t. xxiv., p. 5.—Andral, in Archives Gener.
de Med., t. vi., p. 502; et Anat. PathoJog., t. n.—Benedict,
Remark, uber  die Krankh. der Brust und Achsel-Drusen,
4to.  Breslau, 1825.—F. G. Becker, De Glandulis Thoracis
Lymphaticis, atque Thvmo, Specimen pathologicum, <kc,
4to.  Berlin, 1826.—T.  Fideli, De Lymphangioitide, ejusque
Formis Diversis, 8vo.  Patavii, 1825.—Gendrin, Histoire del
Inflammations, 8vo.  Paris, 1829.—W. Cullen and R. Cars-
well,  in Transact, of Med. and Chirurg. Soc. of Edin., vol.
i.—/. E. Dezeimeris, in Archives Gener. de Medicine, t.
xxii., p. 5.—Amussat, in Ibid., t. xiv., p. Ill ; et t. xxi., p.
608 ;  et Lippi, in Ibid., t. xx., p. 612.—Cruveilhier, Anat.
Pathol, du Corps Humain, livr. xi.—Kastner, Das Weisse
Blut; in Physiol. Pathol. Bezichung Betracht, &c.   Er-
lung, 8vo, 1832.—Dubled, in Amer. Journal of Med. Scien-
ces, vol. vi., p. 216 and 220.—A. Velpeau,  Mem. sur lei
Mai. du Systeme Lymphatique, in Archives Gener.de Med.,
2d Ser., t. viii., p. 129  et 308; et Seconde Mem. Inflamma-
tion Aigue des Ganglions, Ibid., t. x., p. 5.—Velpeau, Brit.
and Foreign Med. Review, Oct., 1836, p. 556.—G. Breschet,
Le Systeme Lymphatique, These de  Concours pour  une
Chaire d'Anat. de Paris, 4to, 1836.—Ollivier, in Diet, de
Med., 2d edit., art. Lymphatiques, Pathol.—(See, also, the
works on  Pathological Anatomy, by  Portal, Baii.lie,
Voigtel, Meckel, Otto, and Andral.)
  [Am. Bibliog. and Refer.—E. Geddings, Functions of
the Lymphatics, in the Phil. Jour, of the Med. and Phys.
Sciences, Aug.,  1827.—S. D. Gross, Pathol. Anatomy, 2d
ed.   Phil., 1845.— W. E. Horner, Lessons in Practical Anat-
omy,  for the use of Dissectors, 8vo ; et Special Anatomy and
Histology, 2 vols., 8vo.—/. Hope, Pathol. Anatomy, &c,
edited by L. M. Lawson, 48 plates, 8vo.—J. G. A. Lugol,
Researches on Scrofulous Diseases, translated by A. Sidney
Doane, 12mo.  New-York, 1845.—S. Jackson, Principles of
Medicine, founded on  the Structure and Functions of the
Animal Organism, 8vo. Phil.—R. Dunglison, Human Phys-
iology, 2 vols., Svo.—H. M. Edwards, Outlines of Anatomy
and Physiology, translated by /. F. W. Lane, Svo.—D. Oli-
ver, First Lines of Physiology, 8vo.—W. B. Carpenter, Prin-
ciples of Human Physiology, &c, with Notes, by M. Cly
mer, 8vo.  Phil.—J. Muller, Elements of Physiology, trans-
lated by Baly, ed. by John Bell, 8vo.  Phil.,  1814.]

   MALARIA.—See Endemic Influences.
   MAMMA, DISEASES OF THE.—As these
diseases come chiefly under the cognizance of
the surgeon, a brief notice of them only will be
required in this work.  Diseases of the breast
are either malignant or non-malignant: this dis-
tinction, however, must only be adopted as a
general one,  for tumours which have long ex-
isted in an indolent state, occasioning no  se-
rious symptoms, may become malignant under
the  influence of constitutional disease, of the
changes accompanying the  cessation  of the
menses, and of depressing passions ofthe mind.
Sir  A. Cooper, admitting this limitation,  dis-
tributes diseases of the breast into three class-
es :  "1st. Those which are the result  of com-
mon inflammation, acute or chronic ; 2d. Those
which arise from peculiar or specific action, but
which are not malignant, and do  not contami-
nate other  structures;  3d.  Those which  are
not  only founded on local, malignant, and spe-
cific actions, but are connected with a peculiar
and  unhealthy state ofthe constitution."
   2. M. Velpeau  divides diseases ofthe mam-
ma  into, 1st. Inflammations and their conse-
quences ; and, 2d. Tumours of various kinds.
Both  these divisions  are defective;  for there
are  affections of the mamma which consist nei-
ther of inflammation nor of tumour, but which
are  functional and nervous.  These have hard-
ly received sufficient attention from systematic
writers; indeed,  with a few exceptions, they
have not  even been noticed, and, when  no-
ticed, but  imperfectly.   The circumstance of
their being very commonly sympathetic, either 
MAMMA—Functional and Painful Affections  of the.              929
of disorder of the uterine functions, or of preg-
nancy, should not excuse  this neglect,  since
they do not always depend upon this cause, and
even when they are so associated, they are oft-
en the most prominent and distressing part of
the disorder.  I shall, therefore, divide the af-
fections  of the mamma into, 1st.  Functional
and  painful disorders;  2d. Inflammations and
their immediate  consequences;  3d. Tumours
and  morbid growths not primarily or generally
malignant and contaminating;  and, 4th. Tu-
mours or formations of a malignant and con-
taminating nature.
  3. I. Functional  and Painful Affections.
—The functions of the mamma may be either
imperfectly or not all performed  at the period
when they  are destined by nature to be dis-
charged, or, after they have commenced at this
period, they may suddenly and entirely cease.
These functions may likewise be performed in
an excessive manner, either absolutely or rel-
atively to the constitutional powers ofthe nurse.
WTith the exception of deficiency and suppression
of the milk, and ofpainful affection of the mamma,
the other functional disorders of this organ are
treated of in the article Lactation.
i. Deficiency or Suppression of the Milk.—
  Syn. Agalactia, ayaXaxria (from a, priv., and
  yahaKToc, milk).  Agalactie, Fr.  Der Mangel
  und Milch, Germ.
     Ci.assif.—I.  Class, II. Order (Author).
  4. Defin.—The non-appearance or the suppres-
sion of the function of the mamma at the period in-
tended for the performance of it.
  5. After parturition the function ofthe mam-
ma is generally discharged with  more or less
activity ; but it may not be manifested, or, hav-
ing been performed for a time, it may prema
turely or quickly eease.  This non-performance
of the office of the organ may be either primary,
or consecutive and symptomatic, more frequent-
ly the latter.
  6. A.  Primary agalactia is generally caused
by powerful mental emotions ; by constitution-
al debility; by want,  misery, and starvation ;
and particularly by cold applied to the body gen-
erally, or to the  mammae more  especially,  in
connexion with inanition.   When it proceeds
from mental emotions, the disorder is often only
of temporary duration ; but when it arises from
other causes, it is generally permanent.
  7. B.  Sympathetic agalactia is often  conse-
quent upon  fever and inflammations occurring
after delivery,  or at any period of lactation,
more particularly upon peritonitis, hysteritis,
and  excessive  discharges, &c.   When  these
diseases appear  soon  after  parturition, the
mammae do not become full and enlarged,  as
usually observed  at this period, but are flaccid,
and secrete little or no milk ; the elements of
which, thereby accumulating in the circulation,
favour the production of effusion in the seat of
inflammation.  If the disease, of which agalac-
tia is the consequence, is severe, or continue
for any considerable time, the function of the
mamma  is rarely resumed ; but if it be slight,
or of short duration,  the milk returns to  the
breast with  the subsidence of the malady.
  8.  The diagnosis of agalactia should not  be
overlooked, and the affection, whether primary
or symptomatic, should not be confounded with
the retention of the milk caused by inflamma-
tion  of the mamma, and by obstruction ©f the
    II.               117
lactiferous ducts.   In these cases, the mamma
is  hard, painful, and swollen; and  the  excre-
tion rather than the secretion of milk is impe-
ded or interrupted.
  9.  The circumstance of partial or complete
agalactia being sometimes concealed by nurses,
particularly by those who are hired to suckle,
should be kept in recollection ; and, where the
infant presents any indication of insufficient nu-
trition, or is peevish, irritable, and  dissatisfied
when applied to  the breast, the state  of the
mammae should be ascertained.
   10. The consecutive states of agalactia, and the
treatment of the affection  in its several  forms,
are fully stated in the article Lactation (see T
18, et seq.).
ii. Painful Affection  of the Mamma.—Syn.
  Mastodynia (from Maorof, mamma, and bdvvn,
  pain).  Der Schmerz  in den Brusten,  Germ.
  Mastodynie, Douleur des Mammelles,  Fr.
    Classif.—II. Class, I. Order (Author).
   11. Defin.—Pain, more or less severe, in one or
both mamma, most frequently in one only; general-
ly recurring, and with local heat, or general fever.
  12. Painful  affection of the mamma is most
frequent during the early months of  pregnancy,
and in connexion with functional disorder  or
organic disease of the uterus and ovaria.   In
its slighter  forms, it sometimes  accompanies
the irregular appearances ofthe catamenia soon
after puberty, and suppression of the discharge,
either  then or at later epochs.   Complete  or
violent neuralgia of the mamma is rare, but less
severe pains are not  infrequent in nervous and
hysterical females, and in those  who are the
victims of tight lacing, especially when the ute-
rus or ovaria are the seat of irritation, or in the
circumstances just alluded to.
   13. a. When the affection  is purely nervous,
it is characterized by the nervous temperament,
and hysterical tendency ;  by the recurring, and
even periodic form ; and by the absence of local
or general  plethora, and of hardness or fulness
of the organ.   In these cases, the left mamma
is more frequently  affected  than  the  right.
When it depends upon congestion of, and vas-
cular determination to, the mamma, the  pain is
more continued, although attended  by exacer-
bations ; and it is more liable to occur  in this
form  in sanguine and  irritable temperaments,
in females  of a full habit,  and in the course  of
pregnancy  and suppression  of the  catamenia,
than in other circumstances.   M. Capuron re-
marks that this affection  may be so severe in
irritable females  as  to  cause agitation, sleep-
lessness, and delirium.   In those of  a full habit,
the mammae sometimes become full and some-
what hard, and the pain is more obviously con-
nected with distention of the fibrous  envelope
of the gland, both mammae being more frequent-
ly affected than one  only.  Females who have
experienced pain in  the mammae before mar-
riage generally have a return of it afterward
when they become pregnant; and it may con-
tinue for a considerable time, or recur at inter-
vals.   If it be attended by congestion or vascu-
lar determination, these are  liable  to increase
as the period of parturition approaches ;  and in
plethoric females it  may  terminate in inflam-
mation and abscess after delivery.
   14. b. Diagnosis.—In all cases of pain in the
mamma, the state ofthe organ should be care-
fully ascertained, as respects the existence  of 
930                         MAMMA—Inflammations of thk.
inflammation or of tumour.  The former will
be indicated by local heat, fulness, tenderness,
and fever ; and when these are absent, and no
tumour exists, the  state and functions of the
uterus require attention.   This affection of the
mamma rarely occurs unconnected with some
change in the state ofthe uterus and its appen-
dages, or with pregnancy;  and this latter should
be suspected when  the pain is associated with
suppression of the catamenia.  The pain may,
however, occur before this discharge has made
its appearance, and it may be the first indication
ofthe  accession of this change of female life.
  15.  c.  Treatment.—The indications of cure
should be entirely based upon the associations
of the complaint, particularly with the states
of the  uterus.   If this organ is the  seat of ob-
vious disorder or actual disease, the treatment
should be directed  chiefly to the removal of
such disorder.   The pain in the mamma is here
merely a symptom  of the  uterine disease.  If
it be consequent upon pregnancy, it is equally
a symptom, and one which requires palliatives
only;  but these should  not be neglected, as a
persistence of the affection may excite fever,
or other disturbance  of a serious nature.  In
this case, anodyne fomentations, cooling aperi-
ents, narcotics  given  so as to procure repose,
gentle  frictions of the mamma with soothing or
powerfully anodyne liniments, and  belladonna
and camphor plasters, are the most appropriate
means.  If the  patient  be plethoric, and the
mamma  full and tense, a small or moderate
blood-letting, and diaphoretics, as Dover's pow-
der, the liquor ammoniae acetatis with spiritus
aetheris nitrici, antimonials, &c, are the safest
remedies.
  16. If the affection  present a nervous charac-
ter, the circumstances tending to increase the
nervous disposition  should be avoided.  These,
however, the physician often can only suspect;
and certain of them he can hardly mention, al-
though there is no doubt of their having induced
and prolonged the disorder.  Local excitement,
mental emotion, a heated imagination, tight
lacing, &c, are all often more or less concern-
ed in producing the complaint, whether  it ap-
pears at the period of puberty or at later epochs;
and, when this is the case, the treatment fre-
quently fails, if it be  not assisted by an  aban-
donment of the cause.  In this state of the dis-
order,  however, the local means above men-
tioned  (§ 15) should be  aided by such as will
regulate or promote the catamenia, or subdue
uterine irritation, and by those which will re-
store the impaired tone of the nervous systems
and of the organic functions;  especially by
camphor, sulphate of  quinine, the sulphate of*
iron, and anodynes.  The preparations of iodine,
the iodide of potassium with liquor  potassae,
the iodide of iron, and the various  chalybeate
preparations and mineral waters, may be pre-
scribed, particularly when the  uterine functions
are disordered, or when the blood is deficient
in quantity or in haematozine.
II. Inflammations of  the Mamma.—Syn.  Mas-
  titis  (from fiaoroc, mamma); Mastoitis; In-
  flammation des Mammelles, Mastoite, Fr.  Ent-
  ziindung der  Brilste, Germ.
    Classif.—III. Class, I. Order (Author).
  Defin.—Pain, tenderness, and tension of the
mamma, with febrile commotion.
  17. i. Inflammation of  the Nipple.—Vari-
ous inflammatory affections are confined or ex-
tend  to  the  nipple, and occasion, when  neg-
lected, unpleasant or painful effects.  The chief
of these are simple excoriations, eczematous and
other eruptions, cracks, fissures, and ulcerations.
Sore  or inflammatory states of the nipple are
very  frequent, and are often a source of great
distress.   They are most  common with  first
children, but some  women suffer from them
after  all  their confinements.   Inflammatory
appearances are seen two or three days after
the application of the infant to the breast, and
continue with farther changes for an uncertain
time.—a.  At first the nipple and areola are dry,
rough, red, and harsh, and then excoriated, hu-
mid, minutely granulated, often minutely crack-
ed, chapped, or fissured,  especially at the  base
of the nipple, and  acutely painful.   When the
excoriation is considerable, a serous discharge
is poured out, and extends the  excoriation lo
the surrounding skin.   In more  severe cases
the nipple exhibits two or three deep fissures,
and these may become so extensively ulcerated
as to  be partly or  even  altogether  destroyed.
In most of these, suckling not only aggravates
the symptoms, but  also causes the sores  to
bleed, and occasions extreme torture.  When
the sores prevent  the sufficient  application of
the child to the breast, the consequent accumu-
lation of milk occasions  distention and  inflam-
mation of the mamma.
   18.  b. The causes of sore nipples are  chiefly
the too frequent application of the infant to the
breast, thereby occasioning the removal of the
protecting sebaceous secretion of the part, and
favouring inflammatory irritation, vascular in-
jection, and its usual consequences.  The  con-
stitution, habits, and modes of living of  the pa-
tient,  particularly the use of irritating and ex-
citing articles of diet, and of heating beverages,
also favour the occurrence of this affection.
The state  of the  child's mouth, tongue, and
gums, more  especially  aphthae  of these, fre-
quently affects the nipple ;  while, on the other
hand, the discharge  from the sores of the nip-
ple often inflames the mouth ofthe infant.
   19.  c. Treatment.—In order to prevent this af-
fection, Dr. Churchill advises  the nipples  to
be washed with soap and water, and dried, and
afterward bathed with spirit and  water, night
and morning, during the last month of pregnan-
cy. Sir A. Cooper  suggests washing the nip-
ples some time before lying-in with strong brine,
in order to harden the cuticle, and render it less
prone to crack.  Dr. Burns  states, that  a com-
bination of white wax and butter is often  use-
ful ;  and that stimulating  ointments, such as
the unguent, hydrarg. nit. diluted with axunge,
are sometimes of service  ; or that the parts may
be touched with burned alum or  nitrate  of sil-
ver, or  dusted with some  mild, dry powder.
Some physicians prescribe solutions of alum ;
some, solutions of* sulphate of zinc ; and  oth-
ers, the supernatant liquor of a mixture of lime-
water and the chloride of mercury.  One of the
best applications is a solution of a drajhm of
borax in four ounces of water and half an ounce
of spirit of wine, or in equal quantities  of wa-
ter and dilute acetic acid.  Pure and fresh palm
oil is one of the most efficacious applications to
the nipple, and the safest to the infant;  it need
not be washed off previously to applying the
child*  to the bosom,  unless it be  made the ve- 
MAMMA—Acute Inflammation of  the.
931
hide for other substances.  Several writers ad-
vise, particularly when chaps, cracks, or fiss-
ures exist, a weak solution of the nitrate of sil-
ver to be applied after each period of suckling,
the  nipple  being  washed  before the infant  is
again held to  the breast.   Various  mechanical
means have been  employed where  fissures, ul-
cerations, &c., exist.   Shields, with prepared
cow's teats, are the best of these.  Feeding the
infant two or  three times a day, or a tempora-
ry recourse to a nurse, will facilitate the cure;
hut the milk should not be allowed to accumu-
late, lest inflammation of  the breast itself su-
pervene.*
  20. ii. Acute Inflammation  of the Breast.
—A. The symptoms of this disease are  nearly
those  which  characterize acute inflammation
of other glandular parts, somewhat modified in
their progress and results by the peculiar func-
tions and relations of the organ.   Sir A. Coop-
er  describes  an adhesive, a  suppurative, and
an  ulcerative stage, the existence of each of
which is readily recognised during the progress
of the disease.  The severity of the symptoms
depends upon the principal seat and extent of
the  inflammation.   When the cellular  tissue
and  skin are  alone involved, local pain, sore-
ness, with circumscribed hardness and tension,
are  felt, with slight inflammatory fever.  But
when  the gland itself, its connecting cellular
tissue, and the fascia  are  implicated, the pain
is then very severe, and extends to the axilla ;
the  swelling  is then more general, and  more
considerable, the tension greater, and the fever
more intense;  the skin being hot, the  pulse
quick and full, with thirst, headache, sleepless-
ness, &c.   If the gland be generally inflamed,
the breast has an  irregular or nodulated feel, as
if consisting of several tumours.   The secre-
tion of milk is suspended, at least for a time ;
but it generally takes place after the acute stage
has subsided.   In  this, the adhesive stage, lymph
is effused into the interstices of the inflamed
tissues, and a hard  and exquisitely sensitive
swelling is  produced.
  21. After a while an inflammatory blush ap-
pears on  the surface, the pain becomes throb-
bing and very intense, rigours or chills, succeed-
ed by heat and perspiration, indicate the forma-
tion of pus ; a particular portion of the tumour,
commonly where the surface was first red, be-
comes smooth and prominent, and fluctuation
is sensible  to the touch.  Detachment  of the
cuticle follows, with ulceration of the cutaneous
textures, and discharge of matter.  The whole
process usually occupies from ten days to three
weeks ; but its duration depends upon the in-
tensity ofthe  inflammation, the constitution  of
the patient, and the depth of the abscess.
  22. The pointing of abscess of the mamma is
generally near the nipple; and when the ab-
scess is superficial, or implicates  chiefly the
cellular tissue, the matter discharged consists
of digested pus, usually contained  in only one
cyst ar cavity ; but when it is more extensive,
invading the  gland and fascia, the matter  is
sometimes  contained  in several cavities, and
  * {Creosote diluted with lard makes a very good applica-
tion in cases of sore or inflamed nipple, as does also the
tincture of catechu, or of kino, the acetate of lead, or Gou-
lard's lotion. An artificial nipple, of a very ingenious
const ruction, and invented by Dr. PRatt of this city, is one
of the most successful  and ingenious contrivances in these
cases  that we are  acquainted with.]
sloughs of cellular tissue  occasionally are dis-
charged.  In a healthy person, the abscess soon
heals up after the matter has been completely
discharged, leaving only some hardness for a
time.
  23. In scrofulous constitutions,  however, or
in cachectic habits, and in persons whose minds
have been  harassed, and vital energies  de-
pressed, or circulating fluids contaminated, by
absorption of morbid secretions from the ute-
rus, or by residence in an ill-ventilated or crowd-
ed hospital, a much more severe, rapid, or even
a more  protracted disease presents itself.  Re-
curring chills or rigours, followed  by  heat and
perspiration ;  oedema ofthe surrounding parts ;
deep-seated fluctuation, or diffused suppuration;
low  or  adynamic fever;  and extension  of an
asthenic form of inflammation to adjoining parts,
with the usual ill consequences, either endan-
ger or carry off the patient.   In the more pro-
tracted cases, suppuration takes place slowly,
an abscess forms, bursts,  reforms  in the vicin-
ity, opens, and extends, and is ultimately fol-
lowed by sinuses, hectic fever, and its usual at-
tendants.
  24. B. Causes.—According to Sir A. Cooper,
the chief cause of this disease is  the rush of
blood to the breast every time the  infant is ap-
plied, and which affords the secretion of the or-
gan.  It is doubtful, however, whether this is
correct, for we do not observe other parts, the
functions of which require great or sudden de-
terminations of blood, more liable to inflamma-
tion  than organs continuously engaged.  But it
cannot be disputed  that there are  circumstan-
ces connected with the  functions of the mam-
ma which favour the occurrence of the disease,
since we seldom observe it  unconnected with
lactation ;  and when it is  independent of lacta-
tion, it  occurs chiefly in consequence  of local
injury, or morbid states ofthe uterus.
  25. The irritation, congestion, and  vascular
determination preceding the seeretion of milk
is generally attended by fulness and slight ten-
derness  of the breasts, and  feverishness.   If
these local conditions are increased, or exceed
moderate limits, the secretion is frequently in-
terrupted,  and the  breasts become distended,
tense, hot, and painful; this  state  readily pass-
ing into  inflammation, if it be not soon remo-
ved, particularly after the delivery of a first
child.   Dr. Burns remarks, that some have the
breasts prodigiously distended when  the  milk
first comes, and the hardness extends even to
the axilla.   If, in these cases, the nipple be sunk
or flat, or if the milk do not run freely, the fas-
cia,  particularly  in  some habits,  rapidly in-
flames.   In others, the dense cellular substance
in which the acini and ducts are imbedded, or
the acini themselves, become inflamed.  This
interruption to the  flow of milk, and the con-
sequent lacteal and vascular  congestion, is one
of the chief causes of inflammation.  The dis-
ease may also extend, as noticed above (y 17),
from the nipple to more deeply-seated tissues
Moving the arms too freely,  exposure to cold,
mental  emotions,  and a  heating  diet, or the
abuse of stimulants, especially when the breasts
are congested and enlarged,  are also  frequent
concurrent causes of mastoitis.
  26. C.  Treatment.—The first object should be
to procure resolution ofthe inflammation. This
is to be attempted by the application of leech- 
932
MAMMA—Chronic Inflammation of the.
 es;  by venaesection, if the state ofthe system
 and of vascular action permit it; by the exhi-
 bition of tartar emetic in small and frequent do-
 ses ;  by  administering purgatives, especially
 those of the saline  kind ; by giving diaphoret-
 ics and diuretics ;  by low diet;  by preventing
 the breast from hanging down, and keeping the
 arm of the affected side motionless in a sling ;
 and by drawing off the milk very gently by suc-
 tion at proper intervals.  In order to diminish
 vascular determination to the breast and  the
 secretion of milk, no means are more efficacious
 than purging by saline medicines, and giving
 antimonials, so as to produce  slight and contin-
 ued nausea.  The saline diaphoretics may also
 be given, with diuretics, especially the solution
 of the acetate of ammonia with  the nitrate of
 potash, and the sweet spirits  of nitre in cam-
 phor julap; and, if pain be urgent,  opium or
 other anodynes may be added.  As in other in-
 stances of topical inflammation, authorities are
 divided between refrigerating and warm and
 emollient applications to the part.  In  some
 cases, at a  very early period, cold applications
 are  useful adjuvants of the  above treatment;
 but emollient poultices and tepid or warm fo-
 mentations are most frequently beneficial.*
   27. When suppuration cannot be prevented,
 the case is  to be treated like any other abscess.
 With respect to the opening of the abscess as
 soon as fluctuation is detected, the rule stated
 by Sir A. Cooper should be followed.   " The
 surgeon should never wait for an abscess of
 the breast to approach the  surface, but make
 an opening as soon  as the slightest degree of
 fluctuation  is perceptible."  The rigid observ-
 ance of this rule will generally prevent the for-
 mation of sinuses, the treatment of which does
 not come within the scope of this work.
   28.  In all the stages of this disease, some one
 or other ofthe preparations of opium should be
 given to allay irritation or intense pain.   In  the
 states of the malady characterized by general
 irritation and vital depression, by irritative or
 adynamic fever, as noticed above (§ 23), opium
 in large doses, with camphor, stimulants, aro-
 inatics, and alkaline carbonates, and the gener-
 al treatment advised  for asthenic inflammation
 and  diffusive abscess (see art. Abscess, § 62 ;
 and  Inflammation, § 239, et seq.), are particu-
 larly indicated.
   29.  After an abscess of the breast has been
 opened, the diet may be improved ; and if the
 discharge be profuse, and the pulse be deficient
 in power, tonics should be prescribed.   If the
 abscess be  small and superficial, the infant may
 suck the affected breast; but  if it be large, it
 should be artificially drawn, and the infant con-
 fined to the other breast.  However, the effect
 of sucking the  sound breast  should be  closely
 watched, as inflammation of it,  also, may be
 thereby induced, while the disease of the one
 first  affected may  be aggravated.  In  either
 case,  the infant should be removed altogether.
In cases of  spreading abscess or sinuses, bark,
wine,  and  generous diet,  with  pure  air,  or
 change of air, are always necessary.
  30.  iii.  Chronic  Inflammation  of  the
 Breast.—a. In  the acute form of mastoitis,
 the disease  seldom continues longer than five

  * [Some of the best, of these are, the emplastrum ammo-
r-aci cum hydrargyro, the iodine ointment, and a solution
 of muriate of ammonia with rectified spirit of wine.]
weeks;  and  when  resolution  does not  lake
place, it generally arrives at the stage of sup-
puration in a few days.  But a slighter state of
inflammation of the organ may exist, and, from
the state of the local and general symptoms-,
be confounded with another disease.  In this
case, the little pain which is felt, the  absence
of heat, of redness of the skin, and of febrile
symptoms, and  the want of rigours or chills,
often prevent  the suspicion of the formation ol
matter, which is generally indistinct and deep-
seated ; and suggest the existence of a malig-
nant tumour, requiring an operation for its re-
moval, which has been even actually performed
or attempted.
  31. b. The  Treatment of these cases should
consist of means to promote  the secretions and
excretions, and to improve the  state of consti-
tutional power, which is generally more or less
in fault.  The pilula hydrarg.  chloridi comp.,
with soap at night, and tonic decoctions or in-
fusions, with  alkalies, &e, during the day, are
usually indicated.  If matter have not yet form-
ed, Sir A. Cooper recommends the application
of discutient plasters and stimulating embroca-
tions, in order to promote the absorption of in-
filtrated fluid.*  But when  matter  is  formed,
the abscess should be opened  and poulticed ;
tonic medicines should be exhibited, and a gen-
erous diet allowed.  The glands in the axillae
sometimes become enlarged from irritation, but
subside when the disease in the breast is re-
moved.
  32. iv.  Chronic Inflammation of the  lac-
tiferous Tubes.—Lacteal or lactiferous Swelling,
A. Cooper.—This disease sometimes  follows
inflammation of the  nipple, and consists of in-
flammation, generally  chronic,  of one of the
lactiferous tubes near the nipple, by which its
canal is narrowed, or entirely obstructed, to
the extent of half an  inch or more, while the
portion which is  not  thus  affected becomes
painfully distended with milk.
  33. a. The symptoms are as follows:  The tu-
mour is confined to one part of the breast, from
the nipple to the circumference ; and it has not
been preceded by redness, or any other symp-
tom  of inflammation of the  part which is dis-
tended so as to form the tumour.  The patient
complains of a severe sense of distention, which
is increased  when the child begins to  suck.
There is distinct fluctuation  in the tumour,
while no other symptom of abscess is present:
the cutaneous veins  are enlarged, but the part
is not discoloured.  If the swelling be opened,
several ounces of milk are discharged, which,
being suffered to rest for a few hours, forms a
cream upon its surface.  If a small puncture
only be made, the milk discharged, and the or-
ifice allowed to close, the fluid re-accumulates,
and the  symptoms are renewed.  When the
  * [We believe that this affection may generally be treat-
ed successfully by pursuing the mode of treatment recom-
mended by Astlby  Cooper, viz., applying, in  the early
stage, a lotion of °jjj. of spirit of wine, and ;v. of water, or of
liquor plumbi dilutus, to the part, and purging the patient
by giving repeated doses of castor oil or sulphate of mag-
nesia.  If the patient suffer from the cold produced by the
evaporation of the spirit, a simple tepid poultice may be
substituted for it, occasionally applying leeches to the swell-
ing, still recollecting that the chief dependance is upon
puTging. We have succeeded in a great number of cases, by
pursuing the method laid down by Dewees, of fomenting
the inflamed breast for several  hours continuously with te-
pid vinegar and water.] 
MAMMA—Organic Lesions of the.
933
distention is excessive, ulceration sometimes
takes place;  the milk is discharged through a
small  aperture near  the nipple, and this  dis-
charge often continues during the whole period
of lactation.*
  34. b. The treatment should consist in remo-
ving the child, which will soon occasion a ces-
sation of the secretion of milk, and then a sim-
ple puncture may be made, which will relieve
the distended tube.   If, however, the child be
suffered to continue at the breast,  the opening
should  be made larger,  so that  the milk may
escape while the child is sucking, as happens
when a natural relief is  effected by ulceration.
   [It is well to  recollect, as Cooper has sug-
gested, that this disease resembles, in its na-
ture, the ranula, excepting in the fluid secreted.
The one is an obstruction of the sub-maxillary
duct and accumulation of saliva ;  the other is
an obstructed lactiferous tube, which is follow-
ed by an  immense collection of milk, from its
escape  being prevented at the nipple, owing to
the obliteration of the duct at that part.   (Anat.
and Dis. ofthe Breast, Am. ed.  Philad., 1845.)]
III. Organic Lesions of the Mamma general-
  ly occurring  independently  of Inflamma-
  tion.
    Classif.—IV. Class, I. Order (Author).
  35.  This class of diseases of the  breast sel-
dom originates in any form of inflammatory ac-
tion, or, at least, in an unequivocal and mani-
fest state of inflammation ;  but rather in con-
ditions  of the part and of the system very dif-
ferent from it—especially from  true or sthenic
acute  inflammation.   This class is mostly ref-
erable to low states of vital power and vascu-
lar action, in connexion with altered or morbid
nutrition and secretion in the organ—to local
   * [Jan. 3,1842.—A female was presented at the Clinique
 of Professor W. Parker, at the College of Phys. and Sur-
 geons of this city, having an enormous collection of milk in
 the breast (New-York Med. Gazette, vol. ii., p. 17). The
 patient was about 30 years of age, apparently in good health,
 and had an infant nine months old, which she nursed regu-
 larly from both breasts.  The breast began to increase in
 size in July,  and continued  gradually to grow, without ex-
 citing pain or febrile symptoms. The tumour was not pain-
 ful, but caused considerable inconvenience  from its size.
 The  nipple and skin were both natural, the blood-vessels
 of the breast somewhat enlarged.  On passing in a  trocar,
 milk gushed  forth in a free  stream, which was collected in
 basins; it was perfectly sweet and unchanged, and meas-
 ured three quarts.  On being allowed to stand for 24 hours,
 it gave a good quantity of cream.  Jan. 10th.—The patient
 again appeared at the Clinique, when the opening made by
 the trockar was found healed, and the milk had again ac-
 cumulated in the breast, which was pendulous, and some-
 what pediculated, and measured 22 inches in circumference.
 Fluctuation was more distinct at some points than at  others,
 but was  evident  all  over the tumour.  The trocar was
 again plunged in, and about two quarts of pure, sweet milk
 drawn off.  The patient was advised to wean  her child.
 Jan. 17.—The patient again presented  herself,  when the
 milk  was found to have accumulated, although her child
 had been weaned.  A new puncture was made, and three
 pints of fluid were drawn off; a tent was then introduced
 and retained, so as to keep the opening from closing. " In
 this way," said Professor P., " the milk will be discharged
 aa soon as secreted, all accumulation prevented, and the se-
 cretion will,  of course, be diminished and gradually cease,
 the child being weaned ; we shall thus  get rid,  finally, of
 the disease."—(Loc. cit.) A still more remarkable case is
 mentioned by Scarpa (Am. Med. Recorder, vol. ii., p. 472),
 of a young female, whose left breast, after her second con-
 finement, in the course of two months acquired such  a size,
 that it measured 34 inches in circumference, and rested,
 when she was sitting, on the corresponding thigh. The
 skin presented  no particular alteration, except that it was
 rather tense and shining, the subcutaneous veins being dila-
ted.  A flow  of pure milk followed the introduction of the
trocar, and ten pints of that fluid were drawn off iu a con-
tinuous stream.—(Gross.)]
 irritation  and lesion  allied with constitutional
 vice or disorder.
   36. i.  Hemorrhagic  Congestion  of  the
 Mamma.—Ecchymosis of the Breast, A. Cooper.
 —This change  is generally associated with a
 considerable degree of mastodymia.  It consists
'bf a full and bruised appearance of the organs, ac-
 companied with pain and exquisite  sensibility or
 tenderness.—a. It occurs chiefly in females un-
 der twenty-five years of age, and is preceded
 by severe pain in the  breast and arm.   The ex-
 travasation  of blood  occasioning  the ecchy-
 mosis begins a few days before menstruation,
 and either is limited to a single spot, appearing
 as if a severe blow had been inflicted, or con-
 sists of  several small  spots : generally  one
 large patch and several small and paler patches
 are  observed.   It occurs chiefly in females of
 delicate fibre, who have large bosoms.  The
 part is exquisitely tender,  and the pain passes
 down along the inner side of the arm to the
 ends of the fingers.   This  affection sometimes
 disappears a week after  menstruation ; but, in
 the  more  severe cases,  it continues  until the
 next menstrual period.  It is evidently a con-
 sequence  of increased determination of blood
 to the organ prior to the catainenial discharge,
 and indicates  great irritability of the  system,
 in connexion with weakness of the capillaries,
 whereby they are incapable of resisting the de-
 termination of blood to them.  It  is generally
 attended by irregularity of the catamenia, and
 constitutional debility and irritability.
   37. b. The treatment should be directed to the
 uterine and constitutional  relations of this af-
 fection.   The preparations of iron, the mineral
 acids, sulphate of quinine,  or sulphate of iron,
 in the compound infusion of roses, or other ap-
 propriate tonics,  may be prescribed ;  and  the
 liquor ammoniae acetatis with spirits of wine,
 tincture of opium and rose water, may be ap-
 plied locally.
   38. ii. Atrophy of the Mamma.—Absorption
 of the mammary gland, or,  rather, wasting of
 this part,  usually occurs at an advanced  age,
 or subsequently to the  disappearance  of  the
 catamenia; and it has been said to be produ-
 ced by the excessive use of the  preparations
 of iodine  ; but probably, in  some of the cases
 where this effect has been  said to have been
 produced,  the adipose substance in which  the
 gland is imbedded is the part chiefly absorbed.
 Atrophy of this organ does not appear to  fol-
 low  the tumefaction  of it  sometimes conse-
 quent upon cynanche parotidea. (Cumin, Edin.
 Med.  and  Surg. Journ , vol.  xxvii.,  p. 227.)
  39. iii.  Hypertrophy  of  the Mamma.—En-
 largement of the  organ is sometimes observed
 to a very great extent.  In  most of the slighter
 cases, however,  particularly when both mam-
 mae  are enlarged, the hypertrophy is chiefly
 owing to   the great  increase of adipose sub-
 stance around the gland.—a. True hypertrophy
 of this organ is independent of any morbid
 change of structure, and of any distinct tumour.
 It is entirely an unusual, and sometimes an al-
 most monstrous growth of the gland.   The in-
 crease of size is generally uniform, and it is at
 the same  time more or less pendulous.  At the
commencement, indications of increased deter-
 mination of blood to it are sometimes evinced,
as heat, uneasiness, augmented sensibility, &c.
True hypertrophy of the mamma  is called, by 
934                         MAMMA—Organic Lesions of the.
Sir A. Cooper, "the large and pendulous breast."
It  consists in an increase of the substance of
the mammary gland, the lobes of which can be
distinctly felt enlarged and hardened ; and they
are sometimes  tender on pressure.  This dis-
ease generally commences soon after puberty,
and is believed to  be always connected with
defective  or disordered  menstruation.  The
breast, in many cases,  has attained  so enor-
mous a magnitude as to render extirpation ab-
solutely necessary.   In a  case mentioned by
Mr. Hey, after  the  removal of the left  breast,
the menses, which had  been entirely suppress-
ed, returned, and the right breast diminished
to  less than half the size it was before  the op-
eration.  The amputated breast weighed elev-
en pounds four ounces.*
  40.  Sir A. Cooper  describes a peculiar form
of hypertrophy  of the mamma incident to un-
married women of the  age of thirty or thirty-
five, in whom the menses are defective in quan-
tity, and who are the subjects  of severe leu-
corrhoea.  The breasts become  enlarged, but
not pendulous.  On  careful examination, the
lobes of the gland can be distinctly felt enlarged
and hardened, and moving freely on one anoth-
er.  Both breasts are affected, but one  usually
more than  the other, and  there is occasional
pain, especially just before the appearance of
the menses, which are scanty, pale,  and of
short duration.  Exposure of the part  to cold
augments the  pain, and, in these cases, cold
has a great influence  in lessening the menstru-
al secretion.  An enlarged absorbent gland is
sometimes found in each axilla ; but this arises
from simple irritation. After a while the breasts
begin to waste, and  in  a few  years are nearly
absorbed.
   41. b.  The treatment  of this affection is that
of amenorrhcea, of which it is generally a con-
sequence.   In  the first  variety of it local means
are not likely to be of any service.   In  the sec-
ond variety Sir A. Cooper recommends the ap-
plication of the emplastrum ammoniaci cum
hydrargyro, and of leeches when there  is pain.
In both varieties the  preparations of iodine are
the most appropriate remedies,  and when judi-
ciously prescribed, and combined with  deob-
struents and emmenagogues, are often of ser-
vice.   The iodide of potassium alone,  or with
liquor potassae  and conium ;  the iodide  of iron,
and the iod ides of mercury, should be preferred,
as they exert an emmenagogue operation, while
they diminish the size ofthe mamma.
   42. iv. Scrofulous Tumours of the Breast.
—a. In women of  a strumous diathesis  the
  * [Dr. S. C. Houston has reported (Am. Journ. of Med.
Sciences, vol. xiv.) a remarkable case of hypertrophy ofthe
mamma in a coloured girl, aged 16, who died in the Phila-
delphia Almshouse in 1834.  The  left breast, which began
to enlarge much earlier than the right, weighed twenty
pounds, and measured 42  inches around the base, forming
an oviform mass, which extended from the lower part of the
neck to some  distance beneath the umbilicus. The other
breast, which was  of the same shape as the left, was also
enormously enlarged, yet it was perfectly sound, presenting
not the slightest structural lesion.  Around both glands the
cellulo-adipose tissue was in a state of hypertrophy, and in
neither could there be detected  any trace of the nipple.
The girl had menstruated, and enjoyed  good health until a
few weeks before  her death, which was occasioned by a
contusion of the left mamma, terminating in gangrene.—
(Gross )  Dorsten, a German physician, relates a case,
where the enlargement was attended with retention of the
milk, and the left breast  was found to weigh 64 pounds.
Here, also, no decided structural change could be detected
in the gland, except the mere hypertrophy of the adjacent
cellular texture.]
mamma is subject to various indolent tumours,
which in their earlier stages are not easily dis-
tinguished from diseases of a much more seri-
ous nature.   Sometimes a hard lump forms in
the organ and remains almost  quiescent  for
months, or even years; or the whole gland may
be affected with scrofulous enlargement.  The
general tendency of the disease, however, is to
the slow and imperfect suppuration character-
istic of strumous  action; and the matter has
the curdy appearance  which  the contents  of
scrofulous abscesses always  present.   Ulcer-
ations of great depth and extent sometimes re-
sult, but the topical disease  usually produces
no  proportionate  effects  on  the  constitution.
In this disease the part is always enlarged,  not
contracted, as in one form of carcinoma.  The
tumour is tender when grasped, but it does not
present the  stony hardness  observed  in  the
latter malady.   According to Dr.  Cumin, it is
never attended by retraction of the nipple. The
indications of the  strumous diathesis of the pa-
tient, together with the characteristics of scrof-
ulous ulceration in the part, will farther deter-
mine the nature of the disease.
  43. b.  The treatment of scrofulous tumours
of the breast is the same as that  just recom-
mended (t; 41), namely, the  exhibition of  the
preparations of iodine ; of Brandish's alkaline
solution, conium, &c.; or the  means advised
in the article Scrofula.  Strict attention should
be directed to the uterine functions;  the cata-
menia ought to be promoted and the general
health improved.
  44. v. Adipose Tumours are but rarely found
in the breasts, but they reach a very consider-
able magnitude.   In the cases described by Sir
A.  Cooper, the tumours formed, in one case,
between the gland and the surface of the pec-
toral muscle, and in another, between the  dif-
ferent portions ofthe mammary gland.
  45. In the treatment of these tumours, the in-
ternal use of the iodide of potassium, with or
without the liquor potassae, should not be over-
looked, as I  have found these  remedies succeed
in  removing adipose tumours in  other  situa-
tions.
  46. vi.  Chronic Mammary Tumour.—a. This
disease generally attacks females  between the
ages of seventeen and thirty-five.  It is often
independent of very manifest  constitutional  dis-
order, and it does not necessarily affect the gen-
eral health,  unless by occasioning anxiety in the
mind ofthe patient as to its  nature.  But it is
usually connected with uterine irritation or dis-
order.  It occurs  chiefly in single women, or in
those who have not had children.   The tumour
grows from the periphery of  the breast, rather
than from its  interior, and it therefore gener-
ally appears  to  be  superficial:  occasionally,
however, it springs from the  posterior surface,
and it is then  deep-seated, and not so readily
discriminated.   It is extremely moveable,  and
glides easily over the surface of the breast, to
which it is attached chiefly by an aponeurosis.
It begins and  often continues for many years
without exciting pain ; in some cases, however,
it is attended  with  an aching pain, which  ex-
tends to the shoulder.  It is not generally ten-
der to the  touch, but Sir A. Cooper has occa-
sionally found  it  so just before the menstrual
periods.  Its growth is very slow, and it seldom
attains any great magnitude, usually weighing 
MAMMA—Organic  Lesions of the.
935
from one to four ounces.  One, however, which
was removed by Mr. Bond, of Brighton, weigh-
ed a pound and a half, and Sir A. Cooper men-
tions a case which occurred in Guy's Hospital,
and which he  believes to have been of this
nature,  where  the  tumour  weighed  several
pounds, and had ulcerated at its most prominent
part.  These tumours are originally quite free
from malignancy ; they  exist for many  years
almost in a stationary condition,  and then grad-
ually diminish and disappear.
  47. b.  The most distinctive anatomical feature
of this tumour is its lobulated structure, which
may be felt by careful manipulation before its
removal.  On dissection, the tumour is found to
be contained in a bag formed of a fibrous struc-
ture, similar to that which  envelops  and  en-
ters the interstices  of the mammary gland :
and this envelope becomes denser in proportion
to the  magnitude of the tumour.  When first
laid bare, the tumour appears to be composed
of large  lobes,  like those of the  breast;  but
when more completely unravelled, it is  found
to consist of smaller and smaller lobes, similar
in form, and easily separable by maceration in
water.   Sir A. Cooper observes, "The impres
sion made upon the mind during the dissection
of the  tumour  is, that Nature has formed an
additional portion of breast, composed  of simi-
lar lobes, but perhaps differing in the  absence
of lactiferous tubes.   When first opened, they
appear red in the circumference, but whiter in
the interior."
  48. c. The diagnostic marks of this disease
are, the youth of the patient, scirrus rarely ap-
pearing before thirty, this disease seldom after
it; absence of pain, or of pain  similar to that
of cancer, the pain sometimes felt being slight,
and considerable swelling existing for  years
without it;  the general health being either not
at all or slightly affected ;* the slow progress
of the swelling, and its stationary condition for
many months, or even years ; its extreme mo-
bility, its superficial position, or  its situation
upon or  in connexion  with the gland rather
than in it; and, lastly, its lobulated feel, it be-
ing distinctly composed of numerous lobes con-
glomerated into one mass, with a divided sur-
face.   The glands of the axilla very rarely en-
large, the enlargement being the result of irri-
tation only.
  49. I believe that Sir Astley  Cooper is cor-
rect in his observation that, although these tu-
mours  are not  in their commencement malig-
nant, and they continue for many  years free
from the disposition  to become so, yet, if they
remain until the period of the cessation of men-
struation, they may assume a  new or malig-
nant action.   I believe, moreover, that pro-
tracted anxiety, and  the depressing emotions
generally, may  produce the same effect, even
before this period occurs.
  50  d.  The cause of this disease is chiefly
vascular determination consequent upon irrita-
tion seated principally in  the uterine organs
  * When the patient perceives the physician to be suspi-
cious of its malignant nature, her anxiety may so disorder
the general health as to increase the difficulty of the diag-
nosis.   Such was the case in respect of a lady sent to me a
few years ago from  the country by her medical attendants
r'or my opinion.  I readily recognised the non-malignant
sature ofthe malady, and in this opinion both Sir A. Coop-
er and Sir B. BnoriE, who subsequently met me  in con-
ciliation on it, entirely concurred.
and extending to the mamma.   Hence it is oft-
en associated with signs of uterine excitement
or irritation, or with disorder of the catamenia.
It is sometimes ascribed to a  blow, or to the
pressure of  stays; but these are rather  con-
curring or additional than the only causes.
  51. e. The treatment should be directed chief.
Iy to the state  of the uterine organs ;  for the
disease is seldom much influenced by  means
directly applied to  it.  The  disappearance of
the tumour is generally owing to  the cessation
of the uterine irritation in which  it originated,
or to the mamma being  called upon to exercise
its natural function  in  the secretion of milk.
The  catamenial discharge ought to receive at-
tention as regards its time, its quantity, its col-
our, and its duration.  When it is scanty,  diffi-
cult, attended by pain, pale, or  delayed, I  have
found an occasional purgative  of calomel and
compound extract of colocynth, and the prepa-
rations of iron or of  iodine, more particularly
the iodide of iron, the iodides of mercury  with
conium, or the iodide of potassium with liquor
potassae and  tonic infusions, extremely  benefi-
cial.   The mist, ferri composita with conium,
and attention to the biliary and digestive func-
tions, are also very serviceable.   Where these
functions are torpid, the pilula hydrarg. chloridi
composita with  soap and conium at bedtime ;
and the infusum calumbae, vel infus. cascarillae,
cum  infuso rhaei et sodae sub-carbon, &c, twice
a day,  will generally be of service.  The em-
plastum  ammoniaci  cum  hydrargyro,  and a
weak iodine ointment, are the  best local appli-
cations; but  these should not supersede  the in-
ternal use of some one of the  preparations of
iodine, in small doses, and for a sufficiently
long period.   Pregnancy and lactation are, how-
ever, the most certain means of removing this
disease.  A young lady resident  in a country
town had this  disease,  and two or three sur-
geons were consulted respecting  it.   She was
engaged to be  married, and her intended hus-
band was made acquainted with her complaint.
Owing to the opinion then given,  the marriage
was  delayed  for more than  two  years, during
which  time  the disorder was stationary.   An-
other surgeon  was consulted, who recognised
the true nature of the disease,  and sent her to
London for my opinion.  I advised her no longer
to delay her marriage.  Sir A.  Cooper was af-
terward consulted, and  concurred in this opin-
ion.  The disease afterward gradually disap-
peared.
  52. vii. Painful  Tumour of the Mamma.—
Irritable  Tumour of the  Breast,  A. Cooper.—a.
The female  breast, as already  stated, is liable
to severe hysterical or neuralgic pain, quite
unattended  by  swelling  or  distinct tumour.
But similar pains to those above noticed (y 11)
are sometimes associated with slight tumefac-
tion of one or more of the lobes of the organ  ;
and more rarely they are attendant upon a spe-
cific tumour, described by Sir A. Cooper.  In
the neuralgic affection, without any circumscri-
bed tumour, the swelling appears to be merely
an incidental complication, as  in neuralgia of
the  face and other parts.  The  pain, though
greatest at some particular part, generally per-
vades  the whole breast, and extends  to the
shoulder, axilla, arm, and fingers  of the affect-
ed side, sometimes also extending downward
even to the hip.  The slightest pressure on the 
936                        MAMMA—Organic Lesions of the".
breast occasions intolerable pain, and alternate
sensations of heat  and cold are felt in the af-
fected part.   The  intensity of the pain often
occasions sickness and vomiting.  The symp-
toms are much augmented just before menstru-
ation, somewhat relieved during its  continu-
ance, and diminished after its cessation.
  53. Besides this irritable state of the whole
or part of the breast, a distinctly circumscribed
tumour  is sometimes found,  often not larger
than a pea, and  seldom exceeding the size of a
marble.   It is highly sensitive to the touch, very
moveable, and acutely painful at intervals, espe-
cially prior to menstruation.  Occasionally sev-
eral such tumours coexist, but there is usually
only one.  These tumours continue for years.
Sir A. Cooper has never known them to sup-
purate.   They sometimes spontaneously cease
to be painful, or disappear altogether.
  54. b. On  dissection, they are found to con-
sist of a solid, semi-transparent substance, with
fibres irregularly  interwoven.  They  seem to
be productions ofthe cellular membrane rather
than of the  glandular substance  of the part;
and similar tumours are met with  in the cellular
membrane of other parts of the body, which
are attended with  the like painful sensations.
Sir A. Cooper has not been able to trace any
large filament of a nerve  into them.
  55. These painful or neuralgic tumours of
the breast are met with generally between the
ages of sixteen and thirty ; and from  this, as
well as from other circumstances, cannot be
confounded  with other diseases.   They affect
principally females of a nervous temperament;
are commonly  connected with deficient, diffi-
cult, or suppressed menstruation.   In some ca-
ses, however, Sir A. Cooper has observed them
associated with morbidly abundant menstrua-
tion.  In a  case of this  affection for which  I
was lately consulted, and which  has  been re-
moved by treatment directed chiefly to the ute-
rine organs,  a severe  return of it occurred du-
ring the second  month after marriage, evidently
in connexion with early pregnancy.  I have ob-
served these affections complicated with leu-
corrhcea as well as with catamenial disorder.
  56. c. The treatment of this affection should
be directed,  1st. To the alleviation of the local
suffering ; 2d.  To the subduing the  general
irritability ;  and, 3d. To the restoration of the
uterine organs to a healthy condition.
  57. a. Sir  A.  Cooper states that the best lo-
cal remedies  are, a plaster consisting  of equal
parts of soap cerate and extract of belladonna ;
poultices of  bread with solution of belladonna ;
and  oil silk, or hare  skin, or some other fur
worn upon the  breast.  Leeches may be used
when the pain is very severe ; but if prescribed
for weak or  reduced constitutions, or when the
disease  is connected with anaemia, or too fre-
quently resorted to, they aggravate the irrita-
bility of the  system.
  58. b. To  remove the general irritability, the
treatment advised for Nkuralgic Affections
are the  most efficacious,  with proper attention
to the uterine functions.  If the biliary organs
be sluggish,  the chloride of mercury, or Plum
mer's or blue pill, with soap, opium, and coni-
um, should be given at night; and a stomach-
ic or an emmenagogue aperient in the morn-
ing ; the preparations of iron, or of bark with
soda or potash, or camphor  being taken du-
ring the  day.   Sir A. Cooper advises the fol-
lowing pill to be taken twice or three times  in
the day.
  No. 290.  R  Extract! Conii; Ext. Papaveris, M, gr. ii. ;
Extr. Stramonii c Seminibus, gr. i, vel ss.  M. Fiat 1 ilula,
bis terve in die sumenda.
  59. c. In order to remove the uterine disor-
der, the carbonate of iron, the ammoniated iron,
the compound  myrrh mixture, the compound
aloes mixture,  and similar means, combined
with such others as the peculiarities of the ute-
rine disorder will suggest, ought to be prescri-
bed.  These means may be promoted by a re-
course to a hip bath of sea water or of artificial
salt water, of a temperature of about 100°  or
103°.  A salt-water shower bath, or the salt-
water  douche, on the loins and hips, will  also
be  of service when aided by regular exercise
in a dry, temperate, and pure air ; by attention
to diet and regimen ;  and by due regulation  of
the mental emotions and desires.
   60.  viii.  Cartilaginous  and  Ossific  Tu-
mour.—According to  Sir A. Cooper, these tu-
mours are consequences of chronic and specif-
ic inflammation of the  breast, during which a
gelatin  is effused resembling that in  which
bone is formed in  the foetus.  But the forma-
tion of bone  in the foetus is not an inflamma-
tory process.  He supposes that blood-vessels
and absorbents enter the  eff«6ed gelatin from
the adjoining parts ; and as the latter remove
portions  of  it, the former deposite the  ossific
matter in the  interstices.   Bayle describes
ossification  as  the last stage of what be de-
nominates  fibrous tumour of the  breast.  Sir
A.  Cooper removed a tumour of the kind un-
der  consideration  from a woman  thirty-two
years of age.  It was of fourteen years' stand-
ing, excessively hard, and very painful.   The
pain was increased before  menstruation, and
greatly relieved after  it.  The skin covering it
felt  very warm  in comparison with the  sur-
rounding parts, and required the  constant ap-
plication of evaporating lotions.  On dissection,
the greater part of it presented the appearance
ofthe cartilage  which supplies the place of bone
in the young subject;  the rest was osseous.
The most remarkable case on record is that  of
a nun, in whom the mammae were  found after
death  transformed into hemispheres of bone.
(Miscel.Nat.  Curios., Dec. ii.. An. vi.)
  61. ix. Cystic  and  Hydatidic Tumours of
the .Mamma. — Tumours  of this  description
have been described by Sir A. Cooper, M. Vel-
peau, Dr. Warren, and Dr. Cumin.  The  first
of these writers has described four varieties  of
hydatid diseases of the organ, three of which
he  considers not to be malignant; the fourth
to  be  malignant.   A more  correct division
would  be into those consisting, 1st. Of serous
cysts ; and, 2d.  True hydatids ; and it is not im-
probable  that the former may assume various
forms, or be variously transformed, as respects
the  characters and number of the cysts, the
appearances  of their  coats, and the nature  of
their contents, in the  progress of their growth,
and by peculiarities  and  changes  in the pa-
tient's constitution and health.  Indeed, any
one of them may possibly assume the cancer-
ous or malignant character, owing to these cir-
cumstances.
   62. A. The cystic tumours vary  remarkably
not  only as  respects  the  number  and size  of 
MAMMA—Organic  Lesions of the.
937
the cysts forming the tumour, but as respects
the number and appearances of their tunics,
and the nature of their contents.  Some of these
tumours  present one large cyst, with various
partitions ;  others  consist  of several cysts,
more or less distinct;  others, again,  are  form-
ed of several concentric tunics : some contain
a sero-mucous  fluid; others, a sero-sanguine-
ous liquid.
  63.  Sir A. Cooper  describes as follows his
first species, or tumours consisting  of simple
serous cysts, or  bags ;  he, however,  confounds
simple cysts with hydatids (see art. Hydatids).
In  this  form  of disease, the  breast  gradually
swells, and is, at first, free from pain and ten-
derness.  It becomes hard, without fluctuation;
and grows slowly for  months, or even years,
sometimes acquiring  a very considerable  size.
At  an early stage the  swelling  feels  entirely
solid, and greatly resembles  a simple  chronic
enlargement of the breast; but, after a  great
length of time,  fluctuation may be detected at
one part  of it.   The tumour then begins  to in-
crease more rapidly, and fluctuation  may soon
be detected in several parts.   There is still, in
most cases, little or no pain ; some patients,
however, feel an unusual heat in the part, and
others experience pain in the breast  and shoul-
der.  The tumour is extremely moveable on the
pectoral  muscle, and  is  very pendulous.   In
some cases, the whole of the  mammary  gland
becomes  involved ;  in others, only a small por-
tion of it.  Such tumours often  attain a very
considerable size:  Sir  A. Cooper states that
the largest he ever saw weighed  nine pounds  ;
but that,  in other cases, although the diseased
breast was entirely filled with cysts, it never
exceeded twice the size of the healthy one.
At  length, one of the fluctuating portions slow-
ly inflames, ulcerates, and  discharges  a  large
quantity of a fluid resembling serum, but some-
what more glairy.   If the sac be  entirely emp-
tied, and the external  opening  closed, it is  a
long time before the  fluid reaccumulates, and
occasionally the sac is obliterated by  the ad-
hesion  of its sides.   Sometimes  several cysts
burst in  succession, at distant periods,  form-
ing sinuses which  are very  difficult to  heal.
Except during  the  process  of ulceration, the
general health  is  not at all disturbed.   Even
when  the tumour is large, ulcerated, and dis-
charging  profusely,  the axillary glands remain
unaffected ;  or,  if one be  slightly enlarged, it
is from simple  irritation, and the enlargement
subsides  when the disease iii the breast  is re-
moved.*
  64.  The second species of cystic tumour de-
scribed by Sir A. Cooper seems hardly entitled
to rank as such, since it is formed on a single
case, and  a doubt  is  expressed  whether even
this might not have been of the  nature of the
globular or true hydatid.   It is represented as
undistinguishable from the preceding  species
except by  dissection.   In the case examined by
Sir A. Cooper  the tumour consisted of  vast
numbers  of cystic  formations, the largest  of
which did not exceed the size of a barleycorn.
They  were  oval, and  composed  of numerous
lamella, which could be peeled from each other,
and which were very vascular.
  65.  B.  The true globular hydatidic tumour, the
third species of hydatid tumour of Sir A. Coop-
er, is similar to hydatid  productions in other
parts ofthe body.   Sir A. has  found the globu-
lar hydatid  only to exist  singly in the breast,
although great numbers are found congregated
in other parts.   When one of these hydatids is
developed in the breast, inflammation is exci-
ted, and a wall of fibrin surrounds it.   The tu-
mour  feels hard, and  while it  is small no  fluc-
tuation is  perceptible ; but as it increases, and
the fluid becomes more abundant, a fluctuation
may be felt in the centre of the tumour.   Some-
times, when the hydatid has attained a consid-
erable size,  it occasions suppuration;  and the
these cysts projecting into their cavities.  These excres-
cences seem to  consist of albumen or fibrin, which, after
some time (if not immediately), becomes organized. They
are  covered by a thin, delicate membrane, which seems to
be reflected over them from the inner surface of the cyst;
but  whether they are originally formed between two layers
of the membrane of the cyst, or whether they are at first
mere deposites of fibrin or albumen on the inner surface of
the  cyst, a thin membrane being formed on their surface
afterward, remains to be determined by future observations.
3d. There is some reason for believing that a similar growth
of fibrinous substance  may take place from the external
surface of the cysts connecting different cysts  with each
other.  4th. Under certain circumstances, the cysts become
completely filled up by the morbid growths, so that their
cavities are obliterated, the tumour being thus converted
into a solid mass, in which,  however, the remains of the
cysts are perceptible ;  and this is the prelude to a still far-
ther change, in  which the greater part  of the cysts have
wholly disappeared, a  solid mass of an indistinctly lamina-
ted  texture occupying their place.  5th. If one ofthe mem-
branous cysts be artificially laid open, or if it burst from
over-distention with serum, the fibrinous excrescence from
its inner surface being no longer restrained by the pressure
of the skin, increases in size, and protrudes externally in the
form of a fungus, giving to the tumour a new and more for-
midable character. In  this last stage of the disease, it is ev-
ident that spreading ulceration, sloughing, and haemorrhage,
the  usual results of an ulcer  occurring in a diseased struc-
ture, must ensue ; and that no remedy is likely to be of any
service to the patient, except the  removal of the  affected
parts by a surgical operation.   Mr. Brodie thinks that it is
essential to  a  proper mode of treatment  that  we should
distinguish those cases in which the disease is still in its
earliest stage from those in  which  the growth of a solid
fibrinous substance has become superadded to this simple
original structure.  In the first order of cases, Mr. B. rec-
ommends to evacuate the fluid contents of the cyst by pene-
trating it with a grooved needle, and applying the follow-
ing embrocation to the breast: R Spiritus Camphorati, Spir-
itus tenuioris, aa, jiijss.; Liquor Plumbi Diacetatis, f.  Fiat
embrocatio.  A piece of flannel is to be soaked in this embro-
cation and applied over the swollen breast, renewing the ap-
plication six or  eight times in the day and night until the
skin becomes inflamed ; then to omit the application for two
or three days, but to resume the  use of it as soon as the
inflammation has subsided. This course will sometimes ac-
complish a cure in three or four weeks ; in other cases, it
is to be continued, with occasional intermissions, for sever-
al months ; or a  succession of  small blisters may be applied,
keeping the surface discharging for several days with the
savin cerate, or  a solution of 3j. of iodine in Jj. of alcohol
may be applied  to the skin once or twice daily, by means
of a camel's-hair brush.  After the growth of solid sub-
stance has  begun, there is, of course, no remedy but the
removal ofthe breast by an operation.]
  * [Sir Benjamin Brodie states that the account which
Sir Astle-Y Cooper has given of the hydatid breast has
been taken chiefly from cases of " Sero-cystic Tumours of
the Breast" (Clinical Lectures on Surgery.  Phil., 1846, p.
206).  According to Brodie, the first perceptible indication
of the disease is a globular tumour imbedded in the glandu-
lar structure of the breast, and, to a certain extent, moveable
underneath the skin.  Sometimes there is only one such tu-
mour ; at other times there are two or three, or many more ;
but it is only after they have attained considerable magni-
tude that we are able  to ascertain the numbe.r. In most
cases the disease is confined to one breast, though some-
limes both breasts are affected.  The pathological history
of the disease, according to Mr. B., is as follows: 1st. A
greater or less number of membranous cysts are generated
in the breast, containing serum.  The latter is, al first, of
a light yellow colour, and transparent, but afterward be-
comes of a darker colour, and opaque.  There is reason to
believe that these cysts are formed by a dilatation of  some
of the lactiferous tubes.  2d. Morbid growths or excrescen-
ces are generated from the inner surface of one or more of 
938
MEASLES—Definition.
cyst being discharged along with the matter, a ]
spontaneous cure is effected.
   66.  C.  Diagnosis.—Cystic and  hydatidic tu-
mours of the breast, in their first stage, may be
confounded with chronic inflammation, but are
distinguishable  from it  by the absence of ten-
derness on pressure, and still more decidedly
by the unimpaired health of the patient.  In the
second stage, when  fluctuation is perceptible,
they may be distinguished from abscess by ob-
serving  that  the  fluctuation exists  at  more
points than one; and the puncture of a cyst
will at once remove  all ambiguity.  These tu-
mours  of the  breast  are distinguished from
scirrus by the absence of lancinating pain and
stony  hardness which characterize the latter,
by their mobility on the pectoral muscle,  by
their pendulous state, and by the unimpaired
general health of the patient.  Sir A. Cooper,
however, has seen a case in which true scir-
rus was combined with hydatids ;  and Mr. S.
Cooper has met with a similar instance.  The
former of these writers has never  seen those
tumours  seated in both  breasts  at the same
time.  They  are met with  at all  ages after
puberty, but seem more  frequent under  than
above the age of thirty or thirty-five.   Of the
cases  adduced  by Sir A. Cooper, sixty years
was the greatest age.
   67.  Although neither serous cysts,  nor true
globular  hydatids of the breast, are of  them-
selves dangerous, yet I agree with Dr. Cumin
in  suspecting that they occasionally give rise
to, or rather are transformed into,  other morbid
changes of a very serious nature.   The con-
tents of the cysts  are at first a straw-coloured
serum ; but in time this may  acquire a greenish
colour, and even  a foetid odour.   Indeed, I be-
lieve that not only these tumours, but also the
other chronic tumours noticed above, the cystic
and hydatidic  more  especially, may assume,
particularly in  persons above thirty years  of
age, a scirrous  or malignant  character ; when
anxiety of mind, the depressing emotions, and
other  causes of  physical  depression and ex-
haustion, have  permanently  lowered  the vital
energies, and weakened vital resistance to the
local mischief.
   68.  The morbid  anatomy of cystic and hyda-
tidic tumours is so  similar in all parts of the
body,  that we  need  not  here dwell  on their
particular characteristics  as  occurring in  the
breast.  The reader  will  find them  minutely
detailed, as respects  this organ, in Sir A. Coop-
er's work, and in the article  by  M. Velpeau,
referred to in the Bibliography.
   69. D.  Neither local applications nor internal
medicines are of any service in this disease, the
treatment of which is purely surgical.  If there
be only one large cyst, the fluid may be evacu-
ated by a simple puncture, and in some cases
it will not again accumulate; but where the
enlargement of the breast is excessive, and the
cysts numerous, and  especially where the pa-
tient is under great apprehension  of some ma-
lignant disease, the tumour should be removed,
taking care to extirpate every part ofthe mor-
bid formation, since,  if a single cyst be allowed
to remain, the disease will be renewed.
   70.  E.  The third  or  malignant  class  of dis-
eases ofthe breast comprise chiefly cancer and
fungus hematodes, or  encephaloid disease.  But,
after what I have stated  in other parts of the
! work, it is unnecessary to advance anything at
 this place  respecting these maladies when af-
 fecting the mamma.  The reader will  find all
 that is requisite  to be considered respecting
 them in the articles Cancer and  Fungoid Dis-
 ease.
   Bibliog. and Refer.—Jusiamond, Tracts, &c. 4to.—
 W. Rowley, Pract. Treatise on the Diseases of the Breasts
 of Women, 8vo.  Lond., 1772.—Clubbe, Treatise on the In-
 flammat. of the Breast, 8vo.  London, \""9.—Schlegel, De
 Statu sano et MorbosoMammarum in Gravidis et Puerperis,
 4to.  Jena, 1791.—A. G. Richter, Medicinische u. Chirurg.
 Bemerkungen, t. i., ch. i.—/. Noth, Observ. on the  Treat-
 ment of Scirrus, Tumours, and Cancers of the Breast, 4to.
 London, 1804.— Vogl. De Mamniarum Structure et Morbis.
 Wittem., 1805.— J. Burns. Principles of  Midwifery, &c,
 8vo, p. 623.—Desruelles, Observat. et Reflex, sur les Kystei
 des Mammelles, in Journ. Univers. des Sc. Med., t. xxvii.,
 p. 356, 1822.—V. ab  Hildenbrand, Institutiones Practieo-
 Medicte, t. ii., p. 271.—Dewees, Treat, on Diseases of Fe-
 males,  8vo,  p. 427. — Benedict, Bemerkungen  iiber die
 Krankh. der Briiste und Achseldriisen, 4to. Breslau, 1825.
 —Graefe, Archives Gener. de  Med., t. xvi., p. 593.—H.
 Earle, in London Medical Gazette, vol. %., p. 153.—Cumin,
 in Edin. Med. and Surg. Journ., vol. xxvii., p. 1.—A. Cooper,
 Illustrations of Diseases of the Breast, 4to. Lond., 1829.—
 Ncvermann,  De Mammarum Morbis Curandis, &c, 8vo.
 Rostock, lfcSl.—Beatty, Dublin  Journal of Med. Sciences,
 vol. iv., p. 340.—Velpeau, in  Diet, de Medecine, 2d edit.,
 art Mammelles.—A. Duges, Diet, de Med. et de Chirurg.
 Prat., art. Mastoite.— F. Churchill, Observat. on the Dis.
 incident to Pregnancy and Childbed, 8vo, p. 447. Dublin,
 1840.
   [Ad. Bibliog. and Refer.—Astley Cooper, The Anat-
 omy and Diseases of the Breast, with 35 Plates, 8vo. Phil.,
 1845.—/. C. Warren,  Surgical Observations on Tumours,
 with Cases and Operations, 16 coloured Plates, 8vo.  Bnst.,
 1840.—Colombat de VIsere, A Treatise on the Diseases and
 Special Hygiene of Females, translated by C. D. Meigs, 8vo.
 Philad , 1845— F. Churchill,  The Diseases of Females, in-
 cluding those of Pregnancy and Childbed, with Notes, by
 Robert M. Huston, Svo.   Philad., 1845.— Velpeau, On Dis-
 eases of the Breast, transl. by Dr. Parkman, p. 56.  Phil.,
 1841.—S. D. Gross, Pathological Anatomy, 2d edit., 8vo.
 Phil., 1845.]
 MANIA.—See Insanity.
 MEASLES.—Synon. Morbilli (a  lesser plague
    in the Italian), Morton, Sydenham, Juncker.
    Febris Morbillosa, Hoffmann.   Rubeola, Sau-
    vages, Cullen,  Willan, etc.  Roseola,  Auct.
    var.   Phenicismus, Ploucquet.   Synocha Mor-
    billosa, Chrichton.   Cauma Rubeola, Young.
    Exanthesis Rubeola, Good.  Masern, Rdtheln,
    Flecken,  Kindsflecken, Germ.   Rougeole, Fr.
    Rosolia, Rossole, Morbilli, Ital.
      Classif.—I.  Class,  III. Order (Cullen).
        III.  Class,   III.  Order   (Good).   III.
        Class, III. Order (Author in  Preface).
    1. Defin.—After catarrhal symptoms, the erup-
 tion, generally on the fourth  day,  of a crimson
 rash, consisting of stigmatized dots, slightly ele-
 vated,  and disposed  in irregular circles or cres-
 cents,  usually desquamating on the seventh day,
 and accompanied with inflammatory fever; the dis-
 ease being an infectious exanthematic fever, fre-
 quently occurring  epidemically, and affecting  the
 system only once.
   2. This disease attacks chiefly children, but
 no  age is exempt from  it, and it appears in all
 climates.  It generally commences from seven
 to fourteen days after the recepton ofthe con-
 tagion, with horripilations followed by catarrhal
 fever, on the third, fourth, fifth,  or even sixth
 day of which, but usually  on the fourth, a crim-
 son rash appears, and after a continuance of
 four days, gradually declines with a  fever.  It
 may attack the foetus in utero when  the moth-
 er is affected by  it.   It is usually most severe
 in young children, especially during  teething,
 and soon after weaning, at the time ofthe sec
 ond dentition, and at the approaching period of
 puberty.  It is comparatively slight in adults ■ 
MEASLES—History—Description
939
but to this there are many exceptions, the se-
verity of the disease, even in them, depending
much upon the prevailing epidemic, and  upon
the climate in which the epidemic occurs.
  3. I. History.—Several writers, and among
others Sennert, Welsch, Manard, Odier, and
Bateman, suppose that measles were known to
the ancients.   Odier has  even contended that
the plague of Athens, described by Thucydides,
was an  epidemic  visitation  of  this  disease.
Gruner (Antiquit. Morbor.,p.51) and Sprengel,
however, as well as many other judicious au-
thors, have shown  that the earliest accounts
we have of this disease  refer it to about the
period at which smallpox was conveyeed from
Arabia to Egypt, and thence into Europe.
  4. The earliest account which  has been fur-
nished of measles is contained in the Pandects
of Rhazes, who describes it under the name of
Hhasbah, not, however, from  his own  observa-
tions only, but also from the information con-
veyed by Ahron, who  lived in 662 at Alexan-
dria.  (Jeberlacher (Ueber die  Grundlosigheit
der ersten Schilderung, &c.   Wien, 1805) en-
tertains,  however,  an  opposite  opinion as to
the description  of Rhazes being applicable to
measles,  but, in my opinion, without sufficient
grounds.   Avicenna and  Mesue  have also de-
scribed measles (Hhasbah), and distinguished it
from smallpox (Dschadari), and the  morbillous
form of scarlatina (Hhamikah).
  5. It has been supposed by Schn.urrer(Chron-
ik der Seuchen, s. 117), that the epidemic which
prevailed, A.D. 455, through Phrygia, Cappa-
docia, and Cilicia, and is described by Eusebius
as being  accompanied with inflammation of the
whole skin, turgidity of the eyes, and violent
cough, was measles in a severe  form ; but the
imperfect description  given of  that epidemic
leaves room only for supposition.
  6. The invasion  of  Spain  by  the Saracens
in the eighth century most likely extended this
disease to Europe at the same time with small-
pox.  Mention is made in the chronicles ofthe
time that an epidemic prevailed in Italy in 876,
which was characterized  by pain and  turgidity
of the eyes, severe cough, &c,  and which, as
Schnurrer .supposes, may possibly have been
this disease.  About the middle  of the twelfth
century,  Synesius (De  Febribus, edit. Barnardi,
Anat., 1749) translated into Greek the work of
an  Arabian  physician, Abn Dschafar, where
smallpox ((bbvuraivovo-n Xoiuiktj)  is distinguish-
ed  from  measles (erepa  Xekttj koi  itokvtj a-ov-
uikti).
  7. However, measles were very generally con-
founded  with smallpox even as  late  as  1674.
Among the  last writers  who committed this
error were Lange and Diemerbroeck, while the
distinction was first clearly made by Forestus
(1597), Schenck (1600), Riverius (1655), and
particularly by Sydenham (1676), and F. Hoff-
mann (1718), who, with Huxham  and Lepecque
de  la Cloture, have  recorded the  history of
several epidemics,  and added greatly to our
knowledge of the disease.  At the same  time,
it may be noticed that Morton and  Watson
confounded measles  with scarlet fever, and view-
ed the latter as a severe  variety  of  the former
disease ;  and, as Dr. G. Burrows has remark-
ed, it was not until the appearance of Dr. With-
ering's Essay on Scarlet Fever, in 1793, and of
Dr. Willan's Treatise on Cutaneous Diseases,
that the profession was fully convinced of the
distinct nature of the two diseases.
  8.  II. Description of Measles.—Instead of
dividing* this disease into different varieties or
forms, as the Rubeola vulgaris, the Rubeola ma-
ligna, and the Rubeola sine catarrho, &c., I shall
first describe the regular form of the disease, and
next notice those modifications, complications, and
irregularities which it presents,  according to the
influence of individual constitution,  epidemic
prevalence, and of climate.
  9.  i. The Regular Form of Measles.—Ru-
beola vulgaris, Willan, Bateman, &c.   Morbilli
regularis,  Sydenham.   Rougeole vulgaire, Fr.
The  progress of the disease,  in its regular and
common form, is similar to that of all the erup-
tive  fevers,  and consists of four well-marked
stages, namely, 1st. The period  of febrile commo-
tion ; 2d. That of eruption ; 3d. The stage offlo-
rescence; and, 4th. That of desquamation.
  10. 1st. The period of febrile commotion, or of
precursory fever,  is that in which the infection
of the whole frame has commenced, and that
febrile action appears, which produces, after a
certain period, the cutaneous  eruption.   This
stage usually commences with  chills, horripila-
tions, shudderings, or rigours, alternating with
heat  of skin, and accompanied by a turgidity,
erethism, or catarrhal irritation of the mucous
membranes, particularly those ofthe respirato-
ry apparatus.  The patient is affected with fre-
quent sneezing,  coryza, stuffing of the nose,
sometimes with dryness and redness of the  pi-
tuitary membrane ; with  heat,  redness, turgid-
ity, and watering  of the eyes;  sensibility to
light, heaviness, or pain in  the head, somno-
lency in very young children, and in older sub-
jects, wakefulness ; frightful dreams; pain or
aching in  the back and loins ;  soreness,  pain,
and tenderness at the epigastrium, and  with
slight hoarseness and dry cough.  Sometimes
the eyelids and sub-maxillary glands are slight-
ly swollen.   The appetite is diminished or abol-
ished, while the desire  for cold drinks is much
increased.  The tongue  is  white and loaded,
and an unpleasant taste in the mouth is often
complained of.   There are frequently nausea,
vomiting,  and a lax or irregular state of the
bowels. The febrile commotion rarely amounts
to the production of convulsions or delirium;
but generally more or less exasperation of  fe-
ver, preceded by chills  and horripilations, and
accompanied with a full, hard pulse, oppression
at the chest, and difficulty of breathing occurs
towards evening, and remits towards morning,
when a slight moisture appears in the skin un-
til the eruption  appears.  Instances, however,
are not uncommon of so slight a grade of the
disease as  not  to  render it  necessary for the
patient to keep his bed; and yet, in some of
those cases, the patient may have complained
for several  days of catarrhal  fever.   In the
more severe cases, haemorrhage  sometimes
takes place from the nostrils, or a haemorrhagic
discharge occurs from the uterus, in this stage
with considerable relief.
  11. 2d. Stage of Eruption.—During the third
febrile exacerbation, generally about the fourth
day from the first occurrence of horripilations,
an eruption  takes place first on  the face, par-
ticularly the cheeks, around  the eyelids, nose,
and ears;  and next on  the neck, breast, arms,
hands, and abdomen ;  and  last  on the lower 
940                  MEASLES—Modifications, Complications, etc.
extremities, with more or less turgidity of the
countenance, particularly ofthe eyelids.  Some-
times great restlessness, anxiety, convulsive
movements, inequality of pulse, pain and sense
of fulness in the head, slight delirium, or epi-
staxis usher in the eruption, which is  generally
completed in twenty-four hours.   At this pe-
riod  the tongue  is red at its  point and  edges,
loaded or furred at  its base, and the  fauces
exhibit some obscure patches resembling the
cutaneous eruption.   The  eruption is at first
discrete and scanty, resembling  the  bites of
fleas.  The stigmata increase, are of a crimson
or reddish colour, slightly  elevated above the
skin, and rough  to the touch, particularly on
the face, and early in the eruption.  When ex-
amined with a glass, they have a rounded, or,
rather, an  elliptic  form, resembling linseed.
When the papulae are fully formed they are of
a lively red, but  contain no fluid ; when press-
ed by the finger they  momentarily lose their
colour, which returns rapidly upon  removing
the pressure;  and their  circumference  is not
defined, their colour being deepest in the cen-
tre, and becoming paler until they insensibly
pass  into the natural tint of the skin.  Wede-
kind (Ueber die  Maseru.   Roschlamb's  Maga-
zin, iv., B, No. 6) observed an extremely fine
hair, scarcely discernible by the unassisted eye,
penetrating each ofthe morbillous papulae.  If
the eruption is very scanty, it is never equally
diffused over the surface, but appears in clus-
ters  in different parts, separated from each oth-
er by large patches of healthy skin.   Although
the papulae, or stigmata, may approximate near-
ly to each other, and coalesce into  patches,
they never completely run into each other, par-
ticularly in the early period of the eruption.  In
the more severe cases, however, especially in
adult subjects, they often coalesce much more
closely, the cutaneous surface assuming a deep
red.   The more acute  the  fever,  the more  co-
pious is the eruption, which  scarcely ever di-
minishes the fever, but, on the contrary, is oft-
en increased by it, until the period of desqua-
mation.  During the eruptive stage the tran-
spiration and  breath have a peculiar  odour,
which generally  continues till the seventh day,
and is at first of a slightly sweetish, and after-
ward of an  acidulous character, and  has been
likened by Heim to that given out by  a recent-
ly killed goose.
   12. 3d. The Period of Florescence.—The erup-
tion continues generally in full force for nearly
three days, namely, from the fifth, when it is
usually fully out, till the seventh, when  it sub-
sides ; but this stage presents no distinct marks
from the foregoing, for the eruption on the face
and neck generally declines on the sixth, while
it is  fully out on the body and  limbs, or even
only  breaking out on  the lower extremities.
The  stigmata coalesce more closely, the skin
becomes more uniformly red, tense, or  turgid,
extremely hot and itching, and the tumefaction
of the face and eyelids, particularly on the
fourth  and  fifth  day,  is  very marked.  The
tongue and fauces now evince an evident par-
ticipation in the eruption.  The fever and ca-
tarrhal symptoms show scarcely any remission,
but are even  sometimes increased.  Intoler-
ance of light, dryness of the  nostrils, hoarse-
ness and dyspnoea, and a  hoarse clangous or
barking cough, at first dry, and afterward fre-
quently followed by the expectoration of a thin
mucus, containing dense, rounded, albuminous
particles, continue during this period.  I owards
evening,  the fever, restlessness, and heat of
skin increase.  Sometimes  a slight diarrhrea
occurs, from which the  patient  experiences
some relief.  The urine is generally of  a deep
colour, and scanty.
  13. 4th. Period of Desquamation.—On the sev-
enth and eighth days from the commencement
of the first stage, the eruption declines on all
the upper part ofthe body ; but the subsidence
and desquamation of it have generally begun a
day or two earlier on the face  and neck, the
turgidity of which is now  much diminished.
On  the eighth and ninth days, and in the same
order as  the  eruption appeared,  it subsides,
with desquamation of the cuticle ; and on the
tenth and eleventh days it has  entirely disap-
peared, leaving in its place a furfuraceous des-
quamation,  passing off generally  with an in-
creased and troublesome itching,  and a slight
moisture on the surface.   The more prominent
and copious the eruption, the more marked the
desquamation becomes.   Generally, when the
eruption  is very slight, the skin continues un-
changed.   In the dburse of  this stage, critical
perspiration, a copious sediment in the urine,
and free  evacuation, frequently supervene and
contribute  to  its  felicitous  termination.  But
the pectoral symptoms usually continue longer,
and occasionally  with increased severity,  par-
ticularly  the cough, hoarseness, and the expec-
toration  already  described.   With the subsi-
dence of these,  the system returns  to the
healthy state.
  14. ii.  Modifications,  Complications, and
Irregularities of Measles.—There are va-
rious circumstances which contribute to modify
the progress and character of measles.  Of these,
the most important are the prevailing nature of
the epidemic, the season of  the year, the state
of  the atmosphere in  respect  of temperature
and moisture, the nature of the  locality, the
ventilation of the  place and apartments, the
previous health of the patient, and his temper-
ament and habit  of body.   But I believe that
there are few causes proper to the individual
that has  greater influence on the character of
the disease than the vital powers of the sys-
tem, and the disposition which the patient may
possess to affections of some vital or important
organ.
  15. A. Measles with predominance of  Inflam-
matory Character.—a. This form of the disease
is generally  ushered in  with  marked  febrile
symptoms  of  the inflammatory  type  ;  full,
strong, or oppressed and  frequent pulse  ; great
heat of skin; a  phlogistic appearance  of the
blood drawn  from a vein ;  severe catarrhal
symptoms, with acute coryza;  marked injec-
tion and  turgidity of the conjunctiva; watery
discharge from  the eyes ;   constant  cough;
with oppression at the chest, great difficulty of
respiration, bloody sputa, and other symptoms
of inflammation of the mucous membrane of the
air  passages and  lungs, and occasionally  with
acute pain and other signs of  pneumonia or
pleuro-pneumonia.  The  eruption appears rap-
idly and copiously, with convulsions in  young
children, and delirium in older patients, or, at
least, with most severe pains in the head, after
which a  slight amelioration  is sometimes ob- 
MEASLES—Modifications, Complications, etc
941
served.   The  eruption is more  intensely red,
more prominent, and more closely coalescent,
so as to occasion a nearly erysipelatous red-
ness and tumefaction  of the face  and  other
parts, than in the common form of the disease.
Desquamation also often takes  place  earlier,
and  is  not  infrequently  complicated with, or
followed by, marked inflammation of the lungs
and bronchial membrane, or even  by  various
modifications of croup.
  16. This state of the disease is  most frequent
during the epidemics which occur in winter and
spring; in persons of a  robust,  sanguine, and
irritable temperament,  and plethoric habit.  It
occurs  sporadically  in those who are exposed
soon after infection to  cold in any form, partic-
ularly to a cold, dry air after the  body has been
heated ; and in children who  are teething, and
Who have been highly or grossly fed, and kept
in warm apartments, and are of an inflamma-
tory and plethoric habit.
  17. b. This  form  of  measles is so very fre-
quently complicated with serious inflammation of
the  air passages and lungs, and  is so liable to
kindle up those diseases towards its decline, or
to dispose to them  during convalescence, that
strict attention  should be directed  to  the cir-
cumstance.
  18. a. When  extensive or severe bronchitis
occurs  during the course of this type of mea-
sles, the patient is often suddenly attacked with
great difficulty of breathing; the face  is  pale,
if it precede the eruption, but generally some-
what livid, or  of a deep crimson, if it occur du-
ring the eruption.   Sometimes the eruption ei-
ther appears only partially, or recedes prema-
turely ;  the lips are also livid;  the chest and
diaphragm,  as evinced by  the motions of the
abdomen, labour much during respiration, and
a sonorous, sibillous, and,  lastly, a  mucous
rhonchus, is heard on auscultation.  The coun-
tenance becomes anxious; the  expectoration
is more or less abundant, and attended  with se-
vere paroxysms of cough ; the pulse is  quick,
small, or oppressed ; and the skin  either cool
or warm in parts only.   This state of disease
is not merely  a  severe form  of bronchitis, but
an association of it with congestion ofthe lungs,
to which a similar state of the brain is  some-
times superadded.  The pulmonary affection,
in this  severe form, may soon  terminate the
life ofthe patient, chiefly in consequence ofthe
effusion which takes place in the air passages,
together with the loaded state of the vessels of
the encephalon.
   19. In the less severe forms of the complica-
tion of bronchitis with measles, or when the
bronchitis is not conjoined with  congestion of
the organ,  the  symptoms are  less marked ;
there is less urgent oppression at the chest, and
the lividity of the countenance is generally ab-
sent.   But these less severe  states of bronchi-
tis not infrequently superinduce inflammation of
the substance  of part of the lungs or of a whole
lobe.  In this case the sputum becomes more
purulent, more rounded, and sometimes streak-
ed with blood ; respiration is puerile in the vi-
cinity of the affected  part, in which the respi-
ratory murmur is either feebly heard, or is at-
tended by crepitating rattle, or the  sound is no
longer detected  in it, while the chest is dull, in
this situation, upon percussion.   At the  same
time, the respiratory motions are quick, labour-
ed, unequal, and imperfect.
  20. /?. Pleuritis may occur during the course
of this type of measles, and the inflammatory
action  may either originate in, or may extend
to the pleura from the affected part of the lungs.
But in either case we  seldom find in measles
that the pleura becomes inflamed without a por-
tion of the lungs participating in  the diseased
action.  The presence  of acute pain  generally
indicates this complication, with immobility of
the ribs, quick  inspiration, and  slower  expira-
tion, and pain on percussion, which  gives no
farther information, unless effusion has taken
place, when a dull sound will be  emitted, and
the cegophonous sound heard on  auscultation.
This form of complication not infrequently ter-
minates in hydrothorax, particularly  after the
disappearance ofthe eruption.
  21. y. Another severe and dangerous compli-
cation, viz., croup, sometimes occurs in this form
of measles.  It generally appears during the
stages  of eruption and florescence, and more
rarely subsequently.  It is chiefly characterized
by hoarseness and ringing, croupy cough, follow-
ed by difficult and sibillous inspiration  ; by sore-
ness and  tumefaction  about the larynx  and
trachea; and by the expectoration, after the par-
oxysms of strangulating cough, of a ropy, clear
fluid,  sometimes  with membranous  threads.
It very seldom happens that the inflammation
of the larynx  and  trachea,  constituting the
croupy complication, occurs without  some de-
gree of inflammatory action being extended to
the bronchi, or  even  to a portion of that sub-
stance ofthe lungs.   When a fatal termination
occurs in this state of disease, the air passages
present more or less of the usual marks of in-
flammatory action, and are loaded with a thick,
tenacious  mucus, or  contain false membranes,
or both.
   22.  B. Measles with  Predominance of Gastric
and Bilious Disorder.—a. This form was first de-
scribed with accuracy, and the  importance of
attending  to its character pointed out  by Stoll.
It is chiefly marked by accumulations of sordes
in the stomach and bowels ; by loaded tongue;
pain and tenderness at the epigastrium, hypo-
chondria,  and  bowels ; by morbid, bilious, and
offensive alvine evacuations ; by the great se-
verity of the cough ;  by depression of the ener-
gies of the frame ; the slower  and less abun-
dant eruption on the  skin ; by weakness and
frequency of pulse ;  and by severe pains in the
loins, limbs, and forehead.  It sometimes char-
acterizes summer and autumnal epidemics, par-
ticularly during or soon after warm and moist
seasons ;  and it  occurs  sporadically in weak
children during the periods ofthe first and sec-
ond dentition ; in the imperfectly nourished, and
in those who have had their bowels  long neg-
lected.
   23. b. This form of measles is frequently com-
plicated with irritation of the mucous  surface of
the stomach, or with  disorder of the liver.  But
when this latter organ is principally attacked,
it is more generally congested than otherwise
affected.  The complication of this modification
of measles with  gastric irritation is very fre-
quent in children during the periods of dentition,
and is generally indicated by nausea  and vom-
iting, tenderness or pain, or heat at the epigas-
trium ; an imperfect, impeded, or irregular state
of the eruption, and its premature disappear-
ance.  Congestion of the liver is much more sel- 
942                   MEASLES—Modifications, Complications, etc.
dom met with, and chiefly occurs in older sub-
jects.  It is generally attended by pain and ful-
ness in the right hypochondrium, sallowness of
the countenance, an irregular and morbid state
of the alvine evacuations, and a dark, muddy
state ofthe urine.
  24. c. Diarrhea is  not an infrequent compli-
cation in this form of measles.  It  may appear
early in the disease.  When this is the case the
eruption is often delayed, or it is scanty, imper-
fect, or irregular.  It may also take  place du-
ring the period of desquamation, assuming the
character at first of a salutary crisis; but, in
consequence of error in diet, or exposure to
cold, putting on a more serious appearance, or
even passing into a state approaching to dysen-
tery.  When this occurs, the appearance of the
evacuations, and the  state ofthe cutaneous sur-
face, require the attentive examination  of the
practitioner, as being the chief guides to this
state of the disease, and to successful treat-
ment.   Dr. Abercrombie, of Cape Town,  de-
scribed to me an epidemic prevalence of mea-
sles in the colony which presented much of this
character; the complication  with  diarrhea, or
enteritis, or dysentery, or  the supervention of
these during the decline of the measles, or even
some time after recovery from that disease, be-
ing very frequent and uncommonly fatal.
   25.  C. Measles with Predominance of the Ner-
vous Character.—In this form ofthe disease the
patient is, from the  commencement, much de-
pressed in mind ; is severely affected with chills
and rigours, which  pass  into a burning heat,
with inquietude, general pain  and lassitude, par-
ticularly about the loins and limbs, with delir-
ium or somnolency, leipothymia, harsh heat and
dryness of the  skin, and dry, loaded  tongue.
The eruption sometimes appears as early as the
second or third day, frequently with convulsions,
and rapidly extends to all parts of  the  body.
The patches of the eruption are scarcely at all,
or only slightly prominent; are paler than  the
regular  disease, and more  readily  disappear.
The febrile and nervous  symptoms  are never
diminished, but, on the contrary, increased by
the  eruption, particularly if it disappear prema-
turely, or is repelled  by any cause.  Sometimes,
still more severe and frequently fatal symptoms
accompany this form of  the disease, such as
dyspnoea, dry cough, anxiety, oppression at the
chest  and praecordia, cardialga, dryness  and
trembling of the tongue,  dryness  and redness
of the fauces, loss of voice, vomiting, loss of
recollection, with  stupor, starting of the ten-
dons, tumefied abdomen, very quick, weak, soft,
and open pulse, and a crude, scanty urine.  The
character of the disease so  nearly approaches
to the typhoid type  of fever, that it has been
termed  by  several  authors  typhoid measles.
Critical evacuations sometimes occur towards
its close, or abortive efforts  at evacuation, oc-
casioning fatal  determination  to  some weak-
ened  organ, or subsequent  visceral disease,
which can be removed with great difficulty only.
 The cuticle is frequently not thrown off in  this
 form of measles.
   26. Measles with  the nervous character oc-
 curs generally at  the  same  season  and in the
 same class of subjects as the foregoing  variety
 (y 12).  It characterizes certain epidemics, par-
 ticularly those which occur at the same period
 as epidemic continued fever; and it evidently
evinces a more marked determination of the
febrile action towards the large  nervous cen-
tres, particularly the substance and membranes
of the brain.  This determination is often re-
markably increased about the eruptive and sub-
sequent stages, or upon  the imperfect appear-
ance of the eruption, or its repression.
  27. D. Measles presenting a Malignant or Sep-
tic Character.—Rubeola maligna; R Putrida; R
Scptica, Auct. var.  To many of the  symptoms
which I have detailed, as marking the nervous
form of measles (y 25), are generally superadd-
ed, most commonly during the stages of erup-
tion  and florescence, or occasionally  somewhat
later, the eruption of petechiae, lividity and sore.
ness of the fauces and throat generally ; an ex-
udation, or more copious flux of dark decom-
posed blood from the  nostrils, mouth, or vagi-
na :  a profuse and exhausting diarrhoea ; dark,
offensive motions ; dysenteric  symptoms, and
viscid perspirations.   The measly eruption be-
comes, either previously to or contemporane-
ously with the above symptoms, discoloured, of
a deeper and darker red, or livid ; and the cu-
ticle  is readily rubbed off upon the  decline or
detumescence  of the papulae.   This form of
measles presents a similar state to that of pur-
pura haemorrhagica, or of land scurvy, compli-
cated with the exanthematous fever.
   28.  Malignant measles occurs chiefly in hot,
warm, moist, and miasmatous climates, in close
or crowded localities ; and during hot and moist
seasons, in cachectic  habits, in  the ill-fed, or
in those in whom the energy of the digestive
and assimilatory functions is greatly impaired,
and who have been subjected to those agents
which act most injuriously on  the  powers of
life and the tonicity of the moving fibres, con-
taminating the circulating fluids, and occasion-
ing  the liquescence  of the  soft solids  of the
 body.  I have seen it prevalent  in the natives
of warm climates, and in  those who inhabit
marshy, moist, and miasmatous  districts, both
in temperate and warm seasons.  I have like-
wise observed it in natives of some ofthe north-
ern countries of Europe who have been  imper-
fectly fed, and whose only animal food consist-
ed of fish, frequently stale, and eaten with little
salt, or who have lived in ill-ventilated and low
apartments.   The nervous form  of measles oc-
curs  most commonly  in  scattered or isolated
cases, while the malignant variety more com-
monly presents an epidemic character, the for-
mer more evidently depending upon individual
predisposition ;  the latter to more generally pre-
vailing causes, as unwholesome  food or  modes
of living, general scarcity of provisions, delete-
rious miasms, and epidemic constitutions ofthe
 atmosphere.
   29. E. Of certain irregularities  often presented
 by Measles.—a. Sometimes the eruption is more
 languid, or retarded beyond the usual period.  It
 may likewise  be precocious, precipitous, or irreg-
 ular, as to  the  parts on which  it appears, and
 the  succession of its progress.   The form and
 character ofthe eruption may differ greatly ;  it
 may be very pale or very red, dark red, or even
 livid, as in the malignant form; it may  like-
 wise  be scarcely perceived rising above the
 rest  of  the cutaneous surface, nearly smooth,
 or it may be very prominent and rough to the
 touch, and discrete, or it may coalesce so close-
 ly as to appear confluent. As respects  the pe- 
MEASLES—Terminations of.
943
riod  of its disappearance, this may be prema-
ture, and the desquamation subsequently be ei-
ther  imperfect or altogether wanting.
  30. a. Measles without the catarrhal symptoms
—Morbilli  sine  catarrho auctorum—not  infre-
quently occur during the epidemic  appearance
of the disease ; or an  eruption presenting all
the characters  of measles  sometimes is met
with, but without the  usual catarrhal symp-
toms, and without, or with  slight febrile com-
motion.  This  variety  was first described by
Willan, and as it does not protect the consti-
tution from the  regular form of measles, it is
considered by Frank, Hildenbrand, and Will-
iams  as spurious, and as an eruption only re-
sembling measles, and  symptomatic of gastric
disorder.   Dr.  G. Burrows,  however, thinks
that  this objection cannot be admitted ; for, be-
sides the opinion of Willan, Bateman,  and
others, that it is a distinct  variety, the recur-
rence of measles in the same person has been
seen by these and other writers.  In the most
of the pases of this eruption that  I have ob-
served, the stages of the disease wanted the
regularity of true measles, and the desquama-
tion was not so marked  or complete as in them.
In many,  also,  of the  imputed instances of a
second attack of measles, some doubt may be
entertained as to one or other having been the
regular disease.   I  believe, however,  that  I
have seen instances of an  undoubted second
attack.*
  31. b. Measles without the Eruption—Morbil-
lous  Fever without the Exantheme.—Fcbris mor-
billosa sine  Exanthemate, Hildenbrand.—Sev-
eral  writers  have contended  that,  during the
epidemic prevalence of measles, some children
may  have all the catarrhal and febrile  symp-
toms of measles, and yet no eruption will ap-
pear, such children notwithstanding being pro-
tected against a subsequent  attack.  I have met
with two or three instances, when measles was
prevalent in a  family,  of one of the children
having all  the  catarrhal  and  constitutional
symptoms without  any eruption  appearing,
and   have  attributed   this   to  impaired vital
power,  to an anaemic state ofthe vascular sys-
tem, and to impaired vascular  action, probably
also  associated with  predominant  disorder of
some internal  viscus.   I have  seen other in-
stances where  the disease has  advanced far,
the febrile symptoms having continued for sev-
eral days,  when a scanty, imperfect, or evan-
escent  eruption has at length  appeared after
the exhibition of stimulants or tonics.
   32. c. The connexion of hooping-cough with
measles has frequently been remarked upon.
Indeed, the occurrence of measles sometimes
presents a very intimate association with per-
tussis, the epidemic appearance of the one be-
ing  frequently  followed by the other, and the
attack of the one being often followed closely
  * [This form of measles occasionally prevails in this coun-
try, and sometimes goes under the  name of French measles.
Besides lacking the catarrhal symptoms, the eruption ap-
pears at  an earlier period, and is  diffused over the surface
in specks instead of a succession of well-defined crescents ;
it also is more transient, usually subsiding in 24 hours.  It
may exist at the same time  with common measles, or sep-
arately ; in some cases it has been succeeded by the former
in a few days, showing that it affords no protection against
an attack of catarrhal measles.  Professor Chapman sup-
poses that it is an efflorescence of  another nature, depend-
ant on some very different cause ; or that, if it is of a mor-
billous chnracter.it is illegitimate, and therefore truly called
rubeola spuria.]
by the other in the same subject.   Some phy-
sicians, as De Haen and Macbride, conceive
that they have seen  measles associated with
smallpox in the same person.   But I agree with
Reil and Hildenbrand in considering this opin-
ion to have originated in mistake.
  33. III. The Terminations of Measles.—i.
Resolution  or  restoration to the healthy state
usually takes place from the resistance which
the vital energy opposes to the morbid changes
characterizing the disease, and to the influence
of this energy on  those organs which are the
emunctories ofthe frame.  When the train of
phenomena is not interfered with, the disease
frequently, about  the seventh or ninth day,
presents some critical evacuation, which tends
greatly to the restoration of the healthy func-
tions, especially a copious and general perspi-
ration ; a paler and more abundant secretion of
urine, which deposites a copious sediment;  di-
arrhoea continuing for two  or three days, but
readily becoming hurtful if it be not judiciously
managed ; a copious discharge of mucus, which
often removes  the remaining irritation  of the
bronchial surface with the hoarseness ; and the
furfuraceous discharge and  transpiration which
takes place from the cutaneous  surface after
the exfoliation  of the cuticle.
  34. ii. The  Sequele of Measles.—A.  Some-
times  not only the irregular and  complicated
states of measles, but  even the  more benign
and regular form, leave after them, without any
evident cause, various diseases which place the
lives of patients in great hazard.   The chief of
these  are  pulmonary consumption, the  result
either of a chronic state of the bronchitis which
had accompanied  the measles,  or of organic
lesion of the substance of the lungs, the conse-
quence of the complication of the  disease with
pneumonia, or with broncho-pneumonia, readily
passing into chronic pneumonia, or of tubercles
which had been developed during its progress
and decline,  or which had previously existed.
It is  by no means rare to observe both pneu-
monia and pleuritis,  or both conjoined, super-
vene during the period of desquamation.  The
accession of the former especially is often ex-
tremely furtive and latent.   I have  frequently
seen  patients brought to the Infirmary for Chil-
dren  with the most severe attacks of pneumo-
nia, in an  advanced stage, with all the  symp-
toms fully developed, following an apparently
mild form  of measles ;  and other  cases,  which
had manifestly been advancing for several days
in a concealed manner, and gone on to serious
organic  change before  the parents had been
alarmed.   These  latter are very  frequent du-
ring some epidemics, and particularly after the
inflammatory form of the disease, although
they are not peculiar to this variety, but  equal-
ly  consequent upon the  regular, and  some-
times on the gastric  states of the malady.  In
cases of this description the practitioner has
often no opportunity  of watching the accession
of the local mischief, which may occur so early
in the disease  as to be  a complication of it, or
during the stage  of desquamation.  I  have,
however, observed it still more  frequently—I
may say in many  hundred  instances presented
to me in the institution already referred to—at
an indefinite, but no very  remote period from
the last stage, occurring generally  during re-
covery, either  from an  incautious exposure to 
944                             MEASLES—Sequels of.
the air, or  to cold, early in  convalescence, or I
from  an injudicious management  of this pe-
riod, which, in all exanthematous diseases, re-
quires the  particular care of the physician in
order to prevent their dangerous sequelae  :
often  more dangerous  than  even the original
diseases themselves.   Improper diet,  prema-
ture exposures  to cold, and even atmospheri-
cal vicissitudes, which  cannot be  sufficiently
guarded against, will also frequently occasion
the unfavourable consequences now  pointed
out.
  35.  B. The symptoms indicating  the super-
vention of  disease of the lungs are often ex-
tremely treacherous, particularly if the  local
mischief commences early in the disease, and
if  viewed superficially, or without the aid of
percussion and auscultation.  They chiefly con-
sist of the persistence of cough, expectoration,
frequency of pulse,  and febrile exacerbations,
after  the disappearance of the eruption.   Or,
the different stages ofthe measles having been
completed,  febrile action is  rekindled and ac-
companied  with  oppression,  weight or  uneasi-
ness  in the chest, with  a  dry, spastic cough
and difficulty of breathing, followed  after  a
time with purulent expectoration, occasionally
streaked with blood, evening  exacerbation of
fever, nightly perspirations,  loss of flesh, &c.
In those cases  which  are characterized by a
gradual or insensible concentration of diseased
action in the lungs,  particularly in  the mucous
surface ofthe bronchi and air cells, the expec-
toration which  supervenes' in the latter stages
gradually changes from  a clear, whitish, thin
fluid,  containing numerous  white  albuminous
specks or flocculi, to a thicker, more  opaque,
tenacious, and muco-purulent  matter, till it at
last becomes more decidedly purulent, the sputa
being each distinct  and rounded, less  tena-
cious, not running into each other, and form-
ing a viscid, stringy substance, adhering close-
ly to  the sides  of the  vessel,  but a yellowish,
rounded mass, which imparts a whitish, turbid
appearance to the water in which it is  thrown,
from  mixing partly with this fluid.   But these
and other  symptoms, although most certainly
indicating serious disease of the lungs, give us
no precise  information as to the extent and na-
ture of the existing lesion.   This is only to be
acquired from  an attentive and repeated ex-
amination ofthe chest by means of percussion
and auscultation, and  from  weighing  the evi-
dence thus furnished us in connexion with the j
rational  symptoms in the manner  pointed out
under the articles where these subjects  more
appropriately fall.   The  above remarks are
equally applicable to the occurrence of pleuri-
tis, either as a  complication or as  a sequela of
measles.   When pleuritis,  or  pleuro-pneumo-
nitis, does  occur in either of these ways, it is
extremely  prone to terminate in effusion of a
serous  fluid  into the plurae, as adhesions are
less readily formed in pleuritis when thus com-
plicated than when occurring in an  idiopathic
form.
   36. But effusion into the chest, and even into
the pericardium, may be consequent upon mea-
sles  without any previous  signs of inflamma-
tory  action. When these  results supervene,
the disordered  state of the respiratory and oth-
er functions, and particularly  the information
 conveyed by percussion and auscultation of the
chest, will generally point out  the  nature  and
extent of mischief.  Other dropsical effusions,
particularly anasarca, hydrocephalus, and as-
cites, occasionally are observed as sequela? of
measles, and may be imputed either to increas-
ed  determination  of the  circulation to,  with
diminished tone of the extreme capillaries ter-
minating  in serous surfaces, or to congestion
of  the  vessels, particularly those  conveying
the blood from the adjoining viscera and parts.
As in anasarca, so also in the other forms of
dropsy, the obstruction opposed to transpira-
tion by the state of the  cutaneous surface may
determine an increased exhalation or secretion
of serum into  the  cellular  tissue  underneath
and into the shut cavities.   The occurrence of
anasarca after measles from granular disease
ofthe kidneys is seldom observed.
  37. C.  Enteritis, in some  one or  other of its
forms, more commonly appearing as muco-en-
teritis,  or commencing  in the mucous surface
of the  intestines,  is  a  not  infrequent sequela
of measles, either upon the disappearance of
the eruption or during convalescence, partic-
ularly in  some epidemics.   In  the  remarkable
epidemic which appeared  at the Cape of Good
Hope about 1838,  where the disease had  not
existed for thirty  years, and which few under
thirty years of age  escaped, this sequela was
much  more  fatal  than the  measles itself, al-
though of a very  severe  form.  (See art. In-
testines, Inflammation of.)  Diarrhea, acute or
chronic, the former being often inflammatory
and passing into enteritis as just noticed, or
lapsing into the chronic state, not infrequently
with ulceration of the  intestines, is often ob-
served  consecutively upon measles.
   38. D.  Ophthalmia of a chronic and obstinate
character frequently follows the malady, par-
ticularly in the fair  and  scrofulous  diathesis.
In  addition to these, scrofulous sores and af-
fections of various kinds; enlargements  and
inflammations  of the lymphatic and mesenteric
glands; aphthae and  ulcerations of the cheeks
and gums ; furunculi and abscesses of the cel-
lular tissue, and  fluor albus,  should also be
ranged among the sequelae of measles.
   39. E. When the disease occurs in females
who have reached the period of puberty, it may
be followed by various irregular forms or man-
ifestations  of  hysteria, sometimes connected
with disorder of the catamenia.   Of these, hys
terical or  nervous  cough, occasionally  with
aphonia, is one of the most common, and al-
ways  requires a treatment suited to its hys-
terical character.
   40.  F. A  more particular consideration of
the above sequele of measles is not consistent
with my limits.  The mere reference to them
serves to illustrate  the nature of  the disease,
while it warns the practitioner as to what may
 occur, and hence points out to him  what should
 be guarded against.  These  sequela1, more-
 over, show that the  inflammatory  character of
[ measles is variously modified in respect of the
 degree of vital energy and nervous power with
 which  the vascular system  and  the tissues
 generally are endowed ; that all the vital man-
 ifestations, and even the cohesion of the tex-
 tures,  are  seriously modified  in its progress,
 particularly in certain of its  types; and that
1 while  morbid action of  an acute  and febrile
l kind may exist, even  in  an extreme grade, it 
MEASLES—Appearances observed in Fatal Cases.
945
 may be at the same time conjoined with great
 diminution of the nervous functions  and vital
 energies.
   41.  iii. Not only may measles terminate in a
 return to health, and in other diseases tending gen-
 erally  to  disorganization, but they may termi-
 nate t'n a more immediate manner, in death.  This
 seldom occurs sooner than the stages of efflo-
 rescence and desquamation; but cases  have
 occurred in which a fatal issue has taken place
 about  the period of eruption, congestion of ei-
 ther the  lungs or brain, or even both, occur-
 ring either alone or in conjunction with  effu-
 sion of serum, <kc, into the air cells and small
 bronchial tubes  of the former, and in the ven-
 tricles and between  the membranes of the lat-
 ter, and quickly arresting the functions of these
 vital organs.  In  the later stages of measles
 death generally occurs in a more gradual man-
 ner, and may be imputed:  1st. To inflammato-
 ry disorganization, commencing and rapidly ad-
 vancing in some vital organ, either as a com-
 plication or as a consequence of the general
 febrile commotion and  constitutional affection
 constituting the disease.   In these cases the
 eruption may be extremely  abundant, prema-
 ture in its appearance  and decline ;  but  it is
 much  more commonly either late, extremely
 scanty, irregular in its course, or even scarce-
 ly appearing.  2d.  A fatal result may  be occa-
 sioned by the extreme degree of general adyna-
 mia, or depressed  state of the vital energies,
 owing  to which reaction cannot take place suf-
 ficient to restore the different functions ofthe
 ceconomy to their natural  state; or  the vifal
 manifestations of  the different organs are in-
 capable of sustaining the struggle with, and re-
 moving the morbid impression made upon the
 nervous energies,  and through  them upon the
 different emunctories, secretions, and circula-
 ting fluids, by the exciting cause ofthe disease,
 aided by the different concurrent influences of
 individual  predisposition and pre-existing dis-
 order.   3d. A fatal result may occur in any of
 the advanced stages of the  disease from the
 combination of these two principal pathologi-
 cal states, either of them existing in a  more
 marked degree than the other, in different ca-
 ses, in different epidemics, and  in  different
 seasons.
  42. iv. Appearances .observed in Fatal Ca-
 ses of  Measles.—These vary according to the
 nature of the prevailing epidemic, the season
 ofthe year, the severity of the. attack, and the
 individual predisposition and state of health at
 the period of seizure.  The lesions  detected
 after death have generally a strict reference to
 the particular type of the disease, and to the
 complications which had existed in its course.
 The regular and uncomplicated  measles never
 terminates fatally unless serious or dangerous
 visceral disease occurs on its decline, and ends
 Unfavourably.  It  is different,  however,  with
 the other types or states ofthe disease.—a. In
 fatal instances  of inflammatory  measles,  the
 lungs  always  present  more or less change.
 The mucous surface of the air passages is vas-
 cular, of a reddish or dark-red colour, generally
 in patches of a small size, somewhat  softened
 and turgid, and covered with either a mucous,
muco-puriform, or viscid matter.  In those ca-
ses which have presented signs of the croupy
or bronchitic complication, the above appear-
    n.              119
 ances are very marked about the larynx, epi-
 glottis, and trachea, and are sometimes accom-
 panied either with  infiltration and injection of
 the sub-mucous tissue, or with a thick, whitish,.
 albuminous exudation, approaching in parts to
 an imperfectly formed membrane; but this lat-
 ter is, as far as my  observations have gone, ex-
 tremely  rare.  The above  changes are more
 commonly observed  in  the large and  small
 bronchi,  where the  accumulation of viscid mu-
 cus, containing whiter and denser specks of an
 albuminous  appearance,  is sometimes very
 great. Accompanying these states of the air
 passages the lungs  are often congested  with a
 dark,  frequently fluid, or semi-fluid  blood, a
 similar congestion  likewise existing in the
 veins  and sinuses  of the  encephalon.   After
 the more decidedly pneumonic complication, se-
 rous, or sero-sanguineous infiltration ofthe air
 cells  and connecting  cellular tissue, hepatiza-
 tion or condensation  of portions  of the lungs,
 purulent  infiltration of parts of this organ, or
 the formation of small purulent collections with
 disorganization of the immediately surrounding
 structure, and, lastly,  inflammation of the pleu-
 ra, are the lesions which usually present them-
 selves. When pleuritic symptoms occur during
 the last stages of the disease and  terminate fa-
 tally, effusion of a turbid serum to a greater or
 less extent, injection  and softening of parts of
 the pleura, and more  or less lesion of the sub-
jacent lung, are usually observed.
  43. b. In the nervous type of the disease, the
brain is  generally much more vascular than
 natural, and occasionally somewhat softer ; the
veins and sinuses are congested, and serum, in
various quantities,  is frequently  found  in the
 ventricles and between the membranes.  The
 pia mater is also generally more than usually
vascular, and the arachnoid more or less opaque.
These lesions vary  greatly in degree.  Some-
times they are most remarkable on the surface
of the  hemispheres ; but I have observed them
most  frequently about the base of the brain.
The extent of morbid change  has frequently
 no relation to  the severity of the  nervous type
during the progress of the disease.  In  some
cases  these appearances are very slight, and
yet the character of the disease has been mark-
ed and severe.   In other cases the lesions have
 been considerable, yet the nervous symptoms
 have not been proportionately great.  It seems
 as if the  manner in which the energies of life
 are influenced has  an intimate relation  to the
 intensity of disease and the manifestations of
 the nervous functions in its progress.
  44. c. In the gastric and  bilious type  of the
 disease, the morbid appearances are generally
 most marked in the mucous surface of the
 stomach, intestines, and  oesophagus, and con-
 sist chiefly of inflammatory injection, in patches
 or small grouped specks,  and of softening or
 loss of cohesion of  the  mucous membrane,
 sometimes with injection and slight infiltration
 of serum in the sub-mucous cellular tissue.
 The liver does not often present much appear-
 ance of disease—seldom more than slight in-
 jection or congestion of the portal and hepatic
 veins—the biliary derangement, when it accom-
 panies the disease,  being more functional than
 inflammatory.
  45.  d.  I have had occasion to observe a few
 inspections of fatal malignant measles, but only 
946                              MEASLES—Diagnosis.
three in this country where this character was
marked.   The most  remarkable  features in
these inspections were the softness of the tis-
sues and the facility with which they might be
torn—characters in which even the heart itself
participated.   The serous cavities sometimes
contained a small quantity of serous fluid of
either a turbid or sanguineous appearance.  I
have observed this kind of effusion in the peri-
cardium, but more frequently in  the  pleura.
The lungs  were generally congested, and the
mucous surface of the bronchi, as well as some
parts  of that  of the digestive canal, were of a
darker colour, even without any very marked
injection of the vessels farther than engorge-
ment  ofthe small veins, than in other cases of
the disease.   The bronchial mucous surface
presented, in  parts, small livid or purple ecchy-
moses, similar marks also sometimes appear-
ing in the fauces, stomach, and caecum.
  46. The  veins and sinuses of the brain  were
generally engorged with a dark, semi-fluid blood.
The auricles and large veins contained blood in
a similar state.  The surface of the body  was
livid in parts, mottled, and dotted with petechia;
of a dark colour, approaching to the characters
of purpura  haemorrhagica.
  [Blood in Measles.—Andral and Gavarret
found that  in the measles the fibrin never ex-
ceeded, nor did it ever fall much below Leca-
nu's average (3 parts in 1000); ranging in adults
from 2*f to 3$. This mean is found at the com-
mencement of the disease ; but after the erup-
tion appears, and in the adynamic  form of the
disease, there is a tendency to a diminution of
this principle.  The proportion of blood corpus-
cles, however, is augmented in measles  from
129 in 1000, the natural ratio, to 137, 140, and
146.  It will be observed that in the phlegmasia,
the quantity  of fibrin  is  materially increased
from 3 up to 10 parts in 1000, while the propor-
tion of globules  is  not  increased.  Measles,
therefore, should be ranked with the pyrexia,
so far, at least, as the state of the blood is con-
cerned.  (See Pathologie Hamatologique, Paris,
1843, or Am. Trans., 1844;  also Simon's Ani-
mal Chemistry, Am. ed., p. 255.)]
  47. v.  Tissues most uniformly affected in Mea-
sles.—The  structures  specifically  affected by
this disease are the rete vasculosa of the skin,
the mucous  membranes, particularly those li-
ning the air passages,  and, in a lesser degree,
those of the fauces and stomach.   The redness
observed in  the mouth and throat during the
stages of eruption and florescence is seldom so
intense as  in scarlatina.  The other lesions of
structure observed after measles may partly be
attributed to the interruption of those functions
performed  by the cutaneous and mucous sur-
faces, and  to the consequences thereby pro-
duced on other organs  associated with them in
action, together with the influence of the effi-
cient cause of the disease on the nervous and
vascular system, on the circulating fluids, and,
indeed, on all the vital  manifestations, and
even on the organization of the frame.  These
latter, or more extreme changes, however, are
chiefly manifested in the more* severe or malig-
nant cases, and are not dissimilar from  those
which take place in the advanced course of low
or adynamic fevers, whether exanthematic or
simply continued.
   48. IV.  Diagnosis.—An  exact knowledge of
the symptoms and course ofthe disease in each
of its stages, and in all the states and forms it
may assume, having, at the same time, regard
to its origin, its causes, and the character ol
the reigning epidemic, will generally enable us
to distinguish it from all  other  maladies of a
similar kind.—a. Miliary fever will seldom be
confounded  with measles, as  its  phlyctenae,
containing a serous  or  whitish  fluid, scarcely
ever appear on the face, and are always accom-
panied by perspirations  of an acid  and strong
odour.—b. Urticaria is  distinguished from this
disease by the itching attending it, by the lar-
ger and more elevated  papulae appearing and
disappearing without any order, and by its more
fugacious character. — c.  The  exantheme fre-
quently accompanying true or contagious typhus,
particularly  as described in the article Fever
(v 500-503), has  a close resemblance to the de-
clining eruption of measles.   It is, however,
readily distinguished by the history of both dis-
eases,  unless when  the measles  assume  the
nervous character.   In  this case the difficulty
of diagnosis is much increased.  But the more
protracted stages of typhus, the profound typho-
mania, and the persistence of the eruption long
beyond the period of its disappearance in mea-
sles, with various other subordinate features,
will generally point out  its nature to the atten-
tive observer.—d. The early stages of smallpox
may also be mistaken  for measles; but  the
marked catarrhal symptoms ushering  in  the
latter,  the troublesome  cough, the  small size
of, the stigmata, their superficial, slight, and less
circumscribed character,  and the  absence of
hardness, will readily distinguish  them from
the incipient eruption of smallpox.—e. The dif-
fused,  comparatively smooth, light, scarlet red-
ness, the severe affection of the  fauces,  the
early appearance at once  over all  parts of the
body, and its occasional sudden subsidence and
return, the  burning  heat and dryness  of the
eyes, and the tendency to affection of the di-
gestive mucous surface, mark scarlet fever, with
which, however, measles  have many points of
resemblance, fully pointed out  under that dis-
ease.  It has been  remarked by Ziegler, and
my own experience confirms the justice ofthe
observation, that while measles evince a dis-
position  to  affect the  respiratory apparatus,
scarlet fever has a manifest tendency to disor-
der the cellular tissue.   I  may add to this, that
this latter disease is more intimately associa-
ted with  a  disordered  state of the digestive
mucous surface, and that this surface is more
liable to  be diseased in  the severe forms of the
malady, or after the  sudden subsidence of the
eruption, than is usually  observed to occur in
measles.—/. As to rubeola, or that intermediate
disease between measles  and scarlet fever,  I
will not here point out its distinguishing char-
acters from either one or the other, as this sub-
ject is more fully considered in the article  Ru-
beola.—g. Roseola is often distinguished with
some difficulty from measles ; but it may gen-
erally  be recognised from the circumstance of
its being generally  sympathetic of dentition,
dyspepsia, and a disordered state ofthe digest-
ive organs.   It is very seldom preceded by any
very marked fever, or depression ofthe volun-
tary powers and vital actions, and is not ac-
companied by the catarrhal symptoms charac-
terizing measles.  It does not superinduce the 
MEASLES—Prognosis—Causes.                          947
marbid affections so frequently observed after
this disease.
  49. V. Prognosis.—The prognosis  in mea-
sles  is, in many respects, dependant  on  the
type and complication of the disease.  Measles
is generally less dangerous than the smallpox
and scarlet fever.   The benign or common form
is scarcely attended with any danger, unless as
respects its sequelae, or when officiously inter-
fered with.   The gastric form of the disease is
more serious, but this  seldom  presents much
danger if it be judiciously managed.   The in-
flammatory state should lead us to give a cau-
tious opinion of the result, particularly if it be
complicated  with  croup,  bronchitis,  pneumo-
nia, pleuritis, or haemoptysis.   Of these, croup,
pneumonia, and haemoptysis, especially the last,
are very dangerous complications.   I have met
with several cases of haemoptysis in the differ-
ent stages of measles, but the larger proportion
of them have terminated fatally sooner  or later,
under treatment varied according  to  the fea-
tures of each case.  The nervous and adynamic
or malignant forms of the disease  are seldom
devoid of danger, particularly the latter.
  50. Much, also,  depends upon the  character
of tie reigning  epidemic, which usually, indeed,
assumes some  one  ofthe varieties into which I
have divided the disease.   Some epidemics are
so mild as scarcely to cause any apprehension
as to the result.  Others  are so severe as to
lead us to dread either the immediate or more
remote consequences.   Percival  states that
91 died  out  of 3807 cases.   Watson  had, in
the London Foundling Hospital, 1 death in 10
cases, and in another year, 1 in  3.  In 1793, 6
cases died out of  69 ;  and in 1794, none died
of 28 cases  in this institution.  In 1800, out
of 66, 4 died.  These results confirm the calcu-
lation  of Home, who estimated the deaths at
1 in 12.  The seasons have also some influence,
but chiefly in sporadic cases;  for, during the
epidemic prevalence of  the disease, their ten-
dency is lost in the more predominating char-
acter it then assumes.   Winter, however, is a
less favourable season for the disease  than
summer and autumn.*
  51. a. A premature or retarded eruption gen-
erally indicates a severe disease, and one dis-
posed  to an irregular  form  and  complicated
state.   An obstinate, severe, and hoarse cough,
accompanied with difficulty  of breathing, and
much febrile action, prolonged beyond the pe-
riod of desquamation, evinces a serious affection
ofthe lungs, and danger.  Tumefaction of coun-
tenance ; a pale, yellowish eruption, intermin-
  * [The deaths from measles in the city of New-York, ac-
cording to the reports of the city inspector, from Jan. 1,1819,
to Jan., 1835, inclusive (16 years), was 1387, ranging from
one up to 290 annually.  In some years it has assumed a
very malignant and fatal character,  but generally it is a
mild and manageable disease.  In Philadelphia, during a
series of 20 years, from Jan. I, 1807, to Jan.  I, 1827, there
were reported 667 deaths from measles.  In 7 years there
were no deaths reported by this disease ; in 1823 there were
156 deaths by it.  It appears that by far the greatest mor-
tality from this complaint occurs between the first and fifth
years, after this period but 81, out ofthe above number of
667 deaths, happened.  In Massachusetts (4th Ann. Report
relating^to the Registry and Returns of Births, Marriages,
and Deaths,  1845) there were reported for  the whole state
(Boston excluded) 86 deaths from measles in 1842; 30 in
1843; 32 in 1844; 44 in 1845; which gives  the following
ratio to 10,000 deaths by all specified causes: 1842, 140;
Ib43, 42; 1844,45; 1815,54.  It is to be  recollected that
the reports of deaths in this state are as yet very incomplete,
but are becoming more complete every year.]
gled with petechia?; copious perspirations with-
out relief of the symptoms, but indicating re-
laxation of the tissues  and of the tone of the
extreme vessels; profuse diarrhoea;  haemor-
rhages, particularly those from the air passages
and fauces; livid petechia?;  a dark  or livid
state  of the  eruption ; gangrenous spots or
escars; very  great debility or exhaustion ; a
very frequent, very soft, open, or compressi-
ble pulse,  or an irregular or intermittent pulse;
and the presence of nervous symptoms  in a
marked degree, particularly spasms or convul-
sions, are  severally most unfavourable symptoms.
The disease is generally more severe in chil-
dren during dentition,  and in young  persons
near the  period  of puberty ;  also  in infants
during the first or second or third month.   Con-
vulsions preceding the  eruption, especially du-
ring dentition, are unfavourable signs.   Adults
who have a tendency to  pulmonary diseases,
or who have  previously  been affected with
them;  those of a phthisical or scrofulous diath-
esis ;   persons addicted to the abuse of  ine-
briating liquors, and females in the pregnant or
puerperal  states, generally experience the dis-
ease in a severe form.  However, the measles
are far less dangerous to pregnant women than
either smallpox or scarlet fever.
  52.  The sudden disappearance  of the erup-
tion, followed  by symptoms of internal disease,
or by aggravation of  pre-existing  visceral dis-
order, is generally followed by an unfavourable
termination.   The danger is also great in  pro-
portion to the extent  and confluence of the
eruption, and the violence of the attendant fe-
ver.   The later the eruption is in supervening
upon the fever, the better;  the earlier, the worse.
Very  great  lassitude,  torpor, and  rheumatic
pains of the limbs, if experienced long  before
the eruption,  indicate  a disease of great  se-
verity.  Difficult dentition, and hooping-cough,
concurring with measles, place the patient in
danger.   A fatal issue, within  the course of
the disease,  occurs  most  frequently on the
ninth and  tenth days.   It has been supposed by
some writers  that measles have become more
severe since the introduction of vaccine inocu-
lation ; but  I agree with Hildenbrand in  con-
sidering this to be devoid of foundation.
   53. 6. The favourable indications which occur
during  the  disease  are,  a moderate  eruption
with a mitigation of the fever; a disposition to
an equable moisture  on the skin ;  a moderate
or slight cough, with a mucous and  easy ex-
pectoration  ; a free and unembarrassed respi-
ration ; a free state  of the bowels, and mod-
erate relaxation  of them towards the close of
the disease; hypostatic urine ;  a regular suc-
cession of the changes  of the eruption ; and no
appearance  of any irregularity or complication
with visceral affection, the existence of which,
as I have  already shown, often occasions a fatal
result  at a more  or less remote period, owing
to the tendency to disorganization being greater
in the local affections occurring than when ta-
king place primarily.
   54.  VI. Causes.—The infectious nature of
measles is  sufficiently demonstrated, and re-
quires neither proof nor comment.—a.  The dis-
tance to which the emanation from the body of
an infected  person may infect a sound one has
not been  shown,  nor,  indeed, is  it capable of
satisfactory demonstration ; for it must depend 
948
MEASLES—Causes, btc.
upon the stage and virulence of the disease,
and the susceptibility  of those exposed to the
emanation.  It is probable that the infectious
effluvium commences to emanate from the sub-
ject ofthe disease from the first  appearance of
the eruptive fever, and that it increases in ac-
tivity until the period of desquamation,  after
which it declines ;  but it has not been shown
satisfactorily when all power of infection ceases.
That the infectious effluvium is formed as early
as during the primary fever, and before as well
as after the appearance of the  eruption, has
been proved by several occurrences by  which
exposure to infection  has  been limited to cer-
tain periods ofthe malady.
  55. b. As in other infectious maladies, so in
this, the infection is etexnded and the disease
perpetuated, even after periods of its apparent
cessation or disappearance, by fomites, or by
the imbibition and retention, for a considerable
period,  ofthe miasm given out by the infected.
Dr. Williams adduces an  instance of this, and
similar  instances on a  smaller scale, as respects
the results, must have occurred to  every phy-
sician.  A boy from  the  Foundling  Hospital
visited  at a house where a child was ill of mea-
sles.  The boy returned  in the evening, and
mixed  with his fellows as usual;  but  in the
course of fourteen days he and sixty boys were
ill ofthe disease.  The experiments of Home,
Speranza, and others have furnished numer-
ous other proofs of the propagation ofthe dis-
ease by fomites.
   56. c. Although the chief modes in which the
malady is disseminated  are emanations pro-
ceeding directly from the sick, and emanations
absorbed and retained for a time by woollen or
porous  bodies, and afterward given out, still it
may  be spread by  contagion and  inoculation.
 Home,  Vogel, Wachsel,  Brown, Monro, and
 Tissot have proved  the contagious nature of
measles by inoculation, either with  the blood,
 or with the serum   taken  from the vesicles
 which  are occasionally intermixed with the
 eruption.  It was supposed by some ofthe phy-
 sicians just mentioned that a mild form of the
 disease was produced by  inoculation ; but the
 experiments  made  by Cullen, Rosenstein,
 Girtanner, and Vaidy have not confirmed this
 opinion ; and the inoculation of measles has
 never.been even partially adopted.   The latest
 trial seems to have been made by Speranza in
 1822, who inoculated seven  persons, who had
 the disease regularly and mildly.
   57. d. The latent period, or the time which
 elapses from the impression ofthe morbid efflu-
 vium on the sound constitution until the appear-
 ance of the eruption, varies from six to twenty-
 one days.  In the cases  of the  inoculated dis-
 ease, the eruption appeared on the sixth and
 seventh days.  (See  art. Infection, $ 31.)
   58.  e. The morbid seminium or poison  of
 measles may coexist with some other  morbid
 poisons,  as observed by  various pathologists.
 Macbride states that he occasionally saw mea-
 sles and  smallpox in the same patient at the
 same time, and that the combination was gen-
 erally  fatal.  The coexistence of these mala-
 dies, either taking the precedence, has  been
 noticed also by De Haen, Vogel, Horn, Pinel.
 Bateman, and Willan.  The  coexistence of
 cowpox and measles, and of hooping-cough and
 measles, is not infrequent.
  59  /*. The morbillous miasm, having  pro-
duced its specific effects, leaves the frame ex-
empted from a second  attack.  But  this ex-
emption  is  not  universal.  It is so  general,
however, as to  induce  such  experienced ob-
servers- as Willan and Rosenstein to believe
in its universality ; while the exceptions to this
law are so rare as to be observed only by  few,
and, probably, in certain epidemics only.   Sec-
ond attacks  have been recorded by Burserius,
Roberdien,  Home, Baillie, Webster, and ob-
served also  by the  author.  It has been fully
ascertained  that the spurious disease, which
has been termed " Morbilli sine catarrho," does
not protect the system from true measles ; but
it has not been shown that those cases of mor-
billous fever, unattended by eruptions ($ 31),
admit of a subsequent attack.
  60. That the morbillous miasm contaminates
the circulating fluids, and even the soft solids,
and so infects them as to enable them to prop-
agate the disease, is shown not only by the ex-
periments alluded to above (§  56), wherein the
fluids  communicated the malady, but also by
the fact  of  infants having been born  with the
morbillous eruption when  their mothers have
been the subjects of the disease at the period
of parturition.
  61. As the measles  have been said to have
appeared at the same time, and in the same
country, they have been presumed to  have had
a similar local origin.   But the measles, Dr.
Williams  observes, now prevail all  over the
world,  occur at all seasons, and frequently
without  our being  able  to trace them to any
contagious  source;  so that we may infer that
the morbillous poison  is  generally  diffused
through the atmosphere, and at all times ofthe
year.  But  such can hardly be the case; for,
as  measles  are an infectious as well as a conta-
gious disease (see art. Infection, v 4), and are
diffused chiefly by  fomites, as the  fomites re-
tain the morbillous poison for a long  period in
temperate or cold climates, and as  the suscep-
tibility to infection by it is extremely great, in
the young more particularly,  while the period
which elapses between the first impression  of
the cause and the development of the disease
is long, so it seems the more  probable that the
extension of the poison will be rapid, wide, and
traced with great difficulty, or not traceable at
 all, without the general diffusion of it in the at-
 mosphere supposed by  Dr. Williams.
   62.  A few years ago, the measles were in-
 troduced into the Cape of Good Hope, where
 they had not appeared for about thirty years,
 by a vessel  from Europe, in which several cases
 occurred during  the  voyage.   The disease
 spread, and with its diffusion the difficulty of
 tracing the sources of  infection in individual
 cases increased ; all being susceptible of infec-
 tion under thirty or thirty-one years of age. The
 heat and dryness of the climate during several
 months of  the year being unfavourable to in-
 fection, the malady soon disappeared after those
 susceptible of it had become  infected,  few re-
 maining liable to it but infants born after its
 introduction into the colony.
   [Prof.  Caldwell states that the measles
 prevailed epidemically in the city  and county
 of Philadelphia, beginning in  1772,  every sixth
 year for a period of 50 years.   Prof. Chapman,
 however, remarks, that for the last  35 years, 
MEASLES—Treatment.
949
there has been no interval of exemption from
the disease  for any length of time;  that, al-
though it may have been suspended for a year
or more, it was  generally met with annually,
either sporadically or epidemically.  It seems
to have prevailed occasionally, in an epidemic
form, from the earliest settlement of this coun-
try, and would seem to spread with greater ra-
pidity than almost any other epidemic  malady.
In  1801, for example, it  overran  nearly the
whole  of the United States in  a few months ;
and in  1823 it was scarcely less pervading, af-
fecting even the brute  creation, domestic ani-
mals having been observed to suffer severely
with catarrhal defluxions.   There is, moreover,
no fact better established than that, although
the disease has an epidemic character,  it is also
propagated by a specific contagion, which varies
in virulence according to the constitution ofthe
season.]
   63. g. As to the origin of the disease, nothing
more credible than supposition can be adduced.
Kircher, Linnaeus, and Nyander ascribed this
disease, as well  as  smallpox, plague,  <kc,  to
swarms of minute insects in the atmosphere.
The probability of its origin in a miasm pro-
ceeding from numbers  of persons breathing a
confined air with their cattle has  been hinted
at by  Hildenbrand.   "In diversis ac  dissitis
villis, praesertim in vaccarum stabulis, in quibus
plures  saepe  familiae unacum  prolibus unitae
totam ferme transigunt brumam, morbillosum
emicare vidimus contagium eousque  vigens,
donee plurimis individuis  infectis, talique pacto
hominura dispositione extincta, exhausto igitur
quasi  solo, in quo radices figere posset, in le-
thargi  speciem cadat,  data  recenti occasione
denuo  ad activam vitam surrecturum.   Nostra
quoque sub zona huncce fomitem contagiosum
in morbis catarrhalibus gravioribus, opitulante
constitutione annua, vel specifica plurium hom-
inum  et animalium  cohabitantium   mephite,
primitus oriri posse, conjectura quidem foret,
nobis omnino non improbabilis, quam tamen ob
defectum  observationum  defendere  nondum
auderemus." (Instit. Pract. Med., t. iv., p. 359.)
   64.  A. The predisposing causes of measles are
chiefly the epoch of childhood, or any period
antecedent to puberty.  But a susceptibility of,
or predisposition to the  disease,  exists in  all
persons who have  not been  infected by  it;
probably, however,  decreasing with the prog-
ress of age after the period of puberty.  The
influence of season is not strikingly manifested,
as the  disease may be  epidemic in any season
in temperate climates.  According to the Re-
port of the registrar-general, the deaths from
measles in the metropolis were 173 in the first,
96 in the second, 94 in  the third, and 251 in the
fourth three months of 1836;  251 in  the first,
623 in  the second, 782  in the third, and 380 in
the fourth three months  of 1839 ; 194 in the
first, 275 in the second,  308 in the third, and
355 in  the fourth three months of 1840 ; 158 in
the first, and 147 in the second three months
of 1841.
   65  Although the prevalence of measles  ap-
pears to be but little dependant on season, still
some  influence may be imputed to it—an influ-
ence much insisted upon by Sydenham and oth-
ers, who considered that the disease was usually
most prevalent during the first half of the year.
Mure influence  is evidently owing to certain
epidemic constitutions of the air, which are
manifested chiefly  by their  effects,  than  to
either season or weather;  for, at all seasons,
and in all kinds of weather, merely occasional
cases of the disease may present themselves ;
and these  only  may appear for a long period;
when suddenly the disease may assume an ep-
idemic form, without any circumstance in the
weather or season being observed that can ac-
count for the  change.   Generally, however,
measles are epidemic when catarrhal affections
are also prevalent; and a frequent connexion
has been remarked between epidemic hooping-
cough and this disease.
  66. VII. Treatment.—The scope and object
ofthe treatment of measles are, 1st, to moder-
ate and  preserve the vital actions; 2d, to sub-
due or soothe the more troublesome symptoms;
3d, to aid and direct critical efforts, and prevent
unfavourable  determinations or metastases of
morbid action ;  and, 4th, to prevent or remove
the sequelae or  morbid effects of  the  disease.
These intentions nearly agree with those men-
tioned  by Hildenbrand.  The more general
indication,  however,  to alleviate  unfavourable
symptoms as they arise, comprises the whole of
the foregoing.
  67. a.  During the eruptive stage, it is chiefly
necessary,  as Dr. G. Burrows well observes,
to pay attention to the regular action of the
bowels, to confine the patient to bed, in a moder-
ate temperature, and to a light, farinaceous diet,
with cooling and demulcent drinks.   The heat
of skin preceding the appearance  of the erup-
tion is best treated by moderate doses of the
liquor ammoniae acetatis, and spiritus aetheris
nitrici in camphor mixture : the external appli-
cation of cold at this period is not unattended
by risk, especially of increasing the  bronchial
and pulmonary  symptoms.
   68. In mild cases no farther means than the
above are  requisite  throughout  their course.
Willan, however, prescribed an emetic on the
second  or third evening, conceiving that it al-
leviated the  violence of the catarrhal  symp-
toms, and tended to prevent the diarrhoea which
usually succeeds the disease ; and Dr. Fother-
gill administered repeatedly antimonial emet-
ics.  This latter plan, however, requires caution,
and is suited only to cases in which the tracheal
or the bronchial and pulmonary affection is con-
siderable, and the accumulation of mucus and
muco-albuminous matters in the bronchi is great
and expectorated with difficulty.  Dr. Willan
remarks, that he has not observed any consid-
erable effect from antimonials, or other diapho-
retics,  during the eruption ; that bathing the
feet every evening seems more beneficial; and
that emulsions and mucilages afford little or no
relief to the cough and difficulty of breathing.
   69. b. In the inflammatory state of the disease,
in which the bronchial membrane, and even the
substance  of the lungs,  the conjunctiva, &c,
are the seat of congestive inflammatory action,
blood-letting, general or local, or  even both, is
requisite ;  but, unless symptoms  of inflamma-
tory action present  themselves, this measure
should  be reserved.   Sydenham  directs blood-
letting  when the fever is violent, with difficulty
of breathing, and other pulmonic symptoms.
 Cullen remarks, that as the symptoms ofpneu-
monic inflammation seldom come on during the
eruptive fever, and as this fever is sometimes 
950
MEASLES—Treatment.
violent immediately before the eruption, though
a sufficiently mild disease be to follow, so-bleed-
ing is seldom  necessary during the eruptive
fever, and may often be reserved for periods of
greater danger.  Willan and Bateman are ad-
verse to bleeding early in the disease, because
oppression of breathing, with labouring pulse
on the first or second days of the eruption, usu-
ally  disappear  in  the course of twenty-four
hours.  But when the eruption has disappear-
ed, and the cough, pain of the chest, and diffi-
culty of breathing become severe, bleeding and
cupping become necessary.   When, however,
the symptoms are decidedly inflammatory early
in the disease, bleeding ought not to be defer-
red, for it may be too late if it be put off until
the eruption has disappeared.  As to the quan-
tity of blood which may be taken, no directions
ought to be  given.  It always should be regu-
lated by the character of the epidemic, and the
states of vital  power and reaction.  Patients
in large cities and manufacturing towns cannot
bear losses of blood equally with the well-fed,
and those breathing a pure or country air ; nor
is even the  inflammatory state of this disease
equally tolerant of vascular  depletion with pri-
mary or pure pneumonia or bronchitis.   As in
all diseases which are  produced by an infectious
or contagious miasm, so in  this, although in a
somewhat less  degree than  in some, blood-let-
ting should be practised with caution; and even
the inflammatory complications they may pre-
sent or induce are less under the control of,
and are less benefited by this treatment, than
inflammations which are not thus produced, and
not so allied.
  70. The opinions of writers as to the propri-
ety of blood-letting in measles have been  influ-
enced chiefly by the characters*of the epidemics
which came under their observation-; for, while
most writers of reputation admit the propriety
of this measure in the inflammatory state, they
equally condemn it when no such condition ex-
ists.  Hamilton, Murray, and others did not
have recourse to it, probably in consequence of
the non-inflammatory nature ofthe epidemics
they had to treat; while Morton, Mead, Heber-
den, Horn,  Ferguson, Armstrong, and others
considered that bleeding should form a part of
the treatment of the disease, manifestly owing
to the inflammatory  form   of  the  epidemics
which they observed.  Heberden advised  it
whenever the  breathing is  oppressed.  Mead
states, that " about  forty years ago the measles
raged with great violence in the city, and were
more fatal than even the smallpox," and that
he always opened  a  vein in the beginning of
the distemper,  or as soon  as he could when
called in  late,  "because the  disease  always
brings with  it a peripneumony."  Morton de-
ferred blood-letting until after the eruption is
completed, the malady being, in his  opinion,
most inflammatory at that time.
  71. Every observing  physician must be con-
vinced that  in London especially, and in  most
very large towns, bleeding ought not to be gen-
erally adopted in the  treatment of measles, al-
though it may be practised  with  greater impu-
nity in them than in other infectious maladies ;
and that it should not be neglected in the pneu-
monic and other inflammatory states of the dis-
ease noticed above ($ 42).  Dr. Williams justly
observes, that we should be content with mod-
erating the symptoms by .t;  for as the disease
has a  specific course to run  a sudden cure
ought not to be expected.  The bleeding, also,
shSuld be more moderate during the  eruption
than after its  subsidence; for a mitigation  of
the symptoms may be expected when it disap-
pears.   The presence  of menstruation should
not deter from blood-letting when clearly re-
quired, although it may indicate a more mod-
erate recourse to it.*
  72.  In aid of vascular depletion, when clearly
indicated, and even independently of this agent,
when the powers  of life are too low to admit
of it, calomel and  opium  with antimony, if the
sthenic condition  prevail, or with  camphor or
ammonia, if the  asthenic stale is  prominent,
should be prescribed ;  and the pulmonic com-
plication otherwise treated  conformably with
the principles developed in the article on inflam-
mations  ofthe Bronchi  and Lungs (see these
articles).
  73. In all cases, particularly when the erup-
tion has disappeared,  of visceral affection, or
of the  prominent affection of any important or-
gan, the application of rubefacient embrocations,
blisters, &c, in aid of such other means as the
characters  of individual cases  suggest, will
prove of service.    When the eruption is repel-
led by  exposure to cold, the treatment should
depend upon the frequency and strength of the
pulse,  and the organ chiefly affected;  but in
these cases, a strenuous recourse to warm di-
aphoretics, to the  warm bath, to which salt and
mustard may be added, and to active rubefa-
cients, blisters, and other external derivatives,
is more  especially indicated.
  74. c.  In the gastric form of measles, and par-
ticularly if  associated with hooping-cough, an
ipecacuanha emetic early in  the  disease, or
even repeated in  the course of it, is often of
service.   In these calomel and the milder forms
of mercury, aided  by aperients, are  generally
required to evacuate accumulated biliary and
intestinal secretions. If, in this state ofthe dis-
temper, the eruption be imperfectly evolved, or
if it retrocede prematurely or  suddenly, the
warmer  diaphoretics, external rubefacients  (§
73), &c, should be prescribed.
  75. d.  In the nervous state ofthe disease, par-
ticularly when associated with  convulsive or
spasmodic symptoms, with  singultus, stupor,
startings of the tendons, &c, cupping on the
nape, or leeches applied behind the ears, when
the patient is plethoric,  or  signs  of cerebral
plethora are present,  free evacuations of the
bowels, and camphor, with small doses of opi-
um, or with henbane, are  generally  of great
benefit.  When the eruption is either delayed
  * [We  believe, with Dr. Chapman, that more circum-
spection is necessary in the treatment of measles than it
usually receives, and that its sequelie are, for the most part,
the results of imperfect cures, which might be obviated by
better practice.  General bleeding is certainly one of the
most important means of preventing, as well as obviating,
those serious complications which so often endanger life in
the course of this disease,  and it is a remedy which should
not be postponed, where symptoms of pulmonic affection su-
pervene, as they frequently do.  External revulsives, at the
same time, should also be employed, and  every means used
to relieve congestion of internal organs. We,  however,
meet sometimes with a typhoid form of measles, which
will not bear general bleeding : here we  are to rely on the
warm bath and  other revulsives, warm wine whey, snake-
root, ammonia, camphor, quinine, and, in some cases, cups
or leeches.  In all cases the temperature of the room is to
be carefully regulated, and  the diet anddnnks suited to tha
exigencies of the case.] 
MEASLES—Treatment—Bibliography.
951
 or imperfectly evolved in this variety, ammonia,
 capsicum, aether, various  aromatic spirits, and
 other diffusive stimulants may  be exhibited ;
 and, aided by warm mustard pediluvia, mustard
 poultices, terebinthinate embrocations, and blis-
 ters applied only for a few  hours.   In young
 children,  however, opium  and blisters ought to
 be employed with great caution.
   76. e. The septic, putrid, or malignant form
 of measles requires the exhibition of camphor,
 ammonia, cinchona, or quinine,  the alkaline
 carbonates,  capsicum,  the chlorate of potash,
 the chlorides, creasote, and other medicines of
 the same kind, variously  combined, according
 to the features  of the case.   In it, a free use of
 wine, and small doses  of opium, frequently re-
 peated  and  conjoined  with  aromatics,  stimu-
 lants, &c, are generally  of  use.   It has been
 supposed that local bleedings may be of service
 early in this form ofthe disease ; but, however
 early they may be employed, they are of doubt-
 ful  efficacy.  In  most  respects,  the treatment
 should  be directed as recommended for  ady-
 namic or putrid Fever  (v 559, et  seq.).  In this
 variety, the most  beneficial external applica-
 tions are warm flannels, moistened with spirits
 of turpentine and cajeput oil.  Blisters are at-
 tended  with risk.
   77. /. When diarrhea follows  the disappear-
 ance of the  eruption, diaphoretics with  gentle
 anodynes, as with sirup of poppies, or the par-
 egoric elixir ; the warm bath, rubefacient em-
 brocations on the abdomen,  and mucilaginous
 or farinaceous articles  of diet, are most appro-
 priate.  If the diarrhoea be slight, and the evac-
 uations faeculent, small doses of hydrarg. cum
 creta, of ipecacuanha,  rhubarb and magnesia,
 are most beneficial, and should be  occasionally
 given, even  when  it is found  requisite to  re-
 strain the action of the bowels  by the means
 just mentioned.
   78. g. If  pneumonic  or  bronchitic  symptoms
 follow the disease,  the  means advised for sim-
 ilar states of pneumonia or bronchitis, accord-
 ing to the strength of the patient, and  to the
 severity of such consecutive disease,  must be
 employed.   In  most of these  cases,  external
 derivatives,  and the warm terebinthinate  em-
 brocation, are  very serviceable,  particularly
 after blood-letting has been sufficiently but cau-
 tiously practised.
   79. h. During the course ofthe disease, a low
 diet should be enjoined  ; and even in  the mild-
 est  cases  small quantities only of farinaceous
 food, or rice, arrow-root, &c., should  be allow-
 ed.   Fluids should  be taken at nearly a tepid
 temperature.   Whey, barley-water, and other
 demulcent drinks may  be  given.   In the ady-
 namic and malignant states ofthe disease, Selt-
 zer  water, soda water,  with sherry  negus, &c,
 may be  allowed.  The  chamber should be of a
 moderate  temperature, and be kept free from
 currents of air,  or changes from  heat to cold.
   80.  t.  No fully-ascertained means of prevent-
 ing  the  disease  have yet been demonstrated.
 Inoculation does not promise any  advantages.
 M. Tortual  has recommended the internal use
 of sulphur as a prophylactic ; but its influence
 has  not  yet been satisfactorily  shown.
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decine, t. v., p. 216  ; et Ibid., t. xvi., p. 103.—Speranza, in
Ibid., t. xvii., p. 605.—Fortual, Nouv. Biblioth. Med., t. v.,
p. 221.—Medical Gazette,  vol. xviii., p.  602.—F. Corbyn,
Trans, of Med.  and Phys. Society of Calcutta, vol. vi., p.
477.—Montgomery,  Cyclop, of  Pract. Med., vol. iii., p. 625.
—R. Williams, Elements  of Medicine, vol.  i., on Morbid
Poisons, 8vo.  Lond., 1836, p.  160.—G. Burrows, in Lib. of
Med , vol. i., p. 327.—[See  Eberle, Condie, Stewart, Rilliet
and Barthez, Evunson, Maunsell, and Dewees, " On Chil-
dren." — Hosack,  Eberle,  Dunglison,  Watson, Eliotson,
Stokes and Bell, Groves, M. Hall, Dickson, Chapman, &c]

MEDIASTINUM — Inflammation  of.—Medias-
  tinitis,  Hildenbrand.    Pleuritis  Mediastini,
  Kerstens.
     Classif.—I. Class, III. Order (Author).
   1. Defin.—Obtuse  pain  extending behind  the
sternum  to between the shoulders, with constriction,
internal  heat, anxiety,  dry, short  cough, and  in-
flammatory fever.
  2. Inflammation of  the mediastinum has been
distinguished from a similar disease ofthe rest
of the pleura by several  authors.   When  this
duplicature ofthe pleura is inflamed—an occur- 
IMMATION OF--TREATMENT.
 952                 MEDIASTINUM—Infla

 rence  not  frequently observed, the diagnosis
 is extremely difficult.  The Arabian physician
 Avenzoar is the first who  attempted a history
 of this disease.  According to Friend, he had
 been afflicted with  it.  After him, Salius Di-
 ver sus (De Febri Pest, et Curat, part. Morb., c.
 vi., p. 247) has taken particular notice of it, and
 recorded several cases in which he observed it.
 Morgagni,  Trombell, Sauvages, Kerstens,
 Flajani, and Hildenbrand have also contrib-
 uted much to our knowledge of the disease and
 ihe effects it  produces.
  3. i. Symptoms.—Obtuse and  deep-seated
 pain behind the sternum,  and extending to the
 upper part of the back, between the shoulders,
 and declining towards the  ensiform cartilage.
 A sense of constriction and internal heat in the
 same situation ; great inquietude and anxiety,
 thirst, dry cough, or with scanty coloured ex-
 pectoration, and inflammatory fever.   In  addi-
 tion to these,  Salius Diverscs enumerates
 short and frequent  inspiration, not  materially
 increasing the pain  as in pleurisy, unless on a
 forced  respiration;  hard, frequent pulse, and
 decubitus on the back.
  4. When the disease  is complicated  with
pleurisy, which is often the case, or with pneu-
 monia,  the disease may not be recognised even
 after attentive examination.  If the inflamma-
 tion extend, or be coetaneous with pericarditis
 or carditis, as post-mortem examinations some-
 times show (Portal, Anat. Mid., t. v., p. 28),
 palpitations of the heart, syncope, or leipothy-
 mia, quick, tumultuous, irregular pulse, in ad-
 dition to the foregoing symptoms, will frequent-
 ly  indicate  the nature  of* the complication.
 Mediastinitis occasionally  supervenes in the
 progress of fevers,  and even goes on to sup-
 puration  without being  detected, until  upon
 post-mortem  inspection.
  5. ii.  The causes of mediastinitis are chiefly
 external injuries;  fracture of the sternum ;
 wounds; the suppression  of discharges  ; the
 repulsion of chronic eruptions ; and the usual
 causes of pleuritis  or pneumonia.   (See  arts.
 Lungs, y 80, etseq.,  and Pleura.)
  6. iii. The prognosis in mediastinitis should
 be very guarded.  The disease seems more dis-
 posed than pneumonia to  terminate in abscess ;
 and, even when its violence seems subdued, an
 unfavourable issue  may  take  place.  Vander
 Wiel (Obs. 19., cent, ii.)  records a case which
 suddenly terminated fatally on the eighth day,
 the symptoms  having been apparently dimin-
 ished for a short time before.
  7. iv. The terminations of mediastinitis are,
 1st. In resolution ; 2d. In abscess; 3d. In thick-
 ening and induration ; and, 4th. In death.—(a.)
 Resolution of the inflammation takes place with
 similar phenomena  to those I have stated in
 pleuritis and pneumonia.—b. Death is generally
 occasioned by the extension of the disease to
 the adjoining viscera, and  the effects thereby
 produced upon the functions and organs of cir-
 culation  and respiration.  It may also result
 from the formation of abscess,  or from the con-
 sequences of chronic inflammatory action con-
 tinuing after the more acute  symptoms  have
 disappeared.   Of these I  proceed to take  some
 notice.
  8. c. Abscess in the mediastinum has received
 the notice of physicians since the time of Galen,
 who mentions  a case of it from a wound.   J.
P Petit records an instance of it from a WovV
on the sternum.  Van Swieten details another
consequent upon primary inflammation of this
part; and numerous other cases are furnished
by Balck,  Columbus, Linguet, Vicq  v Azyr,
David, Blancard,  De Fabrici, Portal, &c.
The abscess is generally seated in the cellular
tissue, connecting  the lamina? of pleura form-
ing this partition,  and is the consequence of
inflammation arising  either  spontaneously or
from  injuries, and, according to the  observa-
tions of the above authors,  is often connected
with the scrofulous diathesis and the venereal
taint.  It  may also form in the course of idio-
pathic fevers.
  9. d. The symptoms indicating abscess in the
anterior mediastinum are, after  those which I
have mentioned ($ 3) as characterizing inflam-
mation, the sensation of cold in the course of
the spine, with  chills or rigours, followed by
flushes of heat or  perspirations ;  deep-seated,
heavy, and pulsating pain behind the sternum,
and extending between the shoulders ; oppres-
sion,  palpitations,  syncope, or leipothymia;
slow or hectic fever, with irregular chills or rig-
ours ; dry, short cough,  difficult, wheezing res-
piration, inability to lie down, &c, and all the
phenomena characterizing the presence of pu-
rulent formations.   If the powers of the con-
stitution continue sufficiently long, the purulent
collection endeavours to find its  way externally.
In some cases it becomes effused into the ab-
domen, through the anterior triangular space
over the  centre of the diaphragm.   Occasion-
ally it partially  detaches the pleura from the
sternum and the costal cartilages, and appears
externally at one side of the sternum, forming
a round, soft, fluctuating tumour.   In the case
of a boy aged about six years, who was attend-
ed by the late Mr. Earle and  myself, the ab-
scess made its way externally at the right side
ofthe lower end of the sternum, and recovery
took place.  In  other cases, the matter, after
being long pent up beneath the sternum, de-
stroys and perforates a  portion of this bone.
In some cases of abscess in this situation the
preceding inflammation commences in the ster-
num itself, or its internal surface, and the caries
of it proceed pari passu with the formation of
matter beneath  it.   In cases of this description,
the extent to which the destruction  of bone
takes place and  the external wound are much
greater, so much so in some instances that the
pericardium has been exposed, the heart ap-
pearing through it.  The  immortal Harvey
showed a case of  this description to Charles
II.; and a similar case was observed by Galen.
   10. Abscess in the mediastinum is always a
most dangerous disease, owing both to its prox-
imity to  vital organs, whose functions it im-
pedes, and to the  difficulty  of ascertaining its
existence previously to*  the  appearance of the
most   serious  symptoms.    The  prognostic
should therefore be given  accordingly.   The
cause in which  it  originated, the state of the
vital energies of the frame, and the existence
of scrofulous or venereal taint, will also influ-
ence the diagnosis.
   11. v.  Treatment.—Mediastinitis,  before it
has gone on to suppuration, or to any other un-
favourable termination,  should be  treated as
fully stated in respect of pneumonia and pleuritis.
(See art. Lungs, § 91, et seq., and Pleura.) 
MEL.ENA
953
   12. When  we  have reason  to suspect the
 formation of abscess, the occasional application
 of a few leeches, and persistetice in  the  anti-
 phlogistic treatment and regimen, particularly
 in aperients and  diuretics, will be  serviceable
 as long as the inflammatory symptoms continue,
 and the pulse retains much  force or tone.  In
 an opposite state of the system, when the pulse
 is very  weak, small, quick, and  compressible,
 and the  energies ofthe system seem insufficient
 to resist the extension of local mischief and
 contamination  of the frame,  then vegetable
 tonics and bitters, and the mineral acids, alone
 or combined with tonics, are indicated.  When
 the abscess points externally it should be open-
 ed with  a lancet, its contents partially removed,
 the aperture carefully closed so  as to exclude
 the air, and the operation repeated according
 to circumstances ; employing, at the same time,
 the  medical  treatment  just  indicated,  viz.,
 small depletions,  &c, when action is increas-
 ed ;  and when  the vital energies require sup-
 port,  digestible  nourishment,  and the  tonic
 means now stated,  and the  various remedies
 advised  in the article Abscess (§ 62, et seq.).
   13. When  the  purulent  matter is confined
 below the sternum, producing slow destruction
 of the surrounding  parts, with caries of this
 bone, the majority of authors quoted above rec-
 ommend the  sternum to be trephined, and an
 external outlet to be thus given to the matter.
 Juncker and Platner consider it less danger-
 ous than a similar operation performed on the
 cranium. Dionis adduces a case in which death
 followed the performance of this operation, but
 this  result was probably not caused  by it, or
 even might have been averted by an earlier re-
 course to it.   Petit, Colon, and Lamartiniere
 consider it the only resource in  cases of this
 description, and one which will occasionally be
 successful.  Lassus states, in his work on sur-
 gical pathology, that he treated a physician who
 had a fistulous opening above the zyphoid car-
 tilage, from an abscess  in  the anterior medi-
 astinum, for fifteen months; its enlargement
 had  been  recommended by  some surgeons.
 This was prevented, and the patient recovered
 perfectly in a few months afterward.
   14. Abscess may  also  form in  the  posterior
 mediastinum, though less frequently than in the
 anterior.  In this situation it may be the result
 of inflammation of the vertebrae, or interverte-
 bral substance, or  of caries of the former,  or it
 may  originally  take place  in the connecting
 cellular tissue, and produce caries of the ver-
 tebrae from pressure, constant  dysphagia, and
 disorder of the heart.  When occurring in the
 posterior mediastinum, it may have been caused
 by violent  exertion, rheumatism  affecting the
 fibrous structure ofthe vertebrae, syphilis, scrof-
 ula, &c.   The symptoms produced  are gener-
 ally more severe, and the result more uniform-
 ly fatal,  than when abscess  forms behind  the
 sternum.  Death  often takes  place suddenly,
 and then, and frequently not  until then, is the
 cause made manifest.
   15. vi. Thickening and induration of  the
 laminae of the  mediastinum are generally the
 result of chronic inflammatory action.   Some-
 times these changes are so considerable as to
approach to  the state of cartilage,  in which
state  M.  Portal found them in a case of hy-
drothorax consequent upon bronchitis.
    II.              120
   16.  vii.  Other organic changes in the me-
 diastinum  are occasionally met with, especially
 scrofulous tumours ; enlargement of the thy-
 mus gland ;  lardaceous and albuminous forma-
 tions ; collections of fat and fatty tumours ; ef-
 fusions of blood and serous  infiltrations.  In-
 stances of these are to be found in the writings
 of Bonet,  Morgagni, Lieutand, Riviere, Cor-
 visart, &c.   I saw an instance in which scrof-
 ulous or tubercular depositions in, and enlarge-
 ment of, the lymphatic  glands lodged  in the
 mediastinum occasioned  fatal pressure on the
 trachea  and large blood-vessels.   Portal re-
 cords  a case in which death was occasioned
 by a steatomatous tumour formed in the pos-
 terior mediastinum, and pressing on the large
 vessels and nerves.
  Bibliog. and Refer.—Zacutus Limranus, Med. Pract.
 Hist., i., lib. i., No. 23.—Flajani, Collezione d'Osservazioni,
 t. iii., obs. 54.—Balck, in Journ. fur  die Chirurg., i., st. 1,
 p. 61.—Linguet, in Abscessu Mediastini Celebranda Sterni
 Terebratio. Paris, 1742.—Aaskow, Act. Soc. Med. Haun.,
 i., p. 205. — Bonet, Sepulch. Anat., 1. ii., sec. iv., ob. 2. —
 Morgagni, De Sed. et Caus. Morb., Ep. xxi., ar. 46.—Ker-
 stens, De Pleuritide Mediastini, 1784.—De Jussieu, in Absc.
 Med. Celeb. Sterni Terebr.  Paris, 1778.— Vicq d'Azyr, in
 Ab. Med. Celeb. Sterni Tereb.  Paris, 1774.—Petit, (Euvres
 Posthumes, vol. ii., p. 27.—Portal, Anatomie Medicale, t.
 v., p. 29.—Corvisart, Journ. de Med., t. ii., p. 3.—Colon et
 Lamartiniere, in Mem. de l'Academie de Chirurgie, t. iv.,
 p. bib.—Hildenbrand, Institutiones Medicae, t. iii.  Vienna,
 1823 ; Diet, des Sc. Med., t. xxxii., p. G.—Richerand, No-
 sophog. Chirurgicale, t. iv., p. 185.
 MEL^ENA.—Syn. MeXaiva vovaoc, Hippocra-
  tes.   Morbus niger; Hematcmesis atra; Hep-
  atorrhea; Fluxus spleneticus  ; Auct. var.  Se-
  cessus  niger, Hoffmann.  Melena splenetica,
  Sauvages.   Melenorrhagia, Swediaur.  Mala-
  die noire, Ictire noire, Fr.  Schwartze-krankheit,
  Schwartze-galle,  Schwartze-blutfluss,   Germ.
  Melena, Ital.
    Classif.—IV. Class, I. Order (Author).
  1. Defin.—Discharges from  the bowels, or from
 the stomach, or both by stool and by the mouth, of
 a black, or  nearly  black matter, consequent upon
 visceral or constitutional disease.
  2.  By  Hippocrates  and the ancients gener-
 ally the term melena was applied to the  vomit-
 ing of black fluids ; but, since the appearance of
 the writings of Hoffmann and Sauvages, it has
 been extended, and chiefly confined to the dis-
 charge of a black matter from the bowels.  In
the above definition I have extended its accep-
 tation, so as  to embrace the meaning attached
 to it by both  the ancients and moderns.
  3.  The black  colour of the discharges has
 been variously explained by writers.   By the
 ancients it was  imputed very generally  to the
 altered colour of the bile, and by  the moderns
 as generally  to the admixture  of blood with the
 secretions  and faecal matters in  the bowels.
 Hence, Dr. M. Good divided  melaena into M.
 Cholea and M. Cruenta.   When treating of the
latter state of this consecutive malady,  in the
 article Hemorrhage, Intestinal (<") 190, etseq.),
 I pointed out a third source or variety, namely,
in morbid secretion from  the  mucous follicles.
Dr. Graves has illustrated and confirmed this
view in his excellent clinical lectures.  He re-
marks, that a large man, accustomed to eat and
drink  largely, passed  by  stool and vomited
enormous quantities of black  fluid, and expe-
rienced eructations of sulphuretted hydrogen.
His tongue was as black  as ink.   Dr. Graves
states, that he ascertained, by  numerous exper-
iments, this black fluid to  be a secretion from
the mucous membrane of the bowels. 
954
MELiENA—Forms—Diagnosis—Treatment.
  4. I. Forms.—From what has just now been
stated, it will appear obvious  that melena, in
all its forms, 1st, as resulting from the exuda-
tion of blood  from the digestive mucous sur-
face, or the admixture of it in any way with the
contents of the digestive canal; 2d, as proceed-
ing from a thick, viscid, and black state of the
bile ;  or, 3d, as owing to a  morbid secretion
from the digestive mucous surface and glandu-
lar  apparatus, is  entirely a symptom, or con-
secutive malady ; that it altogether is a contin-
gent phenomenon upon visceral or constitution-
al disorder, or structural disease.
  5. i. The  first, or sanguineous variety of me-
lena, I have treated of at length in that part of
the article Hemorrhage already  referred to.
It is not, therefore, necessary  to  discuss this
part ofthe subject farther at this place.  I may,
however,  add, that this is the most common
form of melaena, and that a black matter is not
infrequently discharged by vomiting and  stool
in malignant diseases—both those  of a  local
character, as carcinoma of the stomach, and
those of a febrile and pestilential nature, as yel-
low fever (see articles Pestilences and Stom-
ach).   But although  this matter is principally
owing to an exudation of blood, either partially
altered previously to its extravasation, or chief-
ly or entirely changed  subsequently to its escape
from the vessels, by admixture with other mat-
ters in the digestive canal; still there is reason
to believe that the states of the bile and other
secretions in those malignant and constitution-
al maladies  contributes somewhat to the black
or very dark hue of these discharges.   In some
of the many cases of malignant puerperal fever
I have seen, the fluids  discharged by vomiting
and by stool have  presented the blackish hue
of melaena ;  and, after the best attention I could
bestow upon the subject, I have considered this
hue to be owing to the state of the secretions
chiefly ;  in some instances, however, partly to
the admixture of a bloody exudation.
  6. ii. The second source of melena, or altered
bile, has  been also  attended to in the articles
Gall-bladder and Ducts and Hemorrhage
from the Intestines (§ 193, 194),  and the
means of distinguishing between melaena from
this and other sources have been there pointed
out.  In this variety the stools, and sometimes
also the  matters vomited, present a greenish-
black hue, the former being of  the consistence
and colour of tar or treacle.   Two females, the
one  about, the other above middle  age,  com-
plained of attacks similar to spasmodic asthma
associated with  chronic disorder of the liver,
and paroxysms resembling the  passing of gall-
stones or spasm of the gall-ducts, the counte-
nance being sallow and  the bowels confined.  I
prescribed the strenuous exhibition of cholo-
gogue  purgatives, which brought away pitchy
evacuations that assumed a greenish hue when
diluted with water, and entirely removed the
attacks.
  7. iii. The third source, or the secretion of a
blackish substance from the internal surface  of
the intestines, is  probably of  much  less fre-
quent occurrence than  the foregoing.   It may
arise in a similar state of the system to that
which disposes to the production of melanosis;
the vital powers, and the state of the circula-
tion and of  the blood in the capillaries of the
digestive  mucous surface and  glands, not ad-
mitting of the due combination of the carbon of
the blood with oxygen, so as to form carbonic
acid to be discharged by the lungs ; but allow-
ing the carbon to accumulate,  so  as to exude
from the surfaces of  secreting  and yielding
membranes.*
  8.  II.  Diagnosis.—As  Hoffmann  has  ob-
served, melaena is to be especially distinguish-
ed by the tormina, spasms, and pain preceding
and accompanying the black evacuations, and
by the danger in which the patient is  placed—
a danger frequently becoming more imminent
with the continuance of this appearance ofthe
discharges.   When, however, it depends upon
the excretion  of long-pent-up and altered bile,
a rapid recovery often  follows the evacuation,
as in the cases just noticed, and in others that
I have seen.  In one of these, the patient, who
is still alive,  and to whom I  was first called
about  twelve  years ago,  has had frequent  at-
tacks  of great severity,  the copious,  black,
treacle-like  stools being always followed by re-
covery ;  these stools presenting first a dark
greenish, and  afterward a yellowish-green hue,
when  diluted  with  water.  If the black dis-
charge be blood altered by the secretions, &c,
it usually presents a reddish hue when diluted
with water, or with water containing a little
carbonate of soda ; and when this kind of dis-
charge is put in a small linen bag,  and plunged
in warm water, the  linen  is stained of a red-
dish colour  ; but when the black fluid,  which is
excreted from the third source mentioned above
(v 7), is thus treated, the colour is not material-
ly altered.  It should, however, be recollected,
that various articles taken into the stomach oc-
casion a black appearance of the evacuations,
as black puddings, the preparations of iron, and
the acetate  of lead when  it meets with sulphu-
retted hydrogen gas, &c. ; that  others give
them a red  colour, as logwood,  bilberries; and
some a blackish green hue, as spinach.
  9. III.  Prognosis.—Melaena is  generally a
dangerous symptom, unless when it proceeds
from the passage of blood in small quantity, or
in a half-digested state, into the intestinal ca-
nal, in some one  of the less important cases of
haemorrhage.   It may attend epistaxis and hae-
matemesis from suppressed menstruation, and
then it cannot be considered a dangerous phe-
nomenon ; but, in most other cases, and even
when  it proceeds from biliary accumulations
and morbid secretions, it may be viewed as a
very unfavourable occurrence.   The prognosis,
however, should depend upon the particular
source of this change, and upon  the various
pathological conditions, especially the state of
vital  power,  existing  in  connexion  with  it.
When it occurs in the course of low, adynamic,
or putrid fevers, or of malignant  diseases, it
indicates a fatal result.
  10.  IV. Treatment.—a. When the black
state of the discharges proceeds from hemor-

  * [We recently made an autopsic examination of a child,
aged three months, that died ansemio, with yellow suffu-
sion of the  eyes and skin, and  serous infiltration into the
cellular tissue, in which there was a congenital deficiency
of the gall-bladder and hepatic ducts. The whole .mtt-stinal
tract was lined with a black deposite, apparently a morbid
secretion, from  the mucou« follicles, and the evacuations had
chiefly been of the same  character from nearly the  period
of birth.  May we not suppose that, in such a case, the car-
bon of the blood, which usually escapes from the liver, is
secreted upon the mucous membrane of the intestinal canal 1
Such, at least,  was my conclusion ] 
MELANOSIS—'
rhage, then the  treatment recommended for
hemorrhages from the stomach and intestines (v
142, 184, et seq.) is the most appropriate, more
particularly the exhibition of spirits of turpen-
tine, as  then  advised.  In addition, however,
to the usual remedies employed to restrain the
exudation of blood, means are required to sup-
port the  powers of life ;  and frequently  such
restoratives should  be of the  most energetic
kind, as brandy,  port wine, the hot spices, &c.
   11.  ft. When the black  matter seems to con-
sist chiefly  of altered  bile, or of morbid intes-
tinal  secretions,  chologogue purgatives,  with
stimulants,  antispasmodics, restoratives,  &c,
are then generally required ; but the treatment
must necessarily much depend upon the pre-
vious history of the case, and the existing path-
ological  states.  Melaena  from  these sources
is a comparatively rare contingency upon pro-
longed disorders or complicated diseases, and
should be treated according to the several forms
which these assume.   (See more especially  on
this subject the article  Hemorrhage  from the
Intestines, §  200, et seq.)
  Bibliog. and  Refer.—F. Hoffmann, Diss, de  Morbo
Nigro Hipp. Opera, supp. ii., 2.   Hal., fol., 1701.—Morgag-
ni, De Cans, et Sed.  Morb.,  Epist. xxx., art. 14, <fcc.—Tis-
sot, De Morbo Nigro, in  Sandifort's Theses, vol. i.,  12mo.
Laos.,  176.—F.  Home, Clinical  Experiments, &c, 8vo.
Edin., 1780, p. 127.—L. di Fojano Loli, Del Motoo  Nero,
ossia del Flusso  gastrico sangnigno Curato, Svo.   Sien.,
1788.—Richter, Medischin. unci Chirurg. Bemerkungen, p.
119.—M. Zucchirolli, Osservazioni della Melsna, ossia Mor-
bo Nero d'lppocrate, 8vo.  Fruola, 1793.—Rubini, in Giorn.
della Societa di Parma, <fec, t. i., No. 2.—Fourcroy, in Me-
moires de la Societe de Medecine, t. v., p. 488.—Barton, in
Philadelph. Med. and Phys. Journ., vol. ii., p. 1.—Graves,
in London Med. Gazette, Aug., 1837, p. 349.—Cruveilhier,
Anat.  Path., livr. 31.—See  the Bibliog. and Refer, to
article Hemorrhage from the Intestines.
MELANCHOLIA. —See Insanity  (y 106, et
   seq.).
MELANOSIS.—Syn. Melanosis   (pUavuatc,
   from p.e2.ac, black, and  voooc, disease).  Me-
   lanotic formations ; Melanoma, Carswell.   Fun-
   gus  Melanodes,  Wardrop.   Degenerescence
   noire,  Breschet.  Melanose, Cancer melane,
   Fr.   Das Schwartz-werden, der  Eingeweide,
   Germ.  Melanotic tumours.
     Classif.—IV. Class, II. Order (Author).
   1. Defin.—A morbid production of a black, or
blackish-brown colour, dissimilar from other struc-
tures,  whether healthy or  diseased, occurring in
various forms in different parts of the  body.
   2. This was described  first  by M. Laennec
(Bulletin  de la Soc.  de I'Ecole  de Med., 1808),
Dupuytren, and Bayle,  as a distinct disease.
It seems, however, to have been  previously no-
ticed by Mr. Wardrop, but considered by him
as a species of fungus haematodes.   The divis-
ion of the several forms of melanosis suggest-
ed by  Laennec has been  very generally adopt-
ed ; but  the results of more recent researches
have suggested different,  or, at least, modified,
arrangements of  these forms.   Melanotic for-
mations,  Dr.  Carswell   remarks,   may  take
place in various and different parts of the body;
may present much  variety of form, and  may
owe their production to different agents.   But,
while  I  admit the first  and  second of  these
propositions, I dispute  the third ; inasmuch as
it is not applicable to  true melanosis, and ap-
plies only to that comprehensive classification
which comprises, as forms of melanosis,  those
alterations in  the colour and texture of  parts
produced by the  introduction of carbonaceous
nRUE—Its Seat.                           955

matter into the system, by the action of chem-
ical agents, and by the stagnation ofthe blood.
These latter alterations have been denominated
spurious melanosis, and will  be briefly  noticed
in the sequel.
   3. I. True Melanosis.— i. Its Seat.—a. The
cellular and adipose tissues axe the most frequent
seat of this disease, and in them it occurs in
the  largest masses  and  most  circumscribed
forms.   Owing to the distribution or extension
of these tissues, it spreads or extends itself, as
in the course of blood-vessels, &c.—b. When
melanosis is found in the skin, it is most com-
monly an extension only of that existing in the
subjacent  cellular or adipose tissues, and is
very rarely a primary alteration of the skin.—
c. Dr. Carswell  believes that this change very
rarely occurs in mucous membranes, those  cases
in which it seems to  exist in these being really
instances of it only in the subjacent cellular tis-
sue.—d. Arterial, venous,  and muscular  tissues ;
serous and synovial membranes ; aponeuroses, ten-
dons, and cartilage,  do not contain melanotic
matter as a primary alteration, although  they
present the dark  brown or black Colour, arising
from contiguity with, or from the imbibition, in-
filtration, or exudation of this matter when in
a  state of fluidity, or from other causes about
to be  noticed.—e. The spongy bones, as  the
sternum, are more frequently affected than the
other bones.—/.  The liver is, of all the com-
pound structures, the most frequently the seat
of melanosis, ranking, in this respect,  next to
the cellular and adipose tissues.—g. Melanosis
occurs much less frequently in the lungs  than
in the liver, nor does it acquire the same bulk
or extent as in that organ.—h. It has been very
rarely seen in the spleen and brain.   Instances,
however, have been met with by Lobstein and
Hooper, of its occurrence in the latter.—i. Me-
lanosis has been occasionally observed in the
eye, in the pancreas, and lymphatic glands, in the
thyroid and parotid glands, in the kidneys, in the
testes, in the ovaries, uterus, and mamma.  In all
these it may exist either alone, or associated
with other morbid products.—k. Melanotic mat-
ter has been detected in  the blood.  Dr. Cars-
well states, that it has chiefly been in the mi-
nute veins of the liver that melanosis has been
found;  the vessels  containing this matter ap-
pearing  like black lines, or striae, or dots, and
sometimes in a pencillated form.—I. Melanotic
fluid or matter is very rarely found  on  the sur-
faces of cavities, natural or accidental, unless
as an exudation from parts underneath, or from
the perforation of melanotic tumours.
   4. Melanosis is  sometimes  found associated
with other morbid productions.   Breschet, An-
dral,  and Lobstein have met with it in the
false membranes formed  on serous surfaces  ;
and the  last-named pathologist has seen it ac-
companying ossific deposites in the coats of ar-
teries.   It is occasionally found associated with
scirrus,  carcinoma, and fungo-haematoid for-
mations, not only in  the same organ, but  even
in the same diseased mass.  This combination
of these morbid productions has induced some
writers to consider melanosis as a species of
cancer ; but the incorrectness of this  opinion
will appear in the sequel.
   5.  ii.  The  Forms of  True  Melanosis.—
These are altogether four:  1. The punctiform  ;
2. The tuberiform;  3. The stratiform; and, 4. 
956
MELANOSIS—Anatomical Relations of.
The liquiform.— A. The puncliform melanosis is
that in which the black  colouring matter  ap-
pears in minute dots or points, grouped togeth-
er, or scattered over a considerable extent of sur-
face.  This form agrees with that which Laen-
nec denominated the infiltrated.  Dr. Carswell
states that this is most frequently met with in
the liver, the cut surface of which appears as
if dusted with soot or charcoal.  Under a lens
the black points appear stellated or pencillated,
and  in  some instances are distinctly seen to
originate in the  ramiform  expansion of a mi-
nute vein filled with black matter.  In other in-
stances, the black substance appears to be de-
posited  in the molecular structure of the organ.
This form is not met with in the brain, nor  in
the cellular, adipose, serous, and fibrous tissues.
  6.  B.  Tuberiform melanosis is by far the most
common form ofthe disease.  It varies in size
from that of a pin's head  to  that of an orange
in man, or to that of a melon in the horse.  The
great size which these tumours sometimes  as-
sume is owing to the agglomeration of a num-
ber of smaller tumours, the size varying with
the number and size of the constituents.  The
form of these tumours is spheroidal or ovoid
when single, and generally lobulated when ag-
gregated.   The single tumour occurs most fre-
quently in compound tissues and organs  ; the
aggregated in the cellular and  adipose tissues.
Both the single  and aggregated  melanotic  tu-
mour may be either encysted or non-encysted.  In
the latter, the black matter is in immediate con-
tact with the tissue of the part.   In the former,
the cyst is  formed of condensed cellular tissue,
stretched out around the  contained matter, and
forming a thin, transparent envelope to  it. En-
cysted melanotic tumours do not occur in a very
perfect  or distinct state in any of  the compound
tissues  or  organs, but chiefly in cellular and
adipose tissues, owing to the  nature of these
tissues.  The melanoid  tumours found occa-
sionally on the surface of the  peritoneum and
pleura,  and there even assuming a peduncula-
ted or polypous appearance, seem to be devel-
oped, in most instances, under the serous mem-
brane, carrying the membrane before and around
them, it thus constituting a thin  cyst or enve-
lope ; yet,  in rare  instances, the black matter
has  been  found  external to, or  upon  the free
serous  surface,  enclosed in a  loose,  spongy
tissue,  or serous covering of  considerable  te-
nacity,  but of great tenuity.
  7. C. Stratiform melanosis occurs only in  se-
rous membranes.  The black matter either may
only paint or stain the serous surface, or it may
form an almost distinct  layer  on this surface.
In the latter case, the consistence of the black
matter  is that of very firm  jelly, or somewhat
greater. It seems to be deposited in a very fine,
transparent, soft, spongy tissue, like  that  en-
closing the melanoid matter in the serous me-
lanotic tumours just described.  This  form of
melanosis  is not often met with  in man, but to
a much greater extent in the horse.
   8. D. Liquiform melanosis is  chiefly formed in
natural or morbid cavities.  It is occasionally
secreted or exuded in these situations, or effused
during  the softening process of melanotic tu-
mours.  It is very  rarely met  with in man.  It
has been observed  in the serous cysts formed
in the ovaries, and the capsules ofthe ova which
have escaped from these organs.
  9  To these four forms of melanosis, which
has been minutely described by Dr. Carswell,
a fifth has been added by Dr. Noak, which  he
denominates melanosis aperta, vel ulcerosa; and
Dr.  Savenko  has proposed  another, which  he
describes as carcinomatous.  The former is more
frequently met with in the horse than in man,
and is merely a consequence of certain changes
produced in the tissues by the matter deposited,
that will be hereafter noticed ; the latter is only
the association of carcinoma with  melanosis.
  10. E. One or more of these forms may co-
exist, and either may exist singly.  The tuber-
iform deposite is the most  common and con-
spicuous of all the forms melanosis assumes.
The  disease is never confined to one tissue  or
organ only  ; but is found to pervade a greater
or less number of these either  simultaneously
or successively.   It may be  almost equally ex-
tensive in all parts which it  invades, or it may
be abundant in one situation and scanty in an-
other.  It may be even so extensive as to ren-
der the natural structure of  the part impercep-
tible.
  11. iii. The Anatomical Relations  of Me-
lanosis.—The texture and form of the part in
which the melanotic  matter  is deposited deter-
mine in a great measure the consistence which
this deposite assumes.  There  is every reason
to infer that the black matter is deposited in a
more or less fluid state, particularly in cellulaT
and adipose tissues ;  and that it acquires addi-
tional consistency by the absorption or imbibi-
tion of its more  liquid parts.  Thus  deposited
in a fluid state in the areolae of the tissue, it
will necessarily assume various forms accord-
ing  to  the  nature of the tissue or compound
structure, to  the  rapidity with  which the de-
posite takes place, and to the abundance ofthe
matter deposited.  Viewing it in  this light, as
well as by the aid of microscopic  observation,
it may be inferred that the melanotic matter is
unorganized—is merely an extravascular depos-
ite or exudation into the areolae either  of nat-
ural  structures or of morbid formations, or of
both.  In many cases it may even be washed
away, leaving the cellular filaments  or  areolae
which  contained  it  porous,  spongy, and retic-
ulated.   Whatever  vessels, therefore, which
may be traced into  melanotic tumours,  belong
to the structure of the part,  and not to the me-
lanoid  matter itself; and when the melanoid
matter is associated with morbid  or new pro-
ductions, the vascularity is  that of these pro-
ductions, and not of the matter deposited in or
colouring them, no  blood-vessels being traced
into the black matter itself.
  [The minute texture of melanosis has been
carefully investigated by Muller,  who finds it
to consist of a fibrous net-work, and of numer-
ous  meshes, occupied by free, unadherent pig-
ment cells, the largest of which are more than
0 00108 of an English inch  in diameter ; while
the  smaller vary from 0 00105 to 0 00039, or
even less.   They are of a pale yellow  colour,
dark, or dark brown, and of a rounded, oval, or
irregular figure ;  some are elongated, and a few
are  actually  caudate, terminating at   one or
both extremities  in a point,  or in a fibril.  The
pigment cells are not present in all specimens,
and the smaller ones are supposed to be young
cells set free by the rupture of the old.  They
are  filled with yellowish or blackish granules, 
MELANOSIS—Progress—Symptoms—Causes.                   957
and a few of the larger ones occasionally con-
tain, independently of these bodies, a nucleus
with its nucleolus.  In some of his examina-
tions, Muller found the granules free, and dis-
persed through the meshes of the  fibrous net-
work.   It  is probable that in  these  instances
the germinal cells  were dissolved, or broken
down so as to allow their contents to escape.
—(Gross.)]
  12. iv. Physical and  Chemical Constitu-
tion.—The black matter itself is without any
marked odour or taste.  It  is opaque, miscible
with water or alcohol.   It putrifies slowly when
exposed to the air or kept in water.   The stain
it imparts  to the hand, or  to  linen,  is readily
washed out.  It  has been  analyzed by Las-
saigne,  Barruel, Hecht, and Henry ; and the
results of all the analyses are, that melanosis
is essentially composed of the colouring matter
of the blood and fatty substance.  M. Foy con-
siders  that it is  the  colouring matter  of the
blood highly carbonized, and this is very prob-
ably the truth.
  13.v. Progress.—The progress ofthe disease
evinces certain changes: 1st, in the  melanotic
deposite ; and, 2d, in the structures in which it
is lodged.—A. As respects the changes in  the me-
lanoid deposite; these consist, first,  of inspissa-
tion or solidification from the absorption ofthe
more watery part of the deposite ;  and, second-
ly, of the softening or liquefaction which con-
secutively takes place.—a. The inspissation of
the matter may be slow or  imperfect, as when
the  matter is  still contained  in the capillary
vessels ; or it may be more rapid and complete,
as when it is exuded into, or combines with,
the molecular structure of a dense organ.  When
formed in an adventitious  cellular  or  serous
tissue, or other morbid production, the changes
in it, especially its inspissation, depend upon
the density ofthe production which it infiltrates,
its density resisting the diffusion of the exuded
matter.
  14. b. After solidification has been carried as
far as the circumstances of the parts permit,
softening takes place.   This change is manifest-
ly brought  about by the size, situation, and ana-
tomical relations of the morbid deposite.  These
occasion, 1st, an irritation in the part, and the
effusion of serum in and around it; 2d,  the ex-
tinction of the vital cohesion  of the tissues in
which the  black matter is deposited.
   15. B. The changes in the structures in which
melanotic matter is contained are readily inferred
from what has been just stated.  The irritation
of the deposited matter acting upon the living
tissues as  a foreign and dead body, induces far-
ther changes. When the deposited matterforms
a tumour, compression of the  surrounding tis-
sues is then added to irritation  ; the latter state,
by increasing effusion, sometimes augmenting
the former, until  ulceration and destruction of
parts take  place.   The irritation produces se-
rous effusion, softening of the containing and
surrounding tissues, disorganization with or
without suppuration, and  ultimately open  ul-
ceration.   The melanotic ulcer thus formed is
either regular or irregular ; its edges are thin,
soft, pale,  or slightly  red, or tinged with black,
bevelled from within outward, and it exudes a
black fluid.  If the margins of the  ulcer are the
seat ofchronic inflammation, they become thick-
ened, infiltrated,  or projecting and  hardened;
 sometimes  they  are  everted, and the internal
 surface presents a  number of excrescences.
 When cut through, they are of a pale gray col-
 our, and  closely resemble scirrus.  Melanotic
 ulceration is comparatively rare, and as yet im-
 perfectly  observed.
   16. vi. Symptoms and Diagnosis.—The symp-
 toms of melanosis are seldom well marked at
 the commencement, unless the  morbid deposi-
 tion occurs in parts which come directly before
 our  senses, and  it is generally  not until  after
 death that we are at all enabled to  ascertain
 its existence.  As far as  the symptoms  have
 been recorded, and  as far as I  have observed
 them in a single case which has  come before
 me in the human subject, melanosis  is chiefly
 characterized during the life of the patient by
 a gradual sinking of the  vital energies, a ca-
 chectic habit of body, a dusky or  ash-coloured
 countenance, and a  marked change of the nu-
 tritive functions, giving rise to great emacia-
 tion, dropsy, a partial cedema of the cellular tis-
 sue, sometimes to effusion into the serous cav-
 ities, to  a weak, quick, and small pulse,  with
 night perspirations towards the termination of
 the disease ; and occasionally, when the lungs
 are affected, to a blackened mucous expectora-
 tion.
   17. It is generally observed, that however im-
 portant or necessary to the continuance of life
 the organ affected by this  malady may be, feb-
 rile excitement never manifests itself in an ac-
 tive or marked form : a circumstance serving,
 in the opinion of Laennec and Lobstein, to dis-
 tinguish during life the consumption depending
 upon melanosis from that  proceeding from  tu-
 bercles in the lungs.   But this is an insufficient
; source of diagnosis, for phthisis may exist with-
 out any febrile symptom beyond rapidity of pulse
 and perspirations.  These symptoms also char-
 acterize the last stages of melanosis, but they
 are unattended  by purulent expectoration and
 the stethoscopic signs of ulcerated cavities in
 the lungs, which are generally present in the
 last stage of phthisis.  Melanosis does not ap-
 pear to give rise to much  pain.   The presence
 of black matters in the discharges from the
 stomach or bowels is no evidence of the exist-
 ence of  melanosis,  as such matters generally
 proceed from very different sources from this,
 as shown in the article Melena.
   18. vii. Remote Causes.—Melanosis has been
 met with in  all  periods of"  life, bul  most fre-
 quently in old age.   It is not confined to  the
 human species, but has been observed in  the
 horse, the  dog, the cat, rabbit, &c, but  most
 frequently in the horse, and particularly those
 which  are  gray  or white.  As to its exciting
 causes, the infrequency of the disease prevents
 me from stating anything with certainty.   Ii
 seems, however, probable that  it  is occasioned
 by whatever lowers the vital energies, and im-
 pedes the functions of the respiratory and  bil-
 iary organs, or the decarbonizing actions of the
 frame.
   19. viii.  Of the origin and nature of this
 substance different  opinions have been enter-
 tained.   The most plausible of these refer it to
 an  altered state of  the colouring part of the
 blood, arising from the presence of an extraor-
 I dinary quantity of carbon ; and infer that  the
 melanoid matter is in its composition nearly al-
 ' lied to  adipose  substance, particularly  as re- 
958
MELANOSIS—Treatment—Spurious.
gards the quantity of carbon composing it. This
seems to be the opinion of Heusinger and Go-
hibr, who refer, in support of it, to the large pro-
portion of the phosphate of iron and carbona-
ceous matter found in this substance upon cal-
cination.  Laennec considered it as a distinct
species of cancer.   He was evidently led to the
adoption of this opinion by the circumstance of
both diseases occurring in nearly similar states
of the vital energies of the frame, and in anal-
ogous conditions ofthe soft solids—an evident
cachexia,  or contamination of the  frame, ap-
parently  existing  in both.  Besides, the fre-
quent association of this  disease with  scirrus
and  carcinoma seemed to favour  this  notion.
But  this can only be viewed as an occasional
complication, as melanosis is also found asso-
ciated with tubercles and other morbid produc-
tions.  Moreover, the parts affected by this dis-
ease often  present no signs of change beyond
the infiltration of black matter ; and cancerous
disease is seldom so generally diffused through
the various tissues and organs as melanosis is.
  20.  Chemical  analysis  has  confirmed the
opinions of Gohier and Heusinger, and shown
that this matter offers some analogy to the col-
ouring matter  and fibrin  of the blood.  MM.
Breschet, Cruveilhier, Carswell, and Lauth
have, moreover, found  it  in the blood-vessels
which have remained undestroyed in softened
melanoid tumours.  M. Treviranus, in experi-
ments  made by him on frogs, observed that,
when the blood-vessels were  deprived  of the
nervous influence, a black matter resembling
the pigmentum  of the choroid was formed  in
the  capillaries  and in  several membranes.
From this it may be inferred, that the black
matter thus formed proceeded from  the depo-
sition of the carbonaceous particles, which, not
having combined with  oxygen, had not been
eliminated from the blood in the form  of car-
bonic acid,  owing to deficient vital and ner-
vous power, and to the  enfeebled and retarded
circulation in the capillary vessels.*
  21. I am therefore of opinion that the mela-
noid matter is produced or secreted from the
blood, owing to an enfeebled state of the vital
influence  of the  system  generally, and the
capillary vessels  in particular; that this state
of the vital  influence is insufficient for  the ac-
complishment ofthe healthy changes induced in
the capillaries  of a part,  or of the  body gen-
erally ;  and that free  carbon accumulates  in
these vessels, which, under the defective vital
energy of the system,  and diminished tone  of
the  extreme vessels, is deposited with other
constituents of the blood: 1st. In tissues not
previously changed in  structure; 2d. In parts
the texture  of which have been variously chan-
ged ; and, 3d. In new formations, as false mem-
branes, carcinomatous growths, and other ma-
lignant productions.
  22. ix. Treatment.—The great  difficulty of
ascertaining the existence of the disease pre-
vious to death  has  prevented the employment
of those means which might have been  tried if
  * [According to an analysis of Dr. Foy, of Paris, melano-
tic matter (obtained from the horse) contains, albumen, 15 ;
fibrin, 625 ; a highly carbonized principle, probably altered
cruor, 3140; water, 18-75;  oxide of iron, 1-75; sub-phos-
phate of lime, 875 ; muriate of potash, 5 ; muriate of soda,
3-75 ; carbonate of soda,JlbO ; carbonate of lime, 3.75 ; car-
bonate of magnesia, 175; tartrate of soda, 1.75.—Total,
10040.]
its presence had been evinced. Upon this sub.
ject, therefore, medical literature is perfectly
barren.   In the uncertainty under  which the
physican is compelled to  act in all cases of
this description, the general conditions of the
frame, and external manifestations of depressed
vital energies, will be the chief circumstances
on which he can found his indications of cure.
His attention will  therefore be chiefly directed
to those  means which are found most energetic
in rousing the powers of life, imparting tone to
the minute capillaries, and  promoting the  func-
tions  of the various assimilating and secreting
viscera  and emunctories of the frame.   With
this view, I can only suggest the employment
of quinine with the mineral acids, or with cam-
phor,  and alternated  with purgatives  or ape-
rients ;  the iodide of potassium and the liquor
potassae with compound decoction of sarsapa-
rilla ;  the muriatic or chloric, or nitro-hydro-
chloric acids; the chlorate of potash, the  chlo-
rides, &c.  In  order  to  excite the decarboni-
zing functions  of  the  liver, while restoratives
are being  prescribed, chologogue purgatives
should also be given occasionally. The patient
should live in a pure, dry atmosphere, and take
due exercise in the open air.
  23.  II. Spurious Melanosis.—Those states
of parts,  or of disease, that resemble  true mela-
nosis, have been  fully described  by  Dr. Cars-
well. This spurious disease is caused: 1st.
By the  introduction of  carbonaceous matter.
2d.  By the action  of chemical agents, and by
the stagnation of the blood in the capillaries.—
A. Spurious melanosis from  the introduction of
carbonaceous matter.—The inhalation  of the car-
bonaceous  matter proceeding from common
combustion was first supposed by Pearson to
discolour the pulmonary tissue.  Laennec after-
ward  entertained  the same  opinion ;  but the
fact was not fully  demonstrated until Dr.  S. C.
Gregory published a  remarkable case which
came  under his care.   This form of spurious
melanosis occurs only in the Lungs, and is de-
scribed in the article on the pathology of these
organs (<") 185).
  24.  B. The  action of chemical agents on the
blood gives rise to a form of spurious melano-
sis.   In  cases of  chemical dissolution or di-
gestion  of the parietes  of the  stomach  after
death by the  acid  contained in the gastric jui-
ces, and in cases of  poisoning  by  acids, the
blood contained in the capillary vessels of the
digestive tube, as well  as  that  which is ex-
travasated, frequently presents a blackish tint,
so as  to  simulate  melanosis of the part.  The
action of sulphuretted hydrogen  gas may also
give the blood  in  the  capillaries of  the intes-
tines, and that effused in the same situation, a
black  colour.   It is chiefly, however,  in a foren-
sic point of view that this subject becomes im-
portant.
  25.  C. The stagnation of the blood in the  capil-
laries  from loss of vital power, and independent-
ly of  the action of acids, or of other chemical
agents,  sometimes imparts  a melanotic ap-
pearance to certain tissues.  This occurs chief-
ly in  the digestive mucous surface,  and in the
lungs.  In the former situation it is not infre-
quently observed after death  from pestilential
cholera; in the latter organ it occurs both in
that malady and in the more sudden forms of
congestion sometimes supervening upon or- 
MENSTRUATION
ganic changes in the substance of that organ,
and in the bronchi.

  Bibliog. and Refer.—Laennec, Bulletins de la Soc. de
l'Ecole de Medecine, No. 2, 1806.—Pearson, in Philosoph.
Transact., 181S, p. 2.—Gohier, Mem. et Observat. sur la
Chirurg. et la Med. Veterinaire, t. i. Lyon, 1813.—Breschet,
Journ. de Physiolog. Experimentale, vol. i., art. 4, Oct.,
1821.—Merat, Diet, des Sciences Medicales, t. xxxii., art.
Melanose. — C.  F. Heusinger, Untersuchungen Uber die
Anomale Kohlen, und Pigmentbildung. Eisen., 1823, p.
95 ;  and Archives Gener. de Med., t. v.—Andral, Diet, de
Med., t. xiv., p. 99 ;  et Precis  d'Anatomie Pathologique, t.
i., p. 446.—Reissessen, Preisschrift uber den Bau der Lun-
gen, p. 46.—Cullen and Carswell, in Med. and Chirurgical
Transact, of Edin., vol. i., p. 264.— T. Fawdington, A Case
of Melanosis, 8vo.  Lond., 1826.—Crampton, Dublin Med.
Trans., vol. i., N. S., 1830.—C. A.Noak, De Melanosi cum
in Hominibus  turn in  ^Equis  Obveniente, 4to, fig. Lips.,
1829.—P. Savenko, Tentamen Patholog. Anatom. de Mela-
nosi. Petrop., 1825.—Lobstein, Traite d'Anatom. Patholo-
gique, t. i., p. 460.—Hooper, The Morbid Anatomy of the
Human Brain, pi. xii., fig. 2 and 3.—R. Carswell, Patho-
logical Anatomy, fasc. iv.  Lond., 1834 ; and Cyclop, of
Pract. Med., vol. iii., p. 85.—/. Hope, Morbid Anatomy, <fec,
8vo.  Lond., 1833, p. ii.—D. Williams, Transact, of Provin-
cial  Medical Association, 8vo, vol. i., 1833.—Cruveilhier,
Anat. Patholog., livr. xix., pi. 3  and 4.—J. Vogel, Icoues
Histologiee Pathologies, 4to.  Leips., 1843, p. 121.

  MEMBRANES—Pathology of.—The read-
er  will find  the  diseases  and  lesions  of mem-
branous tissues fully discussed  in  the articles
Brain,  Bronchi, Digestive Canal, Peritone-
um, and Pleura.
  MENINGITIS.—See Brain (y 3, et seq.).
  MENORRHAGIA.—See Hemorrhage from
the Uterus (§ 220), and more  especially Men-
struation.
MENSES, MENSTRUATION.—Synon. Cata-
  menia (from Kara and  finv); Karaunvta ;  yv-
  vaiKeta, Gr. Menstrua, menstrua purgationes ;
  Menstrui  Cursus, profluvium mulierum, Auct.
  Frauenzeit, Monatzeit, Monatliche reinigung,
  Germ.  Les Regies, les Menstrues,  Menstrua-
  tion, Fr.    Mestrui,   Corso Mestruale,  Ital,
  The Menstrual Flux, the Courses, the Monthly
  Discharge, the Monthly  Period, the Flowers,
  the Catamenia, the Monthly Indisposition.
     Classif.—General and Special Pathol-
       ogy.—Therapeutic s.
  1. The  consideration ofthe derangements to
which menstruation is liable comprises that of
the  chief functional  disorders of the uterine
system;  and in all the  disorders and structu-
ral  diseases of this system, the states of men-
struation  are the  most important phenomena,
enabling us not only to form correct ideas as to
their natures, but also to  devise appropriate and
successful indications of cure.
  2. The derangements of menstruation have
been variously classed and considered by sys-
tematic writers, as well as by those  authors
who have confined their researches to the dis-
eases  of  the female ceconomy.  In the works
of the latter, to which we are  especially enti-
tled to look for a full and comprehensive detail
of these  derangements, the  principal only  of
them are discussed;  and others, which are
often of great importance  in their  local and
constitutional relations,  are altogether over-
looked. Denman,  Burns, Hamilton, Capuron,
Nauche, Dewees,  Boivin, Duges, and Church-
ill  confine themselves to the consideration of
the three  states of disorder usually designated
by  nosologists  amenorrhea, dysmenorrhea, and
menorrhagia.   Others have noticed, in addition
to these,  other  derangements ; but very few
writers have embraced the whole  of them.
Carus has judiciously noticed  premature, de-
I—Phenomena op.                         959

Iayed, and incomplete menstruation.  Dr Blun-
DELLhas comprised offensive catamenia. Joerg
and Mende have not overlooked menstruation
repeated too frequently, nor that which occurs
not often enough, or only at prolonged  periods.
Siebold arranges  the  subject into the preco-
cious and tardy development of the menses,
excessive and scanty discharge, suppression of
it,  painful menstruation, and vicarious men-
struation.  Dr. Power adopted a classification,
which might  have comprised all the disorders
to which this function is liable, viz.—a. Defi-
ciency of the  menstrual actions.—b. Excess of
the  menstrual actions.—c.  Irregularity of the
menstrual actions.  The adoption  of  any ar-
rangement is  of no farther  importance than as
it may the best enable us  to comprise air the
useful and practical considerations  of  the sub-
ject, in such  due order  and relation  to  each
other as may  be made most applicable  in prac-
tice, and most advantageous in advancing our
knowledge of uterine disorders, and  of their
relations to other affections and maladies.
   3. In discussing the subject of menstruation,
I shall consider, first, the phenomena and man-
agement of this function ;  and afterward, the
various disorders and irregularities  to which It
is liable ; and, briefly, the  connexion of these
disorders with other affections and diseases ;
or, more definitely, as follows: i. The phenom-
ena of menstruation,  ii. The management of
the  menstrual periods  in various circumstan-
ces,  iii.  Absent, suspended,  and  suppressed
menstruation, comprising vicarious menstrua-
tion,  iv. Painful and  difficult  menstruation.
v. Excessive  menstruation ; and, vi.  Various
irregularities  of this function not  comprised
under the foregoing heads.   The first  and sec-
ond of these comprise the physiological and hy-
gienic consideration of the  subject;  the others,
the pathological and therapeutical discussion of it.
   4. I. The Phenomena of  Menstruation.—It
is not intended that all the  phenomena  of men-
struation and female puberty slwuld  be  here
noticed, but only those more especially con-
nected with the disorders of menstruation and
of the female ceconomy.   The period  of com-
mencing and  of established puberty in the fe-
male has generally been viewed in connexion
with the occurrence of menstruation.   The re-
lation  generally exists;  but not infrequently
we observe this function to appear, either in a
regular or irregular manner, before the other
indications  of puberty  are fully  developed ;
and as frequently these indications precede, for
a longer  or shorter period, the  establishment
ofthe catamenial flux.   Much of this variabil-
ity in the accession of the  several phenomena
of puberty depends upon the circumstances of
modern society and education, which  will  be
shown hereafter to be so remarkably productive
of the disorders of menstruation.
  5. Up to the period of menstruation,  the ova-
ria and uterus merely exhibit the state of sim-
ple growth with the rest of the ceconomy ;  but
at  this period they become more fully devel-
oped, and the uterus manifests the higher vi-
tal manifestations  of irritability and secretion.
During these local  changes, the whole frame,
and the  mental manifestations, present great-
er activity of development.  The nervous sys-
tem betrays increased susceptibility and sensi-
bility ; the mind acquires extended powers of 
960                       MENSTRUATION—Phenomena op.
emotion and passion, and the imagination be-
comes more lively.   The mamma; and pelvic
viscera  are rapidly developed ; the hips and
thighs enlarge ;  the  ovaria become  red and
swollen ; the Fallopian tubes, with their fim-
briae, as Dr. Ferguson remarks,  are elongated,
erectile, and irritable ; the uterus has acquired
bulk, and a more sanguine hue ; the organs of
the thorax participate in the effects of that ac-
tion, which is increasing  the mammae, so that
the lungs, the larynx, and even the arms ac-
quire the contours of a maturer development.
The intensity of vitality,  and the resistance of
the frame to hurtful agents, are such at this pe-
riod, that the mortality is less at this than at
any other epoch.
  6. If,  on  the other hand, the uterine organs
continue undeveloped, and the menstrual dis-
charge does not appear, the growth of the body
is impaired, and the general character and ap-
pearance of it unhealthy, languid, blighted, and
imperfectly formed.   The mind is  dull, weak,
or depressed.  The emotions and passions are
imperfect, or altogether  absent.  The vegeta-
tive functions are less vigorous;  and fat and
cellular  substance are formed instead of mus-
cular tissue ;  the mammae and lungs are  insuf-
ficiently developed ;  and not  only is life less
intense, but it is of much shorter duration, early
phthisis terminating  a state of  sickly and im-
perfect existence.
  7. Much  discussion has recently taken place
respecting  the period at  which the menses first
make their appearance ; and considerable misap-
prehension  has existed  on the  subject; inas-
much as this flux, when  occurring very  early,
is not always, nor yet so  generally attended as
has been supposed, with  other signs  of devel-
oped or even of advancing puberty.  I have
seen in  public and private practice numerous
cases of very early menstruation, the flux oc-
curring  regularly for months.  In  one  case
brought to the infirmary for children, it was as
early as the^ixth year.   I have seen several
in whom the catamenia  appeared  as early as
the tenth  and eleventh  years in this climate,
and many in warm countries ;  but in most of
these this flux was the chief indication of com-
mencing puberty.  The accession of  menstru-
ation has been supposed to be much  earlier in
warm than in temperate and cold climates ;
but this opinion has been disputed by Mr. Rob-
erton and others.   Having paid  some  atten-
tion to this subject many years ago, I had come
to the conclusion, from  inquiries made  when
travelling both  in hot and in cold countries,
that a considerable  difference  as  to  the  age
actually exists, although  that difference  is not
so great as most physiological  and other wri-
ters have stated it to be ; and I am convinced
that it is partly owing to the difference  in the
constitution ofthe several dark and white races
of  the  species—that it is'as much  owing to
this cause  as to climate.
   8. Besides climate, there are  manifestly oth-
er  circumstances which, in  certain  constitu-
tions, cause an early or premature appearance
of the catamenia ; and which, perhaps, in other
or  opposite constitutions and  temperaments,
tend  to delay or to suppress  altogether this
discharge,  by weakening or exhausting the un-
developed sexual organs. v A  number of  female
children sleeping in  the  same apartment; the
intercourse ofthe sexes at an early^age, as in
manufacturing towns and cities>; the tempera
ture and circumstances in «'hich yjung J™  «»
are placed in cotton and numerous othei-facto-
ries   the excitements  to  wh.ch  thei  mind 8
exposed in these, and  in schools, «fcc , are^ in
temperate climates, the chief causes of the pre-
mature or  early occurrence  of menstruation,
and ofthe subsequent irregularities of this func-
tion   The  influences which are in operation in
large manufacturing localities  often place young
females in  similar physical and moral  condi-
tions  to those of the dark races  in warm cli-
mates, and hence the  difference of  the period
at which menstruation commences in both is
often  not very great.
  9. The following table will show the years
in which 1604 females  experienced  the acces-
sion of the  catamenia:
	272 I 68		160	432	86	460	137	
								
B			o £ c	g		5	I	Total,
£	f? 11			>» ►J	a.		■a 1 IS	1604.
	ft**		£«	<	•<	£		
								
	\<		BS			■<		
9	_._		—	—	1	—	—	1
10	4 —		1	5		—		10
11	10	fi	4	14	3	10	—	47
12	15	10	11	26	14	19	3	98
13	33	13	14	47	6	53	8	174
14	33	9	17	50	18	85	21	233
15	45	lfi	31	76	54	97	sa	351
16	48	8	31	79	7	76	24	273
17	32 ' 4		26	58	6	57	11	194
18	27	2	11	38	5	26	18	127
19	12	_	9	21	8	27	10	87
20	8	_	2	9	3	4	8	34
21	4	—	—	5	—	—	—	9
22	1	—	1	1	—	—	2	5
23								
24	—	3	a	—	—	—	—	5
   10. From the foregoing table it will be seen
that menstruation generally  commences be-
tween the ages of twelve  and  nineteen, and
more frequently at the age of fifteen than at
any other.  Although it is  not  always, at its
commencement, correlative with  other  signs
of puberty still, it must  be viewed as generally
connected with and depending upon the chan-
ges taking place in the ovaria and uterus at this
period, and as being determined by the increas-
ed development and activity of the nervous
system of organic life endowing the uterine
system.   That the ovaries  exert an influence
in determining the occurrence of menstruation,
was supposed by  Friend and many more re-
cent writers, and is not  improbable.  The well-
known case published by Mr. Pott, and cases
of disease of the ovaria which have occurred to
Dr. Montgomery and in my own practice (see
the case  about  to be alluded to), almost dem-
onstrate this influence.  Dr. Power attributed
menstruation to the action ofthe ovaries.  He
conceived that gestation is the  natural condi-
tion of the female organs ; that a female men-
struates because she does not conceive; that
pertain changes take place in the ovarian vesi-
 cles  preparatory  to  the transmission  of the
 ovum, and that  parallel changes are taking
 place in  the  uterus, which may issue in the
formation of the decidua; but that, if the.stim-
j ulus of impregnation be denied, the increased
| action of the uterus is not sufficient to produce
I that effect, although it is sufficient to cause the
I effusion of a fluid, which is the menstrual fluid. 
MENSTRUATION—Phenomena op.                        961
However  this may be, there can  be  no doubt
that the accession ofthe catamenia is the con-
sequence of a periodical excitement, or irrita-
tion ofthe nerves ofthe uterine organs acting
upon the vascular system of these organs, and
determining an  increased afflux of blood to
them;  and hence, that it  is somewhat analo-
gous to the condition in the lower  animals usu-
ally denominated that of " heat."  An opportu-
nity was afforded to Dr. Hooper of examining
the organs of a female .who  was instantane-
ously killed by accident during the  menstrual
period.  The uterus was swollen and vascular;
its structure less  dense  than usual,  and its in-
ternal membrane injected, floccy,  and bedewed
with menstrual fluid.  The ovaries and Fallo-
pian tubes were also swollen and very vascu-
lar.  Other facts  and considerations might be
adduced to prove that menstruation is  the re-
sult of increased nervous and vascular activity
of the  uterine organs;  and this  view  is  that
most accordant with the phenomena which this
function evinces during disease.
  [It is now generally acknowledged that men-
struation,  as well as conception,  is dependant
on the  existence and influence of the ovaries.
The ovarian vesicle was  first discovered by
De Graaf, from whom  it received its  name;
but no important inference was derived from
this discovery, until Purkinje, in 1825, found
this vesicle in the unimpregnated  yolk.   Since
then we have been favoured with the observa-
tions of MM. Caste, Wagner, Schwann, Whar-
ton Jones, Barry,  Bischoff,  Gendrin, Raci-
borski, Lee, Negrier, Boismont, Girdwood,
and others, and which have established, beyond
all  reasonable doubt, that menstruation is the
consequence of the periodical maturation and
rupture of a Graafian vesicle, with the escape
of an ovum from the ovary into  the Fallopian
tube, which is Washed away by the menstrual
blood.   It is based  on the physiological law of
the sex, that an embryonic germ is developed
and brought to perfection at  stated intervals,
corresponding nearly with the revolution of the
lunar period of twenty-eight days each, one
ovum being ripened every month.
  "The  substance of  the ovary,"  says Dr.
Meigs  (Am. ed*. of Colombat,  p. 460), " or its
stroma, is  found to contain a vast multitude of
small points, disseminated within its structure.
Each of these points, discoverable only by the
aid of  a microscope, is  supposed  to be a rudi-
mental germ, ready to commence its work of
development whenever the proper time  may ar-
rive, in its series or turn ; and it proceeds in
that work by such  degrees, that at  least one
such will  be brought to complete maturity,  as
before  said, once  a month, as long as the men-
strual age lasts, and while the woman enjoys
good health.  Now, as  the microscopic ovum
is contained within a double capsule, called the
Graafian vesicle, it happens that the contain-
ing vesicle expands, and grows with great ra-
pidity during the latter part of the process ; it
continues  to rise from the central or internal
parts of the ovary towards the surface, distends
the stroma, puts the tunica  albuginia on the
stretch, and, finally, bursts outward, dischar-
ging its fluid, and the ovum in that fluid, with its
accompanying retinacular or granular  matter,
into the cavity of the belly, or, in case of im-
pregnation, into the fimbria  of the  Fallopian
    II.               121
tube, by which it is conducted to and lodged
in the womb, to constitute the ovum of a gra-
vid uterus.  Now it clearly appears, from the
showing  of Robert Lee, of  London, M. Ne-
grier, of Angus, M. Gendrin, of Paris, and M.
Raciborski, of the  same city, and many oth-
ers, that  if a  woman  die in  menstruating,
or soon afterward, there is found on the sur-
face of the ovary a bloody and ragged opening,
leading into a small pit or crypt, in which is fre-
quently found a small clot of blood, and which
crypt  once contained the fluid, the  granules,
and the ovum of the now broken Graafian ves-
icle.  It also appears, where the rupture has
recently taken place, the entire ovary is found
reddened and turgid, from the hyperaemia indu-
ced in it  by the development of the vesicle,
just as the gum of a young child,  over a large
jaw tooth, is found  to be reddened and engor-
ged from  a hyperaemic irritation  arising from
the pressure of the still  uncut tooth.
  " Different observers  report that they have
found the  ovary of the same side, the Fallopi-
an tube, and the uterus of a bright red colour
in patients dying suddenly during their men-
struation ;  and they declare it to be an invari-
able rule to find the evidence of a recent rup-
ture in all such persons, while the numerous
pits, depressions, and cicatriculae to be noticed
upon the surface of every ovary of females be-
tween fifteen and forty-five years of age are
regarded as the vestiges of these periodical dis-
charges.   Stated developments and bursting of
the Graafian vesicle may be confidently looked
for on one or other ofthe two ovaries. So firmly
does M. Raciborski seem  to regard this doc-
trine as established, that he calls it  a regular
ponte, or laying process, whose appearances and
laws, as far as ascertained, he has published in
his recent work, De la Puberte, &c," &c.—(Loc
cit.)  For an able resume of what is known on
this subject, the reader is referred to an article
by Dr. Purple, of New-York, in the sixth vol-
ume of the New-York Journal of Medicine and
the Collateral Sciences, p. 229, entitled, ,; Men-
struation,  its true Nature and Office, with a Re-
view of the Evidence  of its Vesicular Origin, with
illustrative Cases."  See, also, the Brit, and For.
Med. Review, vol. xvii.,  1844;  R. Lee's " Mid-
wifery ;" Raciborski, in Gaz. des Hopitaux, vol.
iv., 1842;  Lond. Med. Gaz., 1844 (cases by
Ritchie);  and New-York Med. Gaz. (case by
Dr. Post).]
   11. The symptoms indicating the first accession
of the catamenia are  not  always present or con-
stant ; but generally, for some days previous to
the accession of the discharge, headache, heav-
iness, languor, pains in the  back, loins,  and
down the  thighs, are complained of, with indis-
position to exertion.  There is a peculiar dark
tint of the countenance, particularly under the
eyes ; and occasionally uneasiness or a sense of
constriction in the throat, or about the thyroid
gland.   The cutaneous perspiration  has often
a faint or sickly odour,  and  the  smell of the
breath is peculiar.   The mammae are enlarged
and painful, or tender.   The appetite is fastidi-
ous and  capricious, and digestion  impaired.
These symptoms continue one, two, or three
days, and subside as the menses appear.  At
the commencement of  this function, the sec-
ond, third, or even  the  fourth period may not
be  attended by any discharge;  it sometimes 
962
MENSTRUATION—Management or.
thus  recurring  irregularly  at  first,  even  in
healthy females.  The  period continues from
three to six days, and  returns every twenty-
eight days, excepting during gestation and lac-
tation.
   12. In order that this  function should be duly
established and sustained, the following condi-
tions are requisite : 1st.  A healthy development
ofthe female organs of generation ; 2d.  A cer-
tain degree of vigour or organic energy of these
organs ; 3d.  The absence of such lesions  as im-
pair the influence of the ovaries, or interrupt
the functions ofthe uterus ;  4th. A certain de-
gree of constitutional power.  Upon these the
healthy or regular state of the menstrual dis-
charge chiefly depends.
   13. The duration ofthe funetion of menstru-
ation is very generally thirty years, but more fre-
quently above than under this term.   The peri-
ods of commencement have been shown  above.
Those at which the function ceases have been
commonly stated at an earlier age than is gen-
erally observed in this country.   Menstruation
has been said to  cease at about the forty-fifth
year; but, judging from my own inquiries, I
believe that  the  period between forty-five and
fifty is the common period with healthy females.
In warm climates this function may cease be-
tween thirty-nine and forty-five years ;  but in
temperate climates it disappears more frequent-
ly after than before the forty-fifth year—at least
in England.   Mr. Roberton states, that  of
seventy-seven females, ten ceased to menstru-
ate at forty-eight years  ; seven at forty-nine ;
twenty-six at fifty ; two at fifty-one ; and seven
at fifty-two; the catamenia  thus  disappearing
in fifty-five out of seventy-seven, from the years
forty-eight to fifty-two inclusive.
   14. II. Management of the Menstrual Pe-
riod.—i.  During the  presence of the catamenia,
the female  frame betrays increased suscepti-
bility and excitability; and this period is usu-
ally viewed  by females  themselves as one of
greater delicacy and liability to be affected by
injurious agents  and mental emotions.   It is
of much importance to  obtain satisfactory in-
formation as to the regularity and  states  of this
evacuation in all cases in which the health and
disorders of females are concerned, and  there-
fore the inquiries of the physician  respecting
it should be  careful and  precise.—a. When the
female enjoys good health, and the discharge is
regular and natural in every respect, all  that is
required, during  its continuance,  is the  avoid-
ance of all influences, physical and  moral, which
may powerfully  affect  the  body and  mind.
These may  either suppress,  interrupt,  or in-
crease the discharge, and either contemporane-
ously or consecutively produce other very seri-
ous or even dangerous results.  Sudden frights,
fits of anger, and all powerful mental emotions
may have an injurious effect upon  this dis-
charge.  Blood-letting, emetics, purgatives, em-
menagogues, active diuretics, the  more power-
ful diffusive stimulants,  and  astringents ought
not to be resorted to at this period, as they may
morbidly increase the discharge, or even alto-
gether arrest it.  Cold  or warm bathing, hip
and foot baths should also be discontinued du-
ring this period, especially when  it is healthy
or natural.   Care ought  also to be taken  not to
expose the  feet  to wet  or cold ;   and  to avoid
sitting upon  stone, cold, or damp seats, or upon
the ground.  Excessive exertion of every kind;
long  walks,  long  rides  on horseback, or  on
rough roads, and prolonged dancing or stand-
ing ought also  to be avoided, as tending to
produce not merely an increased discharge, but
even  prolapsus  uteri, particularly in  married
females.   Females subject to leucorrhcea ought
not to have recourse to vaginal injections du-
ring or shortly before this period.  Dr. Lococx
remarks, that either "by accident or by criminal
impatience, sexual intercourse has sometimes
been  permitted  during  this period ;  and, al-
though not constantly, yet  such  conduct has
been  frequently  followed by the most serious
effects—generally by profuse haemorrhage ; at
other times by a sudden suppression of the dis-
charge ; to which  have succeeded fever, delir-
ium, obstinate hysteria, confirmed mania, and
even catalepsy."
  15.  ii. On the first appearance of the menstrual
period there is generally little farther required,
as respects the healthy young female,  than
great  care in  avoiding the  injurious physical
and moral influences now mentioned ; and even
when the second, third,  or  fourth periods for
the recurrence of the discharge are passed over,
but little may be necessary if no farther disor-
der be manifest.  If, however, the female be
delicate, or is much confined in-doors, or if the
bowels be  habitually costive, the preparations
of iron or of iodine, with emmenagogue purga-
tives, as aloes with myrrh, &c, may be ad-
ministered,  and  regular  exercise  in the open
air enjoined.  A smart walk should be taken
daily  before breakfast, and  be  repeated twice
in the course of the day.  Confinement  to close
or crowded apartments, and in close or crowd-
ed streets ; and, still more, numbers sleeping
in small, low,  damp, crowded, or ill-ventilated
rooms ; and deprivation of air  and exercise—
of the free use  of the limbs  in an  open and
healthy atmosphere, are the chief causes of the
disorders of menstruation in cities  and  large or
manufacturing towns.  To  these  causes  may
be added  want  of sufficient sleep, prolonged
mental attention and exertion, and whatever
tends  to  impede the  functions of respiration,
digestion,  assimilation, and muscular  action.
Hence all these  injurious agents  ought to be
especially avoided at the epoch of female pu-
berty.
  16.  iii. The period of Ike final cessation ofthe
menses is variable;  and even in healthy  females
the change may  be attended by phenomena re-
quiring discrimination on the part of the physi-
cian.   This period is also one which often ex-
cites the fears of females.  In a few cases, the
uterine functions acquire an increased  activity
shortly before their final cessation, so  that fe-
males who have not had children for years, or
who have been barren hitherto, have unexpect-
edly become pregnant.  More frequently, how-
ever,  females mistake the symptoms often at-
tending the cessation of the menses for those
of pregnancy.  The passing over  of the men-
strual period, swelling and pain ofthe  breasts,
the sickness and disorder of the stomach, and
capricious state  of the appetite, the increase in
size, and the movements occasioned by flatu-
lence  of the bowels often accompanying this
epoch, sometimes  induce a belief  in the mind
of even an experienced female that she is preg-
nant ; and her exact state can be determined 
MENSTRUATION, DI
only by an examination per vaginam, by time,
or by the exhibition of purgatives and carmin-
atives.
   17. Menstruation rarely ceases at once, when
the usual age at which it disappears is arrived
at, unless some accidental  circumstance,  as
fright, exposure to cold, an acute illness, &c,
occurs and occasions it.   More commonly, the
change is gradual, and is attended by irregular-
ities as to the intervals between the  periods,
the duration  of the period, and the abundance
or scantiness of the evacuation.  Sometimes
the discharge returns every two weeks, then
ceases for several weeks, or even months, and
afterward recurs for a few periods as regularly
as ever, and then altogether ceases.  Many fe-
males of delicate constitution, who have com-
plained much during'the earlier epochs of their
existence, or who, up  to the period of this
change, have been liable to hysterical and ner-
vous ailments, have subsequently enjoyed a
much better state of health, and lived long and
healthily, when this change  has been brought
about  carefully and fortunately.   During the
functional activity of the uterine organs, and
while these organs are highly susceptible of ir-
ritation, many of the disorders depending upon
irritation of  them are more  or less frequently
experienced; but  when these organs undergo
the change characterizing this epoch of life, the
susceptibility of irritation subsides, and gradu-
ally disappears; and, consequently, the  disor-
ders which thus originate are no longer felt.
   18. On the other hand, when disease already
exists in some organ, or even when a predis-
position to disease exists, the cessation of the
menses  generally aids  in aggravating the for-
mer, or in developing the  latter.   A disorder,
or even an organic lesion, which may have been
so  slight, or  so little advanced, as to escape
detection as long as the menstrual discharge
has continued, and has proved a periodical der-
ivation from  the affected organ, and a recur-
ring evacuation of the vascular system, will no
longer thus remain latent or continue station-
ary, but will  assume an active and rapid form.
The maladies  which most commonly become
thus developed are the various organic and ma-
lignant diseases of the uterus  and mamma ;
gout, apoplexy, and paralysis; organic diseas-
es of the liver ; dropsies ; structural changes
of the lungs  ; cutaneous eruptions ; ulcers of
the  lower extremities; haemorrhoidal  affec-
tions ; epilepsy, hysteria, and mental disorder,
&c.   In many cases, leucorrhcea occurs, and
continues long at this epoch, and powerfully
tends to  prevent  the vascular  fulness which
might  develop or  aggravate these or  other
diseases.   In some instances, haemorrhoids su-
pervene, and have the same  effect; and even
the appearanee of cutaneous eruptions, or ul-
cers on the extremities, exert some degree of
derivation from an organ disposed to serious
disease.
  19.  iv. The medical management of impending
disease at this epoch is of great importance, and
the earliest indications of disorder should  be
carefully watched  and duly estimated.   Signs
of vascular fulness, of local congestions, and
of oppression of any organ  ought to be met
with local depletions, which should be repeated
according to  the circumstances or urgency of
particular cases.  Vascular fulness or visceral
ELAYED—Diagnosis.                    963

oppletion or obstruction are the chief patholo-
gical conditions at this period  of life ; and al-
though local bleedings are necessary to remove
impending mischief, still, diet and regimen are
the means on which we should chiefly depend
for the permanent removal ofthe evil.   A reg-
ular state of the bowels ;  the occasional exhi-
bition of a mercurial to promote the biliary se-
cretion ;  a light,  farinaceous,  and vegetable
diet, or a very moderate  use of animal food;
and regular exercise in the open air, are means
which are applicable to all cases characterized
by vascular fulness or congestions.   When dis-
ease of some internal organ is actually present,
and when  the more acute or active state has
been subdued by vascular depletions and other
appropriate means, perpetual blisters, setons,
and issues will prove  of  service in removing
the  remaining irritation,  and in preventing a
recurrence of vascular determination to, or con-
gestion of, the affected organ.
  20.  In all cases, the treatment should mainly
depend upon the states of the vascular system,
in connexion with those of the chief viscera ;
nevertheless,  the  nervous manifestations re-
quire attention.  If the nervous system be mor-
bidly susceptible or sensitive, the vascular sys-
tem being neither too full nor oppressed, means
should be used to impart energy to it, and there-
by, as well as by other agents,  to remove this
condition.  If it be connected, as is sometimes
the  case, with a  deficiency of blood, or of
haematozine, the ferrugineous tonics should be
prescribed ; and if painful or convulsive disor-
ders be associated with this state of the vascu-
lar system, narcotics, anodynes, and antispas-
modics may be conjoined with these.   In most
cases of sudden  seizure  attended by convul-
sions— whether  epileptic or  hysterical — al-
though following the cessation  of the menses,
antispasmodics and anodynes constitute a prin-
cipal part of the treatment; and even local de-
pletions  should be  cautiously and sparingly em-
ployed, unless the signs of general or local ful-
ness  be  quite conclusive, and then they ought
to be resorted to in conjunction with the rem-
edies just mentioned.
III.  Absent, Suspended or Suppressed, and
  Vicarious Menstruation.—Synon. Amenor-
  rhea (from  a, priv.,  ptnvec, the menses, and
  beu, I  flow), Vogel, Cullen, Parr,  Young, Pi-
  nel, &c.  Emansio mensium,  retensio mensi-
  um, Auct.  Paramenia   obstructionis, Good.
  Ischomenia,  Swediaur.    Meneschesis,  Plouc-
  quet.  Defectus menstruorum,  suppressio men-
  sium,  Auct. var.  Manque des regies,  sup-
  pression de rigles, Fr.  Mangel des monalblut-
  fluss. Germ.  Suppressione dei menstrui, amc-
  norea,  Ital.  Obstruction.
     Classif.—IV. Class,  V. Order  (Cullen).
       V. Class, I. Order (Good).   I. Class,
       II. Order (Author).
  21.  Defin.—Absence of the  menstrual dis-
charge at the period of life when it is usually reg-
ularly established, or the suspension  or suppres-
sion of it after it had recurred regularly for some
time.
  22.  This subject may be considered under
three distinct heads: 1st. Absence and reten-
tion of the menses; 2d.  Suppression  of the
menses ; and, 3d.  The complication or associ-
ation of either of these with some other disor-
der or malady. 
964
MENSTRUATION,  DELAYED—Diagnosis.
 i. Absent and Retained Menses. — Synon.
   Emansio mensium; retentio mensium ; delayed
   menstruation ; retained menses; obstructed men-
   struation.
   23.  Defin.—A delay in the first appearance of
 the menses, owing to functional disorder or to or-
 ganic change.
   24. The menstrual discharge may be delayed
 or absent, owing to functional inactivity or dis-
 order ; or it may be obstructed or retained by or-
 ganic  change.   Hence,  amenorrhcea presents
 two forms, the distinction between which should
 be preserved; the  one being simple  and func-
 tional, the other structural and obstructive.
   25.  A. Simple or Functional Amenorrhcea.
 —Emansio Mensium; Delayed Menstruation.—
 The differences in the age at which menstrua-
 tion commences have  already  been  noticed.
 In some of those instances in which it has not
 appeared  until three or four or more years after
 the usual period, in which it has been delayed
 merely, the amenorrhcea being simple, or un-
 complicated with organic change or mechani-
 cal obstruction, it will be found that the retard-
 ation has occurred in one  or other of the fol-
 lowing states: a. The development and action
 of the uterine system are not correlative with
 the growth and health of the  body.—b. The
 development of both the uterine organs and the
 whole  frame is apparently natural.—c. The ute-
 rine functions are insufficient to produce  a col-
 oured discharge, uterine leucorrhcea being sub-
 stituted.—a. Some ofthe cases of simple amen-
 orrhcea are actually instances of protracted
 puberty, the whole  frame betraying  imperfect
 growth ; but care should be taken to ascertain
 the nature ofthe case, and the absence or pres-
 ence  of malformation or  obstruction of the
 kind about to  be noticed (y 39).  Siebold and
 Churchill distinguish two principal conditions
 ofthe system in this form of amenorrhcea, viz.,
 a plethoric state conjoined with rigidity of fibre
 and robust health ; and somewhat of deficiency
 of blood, or laxity of fibre, associated with pal-
 lor, and a weak or delicate  constitution.  In
 both, an apparent attempt at menstruation oc-
 curs occasionally, or even monthly, and is  char-
 acterized  by pains in the back  and  loins; by
 weight in  the  lower part of the abdomen ; by
 aching in  the tops of the thighs,  with lassitude
 and uneasiness; and  sometimes by constric-
 tion  about the thyroid  gland.   After  two or
 three days these symptoms cease, without any
 menstrual evacuation, or merely with leucor-
 rhceal  discharge, and are  often  succeeded by
 severe headaches, with intolerance of light and
 sound.  In the more plethoric cases these suf-
 ferings are severe, and occur occasionally be-
 tween  the efforts at menstruation, and are at-
 tended by flushings and throbbings of the face
 and head ; quick, full pulse, thirst, and gener-
 al febrile  action.   In the  pale  and  delicate,
 there  is little  or no fever,  and the symptoms
 are slighter and more chronic.   As these dis-
orders  continue or occur, the functions of the
 digestive organs languish ; the bowels become
irregular ; the  countenance pale ; the strength
reduced;  and   the breathing  short;  and the
general health  gradually declines.   Various
hysterical symptoms, or even severe hysterical
paroxysms, particularly in the more plethoric
cases, occasionally appear ;  and severe attacks
of disease of vital organs are apt to occur, from
 the influence even of their less energetic  ex-
 citing causes.  Naii-he met with two instances
 of fatal disease  of the brain  in  this state of
 menstrual obstruction.   I have seen a similar
 instance,  attended  by  epileptic  convulsions,
 and terminating in  fatal coma ;  also cases  of
 pneumonia, and of congestion  of the lungs, in
 similar circumstances ; but most frequently,
 particularly in the more delicate class of cases,
 this form of amenorrhcea  assumes  the com-
 plicated state about to  be noticed, and the pa-
 tient passes into chlorosis or into tubercular
 consumption ;  or becomes  first chlorotic, and
 subsequently  consumptive.  In  a few  cases,
 however, diarrhoea or some discharge occurs
 and protects for a time the patient  from the
 more dangerous  consequences of the obstruc-
 tion ; or some evacuation takes place, from time
 to time, which proves vicarious ofthe menses,
 as will be noticed in the sequel.
   26.  Dr. Churchill states  that he has re-
 peatedly examined the uterus of patients  la-
 bouring under amenorrhcea; the cervix  uteri
 has generally  been small,  and more pointed
 than usual during the interval; but in all these
 cases  a small-sized bougie could be introduced
 into the cavity without  pain or difficulty.  Du-
 ring the abortive efforts at menstrual discharge
 an  enlargement of the cervix takes place, par-
 ticularly in those cases which  are attended  at
 this period with some leucorrhceal discharge.
  27. b. The diagnosis of simple  amenorrhcea
 has reference chiefly to its simple or uncom-
 plicated  state.  1st. To the absence of  mal-
 formation and mechanical obstruction.  2d. To
 the existence  of some other disorder or mala-
 dy, which  may have preceded or caused this
 condition, or which  may be complicated  with
 it.   If there be periodical exacerbations (which
 do  not always attend simple amenorrhcea, but
 generally  that caused by mechanical obstruc-
 tion), an  examination will  readily detect the
 existence  of  an  obstructive  cause.   When
 these exacerbations are evinced, and no local
 impediment exists, the  form of the disorder
 now being discussed may be inferred to exist;
 and this inference will be confirmed if tbey be
 attended by a colourless discharge, or leucor-
 rhcea.
  28. c. The prognosis of this form of amenor-
 rhcea should be stated with caution or reserva-
 tion in respect of the ultimate result, particu-
 larly where it  is unattended by periodic efforts
 (y 25), or leucorrhceal discharge during these
 efforts. The  more  immediate consequences
 are those complications  presented by the disor-
 der as it becomes prolonged ; as chlorosis and
 disorder of the general health ; continued leu-
 corrhcea ;  sterility, at least during this state of
 the uterine organs; tubercular consumption, va-
 rious nervous ailments, anaemia, scrofulous dis-
 eases of the glands or joints, organic lesions of
 the heart,  epilepsy, hysteria, &c.  The more
 acute, but rarer consequences, of simple amen-
 orrhcea, are inflammations  of, or effusions on,
the brain  and  its membranes ; haemorrhagic
attacks;  inflammations  or  congestions  of the
lungs, &c, as  noticed above (y 25).
  29. d. The causes of amenorrhcea have been
generally considered to  be  indolence and sed^
entary lives ; gross diet, luxurious habits, hot
rooms, soft beds,  and too much sleep : causes
which  may have  some influence  in producing 
MENSTRUATION, DELAYED—Treatment.             -       965
 the complaint in some constitutions, but which
 are often less influential than others that have
 been entirely overlooked, more especially sleep-
 ing in close and crowded rooms ;  want of ex-
 ercise in the open air; constant mental exer-
 tion and occupation at the period of approach-
 ing puberty, to the neglect of the physical aids
 of bodily development; early masturbation, and
 all over-exciting and debilitating and exhaust-
 ing influences; the vicious system of modern
 and fashionable education ; the occupations  of
 the poorer classes during the period of puberty,
 especially employments in warm, ill-ventilated,
 and crowded rooms and factories ;  insufficient
 sleep, prolonged exertion and attention, before
 and during the period of commencing menstru-
 ation ;  residence in  cold,  damp, and malarial
 localities, or low cellars; prolonged  exposure
 to cold, and  insufficient clothing ; nostalgia and
 depressing mental emotions.
   30.  e. The  pathological  conditions to  which
 amenorrhcea has been  attributed are  chiefly
 theoretical—entities of  the imagination, such
 as spasm of the extreme vessels ; torpor of the
 vessels; engorgements of  the vessels,  &c.
 The true condition is most probably an imper-
 fect development, or impaired energy, or  both
 states conjoined, of the uterine organs [espe-
 cially the ovaries], arising from causes which
 impair or exhaust the  organic  nervous ener-
 gies during the progress of growth, or from
 circumstances which determine these energies
 to the brain.  Those causes of simple amenor-
 rhcea which  are characterized by vascular pleth-
 ora furnish no argument against this view ; as
 this state of the vascular system may exist  in
 connexion with inactivity ofthe uterine organs.*
   31. /. Treatment.—It  is obvious that the
 management of amenorrhcea should  be based
 upon the pathological condition of particular
 cases as far as it is manifested, and be directed
 with reference to the  abortive efforts which
 may periodically occur.  If the  obstruction be
 attended by general vascular fulness and ro-
 bust health, local or even general bleeding, but
 chiefly  the  former, may be prescribed ;  and
 preferably at the commencement of, or a day or
 two before the periodic effort, or recurrence of
 the leucorrhceal discharge accompanying it. In
 London and large towns, local bleeding only  is
 required, general blood-letting almost never, or
 only when the complexion  is florid, the habit
 plethoric, and the fibre rigid.  It has been  rec-
 ommended, particularly by obstetric writers, to
 apply leeches to the  vulva in these cases, and
 to take blood by cupping on the loins.   Gener-
 ally, however,  the application of leeches to the

  * [M. Colombat has arranged the causes of primitive
 constitutional amenorrhea under two heads, predisponent
 and occasional; the former including, 1st. The sanguine
 temperament, which is manifested by a plethoric condition,
 and by excessive fulness of the vessels, determining  local
 congestions in  different organs; and, 2d. The lymphatic
 temperament, characterized by a condition of general debil-
 ity, and by a want of activity in the circulatory system.
 Several of the causes of amenorrhcea alleged by our author
 are, perhaps, more often the occasion of menorrhagia than
 retention of the  menstrual flow.  We shall generally be able
 to trace this accident to some defect in the primitive consti-
 tution of  the female ; or, in its absence, to debilitating in-
 fluences, as insufficient nourishment, want of exercise in
 the open  air, abuse of sanguine evacuations, leucorrhcea,
 and other causes which impoverish the blood, the depress-
 ing passions, <fec.  If a state of plethora lead to the same
 result, it may be, as M Colombat has suggested, that the
blood, too rich in fibrin, opposes the periodical exhalation
which constitutes uiensli nation.J
 insides and tops of the thighs, just below the
 groins, is to be preferred, both as being more
 agreeable to young females  than  the  other
 modes, and  as being equally  efficacious.  In-
 deed, cupping on the loins is not to be confided
 in for simple amenorrhcea; and it may even be
 injurious, although prescribed for inflammatory
 states of the uterine organs.   I have seen it
 cause suppression of the menses  when  thus
 employed.
   32. Next to local blood-letting, in the more
 plethoric  cases, active purging by means of cal~
 omel, aloes, extract of colocynth, &e, with as-
 afcetida, myrrh, &c, is the most efficient rem-
 edy, particularly when  persisted in for  some
 days before, and even during  the  periodic ef-
 forts.   In the intervals between these, the em-
 menagogue purgatives may be  given with the
 stimulating emmenagogues,  or with the bibo-
 rate of soda; and the patient should live part-
 ly, or chiefly, on fish and shell-fish, take regu-
 lar and active exercise in the open air, and
 use  the hip bath, especially  at the periods ad-
 verted to.  Having removed vascular fulness by
 these means, and the catamenia not yet appear-
 ing, the treatment may be conducted in many
 respects  as may be  appropriately  directed for
 cases characterized by delicacy of constitution,
 or impaired organic  nervous  energy, connected
 with deficiency of blood, or of haematozine.
   33. For this latter class of patients, the cha-
 lybeate preparations,  particularly the compound
 steel mixture (Griffith's) ;  the tinctura  ferri
 sesqui-chloridi, or the vinum ferri  with tinctu-
 ra lyttae ; the carbonate of iron, in the form  of
 electuary, with confection  of scammony and
 confection of black pepper; the compound steel
 pill with the aloes and myrrh pill; the iodide of
 iron ; the tincture of iodine, or the iodide of po-
 tassium with tonics; chalybeate mineral wa-
 ters ; the tinctura lyttae, or  tincture of capsi-
 cum with tonic infusions ; or pills consisting of
 ox-gall, asafcetida, myrrh, and capsicum, will
 severally  be  employed  with frequent, although
 not with constant advantage.   Dr.  Locock rec-
 ommends pills consisting of myrrh, aloes, sul-
 phate of iron, and oil of savin, a combination
 often prescribed by the celebrated Dr. Gregory.
   34. Dr. Bardsley  prescribed strychnine, conw
 mencing with doses of one twelfth to one fourth
 of a grain, twice or thrice a day, that may be
 slightly increased after a time, or given some-
 what more frequently.  Headache  or twitch-
 ings of the muscles require the suspension of
 it.  Nauche also employed it successfully, but
 gave it  in larger doses.  The cases, however,
 in which  it was most beneficial were those of
 suppression of the menses.  I have preferred
 the extract of nux vomica in combination with
 aloes, commencing with half a grain of the for-
 mer, twice or thrice daily.  It manifestly acts,
 as Dr. Bardsley contends, by  stimulating the
 uterine organs and improving the tone and vig-
 our of the system.   Aconite has been likewise
 tried, and apparently with advantage, by some
 German and French physicians.  I have pre-
 scribed  the alcoholic extract of aconite  with
 decided benefit.   Besides these, various othei
 remedies have been recommended, particularly
the balsams  and  turpentines, melampodium,
savin, cantharides, asafcetida, conium, the ergot
of rye, &c.  This last has been favourably no-
ticed by Dewees, Locock, Roche, Nauche, and 
966
MENSTRUATION,  OBSTRUCTED—Pathologt.
 Pauly.  During  the  use of these  medieines,
 and particularly of the chalybeate preparations,
 a full dose of calomel with aloes should be giv-
 en once in the week at bedtime, and be follow-
 ed by the compound decoction  and  tincture of
 aloes in the morning.   The ammoniated tincture
 of guaiacum has been much  used for this com-
 plaint, and has been very favourably noticed by
 Dr Hannay and others.
   35. Various stimulating enemata  have been
 advised, particularly those with spirits of tur-
 pentine, asafetida, aloes, rue, savin (see F. 130,
 131, 134,  135, 141, 150).  Dr.  Shonlein pre-
 scribes an enema with aloes to be thrown up at
 the period when the  effort at  menstruation
 takes place.  At that time, two or even more of
 the above  substances may be  employed with
 advantage, as proved by some cases in my own
 practice.
  36. The local excitement ofthe uterine organs
 by means of medicated bougies and injections
 was recommended by the ancients  and by the
 older writers, and has been advised by  some
 modern authors.   Lavagna  prescribed a few
 drops of the liquor ammoniae  in an ounce or
 two of milk to be thrown into the vagina, and
 several physicians have tried this practice. Dr.
 Blundell has noticed it favourably.  The in-
jection of a few  drops of eau  de Cologne in
 warm milk was  a  domestic practice in  this
 complaint in some parts of the Continent.  The
 safety of the practice entirely depends upon the
 particular circumstances ofthe case  in which it
 is resorted to.  There can be no doubt of the
 practice being hazardous, if it be not cautious-
 ly employed ; inflammation not  only ofthe va-
 gina, but ofthe uterus also, being likely to fol-
 low the use of a too strong injection.
  37. It has been attempted  to excite the ute-
rine organs  sympathetically  by irritating the
mamma.  Dr. Loudon applied  leeches to the
mammae with this view.  Siebold recommends
warm fomentations ;  Sir James Murray, ex-
hausting glasses ;  and several writers, blisters,
stimulating  plasters,  sinapisms,  &c, to the
breasts, with the  same intention. I have pre-
scribed blisters, sinapisms, and issues to the in-
sides and tops of the thighs ; frictions to the
loins and  back, with  stimulating and rubefa-
cient liniments ; and embrocations of a similar
nature applied more  constantly in  the  same
situations with marked advantage.  Electricity
and galvanism, directed across the uterine or-
gans, have  been advised  by Thomann, Alber-
ti, Birch, Capuron, Ritter, Marcus, Aldini,
Nauche, Siebold, and many others.  The hip
bath, or mustard hip bath, and mustard pediluvia,
are generally of service about the accession of
the periodic efforts at menstruation.  If these
efforts  are attended by leucorrhcea, the  treat-
ment  does not require any material change
from that above advised ; but if the  colourless
discharge  continues  or appears in  the  inter-
vals, it then becomes  an important complica-
tion, which will be noticed hereafter.   Of other
means which have been tried in this  form of
obstruction, notice will be taken  in the sequel,
as being equally appropriate to suppression, as
to absence, retardation, or  deficiency of the
menses.
  38. The diet and regimen should have strict
reference  to  the  pathological  states  of  each
case.  In the plethoric, the diet should be spare,
 and consist chiefly of salt-water fish and ve-
 getables.   In the delicate, weak, and chlorotic,
 the diet ought to  be  nutritious, digestible, and
 sufficient in quantity to supply the deficiencies
 in the  blood  and frame  generally,  new eggs,
 mutton, game, and wine being allowed.  Reg-
 ular exercise on foot or on horseback, and the
 more active amusements  and exercises, should
 also be indulged in, especially in the open air.
   39. B. Amenorrhcea from  Congenital Mal-
 formation and Organic  Lesion. — Obstructed
 Menstruation;  Retained Menses.—The follow-
 ing malformations and organic lesions may oc-
 casion  amenorrhcea : 1st. The ovaria may be
 wanting or diseased.  2d. The uterus may be
 absent.  3d. Both the ovaria and uterus may
 be wanting.  4th.  These organs being present,
 the canal of the cervix uteri may be nearly or
 altogether obliterated.  5th. A false membrane
 may cover the  os  uteri.  6th. The vagina may
 be wanting.  7th. The vagina may have had
 its canal  obliterated,  or the  orifice  closed by
 adhesion of the lower portion and labia.  8th.
 The hymen may be imperforate.  The most of
 these lesions  are  congenital; others are the
 consequences of disease previous to foil puberty.
  40. a. Of the congenital lesions some affect
 the character and development of the whole
 frame:  others  have  no such effect.—a. Defi-
 ciency of the ovaria is attended by a  more or
 less masculine  development of the body at and
 after the period of puberty.  The mammae and
 external genitals are  not fully developed  ; the
 sexual propensities are not  manifested; the
 voice is harsher and deeper than usual; and a
 beard is observed on the upper lip. The gener-
 al health may not be affected.
  41. b. Absence or malformation of the uterus
 has been  noticed by Sibbold, Lauth, Andral,
 Chaussier, Stein,  and others.   If the ovaria
 exist  in cases  of  absence of the uterus, the
general development  of the  body may not be
affected ;  but if they  be also  wanting, in  addi-
 tion to the masculine  character, or mixture of
 masculine with feminine peculiarities, the va-
gina, on examination, will be found  to termi-
nate in a  cul de sac, the  cervix and os  uteri
 will not be detected, or not be developed, and
the uterus will not be  felt from the rectum.  In
these cases, also,  the general  health may be
little affected.
  42. c. When  the  vagina is wanting, both the
ovaria  and the  uterus being present, the  men-
strual secretion may  take place, its  exit only
being prevented,  producing  distention, some-
times to  an  alarming extent,  of the uterus.
The fulness in the hypogastrium is augmented
at monthly periods, and the  general health is
 very much affected.   The  outward signs of fe-
 male puberty are present; but the vulva or ex-
ternal parts present no vaginal canal, or mere-
ly a commencement of it.   In these cases, the
 patient  loses her  complexion, becomes  pale,
 delicate, and thin.   She complains of pains in
the back,  loins, and hips ;  of distention of the
hypogastrium, and of a sense of weight and
bearing down.   These symptoms are increased
every month.   The abdomen  increases in size,
and the density of the swelling is shown by
percussion.  The distention ofthe uterus may
proceed to rupture of its  parietes and to the
escape of the contents into the peritoneum, fol-
lowed by rapidly fatal peritonitis;  but more fre- 
MENSTRUATION, OBSTRUCTED—Treatment.
967
 quently death takes place from the general dis-
 order, with  prominent affection of some vital
 organ, before rupture takes places.
   43. <L Imperforate hymen may be attended by
 many of the symptoms accompanying the early
 Stages of absence of the vagina ;  but even if*
 the cause of disorder be not attended to, the
 distention of the vagina may rupture the hy-
 men before  fatal injury  be produced.   In  this
 case, as well as in the others, careful  exami-
 nations, which  ought always to be made,  will
 show the nature of the mischief, and the mode
 of its removal.
   44. ft. The organic lesions occasioning amenor-
 rhea are as  follows :  a. Disease of the Ovaries.
 —Dr. Churchill states,  that Dr. Montgomery
 met with a  case of a female with an  obscure
 abdominal affection, who had  menstruated for
 a time, and  amenorrhcea  occurred.   On  ex-
 amination after death, it was found that there
 was  only one ovarium, and that  one  had be-
 come completely disorganized.   A delicate fe-
 male was attended by several  practitioners in
 succession, and, lastly, by Dr.  Farre and  the
 author.   Puberty was imperfectly  developed,
 and the menses had  not  appeared at the usual
 term.  She  subsequently died of acute febrile
 phthisis.  The  uterus was found  extremely
 small, and the ovaria remarkably atrophied, and
 converted into a dense fibro-eartilaginous sub-
 stance.  The inspection  was made in my pres-
 ence by two gentlemen who had attended  my
 lectures at the  Middlesex Hospital.
   [Dr. Pott has given the  history of a case in
 which both ovaries were removed, and in con-
 sequence of the operation menstruation  en-
 tirely disappeared, although previously to  the
 extirpation puberty existed; and the function
 had been well  performed.  Dr. Ashwell also
 describes a case (in  Diseases of Females, p. 49,
 Am.  ed.) of complete scirrus ofthe ovaries, at-
 tended by a  similar result.]
   45. b. The canal of the cervix uteri  may have
 become impervious, or the os  uteri may be covered
 by a false membrane.  Cases of this kind are not
 so rare as was  formerly  supposed.  These le-
 sions, however, are more  frequently a cause
 of suppression than of retention or primary ab-
 sence of the  menses.  Instances illustrative of
 these have  been furnished by Rathieu, Dus-
 saussoy, Osiander, and Storr  ; but their  im-
 portance, from  their frequency, was especially
 insisted upon by Dr. Mackintosh. They are usu-
 ally the consequences of inflammation, which
 also may occasion accretion ofthe sides of the
 vagina,- and obliteration of the canal.   Indeed,
 cases  of congenital  obliteration of the  canal
 may have arisen from the same cause during,
 or  soon after fcetal existence.  It  is obvious
 that, in those circumstances, the symptoms of
 the accumulation ofthe menstrual secretion in
 the cavity of the uterus will be much the same
 as those accompanying absence of the vagina
 (v 42), but they  may not  become  so extreme,
 as an attentive  examination will show the  na-
 ture of these cases, and a carefully conducted
 operation may remove the  cause before they
 become urgent or dangerous.*______________
  * [Dr. G. S. Bedford, of New-York, has given us the
history of a very interesting case of retention of the menses
from a closure ofthe cervix uteri (A Pract. Treat, on Mid-
wifery, by M. Chailly, Am. ed.  New-York, 1844),  in a
young married woman, 27 years of age, and who had never
menstruated. In this case there was an indistinct and cir-
    II.
   46.  The labia or lower part of the vagina, or
 both, may have become adherent at any period be-
 fore puberty, but most frequently  before  nine
 or ten  years of age.  This lesion may follow
 inflammation ofthe vulva, or vagina, occurring
 either primarily or as a simple disease, or as a
 complication or consequence of exanthematous
 or other  fevers.   In these circumstances the
 menstrual discharge may burst the obstruction,
 but much more frequently its  accumulation is
 attended by  similar phenomena to those which
 arise from   retention  caused  by  imperforate
 vagina  or imperforate hymen ($ 42, 43).
   47. y. The prognosis and termination of this
 form of amenorrhea entirely depend upon the
 evidence furnished as to the nature of  the mal-
 formation or organic  lesion.   When  there  is
 reason  to infer the absence of  the ovaria or
 uterus,  or both, no immediate  risk of  life may
 be dreaded, although pectoral or other disease
 is  apt to supervene and  carry off the patient.
 If, however,  these organs are  present, and the
 discharge accumulates in the uterus, the result
 will entirely  depend upon the nature of the ob-
 struction, and the possibility of removing it be-
 fore the general  health suffers  so  severely as
 to  prevent  recovery.  All these cases, how-
 ever, are attended by various  contingencies,
 even after the immediate cause of obstruction
 is removed,  that forbid  a confident, or other
 than a  cautious prognosis ; and these contin-
 gencies relate not only to the state and liability
 to disorder ofthe sexual organs, but also to the
 condition and predisposition to disease in the
 lungs and other organs.
   48. 6*. Treatment.—It is obvious that where
 the uterus and ovaria are malformed  and dis-
 organized, [or congenitally absent,] no means
 can be of service.  But where  the  obstruction
 is seated in  the canal of the cervix, in  the os
 uteri, in  the vagina,  or  vulva, well-devised
 methods may remove  it.  Even when  it  is
 caused by congenital absence of the vagina, the
 case may be highly dangerous ; but it  is not
 hopeless, as shown by one in which M. Amussat
 (GazetteMedicale, Dee, 1835) operated.  He suc-
 ceeded in making a passage through the cellu-
 lar tissue interposed between the urethra and
 rectum, until he reached the tumour in the pel-
 vis formed by the distended uterus, and punc-
 tured it; he  afterward established an artificial
 vagina  and   os uteri, and ultimately restored
 the patient to health.
  49. When  the obstruction consists of occlu-
 sion of the cervix uteri, or os uteri, from either
 of the changes noticed  above (§ 45), an artifi-
 cial opening should be made by a trocar, or by
 a similar  instrument  to  that employed by Mr.
 Stafford for dividing strictures of the urethra.
 If the membrane covering the os uteri  be thin,
 or internal to the orifice, it may be punctured
by a strong  probe.  When the vagina  cannot
be  perforated, as in M. Amussat's  case,  the
 uterus may be punctured from the rectum, and

cumscribed fluctuation in the anterior portion of the abdo-
men, extending  about one inch above the umbilicus: on
introducing the  finger into the vagina, the  os tinea? was
found wanting, the lower and central portion of the cervix
being quite smooth and uniform on its surface.  By means
uf a speculum the cervix uteri was brought into  /iew, and
penetrated by a trocar at its lower and central portion, when
about three pints of blood were discharged from the uterin*
cavity. Pregnancy followed in a short time afterward, and
in due time she  wis delivered of » healthy child. Similar
cases are also mentioned in some of our medical journals.] 
963
MENSTRUATION, SUPPRESSED—Pathology of.
its  contents  evacuated.   In cases  requiring
these operations, both external and internal
means should be used to prevent or remove in-
flammatory action, as fomentations,  poultices,
laxatives, anodynes, and refrigerants.
  50. If the vagina or labia have become uni-
ted, the adhesion may be  ruptured by forcible
separation ; but if this be  insufficient, such an
operation as the case may suggest should be
attempted.  Where the hymen  is imperforate,
the difficulty is much less, and is readily re-
moved.
  51. When the menstrual discharge is accu-
mulated  in the uterus, and has only been ob-
structed mechanically, the removal of the ob-
struction is followed by the escape of a dark,
thick, treacle-like fluid, which continues to run
for some days as the uterus slowly contracts.
Dr. Churchill recommends the vagina to be
syringed in these cases with warm water, and
a broad binder to be applied around the abdo-
men.   Care should be taken to preserve the
passage open,  and to promote  the evacuation
at the usual periods, until it is regularly estab-
lished.   Exercise in  the  open  air,  a regular
state of the bowels, chalybeate  medicines, and
the  usual means of promoting the general
health, are the most appropriate to these cases.
   52. In some cases, where the menstrual se-
cretion has been accumulating in the uterus or
vagina, or in both, the absorption of the more
watery parts has left the accumulated matter
not only thick, but grumous and gritty ; and the
internal surface  of these organs has become
inflamed and ulcerated, and their parietes thick-
ened ; very serious, difficult, and chronic  dis-
ease of the uterus and its appendages thus be-
coming disclosed by,  and  following, the  remo-
val of the accumulated matter.
ii. Suppression of the Menses. — Suppressio
   mensium ; Amenorrhea suppressa ; Suppressed
   menstruation.
   53. Defin.—Disappearance of the menses, af-
ter having been established for a  longer or  shorter
period, independently of pregnancy or of their ulti-
mate cessation.
   54. Suppression  of the  menses  may take
place suddenly or gradually.  It may occur du-
 ring the period of menstruation ; or the dis-
 charge may not appear either at or after the
 usual period.  It may disappear gradually, each
 successive discharge being either more scanty
 or longer deferred.   Thus, the suppression may
 be acute or chronic, although  cases will  often
 occur to which the one term may be as applica-
 ble as the other.
   55. A. Acute suppression of the menses is gen-
 erally caused  by exposure to  cold,  or  by wet
 feet, bodily shock, or by violent mental emo-
 tions either just previous to or during the men-
 strual discharge.   The  depressing passions,
 anxiety, insufficient clothing, and want  or mis-
 ery may also produce  it.  Fevers, and  acute
 diseases occurring shortly before the  period,
 and sexual intercourse during it, will often have
 the same effect.
   56. The phenomena or consequences of sud-
 den suppression vary with the habit of body
 and temperament of the patient.   In plethoric
 and robust females, fever, hot skin, headache,
 full, or hard, or bounding pulse, &c, are pro-
 duced ; and,  not infrequently, most severe at-
 tacks of disease, according to the predisposition
of the different organs, are the results.  Haem-
orrhages,  inflammations,  apoplexy,  epilepsy,
palsy, leucorrhcea, &c, are  often  thus  occa-
sioned.   Females  of a less plethoric habit of
body, or of the nervous temperament, are lia-
ble to be seized with hysterical convulsions or
spasms ;  or with hysterical affections of vari-
ous  kinds, these latter often changing  their
seats and forms, with neuralgic pains in differ-
ent situations; with syncope, or with palpita-
tions ;  with aphonia, or with nervous cough;
with vertigo, or with headaches; with nausea
or vomiting ; with pains in the back, sides, or
abdomen ;  with retention of urine, or with par-
tial palsy or paraplegia ; or with any ofthe af-
fections  mentioned  in the articles  Hysteria
and Neuralgia.
  57. B. Chronic suppression of the menses is
commonly a  consequence of the acute,  or of
general debility of health.   It may also proceed
from disease of the ovaria or uterus ; or from
the gradual development of organic change in
some remote or vital organ, as the lungs, liver,
stomach, head, or kidneys.  This form of sup-
pression may be gradual as to quantity, or the
discharge may become pale  by  degrees, or it
may appear after  longer intervals, being also
more scanty until it ceases  altogether; or it
may be variously  irregular  and  uncertain, or
painful, or  difficult, and  then disappear.  In
some instances it ceases, and leucorrhcea takes
its  place.  It may even alternate with leucor-
rhcea.   It may follow low, typhoid, or adynam-
ic fevers, or other diseases which diminish the
quantity or impair the  quality of the blood, or
in which large quantities  of blood have  been
lost.  I have met with many cases in which it
continued long after recovery from continued fe-
vers, the evacuation having been regular up to
nearly the attack of fever, but not returning un-
til many months after recovery from it.
   58. The attendant and  consequent phenom-
ena of chronic catamenial suppression are, im-
pairment of the general health, disorders ofthe
digestive organs, diseases of the lungs, cutane-
ous eruptions ; various nervous, or  hysterical,
or  painful affections ;  chlorosis  or anaemia;
partial attacks of palsy, curvatures ofthe spine;
obstinate constipation and faecal accumulations
in the large  bowels, disorders of the excretion
of  urine, &c.
   59.  C. The  diagnosis of suppressed catame-
 nia is of much importance.  It is necessary to
 ascertain, 1st, whether or not  the patient be
 pregnant; and, 2d,  if  the patient be not preg-
 nant, whether or not the  affections or diseases
 associated with the suppression be the  causes
 or the consequences of it.
   60. a. Pregnancy cannot be inferred to be the
 cause when the suppression takes place sud-
 denly, or from any of the more energetic causes
 producing it, during the period of the discharge.
 The arrest  of menstruation by conception is
 generally unattended by other unpleasant symp-
 toms, but it is commonly followed by morning
 sickness, by alteration of the  volume  of the
 breasts, and of the sebaceous glands and colour
 of the areolae.  The difficulty of distinguishing
 between pregnancy and morbid  suppression of
 the menses occurs chiefly in unmarried females,
 but only  during  the earlier months of utero-
 gestation; and even  during these  months, an
 examination of the mammae, of the abdomen, 
MENSTRUATION, SUPPRESSED—Prognosis—Treatment.            969
and per vaginam, will disclose  the  nature of
the case.   Instances, however,  may occur of
pregnancy with  a perjodic coloured discharge
from the vagina ; and this may be as abundant
during two, three, or more  periods as usually
experienced by  the  patient.  In these cases,
the evacuation generally possesses  a haemor-
rhagic character, and either proceeds only from
the os or cervix uteri, or from a minute separa-
tion of that portion ofthe ovum near the cervix.
  61.  b. In most cases of acute disease appear-
ing in connexion with acute suppression of the
catamenia there will be  no  difficulty in deter-
mining the exact relation in  which the one may
stand to the other ; but,  in cases of chronic or
organic diseases occurring in connexion  with
chronic suppression, it is often difficult to infer
whether the former or the latter has preceded
the other.  Most frequently, however, and par-
ticularly as respects pulmonary disease, the
suppression is the consequence of such disease,
although various concurring causes may assist,
particularly if it have taken  place somewhat
suddenly.  Still, disease ofthe lungs, or ofthe
brain, or of any organ,  may follow  suppressed
menses, according to the predisposition of these
organs, at periods more or less remote  from
the suppression.
   62. The affections themselves, which appear
consequently upon suppression of the menses,
require to be distinguished from each  other,
especially those which  are  truly inflammatory
from  those which are nervous or spasmodic, or
consist chiefly of altered sensibility.  What I
have  stated in the articles Hysteria and Neu-
ralgia will assist the diagnosis ; and generally
it will be found that, when the disease is in-
flammatory, the local and constitutional  symp-
toms nearly correspond with each  other, and
with  the state of the  organic  functions ; but
when the affection is  nervous, although the
pain  and distress may equal, or even exceed
that caused by inflammation, the constitutional
disorder will be slight, the pulse and the  organ-
ic functions being but little disturbed.
   63. D. Prognosis. — The opinion as to the
consequences and ultimate results of suppres-
 sion ofthe menses will necessarily depend upon
the nature of the causes, physical and patholo-
 gical, which have occasioned it, and upon the ef-
 fects of the suppression in those organs which
most frequently sympathize with the genital or-
gans, more especially the lungs, brain, and vas-
 cular system.   The prognosis, therefore, de-
 pends chiefly upon the  antecedent disorder  or
consequent malady  which may present  itself;
 the suppression, however, being a circumstance
 rendering  an opinion of these still more unfa-
vourable than it might otherwise be ; although,
 in itself, and devoid of  all complication,  it may
 be only a passing or contingent  disorder, which
 nature alone may remove, or  which  a judicious
exercise of art may assist her in overcoming.
   64. E. Treatment.—a. The  acute form  of sup-
pression of the menses may  be inferred, from
what has been stated above, to be more amena-
 ble to treatment than the chronic.  The  means
usually employed to recall the discharge  are
more  especially indicated  for  it ;   but  these
should be  selected with reference not only to
the cause of suppression, but also to the ante-
cedent  state of health,  and the associated  or
consequent disorders.   In many cases, the hip
    II.              122
bath, warm mustard pediluvia, and warm drinks
upon getting into bed, if employed immediately
upon  the  occurrence of suppression, will  re-
move it.  If fever, or local inflammations, or
congestions follow,  bleeding,  especially  by
leeches applied  below the groins;  the  more
emmenagogue purgatives, particularly calomel
with aloes, &e,  the spirits of turpentine in  en-
emata, and diaphoretics with diuretics, are  re-
quisite.  If the suppression be  followed by se-
vere cerebral  symptoms, as phrenitis,  coma,
apoplexy, epilepsy, &c, as occasionally observ-
ed, the derivative bleeding should be carried as
far as the circumstances of the case will sug-
gest, and be aided by other derivative means,
and by cold  applications  to  the head, &c.  In
other and less urgent cases purgatives  should
be prescribed, so as to excite,  and determine
the circulation to, the pelvic viscera, without
producing copious  discharges, which, if produ-
ced, may be injurious by deriving the current
of circulation from the uterine organs.
  65.  If, however, the suppression occasion, as
not infrequently observed, inflammation of  the
uterus or of the  ovaria, or of both—consequen-
ces which are  often overlooked, particularly
when slight or sub-acute, or when occurring in
unmarried females—vascular depletions, cool-
ing diaphoretics  and aperients, derivatives,  and
the other  means advised for inflammations of
the ovaria or ofthe uterus are requisite.
  66. In most instances, the chief efforts to
restore the  catamenia should be  made shortlv
before the approach ofthe next period.   Let di-
es may then be  applied to the groins ; a/id the
hip bath,  or pediluvia;  warm  clothing, espe-
cially around the hips and thighs ; and emmen-
agogue purgatives, may also  be prescribed.
The following have proved efficacious in many
instances :
  No. 291. R Hydrarg. Chloridi, gT. xii.; Alogs Socot., 3j.;
Pulv. Capsici, 3j.; Olei Juniperi Sabina;, q. s. M.  Fiant
Pilulae xij., quarum  capiat duas omni nocte.
  No. 292.  R Sodae Biboratis, 3ss.; Aloes Socot.,  Pulv.
Capsici, aa, 3j. ; Olei Lavand.,  q. s.  M.  Fiant Pilulas
xviij., quarum capiat duas ter quotidie.
   67.  While evacuations are required  in  con-
nexion with such means as may excite the  ute-
rine  discharge  when  suppression  occurs in
strong or plethoric females, or  occasions acute
disease of some important organ, as the brain,
lungs, liver, or uterine organs themselves,  oth-
er means are often necessary, when the  sup-
pression takes place in spare, delicate,  or  ner-
vous females.  It should not be overlooked,
however, that local inflammations or conges-
tions may occur in these persons in  such  cir-
cumstances, and require a somewhat similar,
although  less energetic practice ; but more fre-
quently suppression  in  them  demands a re-
course to antispasmodics in conjunction with
 narcotics.  The external and  internal  deriva-
tives, the emmenagogue purgatives  and  ene-
mata  already mentioned, and,  in many instan-
ces, the application of leeches below  the groins
at the proper period, should be prescribed ;  but,
 in addition to these,  antispasmodics, such as
 ammonia, asafcetida, castor, camphor, madder,
 capsicum, rue, savin, &c, variously conjoined
 with each other, and  with  conium, or stramo-
 nium, or belladonna, digitalis, &c, may be  pre
 scribed, particularly when much pain is com-
 plained of, or spasms occur, in consequence of
 the suppression.  In some of these cases, the 
970          MENSTRUATION, SUPPRESSED—Complicated Amenorrhea.
suppression  is  favoured by  poor or deficient
blood ;  and  in these the preparations  of iron
should  be combined with one or more of the
above antispasmodics and narcotics.
  68. b.  The treatment of chronic suppression
of the  menses should also be dependant upon
the cause, and upon antecedent and consecutive
disorder.  If it proceed from progressive or-
ganic disease in the lungs, liver, or  other or-
gans, the treatment should be mainly directed
to the  diseased part;  although, even in these
circumstances, local depletions in the situation
already stated, and other derivative means, may
be employed with benefit.  When it is caused
by repeated or severe inflammations of the ova-
ria or uterus, the  means should have reference
to these.  The ovaria, however, may be  so
changed  by inflammation as to be incapable of
exciting the vascular activity of  the uterus so
as to  produce  the  menstrual discharge; but
these changes are rather inferred from the his-
tory of former disorders than  manifested by ex-
isting phenomena.  When the uterus is affect-
ed so as  to obstruct the discharge, or to cause
its retention, without preventing its production
altogether, the nature of the lesion may be as-
certained, and a remedy be found.  Inflamma-
tion  may close the cervix uteri, or cover the os
uteri with a false membrane, or  may even ob-
literate the vagina, as noticed above.   In these
circumstances,  the  means already indicated (<J
49) should be resorted to.
   69. Even when the obstruction cannot be re-
ferred  to organic disease of the ovaria or ofthe
uterus, there may be  still great  congestion of
these organs ; requiring local depletions for its
removal.  Many of these cases present indica-
tions of debility, and  are attended, moreover,
by leucorrhcea,  which  may be either periodic or
more or less continued, this discharge being
often considered as a consequence of debility
merely.  But the local congestion may be con-
siderable nevertheless ; and although the gen-
eral  pallor and  state of the circulation  may in-
dicate  some degree of anaemia, the  uterine or-
gans may contain an undue proportion of blood.
In these cases, the  employment of stimulating
injections per vaginam, as advised by the an-
cients, and  revived by some moderns, might
convert  suppression from congestion  into ac-
tual  inflammation of  the uterine organs; and
in those cases  where  the congestion and  sup-
pression are associated with leucorrhcea, a re-
course to astringent injections,  in order to re-
move the latter, may be  followed by the  same
bad consequences, if local depletions, and other
suitable  means directed to the removal of the
congestion,  have not preceded such injections
   70.  When uterine  congestion or  inflamma-
tory action is not present, or has  been removed,
the  treatment  should  depend much upon the
states  of the vascular system, and of organic
nervous power.  If the former be not plethoric,
and  if the latter be  much impaired,  the prepar-
ations of iron, with iodine, or other appropriate
medicines ; the ammoniated tincture of guaia-
cum, the stimulating antispasmodics,  and ex-
ternal and  internal derivatives,  are generally
serviceable.
   71.  iii. Complicated Amenorrhcea.—I have
already noticed (v 57)  some  of the most impor-
tant associations of  amenorrhcea,  and shown
that the obstruction, particularly when taking
place slowly, or becoming chronic, is often ow-
ing either to debility or some constitutional in-
firmity, or to the gradual-development of some
organic  malady, as ofthe lungs, brain, liver,
&c.  The complications most frequently  ob-
served are, hemorrhage from various parts, in-
flammations, phthisis, epilepsy, hysteria, chlorosis,
anemia, palsy, retention of urine, chorea,  cutane-
ous eruptions, diarrhea, and various disorders of
the digestive organs.   These require a few re-
marks.
  72.  A. Among the most important of these
are vicarious hemorrhagic discharges from some
organ or part, or vicarious menstruation, as it has
been commonly, but incorrectly, termed.  These
discharges, occurring during suppression, have
been thus termed owing to their recurrence;
but, although  recurring, they are not always
strictly  periodic, or  of monthly appearance.
Writers have been more desirous of recording
cases of  this description, than of  observing
carefully the procession of the morbid states
constituting them; and several have  viewed
the haemorrhagic discharge as an eruption of
the menses in  some singular locality in place
of from the uterus, instead of observing  the se-
quence of morbid actions, and the relations be-
tween the contingent or vicarious  discharge
and the suppression.  Thus haematemesis is a
not infrequent form of the vicarious discharge,
and is usually attributed to a periodic determi-
nation of blood to  the  villous surface  of the
stomach,  instead of the uterus ; but, without
denying  that  such is sometimes the  case, I
have met with instances which have led me to
infer that hepatic or portal obstruction has ta-
ken place in plethoric persons, and given rise
to haemorrhage from the stomach, which either
has anticipated and substituted the  catamenia,
or has occurred in connexion with suppression,
and often in consequence of the operation of
the same causes as have produced suppression.
The same remarks apply equally to the substi-
tution of a haemorrhoidal discharge.
   73. The causes of suppression, also, particu-
larly  those  which determine the flux of blood
from the lower portion of the body to the head,
not infrequently induce epistaxis, or even haem-
orrhagic discharges from the ears,  eyes, &c,
especially in those  who are constitutionally or
otherwise disposed to epistaxis, or haemorrha-
ges from these parts.  In these cases, the ir-
regular distribution of  blood—the  diminished
determination of it to some parts, and its accu-
mulation in others—is followed by its discharge
from  these tissues of the congested organ or
part,  which most readily admit of its  escape.
The circumstance of these vicarious discharges
generally following, and but rarely anticipating,
the precise period at which menstruation should
have occurred, sufficiently indicates the nature
of these occurrences. Besides the situations al-
ready mentioned, haemorrhagic discharges may
recur in connexion with amenorrhcea, from the
bronchi  or lungs,  the  gums,  the fauces, the
mammae, the urinary bladder, the bowels, from
ulcers in any situation,  from varicose veins,
&c.  Of the associations of amenorrhcea with
inflammations, or with phthisis, which are of fre-
quent occurrence,  either preceding the other,
no farther notice need be here taken, than  that
the former are more obstinate and unfavoura-
ble when thus allied, and that the latter  pro- 
MENSTRUATION,  SUPPRESSED—Complicated Amenorrhcea.           971
ceeds much more rapidly to its usual termina-
tion when it is thus complicated.
  74. B. Epilepsy is generally  consecutive  of
acute amenorrhcea when observed in  connex-
ion  with  it;  but  the  numerous and varying
forms  of  hysteria, whether  assuming a  spas-
modic  or a  neuralgic  or  painful  form,  may
either precede or follow the suppression.   The
same remark may be extended to chlorosis, cho-
rea, and anemia, either of which is often thus
associated, and more or less intimately depend-
ant upon amenorrhcea.  The different forms of
palsy are  rarely  seen connected with suppres-
sion otherwise than as a consequence of it.   I
attended,  a few years ago, with Mr. Flockton,
a young lady who was afflicted with prolonged
amenorrhcea,  followed by paraplegia, retention
of  urine, diarrhoea, and  occasional attacks  of
vomiting, with which the diarrhoea often alter-
nated.   She had been many months  in this
state, and a great  diversity of treatment had
been employed  without avail.  The  disease
was ultimately removed by means which will
be  noticed in  the sequel.  Disorders of the  di-
gestive and cutaneous eruptions are too varied
in  their characters to require notice in connex-
ion with amenorrhcea.
   75.  C. The prognosis in complicated amenor-
rhcea depends upon the nature of the associated
disease.  It has generally been considered that
the hemorrhage which often occurs vicariously
in  some cases of this description is not attend-
ed by any risk, and is not followed by other dis-
ease,  or  even by much  functional disorder.
 But, although this may be true in the majority
of cases,  more particularly as respects epistax-
 is,  haemorrhoids,  haematemesis,  &c, it  by  no
means generally obtains, especially as regards
 haemoptysis, and hardly as respects haemateme-
 sis.  Haemoptysis  should always be viewed in
 an  unfavourable light, and its  dependance  as
 much  upon  incipient  tubercles,  or congestive
 inflammation  of the lungs,  or both, as  upon
 amenorrhcea, ought to be inferred.  The prog-
 nosis in the other associations of suppression
 depends as much upon circumstances peculiar
 to  the  patient as upon the particular complica-
 tion present,  and  requires no farther  notice
 than has  been taken above  (y 73, 74).
    76. D.  The  treatment of the  complicated  ob-
 struction should be directed with the same in-
 tentions as have been already stated.   In  the
 acute  complications,  particularly  those  with
 haemorrhagic,  apoplectic, epileptic, and  inflam-
 matory seizures, in plethoric habits, general and
 local  blood-letting, emmenagogue  cathartics,
diaphoretics, (fee, are  requisite ;  and when the
other complications  occur  in  these habits of
body, a similar treatment, especially local blood-
letting in the situation above pointed out, should
be  prescribed, and be aided with the other means
already noticed, according to the particular  as-
sociations observed.
   77.  In  the  more chronic complications, the
means should  be adapted to the peculiarities of
such cases, which  are too numerous to admit
of  even a partial notice.  The most of those,
however,  will  allow of a trial of the means al-
ready advised for delayed and suppressed  men-
struation ; and, although the exact recognition
of  the  complication present should determine
tne mode of treatment, still that which  is  more
immediately directed to. the obstruction should
not be neglected.   The exhibition of the spir-
its of turpentine in alterative or purgative do-
ses, according to circumstances ; a mild course
of mercury, or of iodine, or of both, or of iodine
and iron ;  a recourse to digitalis, conium, stra-
monium, belladonna, madder, rue, savin, &c,
are the most deserving of notice.  Where the
obstruction  is  connected with spasmodic or
painful disorders, turpentine, iron, stramonium,
belladonna, opium, hydrocyanic acid, ammonia,
&c, are severally useful.  When it is related
to chlorosis, chorea, or  anaemia, the  prepara-
tions of iron  are particularly indicated, and the
aid of aloetic and  warm purgatives required.*

  * (Galvano-electricity,  or  electro-magnetism, deserves
more particular mention as an emmenagogue remedy.  We
have succeeded in some chronic cases of amenorrhoea, that
had resisted all other  means, by daily sending a current of
electricity through the uterus, or by inserting one conductor
in a tub of warm water, in which the feet were immersed,
and applying the  other over the  cervical vertebra?, thus
transmitting the fluid through the spinal axis.  Dr. Ash-
well states, that  Dr. Golding  Bird has recently em-
ployed the same remedy with extraordinary success in the
treatment of out patients at Guy's Hospital (London).  In
some of the cases, where, after the condition of the aliment-
ary canal had become healthy, the amenorrhoea continued
with slight  pallor and weakness, electric shocks  passed
through the loins quickly induced menstruation.  In oth-
ers, its continued repetition three or four times  a week led
to a similar result; and instances were not wanting where
a shock suddenly produced the flow.  It is, however, a pow-
erful remedy, and should be employed cautiously, lest  it
may depress the nervous system, and thus protract the dis-
ease ; when moderately applied, it often rouses into activity
the energy of torpid organs and parts; but, when used in
excess, it may altogether destroy their excitability.   It
should not be employed in cases of local congestion or gen-
eral plethora, or during pregnancy, and it should seldom be
used alone.  An injection of ammonia after  the following
formula will often succeed, if followed by a pungent sensa-
tion of heat, tingling,  and some pain in the vagina : R Liq.
Ammon. fort., 3j. vel  3jss.;  Lactis tepid, fxvi. ; M.ft. In-
 jectio vaginalis, a third  part to be passed into the vagina
three times daily.  Its use should be commenced three days
prior* to the expected  period, and the patient, after each in-
jection, should  apply  a napkin to the vulva so  firmly as to
cause the injected fluid to be retained for ten or fifteen min-
 utes.  It is, however, not a safe remedy where there  is
 uterine congestion, as inflammation of the cervix uteri and
 upper part of the vagina is apt to follow.  It is adapted only
to cases of torpor, unattended with congestion  or acute ir-
 ritation.  The strong mustard hip bath, used twice a day,
 the patient remaining in it for nearly an hour each time, at
a temperature of 96° or 98°, is an effectual auxiliary reme-
dy.  The reader cannot be  cautioned too much against in-
jecting stimulating fluids into the uterine cavity, as recom-
mended by some writers, as peritoneal inflammation is very
apt to follow.  Dr. Ashwell highly recommends pulver-
ized mustard, in doses of 8, 10, and 12 grs. in camphor julep,
prior to the menstrual period.  Stimulating injections into
the rectum, composed of 10 grs. of aloes with 5j. of muci-
lage, two or three times a day, will often prove a successful
remedy.  Warm frictions, stimulating embrocations, as the
flesh-brush to the hypogastric and lumbar regions, are also
to be employed night and morning.  The above are the most
important of the direct emmenagogues, so called ; of the in-
direct, or those producing their effect through the medium
of the system, mercury is by far the most important. Dr.
Ashwell cautions against using it in slight cases, or where
there is extreme exhaustion, a predominant irritability, or
a tendency to phthisical or strumous disease ; but in obsti-
nate amenorrhcea, where other treatment has failed, where
there is chronic inflammation or permanent congestion, and
any evidence of incipient structural change, he thinks there
is no remedy comparable with this, in which opinion our
experience leads us to coincide. If tho pulse becomes more
rapid and less strong under its influence, or if constitutional
irritation and weakness daily increase, if there be cough or
diarrhoea, these not having previously existed, its use should
be immediately discontinued ; but where it is doing good,
the tongue becomes clean, moist,  and of a healthy colour ■
digestion improves, and theje is some return of healthy ap-
petite ; the complexion loses its dingy icterode hue, and be-
comes more clear; and the general condition of the patieut
is greatly improved.  Dr. Ashwell thinks that the mer-
curial effect should be carried so far as to produce soreness
of the  gums and moderate salivation, and that these should
be kept up for twelve  or sixteen weeks.  We regard strych-
nine and savin  as very certain emmenagogues, when prop-
erly administered, but it requires judgment in selecting the 
972
MENSTRUATION, DIFFICULT—Description.
IV. Difficult  Menstruation—Syn. Dysmen-
  orrhea, Vogel, Sagar.  Dysmenia, Swediaur.
  Menorrhagia  dijficilis, M. Stillatitia, Amenor-
  rhea difficilis, Amen, partialis, Auct.  Para-
  menia dijficilis, Good.   Menstrua difficilia ; M.
  Dolorosa.   Beschwerliche monatliche reinigung,
  Germ.  Menstruation difficile, Fr.  Menstrua-
  zione difficile, Ital.   Painful menstruation.
  78.  Defin.—Menstruation preceded and accom-
panied by acute pain in the abdomen and hypogas-
trium, and often in the back or mamma, the dis-
charge being frequently scanty, or presenting mor-
bid appearances.
  79.  This form of uterine disorder is  of fre-
quent occurrence, and is not only productive of
extreme suffering, but often of very serious con-
sequences.   Dr. Ashwell remarks, that it oft-
en prevents conception ; and, if pregnancy has
occurred during its continuance, there is risk of
abortion.  Although, in itself, it is  not  a fatal
malady, yet malignant diseases  have followed
its  protracted existence; and  it is generally
very difficult  of cure.
  80.  i.  Causes.—Both married  and single fe-
males, the latter more particularly, are liable to
it.  Dysmenorrhcea may occur in all  tempera-
ments and habits of body ;  but more frequent-
ly in  women of irritable, hysterical,  and  ner-
vous  temperaments, and of spare, strumous,
and phthisical constitutions than in  others.   It
is probably somewhat favoured by indolence and
full or rich living.  The most common exciting
causes are, exposure to cold in any form during
menstruation ;  sudden fright, or shock, or vio-
lent mental emotions or disappointed affections,
especially when occurring at this period; ex-
posures to  cold soon  after parturition or abor-
tions, &c.  Indeed, the same causes which oc-
casion suppression ofthe menses, or inflamma-
tion ofthe uterus, may occasion dysmenorrhcea.
  81. Difficult menstruation may occur at any
period, and is rarely confined to one or two pe-
riods.  It may be traced back in some cases to
the very commencement of the epoch.  The
amount and character of the pain may vary much
It may be  moderate,  and last but a few hours
each time, or it may be so severe as to amount
to extreme torture, and to  occasion  faintings
or severe  retchings; and even to  render the
patient  a permanent  invalid.   The pain  may
also be neuralgic or inflammatory in  its charac-
ter.   Owing to these variations, dysmenorrhcea
has been divided  by  Dr. Churchill  into, 1st,
the neuralgic; 2d, the inflammatory; and, 3d,
the  mechanical or obstructive.   M.  Roche has
treated of  it  as idiopathic and symptomatic, the
latter generally depending upon inflammatory
action in  the  uterus.   Mad. Boivin and M.
Duges have viewed it as commonly proceeding
from inflammation.   Dr. Ashwell  has arran-
ged the forms of amenorrhcea into,  1st. The ir-
ritable or neuralgic ; 2d. The plethoric; 3d. The
congestive; and, 4th. The obstructive.   The chief
objection to this division is that the second and
third  must be necessarily alike;  for, if a pletho-
ric and a congested state of an organ hardly ad-
mits  of being distinguished from each other, in
respect  of their physical conditions, how can
they be recognised by aid merely of their phys
iological phenomena
It would be better, there-
cases to which they are best adapted.  The preparations of
iodine and iron, especially combined with aloes, will often
succeed, even in very obstinate cases.  The mineral waters
of Saratoga, containing, as they do, both these metals, will
frequently bring on the menstrual flow when all other
means have been tried in vain.]
foreT to consider the second variety as  one of
congestion which may sometimes go on to, or
be attended by an inflammatory state of the in-
ternal surface of the uterus, which state, how-
ever, may also exist in the first variety, the neu-
ralgic character, however, predominating, and
distinguishing it.                  ...
  82.  ii. Description.—A. Neuralgic or irritable
dysmenorrhea  occurs  chiefly in unmarried fe-
males, and in the married who  have not borne
children.  Although it may appear at any peri-
od of the menstrual  age, it is most common
about the  thirtieth year.  It  is generally 6b-
served  in  nervous or hysterical  and irritable
temperaments, and in spare and delicate habits
of body.  The monthly paroxysms of pain have
all the characteristics of neuralgia.  They are
often  preceded or followed by headache.  The
pain often commences in the region of  the sa-
crum, and extends around the lower part of the
abdomen and down the thighs.   The suffering
is often very great; in some cases it  is con-
stant, in others it is remittent.  As it  contin-
ues, a forcing or bearing  down  sensation is oc-
casionally present, and aggravates the distress;
and in some instances the torture is so extreme
that the patient rolls about on the abdomen, en-
deavouring to procure ease from pressure; or
is afflicted with constant retchings.  These suf-
ferings  may endure for only a few hours, or
they may continue a day or two before the dis-
charge commences.  This is usually scanty at
first, or in slight gushes ; and the quantity va-
ries in different persons, or even  in the same
person at different periods. It is often altogeth-
er scanty, rarely too much.   It is frequently
natural in appearance ; but it is also often pale,
or mixed with small clots, or  with  shreds, or
with a  bran-like  matter.  More rarely it con-
tains shreds of membrane, as observed by Mor-
gagni, Denman, Burns, Blundell, and  others.
  83. The cervix uteri  undergoes  the usual
change at this painful period ; it becomes swol-
len and softer, with an increase of heat;  and
the os  uteri is somewhat more open  than in
the interval.  As the discharge proceeds, the
pain subsides gradually, but not so  quickly as
in the inflammatory variety; and as it disap-
pears, neuralgic  pains are  sometimes  felt in
other parts.  The pulse is seldom affected du-
ring the attack, farther than being weaker than
usual; and febrile symptoms are rarely  observ-
ed.  In a few cases, the bowels are irregular
during  the  period.   Although  the health may
not suffer in  the interval, yet in the severer
cases, or when  the complaint has been neg-
lected, the patient complains of headaches, of
pains in the back, which are increased by stand-
ing or walking, and of various  disorders of the
digestive organs, consequent upon the  general
impairment of health, arising  from protracted
sufferings.
   84. The membranous shreds passed in some
of these cases, evidently consist of plastic lymph
thrown out in the  cavity of the womb.  In a
few cases, this  substance  has  been  voided
nearly entire as moulded upon the internal sur-
face of the uterus, and has given rise  to  sus-
picions of pregnancy, its expulsion being at-
tended by  violent  forcing  pains.   It  is  dis-
charged, in some instances, during several sue- 
MENSTRUATION, DIFI
cessive  periods, in others only occasionally.
Dr. Denman supposed  that females could not
conceive who voided these  membranes ;  and
such  is  the  case in  the  great majority of
instances,  although  Dr. Blundell  and  Dr.
Churchill believe that conception is possible.
  85. B. Congestive  and Inflammatory Dysmen-
orrhaa.—In some cases the  patient complains
of lumbar pain, of a sense  of weight  and of
bearing  down  in the pelvis  for  two or three
days before the expected return of the menses.
Frequent micturition, constipation of the bow-
els, severe pain in the region of  the  uterus,
restlessness,  and  violent forcing  supervene.
The patient is not feverish, but the  pulse  is
often quick and irritable.  The skin is gener-
ally perspirable.  A sense of exhaustion, with
anxious, pallid countenance, is usually felt as
the affection proceeds.  After some hours, or
even  after a day or two, the attempts  to mic-
turate, or the severe forcing pains, extending
sometimes through  the abdomen, from  the
loins, hypogastrium,  and hips, are  followed by
the expulsion  of  coagula, or occasionally of
portions of membrane, the discharge being gen-
erally scanty, or in irregular gushes, and at in-
tervals sometimes almost colourless.  The for-
cing pains often resemble those of labour, but
the suffering  is generally more  constant than
in it.  Sometimes the uterine pain is attended
by a sensation as if the pelvis contained some
foreign  body that  should come away ; and  in
these cases considerable masses of coagula, or
of albuminous concretions or membrane, have
been passed, affording  much relief.  This con-
gestive form of dysmenorrhcea, when severe or
prolonged, is often followed, for some days, or
even for the greater part ofthe interval, by leu-
corrhcea, which tends  farther to  weaken the
patient, and to superinduce more extensive dis-
ease.
   86. In some females, particularly  in the
plethoric and  in the sanguine temperament, the
disorder assumes  a  more inflammatory form;
or the whole  frame exhibits more or  less in-
flammatory or febrile  commotion.  It usually
occurs earlier  in life than the neuralgic form,
chiefly in the  unmarried or in those who have
had children.   It is commonly caused by cold,
particularly when applied to the feet, thighs,
and hips, as when seated on cold or damp seats.
It may also proceed from some sudden shock
or constitutional disturbance, and may assume
various  grades of severity.  In its slightest
states, it not  infrequently affects plethoric and
robust young  females  from the first menstrual
period until marriage.
   87. It usually commences with chills or slight
rigours, followed by  flushing, feverishness, and
headache, a few days before the  appearance  of
the catamenia; with these the patient  com-
plains of pains in  the back and hypogastrium,
of aching in the limbs and lassitude ; of intoler-
ance  of light and sound, and fever.  The skin
is hot, the pulse full and frequent, the bowels
constipated, and the mammae painful and some-
what swollen  (Dewees) ; but the febrile com-
motion is rarely so high as to cause temporary
or night delirium.  These symptoms subside as
the discharge proceeds, especially when it is
abundant.  When it is scanty, they often con-
tinue in a less degree, or become aggravated
for a time as it disappears ;  but  it  is generally
FiCULT—Description.                   973

more abundant in this than in the other states of
the disease.   It may be accompanied with the
membranous shreds or exudations,  as in the
other varieties.
   88. During the intervals the general health
may not be materially affected, although head-
aches  are not infrequent, and leucorrhcea is
often constant.  The severity of the  attacks is
not so regular in intensity as in the neuralgic
form, and  sometimes a period or two elapses
with little suffering.  On  examining per vagi-
nam during the severity of the pains in the con-
gestive or inflammatory states, evidence of en-
gorgement of the uterus is generally furnished,
with swelling and increased heat of the cervex
uteri, but there is no external tenderness on
pressure.
   89. All the forms of dysmenorrhcea, when
very severe, generally prevent conception ; but
the slighter degrees of the complaint will'not
have this effect.  In one of the severest and
most obstinate cases for which I have been con-
sulted, the patient  had a family after marriage.
   90. C. Obstructive Dysmenorrhea.—Dysmenor-
rhea from mechanical obstruction consists of a
narrowing or stricture of some part of the canal
of the cervix uteri.   This  variety of dysmenor-
rhcea was noticed by several continental au-
thors of the last century, and was  enumerated
by M. Capuron as  one of the chief states of the
disease ;  but  Dr. Mackintosh was the first  to
insist  on its  frequency  and importance,  and
Drs. Churchill and Ashwell have directed
their attention to it; but  they believe that ca-
ses of this kind are rare, and that the stricture
is only a part of the complaint, and often  ex-
erts no influence upon it, inasmuch as the dila-
tation of the stricture was not, in most of their
cases, followed by an  alleviation of suffering.
It is natural to infer that, if the stricture had
been the real cause of the disease, an accumu-
lation  of the menstrual fluid would have taken
place in the cavity of the uterus ;  but this ap-
pears not to have been the case.  Although an
infrequent cause of dysmenorrhcea, it is of suf-
ficient importance to determine its existence in
all doubtful and obstinate cases.
   91.  iii.  Diagnosis of Dysmenorrhea.—This
complaint is readily distinguished;  it is  only
when  it is accompanied with the discharge  of*
an albuminous  exudation or  false membrane
moulded within the  uterus, resembling the de-
cidual nidamentum of the ovum, that a distinc-
tion is required.  The duration  of the  com-
plaint, the state of the menstrual discharge on
former occasions,  the  length of interval from
the  previous  period, a©d  the physical charac-
ters of the substance voided,  are sufficient  to
determine the nature of the case.   Dr. Mont-
gomery has very accurately described this sub-
stance, and has confirmed the account former-
ly given of it by Morgagni.  He states that it
differs from the true decidua  in not being in-
tended to become a medium of nutrition for the
ovum ; hence it is not furnished with a struc-
ture such as  would be necessary for this of-
fice.  It is thin, and unsubstantial in texture ;
of a dirty white or  yellowish colour after the
agitation of it in water;  and is devoid of the
soft, rich, and pulpy appearance and vascular
colour, and of the numerous foramina for the
reception of the nutrient vessels from the ute-
rus, characterizing the true decidua ; it is also 
974
MENSTRUATION, DIFFICULT—Treatment,
destitute of the little cotyledonous sacculi es-
sential to the latter structure.  No trace of the
transparent membranes of an ovum can be dis-
covered within it or attached to it; and should
it happen to come away entire, in the form of
a hollow triangular bag, it never contains a du-
plicature of itself,  forming an inner pouch or re-
flex layer, as in the case of the natural decid-
ual envelopes of the ovum.
  92.  iv. Complications of Dysmenorrhea.—Most
of the complications presented by suppressed
are also observed  associated with painful men-
struation ; and of these, hysteria and disorders
of the digestive  organs are among  the most
frequent.  I have met with instances of a dis-
charge of membranes from  the uterus during
dysmenorrhcea  associated  with  painful dis-
charges of similar membranes from the intes-
tines, and with the severer  forms of hysteria
and.spinal irritation.  Leucorrhcea is an equal-
ly common complication with hysteria,  and is
often  only a part  of the uterine disorder caus-
ing dysmenorrhcea.   Neuralgic and other ner-
vous complaints are not infrequently associated
with it; but the observations I have offered on
the complications of amenorrhcea  (§ 71, et seq.)
are equally  applicable  to  those of dysmenor-
rhcea.
   93. v. Prognosis.—Dysmenorrhcea is danger-
ous only as respects its consequences when neg-
lected, and when it is  complicated with some
pectoral or other  serious disease.  Although it
be obstinate, severe, and prolonged, as long as
the general health does not  suffer, and no oth-
er local malady appears,  its chief importance
consists in the distress it occasions, and the
effect it may have  upon the generative func-
tion  ;  for, although a  female may conceive
who is suffering any of the forms of* the mala-
dy, even in their severest states, as when at-
tended by the expulsion of albuminous exuda-
tions, still this  is  an  infrequent occurrence,
sterility being a  much more  common  result.
Generally, however, the  disease is cured by
medical treatment, or  by  marriage, and child-
bearing ; and  it necessarily disappears  at the
change of life.  The possibility of* its being fol-
lowed, particularly when it  continues up to, or
past  the fortieth  year, by organic, or even by
malignant  disease of the  uterus, especially of
the cervix and os uteri, ought  not to be over-
looked ; and this  contingency is, perhaps, more
likely to occur in the neuralgic than in the in-
flammatory form.  The mechanical state of the
disease may be viewed as more  unfavourable
than  the others; as the  removal of the stric-
ture is not always attended  by a removal of the
malady.  Dr. Mackintosh, however, states that
he cured twenty-four cases out of twenty-sev-
en, and that of the twenty-four, eleven after-
ward had children.  This rate of success has
not been confirmed by the experience of other
physicians.
   94. vi. Pathology.—The questions most agita-
ted in respect of the nature of dysmenorrhcea
 are, whether it depends or not solely upon irri-
tation or altered nervous sensibility, or solely
 upon inflammatory action—whether  it is mere-
 ly neuralgic or entirely inflammatory.   That a
 degree of inflammatory irritation exists in the
 internal surface ofthe uterus, even in the neu-
 ralgic form of the disease, is proved by the for-
 mation and expulsion of a false membrane in
many cases of that form.   That this membrane
is produced by a similar state of inflammatory
action to that which sometimes occurs in other
mucous surfaces, and gives  rise  to a similar
exudation, is most probable, notwithstanding
the absence of general inflammatory phenome-
na  and the  neuralgic  character  of the pain.
The absence  of these phenomena is evidently
owing to the  nervous temperament, and dispo-
sition to morbid or exalted sensibility, in con-
nexion with the state of the vascular system,
and probably, also, to the nature of the more
common exciting causes.  In these cases, the
inflammatory irritation existing in the internal
surface of the uterus excites, or is attended by
an inordinate manifestation of morbid sensibil-
ity, although  it is insufficient to  develop gen-
eral vascular reaction, owing to the general de-
ficiency of blood in the  vascular system, and
hence  the  neuralgic character prevails.  In
those cases which are manifestly congestive or
inflammatory, the nervous susceptibility being
less, while vascular fulness  and disposition to
increased action are much greater, these latter
conditions are  more prominent.  That the al-
buminous exudations,  voided in  the different
varieties ofthe disease, are the results of states
of local  action similar to those  which  some-
times take place in other mucous surfaces, may
be  inferred not only from their  similarity of
characters, but also from other  phenomena,
more particularly from the violence of the pain
attending their detachment from the surface on
which  they are formed, as evinced by their for-
mation in the bowels (see art. Intestines, y 52)
as  in the uterus.   In two of the complicated
cases alluded to above (c) 92), one  of which was
seen also by  Sir B. Brodie and the late Dr. Da-
vis, the other by Dr. Ashwell, in consultation,
the albuminous exudation or membrane was
voided  from  both  the  intestines and uterus,
with violent  suffering referrible to both  these
situations, and with severe and obstinate sym-
pathetic disorders of an  hysterical and neural-
gic nature.
   95.  vii. Treatment.—The  indications of cure
are the same in all the forms of this malady:
these  are, 1st. To alleviate  the suffering at the
menstrual period; and, 2d. To restore during the
intervals the healthy condition of the organ.
   A. The first of these intentions is, however, to
be fulfilled by somewhat different means, in the
several forms of the disease.
   96. a. The neuralgic variety, as I have already
stated (cj 82), ought not be viewed as being en-
tirely devoid of a local inflammatory character,
at  least in many cases, or in those attended by
the production of an albuminous exudation, be-
cause  the symptomatic  phenomena of  inflam-
mation are not manifested.   Therefore,  unless
there be manifest deficiency of blood in the vas-
cular system, leeches should be  applied below
the groins, as above advised (y 67), and  be fol-
lowed by fomentations with hot sponges.   After
the bleeding has ceased, the warm bath, or warm
 hip bath, and the anodynes about to be advised,
may be resorted to, and even repeated.  Where
 local bleeding is not indicated, and after it has
 been employed, opiates, or  henbane, or bella-
 donna, or stramonium, conium conjoined with
 camphor, asafcetida  or other antispasmodics,
 are generally beneficial.   I have prescribed the
 following with advantage: 
MENSTRUATION, DIFFICULT-Treatment.
975
   No. 293. R Soda Biboratis, 3ij.; Extr. Conii, Jss.; Extr
 Stramonii  (vel  Extr.  Alcoholici Aconiti), gr.  iij. •  Pulv
 Capsici  gr. vj.; Olei Juniperi, q. s. M. Fiat massa squalis
 quam divide  m pilulas xviii., e quibus capiat duas, tertiis
 vel quartis horis, ad tertiam vel quartam vicem.
   No 294  R Pilule Galbani Comp., jss.; Extr. Hyoscy-
 ami, 3j.; Soda3 Biboratis, jss. ; Extr. Belladonns, gr. iv. ■
 Ole. Juniperi, q. s.  M.  Fiant piluls xx., quarum capiat
 duas, tertiis vel quartis horis.
   No. 295. R  Camphorse rasae, 3i.; tere cum Mucilag.
 Acacias, Jiij.,  et adde Aquae flor. Auranti, 5vjss.  ; Sodas Bi-
 boratis, 3.J.; Spirit. .Etheris Nit.,  3iij.; Spirit. Juniperi
 Comp., 311J. ;  Tinct. Hyoscyami, Jij.  M.  Fiat  mist, cujus
 capiat coch. ij., larga, secundis vel tertiis horis.
   97.  The  narcotics just  mentioned  may be
 prescribed  in the form of suppository, or in ene-
 mata ; but  they  ought not  also to be given by
 the mouth when  thus employed,  nor should
 they be prescribed in large doses in enemata,
 as serious effects may follow.  In those cases
 which are attended by a sensation of a substance
 pressing down in the pelvis,  as  if requiring to
 be brought away, the ergot of rye and the bi-
 borate of potash will often afford relief, partic-
 ularly when there are coagula, or albuminous
 exudations in the uterus, or passing the cervix.
 Injections, per vaginam, ofthe warm decoction of
 poppies, or of warm  water, containing the ex-
 tract of conium or of hyoscyamus, several times
 a day; and hot fomentations of the same kind
 over thepubes and hypogastrium will frequently
 be of service.  Plasters containing the extract
 of conium, or of belladonna,  or  of aconitum,
 and camphor, may afterward be placed upon the
 sacrum, or  over  the hypogastrium, in the more
 severe and  obstinate cases.
   93. b. The congestive  and inflammatory states
 of dysmenorrhcea require, with very few excep-
 tions, either general  or  local  bleeding, or even
 both, as early as the  attack comes under treat-
 ment.  Leeches applied to the thighs are pref-
 erable to cupping on  the loins in these cases;
 for I have known instances of suppression of*
 the menses caused by the latter.  The bleeding,
 however, should not  be too profuse, as it may
 thereby interfere with the catamenial discharge;
 it may, however, be  repeated  at  the return of
 the period,  according to the peculiarities ofthe
 case.  After vascular depletions, cooling diaph-
 oretics, conjoined  with narcotics,  are gener-
 ally beneficial; particularly the liquor ammoniae
 acetatis, with camphor,  spiritus aetheris nitrici,
 and any ofthe narcotics already noticed.  Warm
 poppy fomentations,  the warm bath,  and  the
 other means already noticed (y 97), will also be
 frequently of service.  The bowels  should be
 kept gently  open by means of cooling laxatives.
   99. B. During  the intervals between the men-
 strual  period, the treatment should  be varied
 conformably not  only with the varieties above
 distinguished, but also with the circumstances
 ofthe case.—a.  In the neuralgic form, much at-
 tention should be paid to the state ofthe digest-
 ive functions, and  to diet and regimen.   The
 biliary secretions ought to be promoted by blue
 pill, or the hydrarg. cum creta, taken alternate
 nights;  and by a stomachic aperient,  the  fol-
 lowing morning or night.   After the abdominal
 secretions and excretions have been improved,
 chalybeate preparations or mineral waters may
 be tried, and  be  aided by residence  in a pure
 air;  by exercise on  horseback, or by  regular
 walking exercise, taken moderately, twice  or
thrice daily;  and by  warm salt  water baths,
followed by cold salt water bathing or the daily
use of shower baths.
   100. The several  preparations of iron  have
 beeji advised in this  complaint.  The iodide of
 iron is one of the most efficacious.   It may be
 given in the sirup of sarsa.  Dr. Locock advises
 the vinum ferri with  the spiritus aetheris sulph.
 comp.   The mistura ferri comp. and the alka-
 line combinations of iron are also very service-
 able.   Dr. Dewees makes  favourable mention
 of the tinctura lyttae,  and more especially ofthe
 tinctura guaiaci and  tinctura guaiaci ammoni-
 ata ; and Dr. Chapman advises the decoctum
 senegse.  Dr. Churchill recommends blisters
 to the sacrum, or a  caustic issue in the same
 situation.   I have prescribed pea issues in the
 insides of the thighs  with success.
   101. The more obstinate cases, and those es-
 pecially which are attended by the expulsion of
 albuminous exudations, may resist most ofthe
 means now mentioned ; particularly when the
 malady is perpetuated by persistence in one of
 its most common exciting causes, namely, mas-
 turbation.   In these circumstances, Plummer's
 pill, or the blue pill, may  be given every night,
 alone  or with soap and ipecacuanha, until the
 gums are affected ; or the spirits of turpentine,
 in the dose of about one drachm, may be taken
 at night and  upon waking  in the morning, on
 the  surface of a cup of milk, or in any  other
 vehicle, for some days before the next menstru-
 al period.   Injections, per  vaginam, of warm
 water containing a little ofthe biborate of soda,
 especially  when  the  period of the catamenia
 approaches; the same substance taken inter-
 nally, alone, or conjoined with any  ofthe more
 congruous medicines already noticed, or with
 the supertartrate  of  potash, when  -the bowels
 require to  be kept freely  open ; and warm  pe-
 diluvia, hip baths, or  the warm bath, continued
 or repeated according  to circumstances, may
 farther be resorted to.
   102.  b. In  the  congestive  and inflammatory
 states  of  dysmenorrhcea, spare diet, regular
 and  active  exercise,  particularly on foot  and
 in the open air, with attention to the state of
 the bowels, should be  especially insisted on.
 If the case prove obstinate, or  continue,  not-
 withstanding  the  more active means advised
 for the treatment  during the menstrual period
 (9 98), it will be necessary to  have recourse
 either to the means already advised for the
 more severe cases attended by the discharge
 of albuminous exudations (y 101), or to a mild
 mercurial every night, the supertartrate of pot-
 ash with biborate  of  soda being taken in the
 morning.  In  some cases of this state of the
 disease, the iodide of potassium and the liquor
 potassae, given in suitable vehicles, have proved
 efficacious.  Of the local  application of iodine
 advised by some recent writers, in some obsti-
 nate cases of dysmenorrhcea, I  have no expe-
 rience ; and I know  of no  circumstance that
 can render it appropriate.   On the approach of
the next menstrual period, leeches applied be-
low the groins, and the means  advised above
(y 101), should be  resorted to.   If the bowels
be confined, the remedies just  mentioned, or
the biborate of soda with aloes, may be prescri-
bed.   In cases of this kind, as well as in sup-
pression of the menses, Dr. Mead  had  great
faith in hellebore given  until a free operation
was effected on the bowels.
  103.  C. The mechanical or obstructive variety
of dysmenorrhea has been  remedied  by the in- 
976
MENSTRUATION, EXCESSIVE—Definition.
troduction of bougies, which, however, require
both care  and dexterity  to prevent injurious
consequences.   As  the removal of the  stric-
ture is not necessarily followed by the cure  of
the complaint, the medical treatment  recom-
mended should also be employed according to
the circumstances ofthe case.*
V. Excessive Menstruation.  Synon. Menor-
  rhagia (from unvec, menses, and bny-n, a rup-
  ture) ; 'Pooc noXh.oc, Hippocrates.   Hernor-
  rhagia uterina, H. uteri, Menstrua immodica,
  M. superflua, Auct. var.  Metrorrhagia, Frank.
  Hysterrhagia sanguinea, Swediaur.   Parame-
  nia superflua,  Good.   Menorrhea, perte ute-
  rine, Fr.   Der Mutterblutfluss, Germ.  Inordi-
  nate or profuse menstruation.
    Classif.—II. Class,  I. Order (Author).
  104. Defin.—A too abundant or a too frequent
return of the uterine discharge.
  105. In the article upon Hemorrhage from
the Uterus, I have treated of " discharges  of
blood from the uterus occurring independently
of the menstrual evacuation," and have con-
sidered them with due reference to the several
periods of life and to the various circumstan-
ces in which they occur (see article referred to,
y 220, et seq.).   I here  confine  myself to the
consideration of excessive or profuse menstrua-
tion, as above defined.
  106. The quantity of blood  discharged from
the uterus at each menstrual period has been
variously estimated.  In temperate climates it
varies from  four to ten ounces, from five  to
seven or eight being the usual amount in this
country.  Less than four may be considered as
scanty, and more than  nine or ten excessive.
That climate influences the quantity of this dis-
charge is extremely probable ; but I do not be-
lieve that it has this effect nearly to the extent
estimated  by some writers ; for it is impossi-
ble to obtain precise information on the sub-
ject.  Even  when  the  quantity is unusually
large, the discharge may  take place in a short
period,  or  during a longer time  in recurring
gushes ;  or it may continue for a long period,
as a slight or moderate drain.
  107. Dr. Churchill distinguishes three forms
of menorrhagia: 1st. That in  which  the dis-
charge is of the natural character, but  is ex-
cessive as respects its quantity, continuance,
or frequency of recurrence.  2d. That in which
the discharge is mixed with clots of blood, but
is not  attended by alteration of the cervix  or
os uteri.  3d. That in which there is change in
the cervix, or in the size or position of the ute-
  * [Dr. Mackintosh states that he treated twenty-seven
cases by bougies, and cured twenty-four, and that, in eleven
of the latter number, pregnancy subsequently occurred.
Recent writers on dysmenorrhea seem, however, to place
but little confidence in this mode of treatment, although
Dr. Ashwell thinks that the views of Dr. Mackintosh
" are more correct than is generally supposed." Some have
recommended the belladonna, in small doses, prior  to the
menstrual effort, but we have had no experience as to its
success.  Dr. Meiqs, of Philadelphia (Am. ed. of Colom-
bat, p. 481), gives the following directions for introducing
a bougie into the uterus : The patient should lie across the
bed, or near the foot of it, with the  knees drawn upward,
and  separated with a pillow.  A flexible block-tin bougie,
of proper size, is next to be conducted along the right index
finger to  its point, which is placed  on the os uteri, and
serves to  guide the bougie to the canal of the cervix.  If
the bougie be somewhat curved, its apex enters without
difficulty, and passing upward slowly, to  the distance of
one inch and a half to two inches, is left in situ for a min-
ute or two, and then withdrawn, to be followed by another
of a larger size.]
rus  This division is not altogether undeserving
of adoption ; but as the discharge must neces-
sarily present the characters either of the men-
strual fluid, or  of haemorrhage, it is preferable
to arrange the forms of the disease according-
ly, namely, into true menorrhagia, and hemor-
rhagic menorrhagia.
  108. i. Menorrhagia,  with  a natural state of
the Discharge—True Menorrhagia.—In this va-
riety the discharge is  excessive, either  as to
its quantity, its  continuance, or the frequency
of its recurrence.   It may come on suddenly
and most abundantly, thus continue for a long-
er or shorter period, almost cease for  some
hours, and then return  more or less copiously.
It may recur or remit in this manner several
times or for several days, the excessive dis-
charge assuming this  form at each  period.
Sometimes it commences and  proceeds  regu-
larly, in  an unusually abundant quantity,  the
period not  being  much prolonged; but, more
frequently, it lasts for a long time, occasionally
for a fortnight or even longer, the quantity  not
being great at any time, but becoming so from
its continuance.  In other cases, the discharge
returns  every  two or  three  weeks, without
being in an augmented  quantity.  This  last
state  is  not infrequent among unmarried  fe-
males of a plethoric system, or sanguine tem-
perament,  with  much activity  of the uterine
organs.
  109.  This variety of menorrhagia is often
associated  with uterine  leucorrhcea, which may
either precede or follow each recurrence  of it.
In some cases, also, leucorrhcea only may have
been the primary  disorder,  menorrhagia  su-
pervening ; while, in others, it  may have fol-
lowed this malady.  An examination per vagi-
nam furnishes  no information, excepting of a
negative  kind.  There is neither heat, nor ten-
derness,  nor swelling ofthe os uteri.
  110. After repeated returns of menorrhagia,
the constitution indicates the debility and loss
of blood produced by it; and the  patient com-
plains of weakness or aching across the  loins
and hips ;  of languor,  exhaustion, faintness,
tinnitus aurium,  giddiness; and of headache,
or throbbings in the temples, or palpitations of
the heart.   The countenance is pallid, and  the
lips, tongue, and gums are  pale.   If the dis-
ease continue, these symptoms become aggra-
vated ; the stomach and bowels are deranged;
pains in the side, particularly the left, are com-
plained of; the face is sallow, and all the indi-
cations of  anaemia appear.  Ultimately, aedema
of the ankles, anasarca, diarrhoea, convulsions,
and various nervous affections, may supervene.
  111. ii.  Menorrhagia  with  discharge of pure
blood, or coagula—Hemorrhagic  Menorrhagia.—
This variety is met with chiefly in married fe-
males of a leucophlegmatic temperament,  and
in those  who have been weakened  by disease,
or by frequent child bearing, or by prolonged
suckling;  and in these  circumstances it is gen-
erally complicated with  leucorrhcea.  But a dif-
ferent, and a more acute  or active state of the
complaint  occasionally  is met with, which  has
been  altogether overlooked by Dr. Churchill.
I have observed it on several occasions,  and it
has also been noticed  by Dr. Ashwell.   This
variety of menorrhagia  has therefore been prop-
erly divided by him into  three states,  viz., the
active, passive, and congestive.  The first  and 
MENSTRUATION, EXCESSIVE—Menorrhagia.                 977
second of these are generally  attended by a
natural state of the cervix and os uteri, while
the third  is  usually accompanied with some
change in  the state and position of these parts.
   112. A. Active or Acnte Hemorrhagic Menor-
rhagia—Inflammatory Menorrhagia.—This is the
least frequent kind of the complaint.  It occurs
chiefly in  robust or plethoric married women,
who live fully, or who addict  themselves  to
sexual excesses ; but it is also, although more
rarely, met with in young, florid, and plethoric
unmarried females ;  and in both classes of pa-
tients it may assume, according to the temper-
ament and habit of body, more «r less of an in-
flammatory, or of  a  spasmodic character.   In
this state  of the complaint, a sense of tension,
weight or fulness  in the pelvis, is complained
of for a day or two before the accession of the
discharge.   Sometimes there is also a sense of
throbbing in the uterus, with pain, swelling, or
tenderness of the mammae ; and  occasionally
 even  pain in the uterine  region.   The pulse is
 quickened, and sometimes fuller  and stronger
 than usual; and there are generally headache,
 costiveness, and sympathetic  fever.   In  the
 spasmodic state, the pain in the uterine region
 is more severe, but it occurs only in paroxysms,
 and is attended by a twisting sensation in the
 pelvis and lower part of the abdomen ;  or it re-
 curs after intervals, and resembles labour-pains.
 These pains usually precede, for a shorter or
 longer period, the discharge, which is extremely
 various as to amount and continuance.   Some-
 times the discharge  comes on in gushes, with
 coagula, and recurs  more or less frequently.
 These generally afford relief, at least for a time,
 the febrile symptoms subside, and the rest of
 the period is passed as in the more  healthy
 state.  But in more severe or protracted cases,
 after a shorter or longer remission, during which
 either a draining merely continues, or the dis-
 charge is in almost a natural state, an exacer-
 bation, in a more or less severe form, takes
 place ; and thus the complaint may return oft-
 ener than once, and be prolonged  for seven or
 eight days, or even much longer, especially if the
 patient attempts to keep about, or to use any ex-
 ertion.  On examination per vaginam, the os ute-
 ri and cervix, sometimes with the vagina, are oft-
 en discovered to be fuller, hotter, and more ten-
 der than natural.  The discharge usually leaves
 the patient exhausted, and several days elapse
 before her usual health is restored.  This form
 of the complaint may return during several suc-
 cessive periods, each of which may be so pro-
 longed that the intervals between them become
 greatly reduced, and the health remarkably im-
 paired.  In these  cases, this active form  pass-
 es into the  next, or the passive state of the
 complaint.
    113.  B. Passive or chronic hemorrhagic men-
 orrhagia is  generally gradual  in  its accession,
 unless when it is consequent upon the  acute
 state.  It is the most common form of the com-
 plaint, and affects chiefly delicate, hysterical,
 and debilitated females.  It exists in various
 grades, from the slightest increase ofthe men-
 strual discharge to the most severe haemorrha-
 gic prostration.  In some cases, the disease at
 first, or even for several periods, possesses the
 usual features of true  menorrhagia.   In other
 instances, one, two, or more  coagula are ob-
 served at first upon the accession of the period,
     II.              123
and then an  intermission takes place.   The
discharge afterward  recurs more abundantly,
and with larger or more numerous clots.  It
may be so abundant,  or continue so long as to
occasion faintings and great exhaustion; the
back being weak and aching, the countenance
and lips pallid, the strength exhausted, and the
pulse always becoming small, feeble, and quick.
The constitutional symptoms and consequences
of the malady already noticed (y 110), become
urgent or even dangerous, if the discharge be
not checked or arrested.  The uterus, on ex-
amination,  generally  betrays no change.
   114.  C.  Congestive Menorrhagia—Menorrha-
gia with change in the  Uterus.—This variety gen-
erally occurs after forty years of age, or about,
or even after,  the cessation of the  menses.
The discharge is  generally more  profuse, and
its effects more severe in this than in the oth-
er varieties; and  it  takes place in all consti-
tutions, temperaments, and habits  of body.
The attack is  usually preceded for some time
by irregularity of the menses, as to  quantity
and time, as well as  to the duration of the pe-
riods ;  and uterine leucorrhcea has  generally
existed  during the intervals.   About twenty-
four hours  after the discharge has commenced,
large clots are expelled, and the sanguineous
flow becomes still more abundant.  The attack
lasts from  six  to ten days ; but,  in  cases of
longer standing, Dr. Churchill has occasionally
known  it to continue throughout the interval,
and terminate after the next period, either grad-
ually or suddenly ; but it may continue for sev-
eral periods, with remissions merely during the
latter portion of the intervals.  The quantity
lost, in  some instances, has been sufficient, in
one attack, to excite fears  of a  fatal  result.
The discharge  is increased by standing or exer-
tion,  but  it  is not  materially diminished by
the recumbent posture.   In addition to  all the
symptoms  above noticed (y 113), which are oc-
casioned by exhaustion and loss of blood, and
which are still more rapidly and  severely in-
duced in this than in the  preceding varieties,
the  patient complains of weight, dull pain, or
bearing down in the pelvis.   There is also oc-
casionally  dysuria ;  but more frequently irrita-
tion only, extending to the urethra and neck of
the bladder.   The pulse is weak, small, some-
times quick, and  the general health  remarka-
bly impaired.   On  examination  per  vaginam,
the os  uteri is generally found low in the va-
gina, and  is directed more  backward,  and is
more open than in the healthy state.  The cer-
vix uteri is also more swollen, the body of the
organ being thrown forward  so as  to press
upon the bladder. There is no increased heat
of the cervix or vagina, but the former is slight-
 ly tender on pressure, and the body of  the or-
 gan seems somewhat swollen.
   115.  iii. Diagnosis.—A. As respects the Forms
 of the Complaint.—a. The first form of the dis-
 order  is readily distinguished by the absence
 of coagula from the  separation of the discharge
 into  crassamentum   and  serum; when such
 separation takes place, the complaint is no
 longer  true or simple menorrhagia, but one of
 the haemorrhagic varieties.—b. Of these varie-
 ties, the first is distinguished by slight fever,
 pain in the region of the uterus, or spasms in
 this region and in the abdomen, by slight heat
 and tenderness of the os uteri, and by the other 
! 78              MENSTRUATION, EXCESSIVE—Prognosis—Cacse«.
 circumstances of its occurrence as pointed out
 above (y 112).—c. The second of these is not
 attended by fever or by heat, or tenderness of
 the os uteri; but coagula are voided, and the
 parts are generally  soft or relaxed; nervous,
 debilitated, and  hysterical females  being gen-
 erally affected, and anaemia being either present
 or soon supervening.—d. The third or congest-
 ive variety is characterized by the  state and
 position of the cervix and os uteri (y  114), espe-
 cially by fulness  of the former and openness of
 the latter, and by the class of patients in which
 it most commonly occurs.
  116. B. Menorrhagia may  be  mistaken for
 early abortion, or for organic disease  of the
 uterus.—a. Approaching abortion  may be con-
 founded with haemorrhagic menorrhagia until
 the ovum is expelled or detected ;  the  parox-
 ysms of pain, or recurrence of spasms,  attend-
 ing the spasmodic or inflammatory state  of
 menorrhagia, resembling the pains of abortion.
 The retention of a blighted  or of a detached
 ovum often  gives rise to haemorrhage, which
 may be mistaken for menorrhagia; and the re-
 tention, with its consequences, may continue for
 weeks or even  for  months, and yet nothing
 more may be detected on examination  beyond
 greater fulness of the  cervix, and more open-
 ness than usual  of the os uteri.  In these the
 history ofthe case, the continuance  and symp-
 toms  of the  complaint,  and the effects pro-
 duced by the discharge, will suggest its proba-
 ble cause ; and the adoption of the means about
 to be recommended will disclose the nature of,
 as well as terminate, the mischief.  I have been
 consulted in several cases similar to the follow-
 ing : The wife of a friend had passed the usual
 menstrual period a few days when she was at-
 tacked by pains  of a spasmodic nature  in the
 region of the uterus, followed by menorrhagia,
 which subsided upon assuming the  recumbent
 posture.  The discharge recurred, sometimes
 in  gushes, after  more or less marked  remis-
 sions, being generally preceded by pain.   Cup-
 ping,  leeches, anodynes, &c, were  prescribed
 by the surgeon who usually attended her du-
 ring  her confinements.  The  discharge con-
 tinued, and the consequences becoming serious,
 I was requested  to see her.  The  ergot  of rye
 was  prescribed with the biborate of soda, an
 early ovum was expelled, and the recovery was
afterward rapid.   The active form of haemor-
rhagic menorrhagia very closely approximates
to  inflammatory  determination to, or even to
inflammation of  the  uterus; and is to  be  dis-
tinguished from it by the severity and continu-
ance  of the pain, and by general fever being
greater in the latter, the discharge preventing
the former from  passing into an acute state of
inflammation.
  117. b. The difficulty  of distinguishing be-
tween haemorrhagic menorrhagia  and haemor-
rhage caused by  organic disease of the  uterus,
is often very great.  In these latter the haemor-
rhage is irregular, and  occurs at any time, and
without regard to the menstrual period, when
it takes place so early in life ;  it is,  moreover,
attended  by more pain than  menorrhagia, and
by various constitutional indications of malig-
nant or other structural change.  Corroding ul-
cer  or cauliform  excrescence of the os uteri,
 polypus when it  has  descended even partially,
aud ulcerated cancer of the cervix, are  readily
recognised on  examination, when they occa-
sion frequently recurring or protracted haemor-
rhage ; but whether the discharge m caused by
uterine congestion and relaxation merely, or by
a polypus retained  in the uterine cavity, or by
a sub-mucous tumour, or by organic change of
the mucous lining  itself, is difficult  to  deter-
mine.  A favourable diagnosis depends on the
natural state of the uterus as far as may be de-
termined  by examination, on the absence of
great emaciation,  on  the  diminution  of  the
haemorrhage  from  treatment,  on the general
concurrence  of the discharge with the men-
strual periods,  on the  states of the cervix  and
os uteri during  the intervals, and on the appear-
ances of the countenance.  A strumous consti-
tution, as Dr. Ashwell remarks, glandular tu-
mours in other parts, hard tumours of the fun-
dus or body of the uterus, broad ligaments or
ovaries, increasing haemorrhages  and uterine
pain, a gradual deterioration of the  constitu-
tion, and the inefficacy of remedies indicate the
dependance of  the  discharge upon organic le-
sion, and an unfavourable termination.
  118. iv. The prognosis depends upon the evi-
dence furnished as to the existence or non-ex-
istence of organic lesion.  As long as the com-
plaint presents  either of the forms of menor-
rhagia above described, the menstrual periods
being observed, if the  intervals or remissions
are marked accordingly, if there be no sensible
change in the uterus, if the lungs are unaffected,
and the general health not remarkably impair-
ed, a favourable prognosis may be  given.  The
first variety, and active form of the second, are
more readily removed than the other states of
the complaint.  The slighter cases of these may
even cease spontaneously;  but the congestive
form is  generally more obstinate  and severe.
In the severer  cases, pregnancy does  not take
place ; but in the milder cases it may.  When
the disease assumes a more severe, chronic,
and continued form, causing anaemia, nervous
affections, and the more  serious consequences
above alluded to (cj 110,113), it is not altogether
devoid of danger, and a guarded prognosis then
is requisite.  The circumstance of menorrhagia,
when neglected or unsuccessfully treated, being
not infrequently a cause of pulmonary disease,
should not be overlooked.
  119. v. Causes.—a. The predisposing causes
of menorrhagia are, the haemorrhagic diathesis
and hereditary  predisposition, the  earliest and
latest periods of the menstrual epoch, a delicate
or debilitated constitution, general or local vas-
cular  fulness,  and  excitability of the uterine
system.   Several causes both predispose to, and
directly  excite the complaint, particularly vene-
real excesses;  masturbation; prolonged or too
frequent suckling ; leucorrhcea ; indolence, rich
living, and hot beds; spirituous and other liquors
used in  excess; frequent  child-bearing  and
abortions.
  120. b. The other exciting causes  are, local
injuries, falls, concussions of the trunk and pel-
vis, as when falling on the hips ; the use of ir-
ritating  and  exciting purgatives,  particularly
calomel, aloes,  and  colocynth ;  constipation of
the bowels; the irritation of worms in the intes-
tines ; physical efforts, as lifting heavy weights;
exposures to cold, and  mental excitement and
moral emotions.  It is very manifest that these
and other influences will often, directly or indi- 
MENSTRUATION, EXCESSIVE—Treatment.
979
 rfcetly,  occasion increased vascular action  in
 the uterus, or produce increased fulness of,  or
 flow of blood into, the uterine vessels, although
 the vascular system may not be plethoric,  or
 even  may actually be deficient in its due supply
 of blood.   In many instances, the sanguineous
 discharge proves a natural relief to the organ,
 which,  without  such relief, may have  become
 the seat of very acute inflammatory action.
   121.  vi. Treatment.—A. The treatment of the
 first variety, or true menorrhagia, should depend
 much upon the  habit of body of the patient, the
 period at  which it  is prescribed, and upon the
 causes of  the complaint.   The causes should  be
 ascertained, and removed, as far as this  may
 be done—a. When  the  patient  is robust  or
 plethoric, a copious discharge is often salutary,
 and should not he prematurely interfered with,
 or should be allowed to proceed until it ceases
 spontaneously.  Most writers advise  general
 and local  blood-letting, cupping on the  loins  or
 sacrum, &c, and, in  some cases, these deple-
 tions are  both indicated and beneficial, but they
 are as often unnecessary, and in a few instan-
 ces they have proved injurious, by suddenly ar-
 resting the discharge, which  has  not returned
 again in a regular or healthy  form ; or by  giv-
 ing rise to various hysterical affections, partic-
 ularly when the states of general or  of local
 plethora have not been such as to require them.
 In some cases, dry-cupping on the loins, or the
 application of leeches around the anus,  is more
 appropriate and beneficial  than these meas-
 ures.
   122.  b.  When the discharge is really  excess-
 ive, especially in respect of the state of the pa-
 tient, and in the delicate, pallid, and hysterical,
 the patient should maintain the recumbent  pos-
 ture,  on a sofa or mattress, be  restricted  to a
 spare diet and cooling regimen, and take cool-
 ing astringents, as the  infusion of roses with
 sulphuric  acid, or the infusion of cinchona or
 other astringent infusions with nitre.  If the
 bowels  be confined,  the  supertartrate  or  tar-
 trate  of potash may be given with the prepara-
 tions of senna,  or the sulphate or bisulphate of
 potash in  the infusion of  roses.   In other cir-
 cumstances, the acetate of lead with the ace-
 late of morphia, or the sulphate of zinc  with
 opium;  or camphor and ipecacuanha with  opi-
 um ;  or repeated doses of Dover's powder,  will
 be prescribed  with advantage.  The ergot of
 rye has been very generally recommended in
 menorrhagia.   Dr.  Churchill,  Dr.  Ashwell,
 and others advise it in this form of menorrha-
 gia in doses of about  five  grains, three times a
 day.  It is often efficacious, but less frequently
 so in  this  than in the haemorrhagic forms of the
 complaint.  Cold sponging the loins, abdomen,
 and hips,  and cold enemata, may be employed ;
 but injections of cold, astringent fluids into the
 vagina, as directed by  Dgwees and some  French
 physicians, are not unattended by hazard, es-
 pecially  in suddenly checking the discharge,  and
 thereby  risking the occurrence of inflammation
 and internal effusion.  Plugging the vagina, as
 advised  by some writers, or an enema contain-
 ing a scruple of the acetate of lead, as prescri-
 bed by Dr.  Mackintosh, is rarely requisite in  this
 variety of  the complaint.
   123. c. In the intervals between the periods,
strict  reference  should be had to  the state of
the patient.  For the pidhonc  and robust,  a ]
I spare and cooling diet, the bowels being kept
 open by means of the aperients above recom-
 mended (y 122), regular exercise in the open
 air, early rising, and the avoidance of heating
 beverages and of too warm apartments, or too
 soft and warm beds, of full living, luxurious in-
 dulgences, and of the predisposing and exciting
 causes, are especially required.
   124. d. For  the pallid and  delicate,  different
 means are necessary.  To  this class of patients,
 the chalybeates, particularly the tincture of the
 sesquichloride of iron, or  the sulphate of iron
 with quinine and sulphuric acid, are especially
 appropriate.  The chalybeate mineral waters,
 residence  near the sea, or in a dry  and airy
 situation, sponging the loins daily with cold salt
 water, or with a solution of bay salt;  salt-wa-
 ter bathing, or the cold shower bath ;  avoid-
 ance of the causes, as prolonged or excessive
 suckling;  abstaining from, or moderation  in,
 sexual intercourse ; the use of enemata of cold
 water; and a light, nutritious diet, with atten-
 tion to the state of the bowels, are also requi-
 site.   Wine may be taken in small quantity ;
 and the extremities and surface should be kept
 moderately warm, but too much clothing around
 the loins and hips is injurious.
   125. B.  The second, or hemorrhagic variety of
 the  complaint, should be treated on the  same
 principles as have been stated above.—a. During
 the acute or inflammatory form ofthe attack, bleed-
 ing, general or local, or both, is more appropriate
 than  in simple menorrhagia.   This form of the
 complaint, as I have remarked, approaches to
 metritis, into which it would readily pass if the
 discharge did not occasion a resolution of the
 morbidly increased vascular action in, or deter-
 mination to, the womb.  The cases,  however,
 are  comparatively few  in which the  disease
 nearly reaches this state;  but in these, deple-
 tions, according to the state of the pulse ; cool-
 ing  aperients  and diaphoretics;  the  prepara-
 tions of antimony conjoined  with sedatives;
 the acetate of lead with acetate of morphia;
 ipecacuanha with opium, or Dover's  powder,
 are principally indicated.   Dr. Ashwell states
 that  Dr. Cholmely prescribed drastic purges
 for all cases of acute haemorrhagic menorrha-
 gia that came under his care in Guy's  Hospital
 —a practice, doubtless, attended by success in
 the great  majority of instances, owing to  its
 derivative  operation ; but, if these purgatives
 had acted much on the lower bowels, the ute-
 rus may have participated  in the irritation and
 consequent vascular determination.
   126. When the acute  form of haemorrhagic
 menorrhagia is attended by much pain or spasm,
 or by recurrences, or by exacerbations of either
 of these, ipecacuanha with opium, in frequent
 doses ; digitalis with camphor and belladonna,
 and a plaster applied over the sacrum contain-
 ing the extract of belladonna, are generally ben-
 eficial.   If there be any reason to infer that the
 discharge and  pain are perpetuated by the re-
 tention of an early detached or blighted ovum,
 the biborate of soda may be given in solution
 either alone or with the tincture or powder of
 the ergot; or an enema  may be administered,
 containing the spirits of turpentine and the ex-
 tract  or confection of rue ; and an epilhem or
 embrocation with turpentine, or with some one
 of the liniments in the Appendix (F. 297, 311),
 may be placed over the hypogastrium.  In these 
980                  MENSTRUATION—Certain Irreqolahitibs or.
cases, about half an ounce of turpentine may
be taken by the  mouth, with an  equal quantity
of castor oil, either on the surface of milk or
in any suitable  vehicle, and  may even be re-
peated, particularly when the discharge contin-
ues, or resists the other means which have been
here advised, the enemata just prescribed being
also repeated in  these circumstances.
  127. During the  intervals, the treatment of
this form of haemorrhagic menorrhagia should
be  in no respects different from that  advised
for  simple menorrhagia in plethoric habits.  In
many cases,  it should be conducted with the
conviction that  more or less local congestion
or vascular determination continues during the
interval; and, consequently, a cooling regimen,
spare diet, occasional local depletions, refriger-
ants, cooling aperients, and avoidance of the
causes, should be recommended.
  128. b.  The passive or chronic state of haem-
orrhagic  menorrhagia should be  treated, when
the  disease is not severe, nearly  as advised for
simple menorrhagia occurring  in delicate fe-
males.  In this state of the complaint the ergot
is especially  useful, and it may be conjoined
with the biborate of soda ; or the latter may be
given with vegetable tonics, astringents, and
aromatics. In  the more  severe or obstinate
cases, the means just advised (y 126), or those
prescribed for Hemorrhage from the Uterus
(247, et seq.), must be resorted  to.  The cold
douche on the loins and hips; cold astringent
enemata,  or terebinthinate enemata; terebin-
thinate epithems, or embrocations on the hypo-
gastrium ; the recumbent  posture and perfect
quietude, are also beneficial.   Dr. Blundell re-
sorts " to the injection of astringents, not into
the vagina only, but into the uterus itself," in
cases where the bleeding goes on until the pa-
tient is  reduced to  extreme weakness.   In
these, the more  astringent  tonics and mineral
acids, the tinctura ferri  sesquichloridi,  with
tinctura  lyttae,  in the infusion  of quassia  or
calumba ; the bi-sulphate of potash in the infu-
sion of roses, with tincture of henbane, when
the  bowels are  confined;  and,  subsequently,
the vinum ferri,  or other chalybeates, a moder-
ate  use of wine and light, nutritious food, resi-
dence on the  seacoast, or in a dry air, and the
use of the mineral waters recommended for
convalescence from Hemorrhage (v 251), and
the other means advised above (y 123), during
the intervals of simple menorrhagia, are gener-
ally appropriate.
  129. c.  The third form of haemorrhagic men-
orrhagia  requires  but slight  modifications, if
any, of the treatment already stated.  Previous
to the recurrence or exacerbation of an attack,
and when there is evidence of local congestion,
the system not being much reduced, cupping on
the loins, or leeches in the vicinity ofthe anus,
may be prescribed ;  the causes of the complaint,
particularly local  excitements,  sexual  inter-
course,  &c.,  being avoided.  In this state  of
disorder tonic astringents are required, even at
the time when local depletions  are indicated ;
and when these latter should not be resorted
to,  dry cupping  on the loins  may be  directed.
In  this form, as well as in the  preceding, the
ergot of rye  will generally prove efficacious ;
and the several  means just recommended for
passive menorrhagia (y 128) will also be of ser-
vice in this.  If the cervix or body of the ute-
rus be enlarged, the preparations of iodine, es-
pecially the iodide of iron or of mercury, or the
iodide of potassium and liquor potassae, the io-
dide and other preparations of arsenic, and blis-
ters repeatedly applied over the sacrum, or kept
open for some time, or other counter-irritants
in the same situation, will generally  prove ben-
eficial.   The other means already directed for
the preceding states of menorrhagia, during the
period and  intervals, may also  be resorted to
in this,  more particularly the astringent and
terebinthinate enemata, and terebinthinate epi-
thems applied over the hypogastrium.  If this
form of menorrhagia be dependant upon organic
change in the uterus, the treatment should be
mainly  directed  to such change.   (See  art.
Uterus.)  When  menorrhagia assumes those
severe and even extreme forms which are truly
haemorrhagic, the observations which have been
made at due length on the pathology and treat-
ment  of hamorrkagia from the uterus, are  alto-
gether applicable to it.  (See art. Hemorrhage,
y 220, et seq.)
VI. Of certain Irregularities of Menstrua-
  tion NOT COMPRISED  UNDER  THE FOREGOING
  Heads.
  130. I have elsewhere stated that menstrua-
tion may take place prematurely, and that when
the discharge appears irregularly, or only occa-
sionally at an earlier age than that which has
been assigned above to the commencement of
the menstrual epoch, it should be often viewed
as  haemorrhage  from  the uterus or genitals,
rather than early menstruation.  On this sub-
ject I shall, therefore, add nothing at this place
to what I have said in the article Hemorrhage
(see y 222).
  131. i. Irregular Menstruation and its Compli-
cations.—A. In some instances the menses are
premature, but they afterward  cease, and again
recur, sometimes profusely, after irregular and
prolonged periods.  In other cases they are de-
layed, then appear for a few periods, either scan-
tily or profusely, and thus return after irregular
or prolonged intervals.   In many cases, these
irregular states are complicated with leucorrhea,
and if this association be allowed to proceed,
chlorosis  or tubercular disease of the lungs may
supervene, and place the life of the  patient in
the greatest jeopardy.   They may also occur
in connexion with chorea, especially scanty and
irregular menstruation, but not so often as de-
layed menstruation, which generally exists when
chorea continues up to  puberty.  In young fe-
males, particularly  in the scrofulous and deli-
cate, these irregularities, especially when they
are connected with delayed menstruation, are
sometimes associated with enlargement or chronic
inflammation of the lymphatic,  parotid, and sub-
maxillary glands.   I have been consulted in
several instances  on account of glandular en-
largement  in various situations, particularly of
the  glands just  mentioned,  which  had  com-
menced  about the period of  puberty ;  and in
all  these the catamenia had been delayed, or
had appeared scantily, and at  long intervals.
These cases occur chiefly  in large boarding-
schools, where too many sleep in one  apart-
ment, and where due exercise in the open air
is neglected.  They are frequent, also, in fac-
tories in which females about the period of in-
cipient puberty are employed.   At this period,
and also in connexion with delayed or scanty 
MENSTRUATION—Certain Irregularities of—Treatment.             981
menstruation, the slighter forms of goitre are
not infrequent, especially where this latter dis-
ease is endemic.
   132.  These irregularities, as to the time and
abundance ofthe catamenia, are often, also, as-
sociated with the earlier  periods of tubercular
consumption, with general cachexia, and with the
slighter forms  of chlorosis ; complete  amenor-
rhoea more  frequently accompanying the advan-
ced state of this latter complaint.  In these ca-
ses, tubercular disease ofthe lungs is a frequent
termination ofthe malady.*
   133.  B. Treatment.—For these irregular and
complicated  states  of menstruation,  there is  no
  * [Dr. W. Detmold, of New-York, has recorded, in the
New-York Jour, of Med. and Collateral Sciences, vol. i.,
two very interesting cases of complicated menstruation.  Iu
one case, a young lady of 15, who had regularly menstrua-
ted, was attacked with sudden suppression, soon after bleed-
ing for a sore throat, which  came on during the flow.   At
the same time she lost the use of her left leg, which became
very painful, and began to swell from the hips down to the
toes.  Simultaneously with  the swelling of the leg, the
whole surf act ofthe body became covered with black hair, so
that the arms, legs, and chest of the young lady looked
more like those  of a hairy man of  forty, while the upper
lip and cheeks were covered with a delicate dark down, as
we see sometimes in young men approaching the period of
puberty.  Three months after this period, Dr. D. describes
the patient as much emaciated ; anxious countenance, and
expressive of suffering, hair over the  body, lips, &c, as
above described, left leg much  swollen (the circumference
around the  knee beiHg 22 inches) ; the skin was neither
changed in temperature nor in colour; the swelling  was
neither phlegmonous nor osdetnatous; to the touch it was
solid, and felt like a plastic  deposite ; it resembled hyper-
trophy, and the whole limb presented somewhat the appear-
ance of phlegmasia alba.  Outside and above the knee was
a superficial and limited fluctuation, which, on being opened,
discharged for several days a moderate quantity of healthy-
looking pus; and a similar fluctuation appeared, a few
weeks after, directly over the patella. The patient suffered
intense pain from the slightest attempt at moving the limb,
over which she had  no control whatever.  She had two
large ulcers over the sacrum from decubitus, and the pulse
was alwut 108 in a minute, it having been as high as 120.
The appetite was good, and in  a short time the patient be-
gan to improve, the swelling subsided, and the ulcers healed,
and in four months and a half she was able to walk on crutch-
es.  The unnatural growth of hair upon her body and limbs
gradually disappeared, and  in  about six months from the
commencement of the disease, the  menses made  their re-
appearance.   She finally entirely recovered, with the ex-
ception of a  false anchylosis of the knee joint, evidently
caused by plastic deposite in the soft parts and ligamentous
apparatus around the joint. Otherwise, she had the full
use of her limbs, with the exception that, after much exer-
cise, she had a feeling of fatigue in that leg, and it became
slightly (Edematous.
  The second case was one of a married lady, of lymphatic
temperament, who  had  regularly  menstruated until  her
marriage, which took place while yet  very young. Soon
after marriage, her menstrual  functions became deranged,
the pain at each period being so excessive that she had in-
variably to  keep her bed for about a week.  The pain and
uterine spasms were at times so violent as to produce con-
vulsions; and withal, she never lost more than a few drops
«f blood during the first few hours of  each menstrual pe-
riod. She had never, during  the eight years of her mar-
rage, been pregnant.  She  had tried the whole routine of
remedies for difficult and painful menstruation, with only
temporary and partial relief.  Besides her regular attacks
ef illness every four weeks, she complained of a continual
feeling of soreness above the os pubis, which was much in-
creased after sexual intercourse.  The os uteri felt rather
large and soft, and on examination  per speculum, the labia
ofthe os tines showed a dark purple colour, evincing much
nervous congestion at the regular  menstrual period.   Six
leeches were  applied to the os, which bled very profusely,
and the patient had no pain or spasms of any kind during
the menstrual flow, being the first time in about eight years.
Leeches were applied in the same manner every month, upon
the first warning of the approaching menstruation, and each
time with the same beneficial result. During the intervals,
injections of cold water were  employed per vaginam, and
she  slept absque marito.   Under this treatment, w,th a
plain and simple diet, regulating the bowels with  rhubarb,
■he  entirely recovered, the leeches having been applied
four times.   She afterward menstruated with ordinary case
and regularity, and soon became pregnant.—Loc. cit.)
remedy so much to be depended upon as iodine,
in judicious  combinations, particularly  when
aided by change of air, residence on the sea-
coast, salt-water  bathing,  chalybeate  mineral
waters, and  walking  exercise,  or  riding  on
horseback.  The iodine may be combined with
iron, the  liquor  potassae, or other substances,
according to the  features  of  the case.   The
preparations  of iron, particularly the  mistura
ferri  composita, and emmenagogue and' sto-
machic purgatives, are  also indicated. If leucor-
rhea  exist, the means advised  for  that  com-
plaint may be prescribed, or the above  treat-
ment varied  accordingly.  In  the summer  of
1826, I was requested  by Mr. Annesley to see
Miss C, aged sixteen years, who had the parot-
ids,  sub-maxillary glands,  and the  lymphatic
glands  in the neck, near the clavicles, and  in
the axilla, remarkably  enlarged,  and in a state
ofchronic inflammation ; the integuments, how-
ever, had not become discoloured : the catame-
nia had not  appeared.   I  advised a course  of
iodine  in combination with liquor potassae, and
afterward with iron, and persistence in the use
of these for some months in small or moderate
doses ; the catamenia  appeared at first scantily
and irregularly, and the glandular disease grad-
ually disappeared  without proceeding to sup-
puration.   Several cases of a similar descrip-
tion have occurred to me in the  circumstances
alluded to.   These several forms of scanty and
irregular  menstruation, especially  those with
prolonged  intervals between  the periods, re-
quire  much  the same treatment as was advi-
sed for amenorrhcea in delicate constitutions (y
32-38).
   134. ii. Offensive or otherwise morbid catamenia
are occasionally  observed ;  and especially in
the same circumstances as I have  mentioned
 in connexion with the production of  the fore-
 going irregularity.—A. The discharge may not
only be very offensive, but  also discoloured, and
remarkably irritating to the parts  with which
 it comes in contact.   I was  many years  ago
 called  to  a young lady, about  seventeen  years
 of age, in a boarding-school, who was suffering
 in a distressing manner in consequence of the
 irritating and offensive state of  the catamenia.
 There had been no retention of the discharge,
 but it was so irritating as to inflame  the vagi-
 na, the labia, and insides of the thighs, severe
 erythema extending along the limbs,  and for a
 considerable distance  over the hips, and  confi-
 ning her for several days to bed.   She had suf-
 fered in  a much  less  severe  manner in  some
 of the preceding menstrual  periods.  I have
 since  met with instances of  this state of the
 catamenia being complicated, or otherwise con-
 nected, with erysipelas.  These conditions did
 not appear  to  have been  caused by  retention
 of the discharge in the vagina,  as no obstruc-
 tion existed, and there was no other  symptom
 of menstrual disorder.   Dr. Blundell, howev-
 er, makes mention of  partial closing of the ori-
 fice ofthe vagina as being, in  rare instances, a
 cause  of offensive catamenia.   In the cases to
 which I  have here directed attention, the cata-
 menia are offensive, owing generally, at least
 as I have observed, to constitutional  disorder,
 or to a morbid  state ofthe circulating fluids, in
 connexion with impaired action of the principal
 organs of depuration.   Besides this  state, in
 which the discharge is generally also very dark, 
932
MENSTRUATION—Bibliography and  Reference*
black, or pitchy, or greenish-black and very of-
fensive,  and besides the presence in it of mem-
branous  exudations, as described above (y 84),
it sometimes  is  grumous,  at  other  times pale,
or serous.   These conditions ofthe menstrual
discharge may be  preceded or followed by leu-
corrhcea, or be associated with general cachex-
ia, or connected with erysipelas.   In one case
this offensive  and  pitchy condition ofthe men-
ses proved  critical at an  early period of erysip-
elas in the  face, in a female of eighteen years
of age.
   135. B. The treatment  of these states of dis-
ordered  menstruation depends much upon the
affections with which they are associated.   In
most of  those which I have observed, the func-
tions  of the liver, bowels, and  skin were im-
paired ;  and the patients were placed in  unfa-
vourable circumstances  in respect  of  air and
exercise, and  had  neglected the state of their
bowels.   In these, stomachic  purgatives, ton-
ics with alkalies,  emmenagogues  and  altera-
tives, were prescribed  with complete  success,
and were continued during the intervals of in-
disposition, aided  by change  of air, exercise,
the use  of  alkaline  or  chalybeate mineral wa-
ters, sea-bathing,  &c.   In  these cases,  atten-
tion to the state of the  general  health, and to
the  assimilating  and  excreting  functions,  is
the  chief indication of cure.    The articles on
Catalepsy  and  Ecstasy,  Chlorosis, Chorea,
Hemorrhage from  the Uterus, Hysteric Af-
fections, Leucorrhcea,  Ovaria, and Uterus,
may be consulted in connexion with disordered
Menstruation.
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v., n. 33 ;  et  yui«iiK£(u>»', Opera,  p.  590.—Aretaus, L. ii.,
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De Morbis Mulierum, 1. n., c.2.—Attius, Tetrab., 1. iv., sect.
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Acta Haun., vol. i., 81 ; vol. ii., 34 ; vol. v., 74.—Schurig,
Han.atalogia,  p.  271 ;  et Gynsecologia, p. 131.—J. Friend,
Emmenologia, Svo.  Oxf., 17U3.—Bonet, Sepulchretum, 1.
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Pract., t. iv.— Boerhaave, Praxis Med., pars v., p. 218.—T.
Simson, The  System of the Womb, with an  Account of the
Menses, &c, Svo.   Edin., 1729.—Blankard,  Collect. Med.
Phys., cent, iv., No. 9.—Le Tellier, Critical Reflect, ou Dr.
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1731.—J. L. Regemann, De Morbis ex Menstruis  cessanti-
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ica de Mensium Fluxu, &c,  12mo.  Lond., 1752.—J. As-
true, Traite des Maladies des  Feimnes, t. i., 12mo.  Paris,
1701.—Morgagni, De Sed. et Causis Morborum, Ep. xlvii.,
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4to, 1766.  — Linnmus,  in Amuenit. Acad. Upsal, vol. viii.,
p. 237  (Marum cum Ferro m Suppr. Mens.).—J. Stedman,
Physiolog. Essays and  Observat., Svo.  Edin., 1769.— Wal-
ter, in Nouv.  Mem. de Berlin, ann.  1774, p. 81.— De Haen,
Rat. Med., p. vi., c. 2.—Magnan, in  Hist, de la  Societe
Royale de Medecine, 1776, p. 286.—Rathieu. in Ibid., 1777,
p. 78.—J.  Birch, Considerations on the Efficacy of Electri-
city in removing  Female Obstructions, Svo.  Lond., 1779.—
A. Pasta,  Sopra e Mcnstrui delle Donne, 8vo.  Napoli, 1782.
—Brandis, Versuch ueber die Metastasen,  p. 163.— Friar,
Med. Facts and Observat., vol. viii.—I. Leake, Medical In-
structions towards the Prevention and Cure of Chronic or
slow Diseases peculiar to Women,  2d edit., p. 43, et seq.
Lond., 1787.—Boyer, Mem. de l'Acad. des  Sciences, ann.
1771. — Fothergill, in Med. Observat. and Inquiries, vol. v.,
p. 184.—Sherwaen, in  Ed. Med.  Comment., vol. ii.—Adair,
to Ibid., vol. x., p. 47.—De Meza, in Ibid., vol. xii., p. 380 ;
rt in  Acta Reg. Soc  Med. H*vn., vol. in.. P- 'f9'..^--
Mannelli, Medecine all'lnfirm.ta delle  Donne, •^'••"P
17.- Whytt, Works, Ac, p. b^O.-Krebs,  Medicin. Beobach-
tungung, b. ii., St. iv., No. 2.-Home .Clinical Experim
Ac, p. hl.-Pearce, in Mem. of Med. Soc. of London, vol.
iii.. Append., No. 3.-Conradi, Handb. der Pathol  Anat.,
p. 239; et in Hufeland, Journ. der Pract. Arzeyk., b. vi., p.
m.—Gebcl, in Ibid., b. vii., »t. 3, p. 1 il.—-Starke, Klinisch-
es lnstitut.,p.51.—Thomann, De Fluxu Menstruo Natural!
ejus Retentione, 8vo.   Wurz., 1797 ; et Annale* Wurce-
burg,  vol. i., p. 206.—Aldini, Essai »ur le Galvanisme, 4c,
p. j,j.___}, jj/. J. Vigarous, Cours tle-mentaire de Maladies
des Femmes, et Essai sut nouvelle Method* pour etudier
et pour classer les Maladies de ce Sexe, t. i., p. 74, et seq.
Paris, 2 tomes, 1801.—/. P. Frank, De curandis Hominum
Morbis, 1. v.;  De Profluviis, pars ii., 1. vi. ; De Retentioni-
bus, pars iii., p. 101.—P. A. Beclard, sur les Maladies dei
Femmes, a l'Epoque de la Cessation des Menstroes, Svo.
Paris,  1802.—A. Royer-Collard, Essai sur l'Amcnorrhee,
Svo.  Paris, 1802 ; el Diet, des Sc. Med., t. l.—A. Fogg,
Observat. on the Uterine Discharge, Amenorrhea, &c.,8vo.
Newcast., 1803.—Osthoff, Untersuchungen ueber die Ano-
malen der Monatlichen Reinigung,  8vo.  Lerog., 1804.—
Portal, Cours d'Anat. Medicale, t. iii., p. 170 ; t. v., p. 537.
—Oberteuffer, in Stark's N. Archiv.,b. ii., p. 637.—Osiander,
Denkwiirdigheiten, b. ii., p.  183.—Bischoff, in Hufeland,
Journ. der Pract. Heilk., b. xiii., st. 4, p.  117.—Ritter, in
Ibid., b. xvii., st. 3, p. 37.—Reil, Memorab.  Clinica, fasc.
iii., p. 206.—Martin Wall, in Trans, of Med. and  Chirurg.
Soc.,  vol.  ii.—Horn, Archiv.  der  Practischen Heilk. fur
Schlesien, b. iii., st. 1.—C. Hohnbaum, Ueber eine Beson-
dere Art des uebermassigen Monatflusses, Svo.  Erl., 1811.
— J. A. Pitschaft, Unterricht ueber Weibliche Epoche, 8vo.
Heidi., 1812.—Joerg, Krankheiten des Weibes, p.  13fi.—
Capvron, Malad. des Femmes, t.  iii., p. 120. — Siebold,
Francuzimmerkrankheiten, b. i., p. 339. — D. Stewart, A
Treatise on Utenne Hemorrhage, Svo. Lond., 1816.—May
grier, in Diet, des  Sciences Med., t. xxxii., p. 375.—P. A.
Surun, Theorie de la Menstruation, Svo.  Pans, 1819.—
Zuccari, in Revue Medicale, t. ii., p. 292, 1824.—Goupil,
in Ibid., t. i., p. 455, 1825 (Nit. Potassa in very large doses
in Menorrhagia).—Desormeaux, in Diet, de Medecine, t. i.,
p. 166; t. xiv ,p. 175.—J. Hamilton, Outlines of Midwifery,
p. 152.  Edin., 1826.—Berndt, Encyclop. Worterb., b. ii.—
Bonfils, Archives Generales de Med.,t. xix.,p. 112.—Porta,
in Ibid.,t.  xiv.,p. 427 (Tannin in Menorrhagia).—Cavalier,
in Ibid., t. xix., p. 589.—J. Osborne, in Trans, of Irish Coll.
of Phys., t. v., p. 18 (Ipecacuanha Emetics in Menorrhagia).
— Roche, Diet, de Med.  Prat., t. i.—Duges, in Ibid., t. xi.—
W. P. Dewees, in Medico-Chirurg. Review, vol. i., p. 495 ;
and Treatise on the Diseases of  Females, p. 44, et  seq.
Philad., 1828. — Roberton, in Edin. Med. and Surg. Journ.,
vol. xxxviii., p. 277.—Loudon,  in Ibid., vol. xxxviii., p. 61.
—Bardsley, Hosp. Reports, p. 51.—M. Hall, Comment on
some  important Dis. of Females, p. 1, et seq., Svo. Lond.,
1827.—Le Beau, American Journ. of Med. Sciences, Nov.,
1832.—Hooper, On the Morbid Anat. of the Uterus.  Lond.,
1832, pi. i., fig. 2— F. Duparcque, Traite Theor. et Pratique
sur les Alterations Simples et  Cancer, de la Matrice, p. 21.
Paris, 1839.—Nauche, Maladies propres aux Femmes,  Ac,
vol. ii., p. 646.—Locock, Cyclop, of Pract. Med., vol. i., p.
67, 661 ; vol. iii., p. 105, 110.—Petrequin, in Med. and  Chi-
rurg. Rev., vol. xxix., p. 605.—A. B. Granville, Graphic II-
lustr. of Abortion and of the Dis. of Menstruation, <fcc.,4to.
Lond., 1833.—Amussat, Gazette Medicale, Dec, 1835.—•
Mackintosh, Pract. of Phys., vol. ii., p.  425.—O'Reilly, in
Dublin  Journal of Medical Sciences, vol. vi., p. 318.—F.
Churchill, Outlines of the Principal Dis. of Females, p. 60,
et  seq.  Dublin, 1838.—B. Riofrey,  Treatise on Physical
Education, especially adapted  to young Ladies, 2d ed.,8vo.
Lond., 1838.—J. Balbirnie, On the Diagnosis  and  Treat-
ment of Organic Diseases of the Womb,  p. 77, 8vo.  Lond.,
1836.—Waller, On the Funct.  and Dis. ofthe Unimpregna-
ted Uterus, 8vo.   Lond., 1840.—4>. Ashwell, Pract. Treatise
on  the Dis. peculiar to Women, part i., p. 55, et seq.   Lon-
don, 1840.— Ferguson, in Library of Pract.  Med., vol. iv.,
p. 300.
  [Ad. Bibliog. and Refer.—Samuel Ashwell, A Practi-
cal Treatise on the Diseases peculiar to Women, illustra-
ted by Cases, &c, with Notes, by  Paul B. Goddard, 8vo.
Phil., 1846, p. 520.—Colombat de Tlsere, A Treatise on the
Diseases and Special Hygiene of Females ; Am. ed., by C.
D.  Meigs.  Philad., 1846, 8vo.— W. Detmold, in New-York
Jour, of Med. and Coll. Sciences,  vol.  i.—F. C. Stewart,
Case  of vicarious Menstruation, in New-York Jour, of Med.
and Coll. Sciences, vol. ii., p. 327.—Raciborski, Influence
of  Menstruation on Lactation, in New-York Jour, of  Med.
and Coll. Sciences, vol. iii., p.  133.—De Muynck and Kluys-
hens, in New-York Jour, of  Med.  and Coll. Sciences, vol.
iv., p. 107.— H. Parker, Fatal  Menorrhagia, in Bost. Med.
and Surgical Journal, vol. xxii., p. 127.— W. Stockbridge, in
Bost. Med. and Surg. Jour., vol. xxv., p. 99.—E. Wilkinson,
in Bost. Med. and Surg. Jour., vol. xxi.,  p. 176.— C. S.Ala-
goun, in Bost. Med. and Surg. Jour., vol. xxi., p. 160 (Case
of difficult or suppressed Menstruation successfully treated,
by applying belladonna to the os  uteri}.—Af. Bourgeois, 
MESENTERY—Diseases of  the Glands of.
983
Anomalous Menstruation, in Boston Med. and Surg. Jour.,
vol. xvi., p. 163.—Gall, On Law of Menstruation, in Bost.
Med. and Surg. Jour., vol. xiv., p.  190.—/. Eberle, Chronic
Menorrhagia, in Bost. Med. and  Surg. Jour., vol. viii., p.
84.— W. P. Buel, in Am. Jour. Med. Sci., vol. vii., N. S.,
p. 98.—/. E. Taylor, in Am. Jour. Med. Sci., April, 1843.
—M. Aran, On Savin in Menorrhagia,  iu Am. Jour. Med.
Sci., vol. viii.,  N. S., p. 475.—R.  Chambers,  in Am. Jour.
Med Sci., N. S., vol. iii., p. 208.—J. E. Sands, in Western
Journ. of Med. and Surg., Jan , 1842.—T. R. Beck, Statis-
tics of Menstruation, in Am. Jour.  Med. Sci., vol. iv., N. S.,
p 213.—G. S.  Bedford, Am. ed. of Chailly's Midwifery —
Harvey Lindsly, Am. Jour. Med. Sci., vol. xii. (Case of de-
ranged Menstruation, p. 366).]
  MENTAGRA.  See Sycosis.
  MESENTERY AND  ITS GLANDS.—That
portion of the peritoneum forming the  mesentery
is less frequently the seat of disease  than that
which is reflected over the digestive canal and
other viscera, more especially of inflammatory
diseases and their consequences.   The mesen-
teric or lacteal glands are  liable to the same
changes as the lymphatic glands; but the dis-
eases of the former are generally  more dan-
gerous  in their consequences than those ofthe
latter.  As the mesentery and  its  glands are
portions only of two kinds of structure which
are fully discussed in  other  articles,  I shall
consider only those changes of them which,
owing  to their pathological relations,  and  to
 the phenomena they occasion, require a special
notice.
 I.  Mesentery — Inflammations of.—Synon.
   Mesenteritis ; Mesenterite, Fr.  Die Gekrbsen-
   entziindung, Germ.
     Classif.—III. Class,  I. Order (Author).
   2.  Defin.—Pain, deep-seated, and  extending
 from the spine to the umbilicus, increased by press-
 ure, cough,  Jf-c, attended by symptomatic fever.
   3. i.  Symptoms and Diagnosis.—The exist-
 ence of mesenteritis  is determined with great
 difficulty ; for, as Frank observes,  it is seldom
 observed in an  uncomplicated form, but gen-
 erally associated with enteritis.  It also some-
 times is  complicated with peritonitis, nephri-
 tis, or even with pancreatitis ;  and it generally
 escapes detection  until disclosed by post-mor-
 tem examinations.   Mesenteritis  very rarely
 occurs in an acute, primary, and simple form;
 but more frequently in a chronic, secondary, and
 complicated state.—A. The acute form  of  the
 disease is indicated by a constant,  deep-seated
 pain, extending to the  spine and  umbilicus ;
 increased by cough, sudden motion ofthe trunk,
 by sneezing, and pressure  ; and attended by  a
 sense of heat,  by  constipation, vomiting, and
 by fulness  and  hardness of the abdomen.  In
 some  instances the hardness  is unequal, and
 occasionally ischuria is  present, particularly in
children.   The  accompanying fever is general-
ly inflammatory.
   4. B. The chronic state of mesenteritis is  not
 infrequent, either  in a  simple or tubercular
form ;  but  is usuatly consequent upon, or com-
plicated with scrofulous inflammation  or  en-
largement  of  the mesenteric  glands, with
chronic peritonitis or pancreatitis, or with oth-
er diseases of adjoining viscera.   In its tuber-
cular form  it is always associated with tuber-
cular peritonitis, of which  it is merely an  ex-
tension.  It is  hence hardly or never to be
distinguished from those maladies, even when
most prominently marked, or  is  very rarely
suspected to exist until disclosed by a post-
mortem examination ;  and its  symptoms  are
even more  obscure than those ofthe acute, the
obscurity being great in proportion to the com-
plexity and prolonged duration ofthe disease.
  5. C.  Chronic as well  as  acute mesenteritis
is  met  with chiefly in children of a  strumous
diathesis, and  is  caused by the  maladies al-
ready noticed, by  chronic  dysentery,  by dis-
eases of the spinal column, by inflammation of
the psoae muscles, by enteritis, and by aneu-
risms of the  aorta.   The predisposing  and ex-
citing causes of both the  acute and  chronic
forms are, therefore, those which  commonly
occasion those maladies, particularly peritonitis
  6  D. The consequences  of mesenteritis  are
enlargement, inflammation, or induration ofthe
chyliferous glands ;  albuminous exudations on,
and adhesions of the opposite surfaces ; effu-
sions of serous, or sero-albuminous, or sero-
puriform matters  from  the inflamed surface ;
purulent collections between the  laminae of
the  peritoneum forming the  mesentery,  and
the other lesions described in the article Peri-
toneum.
  7. ii. The treatment of mesenteritis is  the
same as that advised for peritonitis,  due regard
being had  to  the  activity or form of  the  dis-
ease, the causes  which produced it,  and the
constitution ofthe patient,  especially the scrof-
ulous, when that is clearly  evinced (see article
Peritoneum).
II.  Disease  of the Glands  op the  Mesen-
  tery.—Syn.  Mesenteric Disease ;  Tabes Mes-
  enterica ;  Mesenteritis  Chronica;  Marasmus,
   Auctorum.    Atrophia  Mesenterica,  Atr. In-
  fantilis, Hoffmann.  Febris Hectica Infantum,
   Sydenham.   Scrofula Mesenterica, Sauvages.
   Padatrophia  Glandularis, Swediaur.  Tabes
   Scrofulosa, Cullen.   Parabysma   Mesenteric
   cum,  Good.  Physconia Mesenterica, Beaumes
   and Sauvages.   Marasmus Infantilis ; Tabes
   Infantum ;  T. Atrophica ; Padatrophia, Auct.
   var.   Carreau, Atrophic  Misenterique, Ente-
   ro-Misenterique,  Fr.   Darrsucht der  Kinder;
   Gerbschwindsucht, Atrophie der Kinder, Germ
   Atrofia,  Ital.   Mesenteric Decline ; Atrophy ;
   Mesenteric Fever; Tubercles of the Mesentery.
     Classif.—IV.  Class,  I. Order (Author).
   8. Defin.—Distended  and enlarged abdomen;
emaciation gradually increasing; irregular and
otherwise disordered bowels, and ultimately hectic
fever, from enlargement and disease of the mesen-
teric glands.
   9. Of the numerous designations imposed on
the malady about to be considered, tabes mesen-
terica, disease of the glands  of the mesentery, and
marasmus  or atrophy from  diseased mesenteric
glands, are the most generally applicable.  Sau-
vages,  and recently Dr. Joy,  have  considered
scrofula mesenterica to  be  most appropriate;
but, although enlargement or other disease of
Ihe mesenteric glands occurs most frequently
in  scrofulous constitutions, it is not  confined
to  them.  The appellation infantile is equally
objectionable ; for, although the disease is most
common in  children, the  disease is not con-
fined to them, or to any age.  The term entero-
mesentirique has been applied to it,  on  the sup-
position that the  affection of the glands is al-
ways consequent upon, or  connected with irri-
tation  or disease of the mucous  surface of the
intestines.   Doubtless such is the  case in the
great majority of instances, but not universal-
ly ; for, as in the  lymphatic glands, in various
situations, especially as observed in scrofulous 
984               MESENTERY—Diseases of the Glands of—Causes.
constitutions, so in the mesenteric glands, dis-
ease may occur primarily and independently of
inflammation or irritation in parts  related to
them.
  10. i. Acute  Disease  of the  Mesenteric
Glands.—An acute form of disease ofthe mes-
enteric glands has been observed but rarely or
never unconnected with  some  other  disease,
particularly fever and dysentery.   Baglivi  no-
ticed this connexion in the fevers occurring in
Rome; and MM. Petit and  Serres described
the association  as  they observed it  in the fe-
ver which was epidemic in Paris during 1811,
1812, and 1813.   Still more recently, MM. Cho-
mel, Louis,  Andral,  and Cruveilhier have
noticed an inflammatory, or, rather, a congest-
ed and enlarged  state of these glands, in many
cases of fever, when the internal surface  ofthe
bowels  was  inflamed  or ulcerated.  I have
seen the same association  of disease in ady-
namic fevers, both in temperate and in tropical
climates ;  and not only  in  these fevers,  but
also in dysentery.   That the affection of the
mesenteric  glands is  merely a complication
contingent upon  irritation of the intestinal mu-
cous surface and glands in these maladies, and
is much more frequently met with in some ep-
idemics, and in  certain localities than in oth-
ers, cannot be disputed ; but it has  no claims
to be considered as a " simple acute inflamma-
tion of the mesenteric glands," as some au-
thors have considered  it; for it occurs chiefly
in connexion with marked asthenia or depres-
sion of the powers  of life ; and is  indicated
merely by enlargement and  increased vascu-
larity, changes consequent  upon irritation  or
congestion  more frequently than  upon actual
inflammation.
  11. Acute  disease of the mesenteric glands
can therefore be viewed only as consecutive or
symptomatic, chiefly of  the maladies  just men-
tioned.  As  a primary  affection I have had  no
knowledge of it, and, as such, I believe it rare-
ly to exist.  In  its symptomatic states I have
observed it often, both in children and in adults,
but in the former most frequently, and only in
post-mortem  examinations.  Although  there
are numerous circumstances which have in-
duced me to infer that the  mesenteric glands
had become affected in the course of dysentery
and the enteric  form  of continued or remittent
fever, yet there are no symptoms by which its
existence can be known with any certainty.
When we observe  these diseases affecting the
strumous  diathesis,  and persons residing in
low, humid,  or  crowded and unhealthy  locali-
ties, and in  ill-ventilated  streets and  apart-
ments, particularly children  so circumstanced ;
when  the  stools are  irregular,  lienteric, or
chalky, or yeasty, very light, or variously  col-
oured ; and when the abdomen is enlarged, and
emaciation rapid, there is some reason to sus-
pect acute  enlargement or  congestion  of the
mesenteric glands.   In these cases the abdo-
men is often hard, or tense, or tympanitic, but
this is occasioned less by the  enlargement ofthe
glands than by concomitant flatulent distention
of the bowels, as shown by  percussion, and by
the comparatively little swelling  of the abdo-
men, which  is often  produced by this state of
the glands alone.
   12. ii. Chronic Disease of the Mesenteric
Glands. — Chronic changes in these  glands
may occur at any period of life, but much more
frequent  during childhood than at any other
epoch.  That these changes are  generally tu-
bercular, and occur in the scrofulous diathesis,
cannot be doubted  ; but instances occasionally
present themselves of induration and enlarge-
ment of these glands, without any proof of tu-
bercular  degeneration, and evidently produced
by either chronic inflammatory action, or irri-
tation  in them, generally consequent upon ir-
ritation of the  intestinal mucous  surface ; but
of these, farther notice  will be taken  in the
sequel.
  13.  iii. Causes.—a. The predisposing causes
of mesenteric decline are, the scrofulous diath-
esis, a delicate  conformation and  weakness of
the digestive organs ; the epochs of infancy and
childhood, especially the period intervening be-
tween the commencement of the first dentition
and the completion of the second ; inappropri-
ate, unwholesome, and insufficient food ; ex-
posure to cold,  and residence in low, cold, and
humid localities.   From the undoubted scrof-
ulous nature of the  disease, in the great ma-
jority of instances, the predisposing causes of
scrofula are to  a great extent influential  in pro-
ducing it.  Although the  scrofulous nature of
tabes mesenterica has  been denied by  a few
writers, yet the frequent dependance of the lat-
ter  upon the former has  been so fully shown
by  Guy-de-Chauliac,  Riolanus, Morgagni,
Portal,  Cullen, Bichat, Meckbl, A.  Cooper,
Baillie,  Cheyne, Joy, and others, that  it can
no  longer be doubted.   Indeed,  the  frequent
appearances of tubercles in the lungs, cervical
and bronchial glands, and in the mesentery, ei-
ther in various  states of succession or  coetane-
ously, is a proof of intimate connexion between
both maladies,  if not of the dependance of the
mesenteric disease upon the strumous diathesis.
Nevertheless, congestion, enlargement, chronic
inflammation and  its consequences,  are met
with in these glands, independently of the scrof-
ulous taint, and consequent merely upon chronic
irritation ofthe  intestinal mucous surface, while
in other cases tubercular change in the mesen-
teric glands may be the  only manifestation of
this taint, although this is rarely the case, as
signs of  it are  generally also evinced in other
parts of the body,  or in the general conforma-
tion.
  14. The disease may occur at any age, even
as early  as the period of birth;  and it not in-
frequently appears  soon after birth, particularly
in infants brought  up by hand, and deprived of
the warmth ofthe mother's bosom ; and in those
which are  suckled by unhealthy,  consumptive,
or  debilitated  nurses, or by nurses who have
suckled for  too long a period.  It commences
more frequently soon after weaning than at any
other time, evidently owing to incongruous or
inappropriate food.  Residence in close, crowd-
ed, cold, and damp situations, without due ex-
posure to the light and rays of the sun ;  insuf-
ficient or unwholesome  nourishment; a want
of requisite exercise in the open air; inadequate
clothing and want of cleanliness ; sleeping in
crowded and ill-ventilated chambers,  and with
insufficient  protection from cold or the night
air, are not infrequent predisposing causes, but
are also influential existing causes of the disease.
Indeed, in the  majority  of cases, improper or
insufficient feeding, and deprivation of pure air, 
MESENTERY—Diseases  of the Glands of—Symptoms.              985
are of themselves the  chief,  if not the  only
causes of the malady.
  15. b. The Exciting Causes.—Besides these,
over-feeding and incongruous articles  of food
are among the most common causes of mesen-
teric disease.   These articles not being suffi-
ciently digested, irritate the intestinal  mucous
surface, and the irritation  is propagated thence
to the glands.   Moreover,  the  chyle  formed
from them is either  imperfectly elaborated, or
retains irritating properties, tending directly to
excite  these glands, and consequently to in-
flame, congest,  or enlarge them   All derange-
ments of the digestive organs, and particularly
of the bowels,  when neglected or prolonged,
especially when affecting  children predisposed
by the influence of any ofthe above causes, or
naturally delicate, or  debilitated  by  previous
disease, may induce  lesions of the  mesenteric
glands, the liability to such lesions being great
in proportion to the amount of debility, and to
the extent to which a scrofulous taint, original
or acquired, may exist.
   16. Mesenteric disease sometimes  occurs
consecutively upon prolonged gastro-enteric in-
flammation or irritation, upon chronic diarrhoea
and dysentery,  upon periodic fevers, and espe-
cially upon the remittent fever of children, with
either of which it may thus become complicated.
In  both temperate and warm climates, espe-
cially in scrofulous  constitutions, chronic in-
flammation, enlargement,  induration,  and tu-
bercles ofthe mesenteric  glands are not infre-
quently found in post-mortem examinations of
these diseases.   In some  cases the changes in
the glands are owing as much to the treatment
of these maladies as to the gastro-enteric irri-
tation  primarily attending  them.   Excessive
purging, the use of drastic medicines, and of
stimulating or irritating substances, cannot fail
of often occasioning, or of perpetuating where
it previously existed, inflammatory irritation of
the intestinal mucous surface, which will some-
times be followed  by the  alterations of the
glands now mentioned.
   17. iv. Symptoms.—Dr. Joy divides  the dis-
ease into two periods.   1.  That in which tuber-
cles exist, in an indolent state, without having
produced irritation in the  glands in which they
are imbedded, or in the  surrounding  cellular
substance.   2.  That in which the  process of
softening and suppuration are going  forward.
But, as he justly admits,  the first  period is at-
tended by no symptoms by which the existence
of disease of these glands can be inferred, ex-
cept in  the  case, which very rarely occurs, of
these being so much enlarged at this period as
to be detected by touch.   Indeed, the only dis-
order that is observable at this period  is refer-
able chiefly to debility, and to  the gastro-in-
testinal surface, and  occasionally also to the
liver; the mesenteric disease generally origi-
nating in these,  coexisting with them, and often
not manifesting itself until it is very far advan-
ced, or gone on  to irremediable disorganization.
Cases are continually presenting themselves of
the disease having proceeded even to  the sec-
ond stage without its presence having been sus-
pected ; and  instances  are recorded  by Mor-
gagni, Bayle, and others, in which  the mesen-
teric glands were in a state of suppuration ; and
yet  the  patients, who had died of some inter-
current malady, were in good condition.
      II.         124
   18. Gardien and Raimann divide the dispase
 into  three stages :  the first,  or  premonitory.
 which  is  characterized  by languor, debility,
 pallor, abdominal distention and flatulence, and
I by disorder of the  stomach and  bowels ; the
 second, by emaciation, by fetid, and sometimes
 white stools, by  hectic fever, and occasionally
 by enlargement of the cervical glands, and ir-
 regular hardness of the abdomen, caused by the
 diseased mesenteric glands ; the third, by colli-
 quative  sweats or diarrhoea, by slight chills or
 rigours, by extreme emaciation; by weak, small,
 and very frequent pulse, and all the phenomena
 of confirmed hectic ;  and by varied, offensive,
 and lienteric evacuations.
   19. It is very obvious to those who have fre-
 quently observed this  malady, that all divisions
 of its course are arbitrary.  When its uncer-
 tain commencement, its consecutive or second-
 ary nature, and its complications and constitu-
 tional effects are considered, the attempt, not
 only to divide its progress into precise  periods,
 but also to describe its phenomena with unerring
 accuracy, must be altogether futile.  To impose
 an air of constancy on what is always changing
 is only to mislead, and is calculated to generate
 a dangerous confidence where a cautious diffi-
 dence only ought to be entertained.  In these
 circumstances—in this disease more especially,
 which is generally the consequence of antece-
 dent disorder, is merely a portion of that con-
 tinued chain of  morbid action commencing in
 faulty organization, or in functional disorder, and
 terminating in organic change—we should con-
 tent  ourselves with  ascertaining and stating
 those phenomena which most commonly attend
 it, with marking their  more common proces-
 sion, and  with cautioning the inexperienced,
 that, although these phenomena are commonly
 present, they are not  invariably or universally
 remarked, and that  they are variously grouped,
 and associated with other symptoms, according
 to the circumstances of individual cases, and
 to the complications of, or changes produced by
 the disease.
   20. a. Most of the early symptoms are referri-
 ble chiefly to debility, manifested principally in
 the digestive organs, and to asthenic inflamma-
 tory irritation of the digestive mucous  surface.
 There are general depression, languor,  and dul-
 ness, with pallor and collapse of the  counte-
 nance.  The lips swell, and  become  slightly
 fissured, especially  at the commissures.   The
 appetite is capricious, variable, sometimes rav-
 enous and perverted ; and flatulence, abdomi-
 nal distention, uneasiness, and general disturb-
 ance follow a full meal.  There is sometimes a
 craving after the most indigestible substances,
 and the more voracious the appetite, the more
 marked become  the abdominal symptoms and
 the emaciation.   The belly is  large and tense,
 but not painful on pressure, unless on firm oi
 prolonged  pressure.   The breath is offensive,
 the tongue loaded,  variable, or streaked; and
 the perspiration is acid, heavy, or nauseous, ow
| ing to the state of the follicular secretion.  At
 an early period, pain  is sometimes felt in the
 back and  loins;  and sharp, lancinating, or gri-
1 ping pains, of short  duration,  but  recurring
 three or four times  in the day, are often  expe-
 rienced deep  seated  in the abdomen.  Occa-
 sionally nausea  and  mucous  vomiting occur,
| without, in some cases, affecting the appetite. 
986           MESENTERY—Diseases of  the Glands of—Complications.
The state of the bowels is at first variable, but
generally much confined, or completely relaxed,
the latter being most frequent or prevalent as
the disease advances   The stools are unnatu-
ral, offensive, mucous, and subsequently yeasty
or  chalky, and occasionally contain worms,
which had been generated probably long before,
owing to chronic debility of the digestive func-
tions.
  21. With the increased fulness, the hardness
of the abdomen becomes more remarkable, and
emaciation advances rapidly.   The pulse is ac-
celerated, particularly towards  evening, and
during sleep profuse perspirations break out
on the forehead and  breast.  Fretfulness, dul-
ness of the mental faculties, and aversion from
all exertion are generally manifested.
  22. b. At an advanced period the emaciation,
hectic symptoms,  and disorder of the  bowels
become  still more remarkable.  The features
are collapsed, sharpened, pale, and wrinkled,
imparting an unnatural appearance of old age.
The eyes are  sunk, without lustre, and sur-
rounded by  a dark or livid circle.  The limbs
are so emaciated as to resemble sticks covered
by loose and wrinkled integuments, and con-
trast strongly with the  hard and tumid abdo-
men.  The appetite frequently is still ravenous,
and  generally,  also,  capricious or perverted ;
and the ingesta passed insufficiently changed,
or altogether undigested. The bowels are very
much relaxed, and the stools are lienteric, and
generally deficient, or entirely deprived of bile.
Their white or chalky appearance has been im-
puted to the presence of chyle rejected by the
lacteals.   It is, however, doubtful whether or
no the food is sufficiently digested to form so
much chyle as  to account for this appearance,
which may be partly owing to a morbid secre-
tion from the intestinal glands.  Sir A. Cooper
supposed that the whitish, earthy-looking state
of the stools is owing to the presence of calca-
reous matter, but the question has not been de-
termined.  Ultimately, the  marasmus becomes
extreme, but delirium or sleeplessness is rarely
observed, and death  takes  place from exhaus-
tion or inanition, or is accelerated by some con-
tingent  inflammation or lesion, as peritonitis,
pneumonia, universal bronchitis,  or serous ef-
fusion within the cranium.  Such is the usual
course of the disease ; but the symptoms vary
not only in different cases, but also in the same
case.
  23. c. The duration of the malady is various,
according to the nature of antecedent and con-
comitant disorders, and of consecutive lesions.
Owing to the common association with it of
chronic  inflammation of the intestinal mucous
membrane, the pain felt in the abdomen is to be
attributed as much to that affection as to the
mesenteric disease, particularly when it is only
occasional,  intermittent, and griping.    That
which  proceeds chiefly from the mesenteric
disease is dull or aching, is referred chiefly to
the centre of the abdomen and back, and  is not
increased by pressure unless it be firmly direct-
ed to the back.  When severe and continued
pain is felt  in the back and  loins, it is some-
times owing to concomitant disease of the ver-
tebrae.  Swelling of the abdomen is very gen-
eral, but it is owing chiefly to flatulent disten-
tion of  the bowels,  consequent upon  debility
and chronic inflammatory irritation of their mu-
cous surface ;  the disease of the glands fonn-
ino but a small part of this swelling.  Accumu-
lation of faecal and indigested matters some-
times also contribute to the abdominal disten-
tion.   It is comparatively rare  that  the  en-
larged glands can be felt through the abdominal
parietes, unless the abdomen be much sunk or
collapsed, as well as emaciated.   The irregu-
lar swelling and hardness sometimes mistaken
for these glands have occasionally been owing
to faecal accumulations in the cells of the co-
lon, to tubercular disease of the peritoneum, or
to some other lesions.  The urine  is often di-
minished in quantity; sometimes it is milky in
appearance, and contains the  earthy  phos-
phates.
  24. v. Complications and Consecutive Le
sions.—This disease is rarely simple  even at
any one period of its course ; and it is but sel-
dom primary, some disorder preceding it, and
accompanying its early or advanced progress.
These disorders have  been  already noticed ($
15, 16); but the most common are chronic in-
flammatory action  in  the intestinal  mucous
surface, tubercular disease of the lungs, intes-
tinal worms, and tubercular enlargement of va-
rious glands, more particularly of the cervical,
bronchial, and axillary glands.   In most cases,
the affection of the bowels both precedes  and ac-
companies  the mesenteric malady, although, in
scrofulous constitutions, the latter may precede
the former  ; but the chronic inflammation, en-
largement,  and induration  of the mesenteric
glands,  without scrofulous infiltration of them,
which is sometimes met with, particularly in
adults, is almost always caused by the intesti-
nal disease, especially by disease of the intes-
tinal glands.   The  same remarks apply to the
form of intestinal irritation attending, and in
some respects  constituting, infantile remittent
fever, in the course of which mesenteric dis-
ease is often developed.  The connexion of this
latter with  intestinal worms is shown by the fre-
quent evacuation of them during the course of
the malady; the worms existing previous to al-
teration of the glands, coexisting with its early
stages, and disappearing as it proceeds to a fa-
tal issue.
  25. Phthisis pulmonalis is very frequently as-
sociated with scrofulous disease of the glands
of the mesentery, and either malady may pre-
cede the other.   Although the disease of the
lungs may not be  attended by that of the glands,
the latter rarely exists for a considerable time
without inducing the former.  Inflammation of
the peritoneum, especially chronic peritonitis, or
even  chronic  tubercular  peritonitis,  may he
complicated with this malady, but commonly as
a consequence of chronic inflammation of the
intestinal glands  and mucous surface ; the in-
flammatory action extending,  with or  without
ulceration,  from  the  internal  to the  external
coats of the bowels.  On examination of fatal
cases of chronic diarrhoea or dysentery, in both
temperate and warm climates, mesenteric dis-
ease is  not infrequent, the malady commencing
with disorder of the intestinal  mucous  surface,
which has  been followed by ulceration, by al-
teration ofthe mesenteric glands, and ultimate-
ly by some form or other of peritonitis, occa-
sionally extending to the surface of the mes-
entery.   Scrofulous disease of the vertebra, ra-
chitis, and inflammation or suppuration of the 
MESENTERY—Diseases of the  Glands  of—Diagnosis.              987
 psoe muscles, or of the adjoining cellular tissue,
 sometimes   also  complicate  the  mesenteric
 malady.
   26.  Of the above complications, more than
 two may coexist in the same case.  Thus, af-
 ter death, I  have observed  extensive  disease
 and agglomeration of  the mesenteric  glands,
 ulceration ofthe intestines, chronic peritonitis,
 and tubercular disease of the lungs—a combi-
 nation by no means infrequent.
   27.  There are also certain alterations, some-
 times  contingent upon  the mesenteric  disease,
 deserving notice.  Of these, serous  effusion
 within the cranium is not the most infrequent.
 The inflamed and suppurating glands may also
 give rise to various changes in their vicinity—
 to peritonitis from perforation of the peritone-
 um, to ulceration into the intestinal canal, and
 to pressure upon adjoining canals and cavities,
 as the  pylorus,  common bile and pancreatic
 ducts, &c.   Sir  A. Cooper  mentions  the  oc-
 currence of adhesion of the suppurating glands
 with the parietes of the abdomen,  and  the dis-
 charge of their  contents externally, or even
 both externally and internally into the intesti-
 nal  canal, thereby giving rise to  an artificial
 anus.   The  appearance  of  pus  in the stools
 consequently upon scrofulous suppuration of
 the  mesenteric glands, has been attributed by
 Schmalz and others to the opening of the ab-
 scesses thus formed in the mesentery  into the
 cavity of the intestines.  This result, however,
 roust be rare ; the  purulent matter observed in
 the  stools being, more  probably, formed by the
 chronically inflamed villous surface ofthe bow-
 els, and by incipient ulcers.  I have seen not
 only in children, but also in adults, compression,
 irritation, and inflammation  of adjoining parts,
 produced by the diseased lacteal glands.   Press-
 ure  upon, and narrowing of the  pylorus, or of
 the  common bile and  pancreatic ducts, occa-
 sioning  vomitings  of  the ingesta, &c, in the
 first case, and jaundice in the second, are not
 very rare consequences of the mesenteric dis-
 ease.   M. Andral states that the ureters, and
 even the vena cava, may be so compressed by
 the  enlarged glands as  to occasion  dropsy.
   28. vi. Diagnosis.—From what I have stated,
 and  from the very frequent complications of the
 malady, it may be inferred that an  accurate di-
 agnosis of it, particularly in the earlier  parts of
 its progress, is  by no  means easy.  The dis-
 eases  with  which  it is most commonly con-
 founded are  chronic  inflammation of the mu-
 cous surface of the bowels,  infantile remittent
 fever, intestinal worms, chronic and tubercular
 peritonitis, and scybala retained in  the cells of
 the colon.  Although it is of importance, espe-
 cially in respect of the prognosis, to ascertain
 the exact pathological  condition, and how  far
 either  of these may exist singly, or be associ-
 ated with one another, or with some different
 malady,  still a  mistake  in their diagnosis  is
 rarely attended by serious results, owing to the
 general indications of cure being nearly the
 same for all,  although the means should be va-
 ried  for each.
  29. The phenomena more particularly indica-
 ting  mesenteric  disease  at an early period are.
 the scrofulous diathesis and  phthisical state of
 the patient, with  a blanched and relaxed skin ;
 irregularity of the  bowels and stools, or diar-
rhoea, the evacuations  being undigested mat-
ters rather than morbid secretions ;  the inges-
tion of food not being followed by  immediate
inconvenience, as increase of pain,  or calls to
evacuation ; the nature ofthe ingesta not sen-
sibly influencing the disease ; the absence of
thirst, heat of skin, and  of tenderness of the
abdomen ;  emaciation, and collapse  of the  fea-
tures ; and  absence of indications in the stools
of irritation ofthe intestinal mucous surface.
  30. A. Infantile remittent fever is liable to be
mistaken for mesenteric disease; and, as I have
above stated ($ 24), it often occasions this mal-
ady.  It is very difficult to distinguish between
these diseases, especially during the early  sta-
ges  of the latter ;  but  in the mesenteric  dis-
ease there is a more general manifestation of
the  scrofulous diathesis, often  with enlarge-
ment of the cervical and other glands, than in
the  infantile remittent.  The  emaciation is
greater and more rapid, while the appetite is
more ravenous  and  more perverted.  The re-
mittent fever is attended by short intervals of
apparent improvement, and always with regu-
lar diurnal  remissions, which are not so  evi-
dent in the  mesenteric  disease until  the  last
stage, when it assumes the truly hectic form  ;
and, in this stage, the extreme emaciation, dis-
tention and  knotty hardness of the abdomen,
the chalky or lienteric state of the stools,  and
the general appearance of the patient, will read-
ily  distinguish it  from infantile remittent (see
article Fever, § 278, et seq., for the  history of
that disease).
  31. B. Chronic  inflammation  of the intestinal
mucous  surface,  while it very frequently occa-
sions mesenteric disease, is readily confounded
with it in its early course.  But the intestinal
affection is attended by greater heat, pain,  and
tenderness  of the abdomen than are observed
in the mesenteric disease ; and by more thirst,
more febrile excitement, and more mucous or
greenish stools, the symptoms  being all  in-
creased by the ingestion of food, especially of
stimulating food.  The common association .of
the intestinal with the mesenteric disease,  and
the frequent origin of the latter in the former,
render the  diagnosis extremely difficult.  Still,
attention and experience will enable the physi-
cian not merely to distinguish between them,
but also to  recognise this complication, as well
as the other associations and consequences of
the disease  alluded to above (§ 24, et seq), par-
ticularly if the causes, the several concurring
influences,  and the effects of treatment be ta-
ken into consideration.
  32. C. The symptoms of the common round
worm of the intestines resemble mesenteric dis-
ease, particularly  in respect of the ravenous
appetite, the tumid  abdomen, and  emaciated
extremities  ; but the absence of the  charac-
ters of scrofula, the itchings of the nose and
anus, frequent starlings, grinding of the teeth,
and the effects of remedies in the former, will
distinguish between them when they are  not
associated;  but  when  associated, as is some-
times the case, the diagnosis  is much  more
difficult.
  33. D. Chwnic peritonitis, simple or tubercu-
lar, may be mistaken for mesenteric disease,
and is not  so readily distinguished from it as
stated by Dr. Pemberton.  It is generally at-
tended by more tenderness and pain on pressure
than the latter, and by superficial pricking pains. 
988
MESENTERY—Appearances of the, after Death—Prognosis.
In chronic peritonitis the abdomen imparts the
sensation of more superficial hardness, or of
being bound down, and it is more  generally
dull  on  percussion  than  the  mesenteric mal-
ady.   Vomitings, also, are more  frequent in
the former than in the latter.  Peritonitis, how-
ever, is  generally a consequence ofchronic in-
flammation  of the intestinal  mucous surface,
which may develop mesenteric  disease  either
previously to, or  coetaneously  with  the peri-
tonitis.   In  this case, the peritonitis will mask
the  mesenteric  disease.    In many  cases of
chronic  peritonitis which I have seen thus de-
veloped  in children, I have met with very few
where the  mesenteric  glands were not found
diseased upon dissection.
  34. E. The frequent association of phthisis
with mesenteric disease above alluded to (<") 25)
may  be  detected, particularly when the former
is advanced, by shortness of breathing, by short,
hacking cough, by the expectoration, by  per-
cussion, and by the stethoscopic signs.  When
the bronchial glands are the seat of tubercles,
and  the lungs  are  comparatively free from
them, the   diagnosis  is  extremely  difficult.
Moreover, tubercular disease within  the chest
may  be  confounded  with mesenteric disease,
the diarrhoea and state ofthe stools  attending
an advanced period of the pulmonary malady
increasing the difficulty of the diagnosis.  It is
only by  a careful examination  of the thorax
and abdomen, by auscultation and percussion,
that  the difference  between them, as well as
the association of both (which is more common
than is  usually suspected), can  be fully  ascer-
tained.
  35. F. When the mesenteric  disease is far
advanced, it generally manifests  itself so  as not
to admit of doubt, unless it be masked by  chron-
ic  peritonitis, or by serous effusion  into the
peritoneal cavity.  At this period the enlarged
glands may  be sometimes felt, especially if the
patient  is examined  early in the morning, and
when fasting.   But scybala retained in the
cells of the colon may be mistaken for  them.
The  enlarged glands, however, are found near-
er to the centre  of the abdomen, and are at-
tended by slight pain when examined with firm
pressure.  Scybala, on the other hand, are de-
tected in the course of the colon, particularly
in the left  iliac fossa, and are not usually ac-
companied by tenderness on examination ; nor
by much emaciation, or  lienteric stools.  In
these cases, which admit of doubt as  to the
presence of scybala, the  use  of purgatives,
aided by enemata, will  generally assist the
diagnosis.   I have met with instances of indi-
gestible substances retained in the cells  of the
colon for many months,  occasioning abdom-
inal  fulness, with hardness,  emaciation,  and
constitutional disorder, which were  mistaken
for mesenteric disease,  but  which  were  re-
moved by the strenuous use of  stomachic pur-
gatives, the substances causing the  disorder
sometimes  resisting the  operation  of  purga-
tives for many days.
  36. vii.  Appearances  after   Death.—The
mesenteric glands present, in the disease  now
described, particularly  as it occurs in  all  cli-
mates and at all ages, although  most common-
ly after  weaning and in childhood, all the chan-
ges described in  the article Lymphatic Glands
(<"> 54, et seq), the  tubercular  changes being i
very much the  most frequent.  At  an early
stage the glands are redder, larger, and denser
than natural; and subsequently tubercular mat-
ter is deposited  either within  or around them,
or both, its accumulation causing atrophy, and
ultimately destruction of the glands, this mat-
ter occupying their places, and, in some instan-
ces, accumulating to such an extent as to give
rise to  an agglomeration of them into  one very
large mass.  Those glands, containing tuber-
cles which  are advanced, are of a dull white
colour  and firm consistence ;  and, when the
deposite is not very large, the lymphatic ves-
sels in  the  glands still allow injections to pass
through them. This circumstance has induced
some to suppose that the tubercular matter is
not accumulated in these vessels, but is de-
posited in the cellular tissue of the glands. Ul-
timately  the  tubercular  matter  softens,  and
presents  appearances  and  produces  changes
similar to those  observed in tubercular disease
ofthe lungs.
  37. Besides the diseased mesenteric glands,
inflammation and ulceration of the intestines,
particularly of the lower portion of the ileum ;
inflammation and adhesion of the peritoneum,
often with  tubercular formations; and tuber-
cular disease ofthe lungs, and ofthe bronchial
and cervical glands, are found  in most instan-
ces.  There are very few cases in which these
alterations  of the  digestive  mucous  surface
and lungs are not observed in addition to the
mesenteric disease.  Tubercles are also occa-
sionally found in other situations, as  in the
liver, brain, &c. ; and serous  effusion  in the
peritoneum and between the membranes ofthe
brain, with or without tubercular formations,
is also  sometimes met with.
  38. viii.  The  nature of the disease is man-
ifest from its early history and ultimate changes,
both classes  of phenomena showing  that the
mesenteric alterations are a part only  of a gen-
eral or constitutional malady—that these alter-
ations, with those  often associated with them
in the lungs, peritoneum, and other glands, are
generally manifestations of scrofula, which, as
they become  developed, react upon the frame,
increasing  debility,  and  producing irritation,
fever, and its usual  consequences.  The com-
mon procession  of disease is generally as fol-
lows :  at first, constitutional vice and debility,
impaired digestive and assimilating functions,
irritation of the  digestive mucous surface, and
imperfectly elaborated chyle ; subsequently, ir-
ritation and  enlargement  of the mesenteric
glands, followed by tubercular  deposites  in
them, and in other organs  or parts ; and, lastly,
constitutional irritation and hectic fever; the
extreme emaciation ultimately produced being
not so  much a consequence of obstruction of
the mesenteric glands, as of the hectic or irri-
tative fever, and of the changes in the bowels,
lungs,  and  other parts.
  39.  ix.  Prognosis.—When  the disease  is
clearly manifested,  the prognosis is unfavoura-
ble ; and no hopes of recovery should  be enter-
tained  when  it is associated with tubercles in
the lungs, or with chronic peritonitis.   On the
other hand, when the disease is not far advan-
ced, and before hectic symptoms are established,
or the  emaciation  become great, or the stools
have assumed a chalky or lienteric appearance,
hopes of recovery may be entertained,  although, 
MESENTERY—Diseases of the—Treatment.
989
 even in these cases, a cautious prognosis should
 be given.  The younger the child, the greater is
 the danger.  The causes and complications of
 the  disease should also in some degree  influ-
 ence the prognosis.   When these causes admit
 of removal; when unwholesome food and im-
 pure air produce the malady, and  may be  re-
 moved ; and when intestinal irritation is the
 only complication, then a more favourable opin-
 ion may be given than in other circumstances.
 An  improvement in the colour and expression
 ofthe face, a reduction ofthe size  ofthe abdo-
 men, a more faeculent  character, and less fre-
 quent passage of the  stools, a gradual recovery
 of flesh, and a diminution or disappearance of
 evening accessions of fever, are  indications of
 recovery.
   40. x. Treatment.—The  indications of cure
 are, 1. To ascertain the predisposing and exci-
 ting causes, and to remove them.  2. To sup-
 port the constitutional powers, to  restore the
 diseased glands  to their  healthy state, and, at
 the same time, to allay irritation ofthe aliment-
 ary canal.  3  To remove associated disorder,
 and to prevent the occurrence of disease in re-
 lated organs or parts.
   41. A.  The removal of the causes, when fully
 accomplished early in the disease, will some-
 times of itself restore the patient to health.   It
 is true, that the early progress of  these cases
 admits of great doubt as to their being cases of
 mesenteric decline.  But, although  they may
 not be fully-developed instances of this malady,
 they are fast  progressing either towards it or
 towards  as  dangerous  a malady, namely, to
 chronic ulceration of the intestines and conse-
 quent peritonitis.  If, in  infants  at the breast,
 the nurse's milk have disagreed, or if the milk
 be poor, innutritious, or disordered by prolonged
 suckling or ill health, the nurse should be chan-
 ged ; and the infant should have  the advantage
 of wholesome milk, and the  warmth of the bo-
 som of a young  and  robust nurse.   When the
 disease manifests itself at this  early age, the
 enjoyment of vital warmth is next in importance
 to wholesome and nutritious food.   If the dis-
 ease be caused by weaning, or by  inappropriate,
 too  much, or incongruous food, causing irrita-
 tion of the digestive mucous surface  and an
 imperfectly elaborated chyle, a change of diet,
 atrial ofthe more digestible and less irritating
 kinds  of food, and a liberal use of asses' milk
 warm from the animal, sometimes with lime-
 water, when the  bowels are much relaxed, are
 means which  should  not  be  neglected.  In all
 instances, but particularly when the patient re-
 sides in large towns, or in close, ill-ventilated
 situations and chambers, change  of air into the
 country, or to  the seaside,  selecting dry and
 elevated localities, is  one of the most success-
 ful means of cure that can be adopted.  These
 advantages will be greatly enhanced by regular
 exercise in the open air, and by exposure to
 light and sunshine.
  42. The  frequent  commencement  of tabes
 mesenterica in  chronic  irritation of the intes-
 tinal canal, in  infantile remittent  fever, and
in  other disorders mentioned above (§  24),
points  out  the  importance of removing these
diseases as soon  as possible ; and as they ori-
ginate  in the same circumstances  and causes
which are so productive  of this malady, treat-
ment will often be unavailable for them, if un-
 aided by change of air and its consequent ad-
 vantages.
   43. B.  Before developing the second indica-
 tion of cure, which comprises the strictly medi-
 cal treatment of the disease, I shall take a brief
 view ofthe means  recommended by other wri-
 ters.  These consisted, in this country, until a
 comparatively recent period, chiefly of mercu-
 rials in  some form or other, generally conjoined
 with purgatives or alteratives ; the use of other
 more rational means being commonly stigma-
 tized with the designation of " inert practice,"
 nothing appearing to many either good or ap-
 propriate,  or efficacious, to which the term
 " active," as regards its immediate operation,
 was not applicable.  No  small mischief arose
 in those days from attempts made to reduce a
 tumid abdomen  by  means of cathartics or pur-
 gatives, the improper use of which  often in-
 creased the flatulent distention, perpetuated in-
 testinal irritation, and thereby, as  well  as  by
 reducing the constitutional powers, augmented
 the mesenteric malady, and developed several
 of its most fatal complications.
   44. a. Mercurials, and more particularly the
 chloride of mercury, have been prescribed for
 this disease  by Baillou,  Bordeu,   Portal,
 White, Curry, and many others.   Underwood
 gave calomel twice or thrice a week, and the
 carbonate of soda during the intermediate days.
 He also had recourse to an infusion of burned
 sponge  and senna;  and  afterward to bitters
 and chalybeates.  Dr. Burns recommended cal-
 omel with  mild  purgatives,  and gentle  tonics
 and frictions ofthe abdomen.  Dr.  Pemberton
 advised calomel to be given at bedtime, salts in
 the morning, and tonics with conium  in the  in-
 tervals.  Mr. Abernethy and his disciples pre-
 scribed calomel, with rhubarb and ginger,  on
 alternate nights ; or blue pill and laxatives, fol-
 lowed by a prolonged course of Plummer's pill
 and sarsaparilla.   Sir A. Cooper  always re-
 sorted  to the bi-chloride of mercury, one grain
 being dissolved in  two ounces of the tincture
 of cinchona or of rhubarb, and a tea-spoonful
 given twice a day.  He also advised plasters
 over the abdomen, or frictions, and a nutritious
 diet.  Farre and others confided in mercurial
 frictions.   Cullen, with much justice, has con-
 demned the use  of mercurials if otherwise pre-
 scribed  than as occasional purgatives or alter-
 atives ; and there is  no doubt of their having
 been hitherto too often employed in  this dis-
 ease in an indiscriminate and empirical manner.
 Still, when the liver is torpid, the stomach is
 irritable, and the lower bowels inactive, the
 milder mercurial preparations, conjoined with
 rhubarb, or with rhubarb and magnesia,  or an
 alkaline carbonate,  are often of essential ser-
 vice ; and I have found the practice advised by
 Sir A. Cooper, modified according to circum-
 stances, sometimes of service.
  45. b. The same remark applies  to the use
 of purgatives generally.  The advantages which
 arise from them can be realized only by a judi-
 cious selection of them, and by the use of them
 appropriately to the  circumstances of the case.
 Fordyce preferred  rhubarb, and conjoined  it
 with the neutral salts, especially the tartrates.
 Herz and Beaumes  also preferred rhubarb, the
former giving it with the acetate of potash.  Most
writers  and  modern  practitioners  have pre-
scribed it, either in substance or infusion, with
D D D 
990
MESENTERY—Diseases of the—Treatment.
the sulphate of potash.   Dr.  A. Thomson has
praised the combination of the two with calum-
ba, directing ten grains of sulph. of potass., six
grains of calumba, and three of rhubarb, thrice
daily, and frictions of the abdomen  with soap
liniment.  While  purgatives have  been thus
generally  employed,  the selection  has  been
chiefly limited to those which are the  least
weakening, or the most likely to produce deob-
struent effects.  The exhibition of tonics with
these, or  in the  intervals between  them, has
been very generally adopted ; and, although the
practice has been inveighed against  by Brous-
sais and his followers as being injurious, in re-
spect not only of the combination of the two
classes of remedies,  but also of the employ-
ment of either of them singly, still it is appro-
priate to many cases, and to certain  states and
stages of the  malady ; and, as regards the re-
sults, more successful than  the  application of
leeches to the abdomen, and the employment
of demulcents recommended by this physician
and his once numerous disciples.
  46. c. Various  alteratives, or  substances in-
tended to produce an alterative and a deobstru-
ent or tonic effect, have been prescribed for this
disease besides mercurials.   Pinel, Hebreard,
Hufeland, and others, have recommended the
muriate of barytes, but Ferriar and Thomson
have not confirmed the opinion expressed of it
by these writers.   Dr. J.  Hamilton was favour-
able to the use of antimomals when aided by a
warm bath  every night, by frictions with an
opiate liniment, and by nourishing diet.  There
are few alteratives more serviceable in mesen-
teric disease than alkalies and alkaline carbon-
ates, conjoined with mild tonics, and there  is
none  more generally prescribed for it.   Still,
neither these,  nor any of the medicine salready
mentioned, should be depended upon  solely,
different means being required with the varying
characters of the  malady.
  47. d. It is  obvious that, when disease is so
far advanced  as  to  enlarge  the  mesenteric
glands, or to occasion symptoms usually attend-
ing or indicating this lesion, it becomes neces-
sary to support the constitutional powers,  while
we endeavour to restore these glands to their healthy
functions and  condition; and it is equally obvi-
ous that neither can the constitutional powers
be supported  nor the glands  be restored to
health as  long as irritation is allowed to exist
in the alimentary canal.  Therefore,  having
cleared away morbid secretions and faecal accu-
mulations, those  substance* which are  most
calculated  to correct, improve, or restrain morbid
action and secretion should be prescribed.  With
this  view, small  doses  of hydrargyrum cum
creta may be given at bedtime, either with Do-
ver's powder  or with ipecacuanha and extract
of poppy or of hop;  and, during the day, crea-
sote  may  be taken with  demulcents, and with
cretaceous mixture and  the compound tincture
of camphor, if the bowels be much relaxed.   A
warm bath should also be used at bedtime, and
the abdomen  be afterward rubbed with a lini-
ment composed of the compound camphor and
the turpentine liniments, to which  a little of
olive oil and of cajeput oil may be added.  The
patient should wear  flannel  next to the  skin,
and sleep in blankets or  in cotton sheets ; and
be allowed light, nutritious diet.   If the bowels
become confined, rhubarb and sulphate of pot-
 ash, or castor or olive oil, may be given ;  ot
 their action may be solicited by means  of  an
 enema containing these oils, alone or with spir-
 its of turpentine.   Having in some degree al-
 layed irritation and corrected morbid secretion
 by these means, or even without having attain-
 ed these ends, these remedies having been pre-
 scribed during a few days, the preparations of
 iodine* should be cautiously resorted to.
   48. But, in order that any advantage may be
 obtained from these preparations, and even that
 mischief may not be caused by them, it is es-
 sentially requisite to prescribe them  in  small
 doses,  and to carefully observe their effects.
 If the  bowels be too much relaxed, the iodide
 of lead or of iron may be given with ipecacuanha
 and extract of hop or  of poppy in the form of
 pill; but in other circumstances, and at an ear-
 ly stage of the disease, the iodide of potassium
 may be prescribed  with the liquor potassae in
 the infusion or decoction of cinchona, or in any
 tonic tincture, with the compound tincture of
 camphor.   The  turpentine liniment, or embroca-
 tion, should also be applied over the abdomen,
 and the diet and regimen advised for this (Hi,
 53) and other scrofulous  diseases  strictly pur-
 sued.
   49. The diseased state of the digestive mu-
 cous surface has  been considered by Brous-
 sais  and his disciples to contraindicate the use
 of iodine, and all tonic and stimulating  sub-
 stances.  But the affection of this  surface is
 not a true inflammation, at least not a sthenic
 form of inflammation, but rather a state of as-
 thenic   capillary  congestion,  which  is more
 readily removed by tonics and  stimulants, es-
 pecially such as  are also astringent, than by
 relaxants  or depressants, and which not infre-
 quently passes rapidly into ulceration if the
 former be not resorted to.
   50. The principal error in the treatment of
 this malady has been that, of viewing and treat-
 ing it as limited to the mesenteric glands, and
 without reference to other lesions often asso-
 ciated  with it, and to  the states of vital de-
 pression and  of anemia, attending not only its
 advanced, but even its early progress, in many
 instances.  In these states, and even  in those
 associated with tubercular disease of the lungs,
 the preparations of iron, in suitable forms oi'
 combination, are  especially  beneficial.   Al-
 though curious, it would be almost endless, to
 notice  the various preparations and numerous
 modes  of  combining them, recommended by
 authors in  this  and in  other  diseases  with
 which it is often associated ; each one, with a
 more ardent  desire to appear original than to
 prove useful, praising his own way of exhibit-
 ing them.   Having had no small experience of
 most of the preparations of iron, I can  state

   * The author was probably the first in this country, and
 certainly among the first in any country, to prescribe these
 medicines in this  and  in other constitutional maladies.
 When he returned to London from the Continent in 1820,
 he brought with him those preparations of iodine which
 had then been tried abroad ;  and as soon as they and oth-
 ers were prepared, or introduced into this country by Mr.
 Morson, he had recourse to  them in  private and public
 practice.  The same remark applies to creasote and some
 other substances.  The first dose of creasote  prescribed
 in this country was by the author,  in consultation with
 Dr. RoscoE.  This medicine,  however, was not then to
 be procured  in London ; Mr. Morson, who was, and still
I is, the principal manufacturer of it, being then obliged to
 obtain it from abroad before the prescription could be pre-
 pared. 
MESENTERY—Diseases of the—Treatment.
991
that  most of them  are more or less beneficial
in those states and associations of this disease
just mentioned, but that some of them are to
be preferred to others.  The iodide of iron pre-
scribed in the sirup of sarsa, and sirup of pop-
pies, if the bowels be too open ; the  mistura
ferri composita, with the  tincture  camphorae
composita, and extractum conii; combinations
of the  oxides of iron with the alkalies  or alka-
line  carbonates ; the  tincture of the  sesqui-
chloride  of iron, or of the ammonio-chloride,
with or  without a small  dose  of  the dilute
nitric acid, and two or three drops of the tinc-
tura opii, or  tinct.  camphorae comp.; the sul-
phate of iron with  the carbonate of an alkali,
and with rhubarb or powdered cascarilla ;  the
compound steel pill with soap, or the compound
soap pill and  ipecacuanha, are preparations and
combinations of them severally employed  by
me in those conditions of the disease in which
the support ofthe vital energies, and the promo-
tion of assimilation  and sanguification, are more
particularly indicated ;  but I have never over-
looked those external means and applications al-
luded to above (§ 47,48), and have generally em-
ployed them  at the same time.  There are va-
rious other recently-introduced preparations of
iron, which are more fashionable than efficient.
I have tried  them  sufficiently, particularly the
lactate, the citrate, the ammonio-citrate, and
the  ammonio-tartrate of iron.   Of  these, the
 first and the last are the most efficacious, and
 to children especially the most palatable.   The
 others are also sufficiently palatable, but this
 is their principal virtue.
   51. While  these or other tonics are being em-
 ployed, the bowels will generally require due
 regulation, by means of narcotics and astrin-
 gents  when  they are too relaxed, and of sto-
 machic or chologogue purgatives when  they are
 costive.   In  all cases, care should be taken to
 preserve a due secretion of bile, as  this fluid is
 necessary not only to the elaboration of healthy
 chyle, but also to a healthy state of the intes-
 tinal mucous  surface.  Hence I have (since
 1818) always prescribed the inspissated ox-gall
 with the above or other medicines, when the
 secretion of  bile has been deficient, and the di-
 gestive mucous surface irritable and relaxed ;
 although, for some years, this substance could
 not  be procured at the principal chemists or
 druggists until I directed the preparation  of it,
 so entirely had it been overlooked in this coun-
 try.   Numerous formulae containing it will be
 found  in the Appendix and in the early part of
 this work.  Long subsequently to  the publica-
 tion of these, and  very recently, some writers
 in periodical works have lauded its properties,
 with attempts at originality to which they had
 not the smallest claims.
     " Miranturque novos fructus, et non sua poma."

   52. C. The third  intention, viz., to  remove as-
sociated disorder,  and to prevent  the occur-
rence of disease in related organs, as far as ei-
ther object can be  attained, can be accomplish-
ed only by fulfilling the indications  already de-
veloped ; for the chief complications,  namely,
irritation of  the digestive mucous  surface, in-
fantile  remittent  fever, tubercular  disease of
the lungs or  of other glands, &c, are best com-
bated by the  means already specified,  aided by
change of air, diet, and regimen; and  these, at
the same time, are the most likely to prevent
the occurrence of more extensive disease, by
supporting the constitutional powers, and pro-
moting the digestive and excreting functions.
Whatever complication  may appear  in the
course of this disease is necessarily character-
ized by asthenia, owing to pre-existing depres-
sion of the vital powers, and to imperfect san-
guification and assimilation, and is irremedia-
ble, unless by restorative means, in conjunc-
tion with such as the nature of the complica-
tion may require.   But in most of these  com-
plications, as well as in the more simple states
of the disease, external derivatives, and means
which will allay or diminish excessive action
and secretion, where either  is augmented, or
which will increase either or both, when im-
paired  or arrested, are chiefly indicated.  A
careful diet and regimen will also materially
advance  these objects.
  53. D.  Diet and regimen constitute a princi-
pal part of the treatment of  this disease  ; but
the former cannot  always be assigned  with
sufficient precision, no particular kind of food
proving beneficial in all cases, and rarely even
in the great majority.   For the youngest  class
of patients, the milk of a healthy nurse, the
warmth of her bosom ;  light, farinaceous  food,
with warm or boiled milk ; ass's milk or goat's
milk, warm from the  animal; change of air,
particularly to the  seaside;  warm salt-water
bathing,  and gentle, but regular exercise in the
open  air and sunshine; and flannel  clothing
next the  skin, are generally  beneficial.   If the
disease appear after weaning, nearly the  same
diet and  regimen as now advised, with  small
quantities of the lightest kinds of animal food,
or animal broths with boiled rice, or with stale
or  toasted bread,  &c, are  required.   At  a
somewhat later period of life, the  farinaceous
kinds of food boiled with milk, and  the  more
digestible articles  of  animal diet, may be al-
lowed  in such quantity as the peculiarities  of
the case and the amount of exercise may sug-
gest.  Sea bathing in summer and autumn is
also necessary.  In general, bulky vegetables
and fruits should not be given ; and the  inter-
vals between  meals ought to be duly regulated,
as  well  as the  quantity of food, according  to
the age  and strength of the  patient, and  stage
of the disease.
   54. E. For the  prevention of the  disease,
when it  is threatened, the means just specified,
particularly change of air ;  sea, or country,  or
pure air; sea bathing, and flannel worn next
the skin ; suckling by  healthy nurses for  a suf-
ficiently  long period—from  nine to  fourteen
months; nourishing and digestible food ; ex-
ercise  in the open air, and  attention to the
states  of all the secretions and excretions, cor-
recting and promoting  them as circumstances
may arise, are the  means on which  only de-
pendance can be placed.

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ter Naturam, 4c, p. 11.—Martini, De Morbis Mesenterii
abstrusioribus, 8vo. Lips., 1630.—Bartholinus, Hist. Anat.,
cent, iv., hist. 96.—Bontius, De Medicina Indorum, cap. ii
— Wharton, Adenographia, cap. ii.—Bonet, Sepulchretum, 1.
ii., sect. vii.,ob. 129, 133.—Morand,in Mem. de l'Academie
des Sciences, ann. 1729.—J. J. Grambs, Anatom. Beschrei-
bung eines MoD.itroson Gewachses am Mesenteno, 4to
Frankf., 1730.—ij. Russet, De Tabe Glandulari,  sive  de
Usu Aquae Marine in  Morbis Glandularum, 8vo.  Lond ,
I'bO.—Delharding, in  Halleri, Collect. Disp. Pract., vii.,
n. 240.—Meckel, in Mem. de l'Acadtmie de Berlin,  1753, p. 
992                          MILIARY ERUPTION—Definition.
67.—Morgagni, De Sed. et Cans. Morb., Ep. xxxiv., art. |
21 ;  xxxix., art. 5, 6, 7, 8 ; xliv., 3, &c.—Lieulaud, Hist. |
Anat. Medica, t. i.. obs. 521, 526, 552, el seq.—Bang, Acta
Reg. Soc. Med. Haun., t. i., p. 259.— Vetter, Aphonsinen,
&c, i., p. 158.—Beaumes. Mem sur la Maladie du Mesen-
tere propre aux Enfans que Ton nomme vulgairement Car-
reau, <kc Nismes, 1788; et Traite de la Premiere Denti-
tion, &c, ch. iii., 3.—Ebhard, De Statu  Mesenteni Natu-
rali  et Praaternaturali, 8vo.  Jena. 1755.—Monro, in Med.
Transact., <fec, vol. ii., n.  18.—R. Willan. in Medical Facis
and  Observations, vol. iii.—Portal, Sur la Phthisie de Nais-
sance, in Mem. de l'Acad. des Sciences, 1781 ; et Cours
d'Auat. Medicale, t. v.. p. 260, et seq.—Cullen, Practice of
Medicine, edit, by J. Thomson, vol. ii., p. 562.—/. P. Frank,
De Cur. Horn. Morbis,' 1. ii.; De Inflammationibus, t. ii., p.
224.—Conradi, Handbuch  der Speciellen Pathol, und The-
rapie, b. ii., p. 206.—Bichat, Anat. Pathologique, &c, par
A. Bcclard, 8vo. Paris, 1828.—Baillie,  Morbid Anatomy,
p. 209.—C. R. Pemberton, Practical Treat,  on  the Dis. of
the  Abdominal Viscera, &c, p. 17.  Lond., 1820.— Under-
wood, On the  Dis. of Children, p. 228.—Horn, Archiv. fur
Pract. Medicin.,b. iii., p. 275.— Hufeland, Voltsliindige Dar-
stellung, <kc, ii.. n. 4.—Bayle, in Journ. de Medecine con-
tinue, t. vi., p. 17, 45.—Laennec, in  Ibid., t. iv., p. 509.—
Rullier, in Ibid., t. xi., App —J. Thomson, Lectures on In-
flammation, &c, p. 136.— J. Burns, Princip. of Midwifery,
<kc, p. 745.—J. Capuron, Traite des Mai. des Enfans, <fcc,
p. 416.—Hildenbrand, Institutiones Practico-Medicae, <kc,
t. iii., p. 290.—Guersent, Diction, de Medicine, t. iv., p. 303.
—Meckel, Handbuch der Pathol. Anat., b. ii., p. ii., p.  379.
—Raimann, Handb. der Spec.  Medec-inischen Pathol,  und
Therapie, b. ii., p. 227—Billard, Traite des Maladies des
Enfans nouveaux nes, 8vo. p. 633.—Louis, Memoires Ana-
tomico-Pathologiques, p. 417.—Broussais, Hist, des Phleg-
masies Chroniques, t. iii., p. 354.—i. Kennedy, Instructions
as to the Management of  Children in Health and Disease,
<fcc  , 8vo, p.  278.   Glasg., 1825.—Andral, Anat. Patholo-
gique, t. ii., p. 448; et  Clinique Medicale, t. iv., p. 616.—
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G. F. Most,  Encyklopadie  der Gesammten Medicinische
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and Evanson, Dis. of Children, 4th edit., 8vo. Lond., 1842.

MILIARY  ERUPTION.—Synon.  Sudor,  Mil-
  iaria, Sudamina ;  Febris Miliaris;  Purpura
   Miliaris;  Miliaris Sudatoria ; Sudor Miliaris;
   Papula  Miliaris,  Auct.   Morbus  Miliarium,
   Allionius.  Exanthema Miliaria, Parr.  Febris
   vesicularis, Febris  purpurata   Miliaris, Hoff-
   mann.  Emphlysis Miliaria, Good.   Purpura
   alba, Purp. Puerperarum, Auctorum.  Hydroa,
   Rayer.   Pourpre blanc, Miliare,  Fr.   Friesel,
   Frieselblattern, Weisse  Friesel, Germ.  Mig-
   liaria, Ital.   Miliary Fever.
     Classif.—1st  Class,  3d Order  (Cullen).
        3d Class, 3d  Order (Good).  III.  Class,
        II.  Order (Author).
   1. Defin.—An eruption of vesicles, seldom ex-
ceeding the size of a millet seed, over a large  sur-
face, generally symptomatic of serious disease, or
caused by a healing regimen and confined air.
   2. The symptomatic miliary eruption here to
be  considered is more correctly designated by
the term  sudamina  than  by any other, and  is
entirely different from the "epidemic sweating
fever"  described in another article (see  Fe-
ver, $ 416), and which is often attended by a
miliary eruption, as there  shown.   This form
of epidemic fever has rarely occurred in mod-
 ern times; and the miliary eruption, formerly
 not infrequently met  with in lying-in women,
 is  now rarely seen, owing to an improved regi-
 men and practice in these circumstances.  Be-
 sides  being caused by irritation ofthe skin, and
 especially by profuse perspirationsy however in-
 duced  ; and besides being an  attendant upon
 the epidemic  fever  just referred  to, the erup
tion  of miliaria or sudamina is met with as an
occasional  symptom :  1.  In  those puerperal
diseases which are characterized by fever, and
a morbid state ofthe circulating fluids, and are
caused by impure air and a  heating regimen.
2.  In  the  early stages of smallpox, measles,
and other eruptive fevers; and in the advanced
state of adynamic or typhoid  fevers.  3.  In the
course of "fever depending upon gastro-intes-
tinal or internal irritation or inflammation.   4.
In connexion with acute rheumatism ; and, 5.
In the course  of puerperal  inflammations  of
serous membranes.   In all  these circumstan-
ces,  this eruption is  more  correctly denomina-
ted sudamina  than  miliaria,  as it  is always
attended by a copious perspiration and increas-
ed heat; and,  although it formerly was not
infrequent  in those  maladies, when a heating
regimen was so generally  adopted during their
treatment,  it  is  now seldom, and even very
rarely observed.
  3. i. The symptoms of epidemic, miliary, or
sweating fever  are fully detailed in the article
Fever (t) 420);  it only remains for me to notice
the  characters  of  the eruption, when  it  is
symptomatic of other maladies, or when it oc-
curs  after  lying-in,  or  in  consequence of co-
pious  perspirations  and   a  heating  regimen.
From what I  have  already  stated, it will  be
seen  that I consider the epidemic fever there
described  to be more correctly designated  by
the name of sweating fever than by that of mil-
iary fever; and that the term miliaria is here
viewed  as synonymous with sudamina.  The
vesicles of this eruption, seldom exceeding the
size of a millet seed, are  sometimes arranged
at some distance from each other, but are gen-
erally distinct, and  form  patches.  They are
seldom  confluent, and rarely coalesce so as to
form bullae. They are at first small and prom-
inent, transparent, and globular, their contents
appearing  as  clear  as limpid water, but be-
coming more  opaque  or  milky.   The surface
upon  which the vesicles  are scattered  varies
in colour : 1.  With  the nature  of  the disease
upon which they are contingent; and, 2. With
the  state of the  vascular system as regards
plethora, &c.   When  this eruption  accompa-
nies  any of the exanthemata, or when the pa-
tient  is plethoric  or robust,  the vesicles form
upon  a  red or  erythematous surface,  and con-
stitute the miliaria rubra of authors, the colour
of the  surface  appearing through  the  limpid
and transparent fluid of the vesicles   But when
the  fluid  becomes  opaque,  white, pearly,  or
milky, and when the vesicles appear on a com-
paratively pale  surface, the term miliaria alba
has been applied to them.    When  they  thus
occur without inflammatory appearances in the
skin,  the term sudamina is most appropriate.
   4.  The vesicles naturally terminate in  resolu-
tion without forming scabs or scars, but  the cu-
ticle covering them  always desquamates.  The
duration of the eruption varies with the circum-
stances which develop them ; but it  is gener-
ally from three to eight days, or longer.  It is
sometimes prolonged by the appearance of the
eruption in different situations successively, or
of a  second crop in  the same place.   The  dis-
appearance of the eruption  has little or no  in-
fluence upon the course of the disease, of which
it is symptomatic, although  some writers have
considered a retrocession of it injurious.   But 
MUSCULAR STRUCTURE—Diseases op.
993
where this has appeared to have been the case,
the retrocession may have been the consequence
of pre-existing internal mischief, rather than
the cause.  As the sudden disappearance of
the eruption is generally caused by the applica-
tion of cold, by improper food and regimen, by
mental emotions, and  other  powerful causes,
the consequent ill effects are to  be attributed
to these chiefly.
  5. ii. The diagnosis of miliaria is easy, owing
both to the appearance of the vesicles, and to
the circumstances in which they  are observed.
The only eruption with which it can be con-
founded  is eczema, the vesicles  of which are
crowded in a small space, and are very conflu-
ent ;  Whereas, in  miliaria, they are distinct and
spread over a large surface, always accompany
an acute  or febrile  disease, are  rapid in their
progress,  and of short duration.
   6. iii. The prognosis of the  acute diseases of
which miliaria is symptomatic is not affected
by it.  The eruption itself only indicates a state
of increased action with determination  to the
cutaneous surface.  In connexion with epidem-
ic fever,  as shown  elsewhere  (see  Fever,  §
419, et seq.), it evinces a serious state of dis-
ease.
   7. iv. Treatment.—The eruption itself requires
comparatively little attention, the disease of
 which it is symptomatic demanding the chief
 care.  In most of the maladies in which it oc-
 curs  a cooling regimen is necessary.  Refrig-
 erant drinks,  and sub-acid fluids, particularly
 those containing  dilute hydrochloric acid, may
 be allowed.  The patient's room  should be well
 ventilated, and the clothes on his bed ought to
 be light.   The  bowels should be kept  gently
 open, and the surface of the  body sponged fre-
 quently with tepid vinegar and water, or by any
 other agreeable fluid.
   Bibliog. and Refer.—G. Welsh, Hist. Morbi qui der
 Friesel dicitur, 4to.   Leips., 1655.—T. Sydenham, Scried.
 Monit. de Novae Febris Ingressu,  8vo.  Lond.,  1686;  et
 Opera, p. 643; also, entire  Works  by Swan,  8vo, p. 495.
 London, 1749.—D. Hamilton, De Febre  Miliari, &c, 8vo.
 Lond., 1710; aad Treatise on Miliary Fever, 8vo.  Lond.,
 1737.—F. Hoffmann,  Opera, t. ii., sect, i., cap. 9.—A. Agos-
 lini, Osservazioni intorno alle Febri Migliari,8vo.  Novar.,
 1755.—^4. W. Beckers, Abhandl. vom Friesel, 8vo.  Blelef.,
 1747.—J. Fordyce, Hist. Febris Miliaris,  <fec, 8vo.  Lond.,
 1758.—C.  Bisset, Essay on  the  Medical Constitution  of
 Great Britain, 8vo.  Lond., 1760.— Van Swieten, Comment.,
 <fec, sect. 723, 982.—Fuller, On Eruptive Fevers, &c,  p.
 157.—Allen, Synopsis, <fcc, art. 1497.—Lieutaud, Synops.
 Univers. Pr. Med., p. 476.—Brocklesby, Med.  Observ. and
 Inquiries, vol. iv., p. 29.—Cullen, Synops. Nosol. Method.,
 vol. ii., p. 140; and Practice of Physic, vol. ii., p. 100.—C.
 White, Treat, on the  Management of Pregnant and Lying-
 in Women, &c, 8vo, p.  27,  3d edit. Lond., 1785.—R.  G.
 Gastelier,  Traite de la Fievre Miliaire des  Femmes  en
 Couches, 8vo. Mont., 1784.—/. Pornieri, Relazione e cura
 della Febbre Migliari, 8vo.  Foligno, 1805.—Schal et Hes-
 sert, Precis Historique et Pratique sur la Fiever Miliaire,
 4to.  Strasb., 1813. — Monfalcon, Diet,  des Sc.  Med.,  t.
 xxxiii.—Chomel,  Diet, de Medecine, t. xiv.—F. E. Fodere,
 Recherches et Observat., <fec, sur PEruption  et la Fievre
 sous le Nom de Miliaires,  8vo.  Paris. 1828.—P. Rayer,
 Theor. and Pract. Treat, on Dis. of the Skin, transl.  by
 Willis, 8vo, p. 350.  Lond.,  1835.—Cazenave and Schedel,
 Manual of Dis. of the Skin, transl., with Addit., by T. H.
Burgess, Svo, p. 59.—Lond., 1842.
MORTIFICATION.—See Gangrene
MOUTH.—See Tongue and Mouth.
MUSCULAR STRUCTURE,  Diseases of.—
   Synon.  Muscular Tissue or System  ; Muscles.
   Muskcln, Heisch,  Germ.    Muscles; Muscu-
   laire Systeme ;  M. Tissu, Fr.   Musculo, Ital.
    Classif.—General and Special Pathol-
       ogy.—Morbid Anatomy.
   1. The muscular system has been usually di-

     ll.                 125
vided into two orders or parts—into the muscu-
lar system of organic life, and that of animal life;
the former being uninfluenced by the will, and
therefore called involuntary, the latter being
powerfully  influenced  by volition,  and  hence
called voluntary.   The power or property of an-
imal bodies, usually denominated Irritability
(see that article), is especially manifested by this
system, and more particularly by the voluntary
order of muscles, or those of animal life.   Ir-
ritability may indeed be viewed as the vital man-
ifestation most especially belonging to this sys-
tem, although not confined to it in  respect of
its lowest grade, or that which I have called, in
the article just referred to ($ 11), " insensible or-
ganic contractility."  I have there also referred
this function of muscles to the nervous system,
or systems supplying and  endowing  them (v 17,
et seq.).  Granting that the muscular structure
derives its  vital manifestations from the ner-
vous system of organic nerves in the involun-
tary muscles, and  from both that system and
spinal nerves in the voluntary muscles, as there
shown (<"> 18), it follows that disorders affecting
the functions and sensibility of muscular struc-
tures are to be chiefly attributed to  one or oth-
er of, or to  both, these systems  of nerves, com-
prising  the  nervous centres controlling them.
In the brief review about to be taken of the al-
terations of muscular structures, I shall first
notice those which are functional, or consist of
alterations of sensation or motion; second, chan-
ges of vital action, and the consequences which
result from them ;  and, third, those which  are
more strictly structural, physical, and mechanical.
I. Alterations  of Motion  and Sensation of
   Muscles.
   2. i. The contractility of, or power of motion
possessed by muscles may be variously affect-
ed : 1st. By changes in the state of the organ-
ic nervous  system, and of its vital endowment,
as evinced  chiefly by the involuntary muscular
system ;  2d. By states  of the cerebro-spinal
nerves, or of the spinal chord, medulla oblonga-
ta, or brain, as manifested chiefly by the volun-
tary muscles ;  3d.  By the circulation of blood
in the muscular structure, and particularly by
interruption of the circulation  through either
the arteries or the veins ;  and, 4th.  By the con-
dition ofthe muscular fibres themselves.
   3. 1st. That the power of motion, or contrac-
tility of muscles,  both involuntary and volun-
tary, is greatly dependant upon the  state of the
organic nervous or ganglial system, is shown
by the  manner in  which  this power is affected
by the numerous causes  and pathological chan-
ges which  powerfully influence—which either
excite or depress—this part of the nervous sys-
tem, as stated in the article Irritability.  The
actions of the heart are the chief index of the
states of the nervous system of organic life in
relation to  muscular motion.
   4. 2d. That the cerebro-spinal nervous sys-
tem remarkably affects  the  muscular system,
especially of voluntary motion, is demonstrated
by many agents and morbid conditions ;  but the
change in this system, whether exciting or im-
pairing the power of muscular contraction, may
be seated either in the nerves supplying volun-
tary muscles,  or in the spinal chord, or in the
brain.  When  a nerve is  divided, or tied, the
muscle  supplied by that nerve  is paralyzed;
when the spinal chord is divided, pressed upon, 
994
MUSCULAR STRUCTURE—Pathology or.
or severely injured,  the  parts  supplied  with
nerves proceeding from that part, and from the
chord below the seat  of injury, are paralyzed ;
and when any part of the medullary, or white
structure of the brain, is  injured,  the muscles
more especially related to that part are para-
lyzed, or removed from the influence of volition.
In all these cases sensibility may be preserved,
the stimulus of volition originating in the brain
being no longer conveyed to the voluntary mus-
cles, owing to lesion either of the white  or
fibrous structure of the brain, or of the spinal
chord, or of the nerves.   Owing also to irrita-
tion of either of these parts of the cerebro-spi-
nal system, the muscular structures connected
with them  may be excited into inordinate ac-
tion ; and lesions  of  either, when slight, may
merely impair, without entirely destroying, the
voluntary motion ofthe muscles related to it.
  5.  While the muscular system of animal life
is thus subjected to the cerebro-spinal nervous
system, it is not to be considered as under this
dominion solely and  entirely;  for many  phe-
nomena connected with disease, and even  with
health,  particularly during sleep,  show  that
conditions of the internal viscera, or of  the or-
gans supplied either altogether or  chiefly  with
the organic nerves, often  affect the voluntary
muscular system in a  very remarkable manner.
In all such  instances, the change in this system
is produced through the medium ofthe organic
or ganglial nerves, which convey  the impres-
sion  or  irritation to the brain, or to the spinal
chord, or even  merely to the roots of the spinal
nerves.   Thus, in cases of intestinal worms, 01
other visceral irritations, the morbid impressior
is not infrequently transmitted by the gangli-
al and sympathetic  nerves, and ultimately ex-
pressed upon the voluntary muscles; and, in
most  instances, without any intermediate
change in the brain, or even in the  spinal chord
itself, the impression  being conveyed directly
from  the viscus affected, by communicating
branches of nerves, to the ganglia  of the roots
of the  spinal  nerves.  Cholera, and  several
states of convulsion, are proofs of this mode of
transmission   of irritation  from  involuntary
parts  to voluntary nerves and muscles ;  and
the phenomena presented by foetuses without
brains, or without both brains and spinal chords,
are also illustrations of it, as shown in the ar-
ticles Cholera, Chorea, Convulsions, &c.
  6. Those inordinate actions of voluntary mus-
cles  resulting  from visceral irritation, are oft-
en so great as  to be entirely beyond the control
of the will, as in the  diseases just noticed, or
unless volition  be very strongly exerted, as in
some instances of hysteria.  Most of the  con-
tractions of voluntary muscles that occur du-
ring sleep'are induced by irritation of internal
viscera ; and the irritation may intermediately
affect the brain and occasion dreaming, accord-
ing to the nature of such irritation or impres-
sion,' or it may be more immediately transmitted
to the voluntary nerves and muscles ultimately
affected, without in any  way impressing the
sensorium.
  7.  3d. That the state of circulation of blood
in muscles  materially affects their contractile
power has been fully proved by experiment and
by pathological  observation.   It is not alone
necessary that a sufficient circulation or supply
of blood should exist in muscular parts in order
 to preserve their functions  and organization,
 but also that  the blood  be duly oxygenized or
 changed from the venous to the arterial state.
 It is fully shown by  disease  and experiment
 that interruptions of the changes produced by
 respiration  on  the  blood  impair  or  disorder
 the  contractility of muscles, by affecting not
 only the cerebro-spinal axis, but also the mus-
 cles themselves ; the  highly venous or unoxy-
 genated blood affects both the cerebro-spinal
 system and the muscular structure itself. The
 phenomena of asphyxia, ofthe advanced stage
 of pestilential cholera, and other diseases  at-
 tended by interruption of the  respiratory pro-
 cesses, fully illustrate this proposition.
  8. When the  principal artery of a limb  is
 tied, and  when  the supply of arterial blood to
 the muscles is not kept up by  a collateral cir-
 culation, the muscles are paralyzed, the limb is
 benumbed, and it soon dies.  When  the ve-
 nous current is entirely interrupted the limb is
 remarkably congested, livid, benumbed, para-
 lyzed, and as if locally  asphyxied.   On the oth-
 er hand, when the supply of blood to muscular
 parts is free,  abundant, and  of a healthy and
 duly oxygenized quality, the  contractile power
 of muscles is thereby increased and perpetu-
 ated.
  9. 4th.  It is evident that the original confor-
 mation, the organization, and the nutrition of
 the muscular  fibre very materially affect the
 amount of its function, or of its  contractile
 power.   Muscular parts acquire increased vas-
 cularity and development with the frequency
 of action, and with  these, augmented power;
 while they become pale, atrophied, weak, and
 at last almost  paralyzed  by  disuse.   These
 changes are chiefly owing to increased  or di-
 minished determination of nervous power and
 of arterial blood to  these parts, according as
 their functions  are discharged ;  but they are
 also owing to the states of nutrition consequent
 upon the amount of function performed.
  10. Of the  above  causes of  disorder of the
 contractile power of  muscles, the most fre-
 quent are those which are seated in some por-
 tion of the cerebro-spinal  system of nerves,
 and at  the same time they are productive of the
 most manifest effects.   This fact is demonstra-
 ted by  disease.  The palsy of a single or of  a
 few  muscles is generally caused by lesion  of
 the motor nerve or nerves supplying  them.
 Palsy of a portion of the body transversely, or
paraplegia, is commonly produced by disease in
 or implicating the spinal chord ; and palsy of
 one side, or hemiplegia, is occasioned by lesion
 of the brain.   Chorea, paralysis agitans, or sha-
 king palsy, the trembling or shaking caused by
 mercury or other metals, or by age, or  by the
 abuse  of spirituous  liquors,  generally depend
 upon the state ofthe spinal chord, and are oft-
 en aggravated,  as in  chorea, by exertions of
 volition, the contractions produced by volition
 being weak, vacillating, and  uncertain, owing
 to the morbid state of the cerebro-spinal sys-
 tem, or to the diseased movements caused by
 the state of this system.  On  the  other hand,
 tetanis, eclampsia, epileptic  and hysteric  convul-
 sions, cramps, &e, are manifestations  in  the
 muscles of irritation of some part of the cere-
 bro-spinal system, more particularly of the spi-
 nal chord, the irritation either  existing prima-*
 rily in  it, or being propagated to it by ganglial 
MUSCULAR STRUCTURE-
!—Inflammation of Muscles.
995
or other nerves, and thence reflected by motor
nerves on the muscles.
   11. ii. Lesions of Sensibility in  Muscles.—
These generally proceed from  repeated, pro-
longed,  or excessive contraction  or exertion,
and vary from the slightest feeling of lassitude
or fatigue to the excessive pain attending spasm
and tetanus.   In some forms, also, of rheuma-
tism, severe  aching pains are referred to the
muscles, a  myalgia, which  may be  owing to
alteration of the sensibility  of the nerves sup-
plying the muscles.
II. Inflammation of Muscles.—Svn.  Mysitis
   (from ^Of, a muscle),  Myitis, Myositis, Hil-
   denbrand.   Muskelentzundung, Germ.  Myo-
   site, Fr.
     Classif.—III.  Class, I. Order (Author).
   12. Defin,— Severe pain of one or more  mus-
cles, with great difficulty or impossibility of con-
tracting them, every attempt to contract them vio-
lently exasperating the pain, and with inflammato-
ry fever.
   13. The muscular fibre is rarely the  seat of
inflammation.  Indeed, it is doubtful whether
or not it is ever inflamed, or can  admit of be-
ing inflamed, owing to its organization.  Most
probably, in those cases in which the muscles
have been found exhibiting evidences of inflam-
mation, the fine cellular tissue connecting the
fasciculi of their  fibres  have been chiefly or
solely affected, this being the most vascular
part of their structure.  There can be no doubt
that some ofthe cases which have been view-
ed as instances of myositis have been cases
either of rheumatism, in which true inflamma-
tion of the muscles does not exist, or of in-
flammation only of the cellular substance sur-
rounding or connecting muscles.   In rare ca-
ses, however, the muscles, in the manner now
stated—chiefly as respects their connecting and
surrounding cellular tissue—are the seat of in-
flammation.   The  muscles  are no farther  af-
fected in rheumatism than  as  respects their
sero-fibrous sheaths and aponeuroses, which
sometimes are implicated in that disease, the
muscular Able itself not being inflamed.
   14. i.  The causes of myositis are chiefly exter-
nal injuries : bruises, wounds, sprains, excess-
ive contraction, or over-exertion ; sudden con-
traction of a muscle when volition has not been
decidedly directed to the part, rupture of the
fibres of muscles  from over-exertion, or from
contraction with imperfect  volition ; disloca-
tions, lifting heavyweights;  injuries or wounds
of aponeuroses or tendons;  and caries or other
diseases of adjoining  bones, especially of the
vertebrae.  The  muscular fibre is  very rarely
inflamed from internal  causes, or from influen-
ces affecting the vital  condition—the sensibil-
ity and vascular actions of muscles—independ-
ently of external  injuries, although  the sero-
fibrous sheaths  of muscles and tendons, and
aponeuroses  are  often inflamed in the course
of rheumatism, owing to internal causes and in-
fluences affecting their vital states.  (See art.
Rheumatism.)
   15. ii. The symptoms of myositis are, extreme
pain, soreness, and tenderness of a muscle or
muscles, the pain  being so much increased by
contraction as to render all attempts at motion
most difficult, or altogether impossible-, in-
creased heat, and indistinct or diffused swell-
ing of the part;  sometimes  subsultus of the
tendons, or rigid contractions, or spasms of ad-
joining  muscles; and always symptomatic in-
flammatory fever, with the usual constitutional
phenomena of such fever.
  16. With the exception of traumatic  myosi-
tis, which may occur in all situations, the mus-
cles which have been the most frequently in-
flamed are, the psoae, the tongue, and the dia-
phragm.  The  muscles of organic life are oft-
ener the  seat  of inflammation than those  of
voluntary motion, particularly the urinary blad-
der, stomach, oesophagus,  heart, &c.;  still it
is doubtful, even  in these, whether or not the
muscular structure is inflamed, otherwise than
in being implicated consecutively.  It is most
probable that the inflammation originates, and
is seated chiefly, in  adjoining or  connecting
tissues, the muscular fibres  being, from their
organization, incapable of experiencing those
changes which have been usually termed in-
flammatory, although their  functions are dis-
turbed or interrupted by the disease in which
they are implicated.*
  17. iii. The consequences of inflammations of
muscles are chiefly exudations of serum or lymph,
softening of the tissue, induration, suppuration,
and gangrene.—A. Exudations of serum or of
lymph may take place, in the course of  myosi-
tis, between the fasciculi of fibres, or from  the
surface of the  fibrous sheaths or aponeuroses
enveloping muscles.  Such is the  case, more
especially, when muscular  parts  become  in-
volved in the course of diffusive or asthenic
inflammations, particularly  of the  connecting
or interposed cellular substance.
  18. B. True  softening of muscular texture in
consequence of inflammation is rarely met with
in the muscles  of the skeleton, unless in some
of the worst instances of diffusive, erysipela-
tous, or asthenic inflammations; and after poi-
soned wounds, and the inoculation of  animal
poisons.  But it is not infrequent in the mus-
cular coats of the alimentary canal and urinary
bladder, in conjunction with a similar change
of  their other coats, more especially  in  the
course of dysentery and adynamic or  enteric
fevers.   It is also observed secondarily in  the
diaphragm, particularly when this  muscle  be-
comes inflamed consecutively upon hepatitis ;
and more rarely even in the heart, during  the
course of malignant, continued, and  exanthe-
matous fevers,  in cachectic diseases, and in the
course of some cases of true carditis.  In most
of the  instances of inflammatory softening of
muscles, the colour of the part is changed to a
more dark or dusky red than natural, or to a
dirty brown.   In some  cases,  however, the
softened part has been paler than usual.
 ' 19. C.  Suppuration is not a frequent  conse-
quence of myositis.   It is most commonly met
with in psoitis,  but very rarely in the other vol-
untary muscles; and still more rarely  in the
substance of the heart.   It occurs chiefly in a
diffused  form,  infiltrating the  cellular  tissue
connecting fasciculi, or interposed  between
muscles.  It is thus met with in some cases of
  * [We recently witnessed a case of inflammation of the
muscular tissue in a hod carrier, who had over-employed
the muscles of the leg in climbing to the top of a high build-
ing with a heavy load on his shoulder. The muscles of the
thigh and leg were intensely painful, swollen, and hard al-
most as a board; motion was impracticable.  The parts
were very hot. and there was much constitutional fever.
The result of the case we never learned.] 
996
MUSCULAR STRUCTURE—Structural Changes or.
caries ofthe vertebrae, the disease of which has
extended to the adjoining muscles and cellular
substance, the matter which  has been formed
infiltrating this substance to a considerable dis-
tance.  The exudation of serum, or of a sanious
lymph, may,  according  to the  states  of vital
power and of the circulating fluids, give rise to
various changes—either to purulent collections,
or to an offensive sanies, contaminating the ad-
joining parts, and sphacelating the cellular and
adipose substances which it infiltrates.
  20.  D. Gangrene is sometimes observed con-
sequent upon acute inflammation, occurring in
an unhealthy habit of body, or during the prog-
ress of malignant fevers.  It may destroy large
masses of flesh ;  but this rarely  takes place ex-
cept some previous or co-existing change  ex-
ists in the nerves or blood-vessels supplying the
gangrened part.  In a case to which I was call-
ed many years ago by my friend Dr. J.  Davies,
of Hertford, gangrene of all the  muscles of one
lower extremity proceeded from inflammation
of the iliac artery and vein associated with
neuritis.
  21.  E. Induration  or  hardening of muscles,
with change in their structure, is generally a
result of slow inflammatory action, and of  the
exudation of lymph, thereby produced, into  the
cellular tissue connecting their fibres.  It is
met with in both the voluntary and involuntary
muscles, in different degrees, and usually  is at-
tended by some  swelling  or enlargement.  In
the more  advanced stages of this change  the
hardening is increased; the  muscle becomes
pale, loses its usual texture, and assumes either
a leathery, a tendinous, or even  a cartilaginous
appearance, while, at the same time, its bulk is
more  or less diminished.
  22.  iv. The treatment of inflammation of mus-
cular  parts is in no respects different from that
of sthenic inflammation of other structures.
The usual antiphlogistic remedies and regimen
should be enforced, with various modifications
as to the extent,  nature, and  variety of  the
means to  be  employed,  which the seat of  the
disease, its causes,  and  the constitution of  the
patient, will suggest.  In  cases where muscu-
lar parts are involved in  inflammations of an
asthenic  or  diffusive character, incisions  are
often  required to  prevent the  contamination
which would follow if the  morbid matter form-
ed in  the part was  not allowed a free exit.  In
all respects the treatment, both constitutional
and local, should be conducted according to  the
form  the  disease  assumes,  and conformably
with the principles fully developed in  the arti-
cles Inflammation, Erysipelas, and diffusive in-
flammation of Cellular Tissue.
III. Changes  of Muscular  Structures  not
  STRICTLY REFERABLE TO INFLAMMATION.
    Classif.—IV.  Class, III. Order (Author).
  23.  A. The  size  of muscles  is much  influ-
enced  by disease.—a.  Atrophy  of muscles is
very common, in consequence of deficient  nu-
trition, of a cachectic state of  the system, of
febrile action, of  masturbation and  venereal
excesses, and of visceral and constitutional dis-
ease.   In these  circumstances  the  wasting is
general;  but it is often  partial, as in the mus-
cles of the legs and lower limbs, particularly in
persons addicted to the excesses just mention-
ed, and in those who are lame.   Disuse of  the
muscles of voluntary motion  always occasions
| their atrophy.   Long-continued pressure has a
 similar effect, whether occasioned by tumours,
 dropsical effusions, or by swellings of any kind.
 In cases of this description large muscles fre-
 quently become expanded, and reduced to a
 membrane.
   24.  b. Hypertrophy seldom occurs in  the vol-
 untary muscles, excepting as a consequence of
 active  exercise, and it then cannot be consid-
 ered as a morbid state.  It is met with in the
 involuntary muscles, as in  the structure of the
 heart,  stomach, and urinary  bladder, and is
 then owing  to  morbidly  increased action.   If
 ever observed under other circumstances  in the
 muscles of the  skeleton, it is merely apparent,
 and occasioned by the deposition of lymph or
 adventitious structures between the muscular
 fibres.
   25.  c. The colour of muscles varies  exceed-
 ingly, according to the abundance of haemato-
 sine in  the blood, and to the  quantity of this
 fluid which they may contain.  When the mus-
 cles are congested with blood, as is frequently
 the case in persons dead from asphyxia, drunk-
 enness, tetanus, sanguineous apoplexy, narcotie
 poisons, &e, they are usually of a deep red or
 dark colour, the blood in the vessels being semi-
 fluid.   In inflammatory and pulmonary diseas-
 es, they are either red or purple-red; in  typhus,
 pestilential cholera, plague, yellow fever, and
 other pestilential maladies, they are bluish-red,
 or of a very dusky red.  In scorbutic persons
 they become, in places, of a dark brown colour.
 In all those  diseases in which there is a defi-
 ciency of blood—in chlorosis, rickets, tubercu-
 lar  affections,  dropsies,  in  many very fat or
 leucophlegmatic persons, and in visceral affec-
 tions diminishing  the  assimilating  processes,
 the muscles are more or  less  pale.  When
 limbs  have been disused, are lame, the joints
 anchylosed, &c, the muscles become not only
 atrophied, but  also remarkably  pale or  even
 white.   A pale  state may also arise in muscles
 of the natural size, from great vascular deple-
 tion.  Changes of texture  are often attended
 with alteration  in the colour;  when the  mus-
 cles are  converted into  fatty or adipocerous
 substance, when indurated  from inflammation,
 and when affected with scirrus, they often be-
 come unusually pale.
   26. d.  Contractions of  muscles  arise chiefly
 from irritations affecting the origins of nerves
 supplying them, or certain parts ofthe  enceph-
 alon in intimate correspondence  with these
 nerves, or the ganglial nerves communicating
 with them.  This alteration of muscles may
 also be connected with injury to, or with irri-
 tation  or  inflammation of their  tendons and
 aponeuroses.   After long contraction, the mus-
 cle becomes atrophied, pale, and reduced to a
 state approaching to that of aponeurotic fibres.
 Remarkable contractions of the circular fibres
 of portions of the hollow viscera are sometimes
 found many hours after death, when these vis-
 cera have been shortly before dissolution the
 seat of severe irritation.
   27. B. The consistence of muscles is extreme-
 ly various.—a. Unusual firmness and dryness of
 the muscular tissue are sometimes met with in
 connexion with change of  texture, and  more
 rarely  without  such  change.  Great firmness
i merely is generally attendant upon contractions,
I and these are associated with dryness,  blanch- 
MUSCULAR STRUCTURE—Structural Changes  of.
997
 ing, and some degree of atrophy when the con-
 traction has been of some duration.  Firmness
 and dryness, when considerable, are common-
 ly local changes affecting chiefly muscles which
 have been long contracted, or pressed upon by
 swellings, tumours, &c.  Isenflamm and Otto
 have, however,  recorded instances  in  which
 the muscles were hard and  dry  throughout.
 These alterations are most frequently observed
 in very aged persons.
   28. b. The consistence of muscles is  often
 more or less diminished throughout, particular-
 ly in the advanced stage of adynamic, typhoid,
 and  putro-adynamic fevers,  in  yellow fever,
 plague, scurvy, dropsy,  and still more so in per-
 sons killed by lightning, or  by a blow on  the
 epigastric  centre, also in cachectic diseases,
 and whenever the blood becomes vitiated  by
 animal or other  poisons.  Softness and flabbi-
 ness in all these maladies are generally the re-
 sults  of impaired vital cohesion of the struc-
 ture, and the colour ofthe muscles is, in these
 circumstances, generally deeper than natural,
 and is owing to  the dark and morbid state of
 the blood.  In tubercular and visceral diseases,
 in paralysis, certain chronic  affections of the
 heart, in chorea, paralysis agitans,  in lameness
 of limbs or anchyloses  of joints, and in chloro-
 sis and anaemia, the flabbiness or softness of
 the muscles  is owing more to deficient circula-
 tion  of blood in,  and impaired nutrition of, the
 muscles, than to  diminished cohesion, the mus-
 cles  thus affected being of a pale yellow  or
 fawn  colour.  Softness of muscles may be re-
 markable in  the  systems both of organic and
 animal life.   I have met with it in both, in all
 the diseases just enumerated, and  even in the
 heart itself.   I observed it in the  heart asso-
 ciated with unusual pallor of the  tissue in a
 case  of chorea  (see London Med.  Repos., vol.
 xv.).   Softening  sometimes occurs locally to a
 great  extent  in  the vicinity of malignant  af-
 fections, as in the lips and cheeks from watery
 cancer, and  near carcinomatous and fungoid
 formations.   In  some  marked  cases of the
 kind, a large portion of muscle has been con-
 verted into a jelly-like,  pulpy, or fungous mass,
 constituting the myomalaxia of some authors.
   29. c. Fatty or adipocerous degeneration of mus-
 cles—Myosteatosis, Myodemia of Lobstein, and
 steatosis of Craigie—is rarely observed.   In
 this state the fibrous structure of the part is
 entirely lost.   Otto states that it occurs chief-
 ly in  the lower extremities after diseases  of
 the knee joint.  In fat persons there  seems to
 be an approach to this state, in the extreme
 paleness of the muscular fibres and the  depo-
 sition  of fat  between them.  This  change has
 likewise been observed to occur in the heart by
 Laennec, Adams, Andral, and others.
  30.  d. Fibrous, cartilaginous, and osseous trans-
 formations  of muscles  are sometimes  seen.
 Muscles  which have been long retracted, par-
 ticularly in old men, after rheumatism, often
 assume a fibrous, or even a fibrocartilaginous
 stale.   M. Cruveilhier has found the muscles
 ofthe  leg transformed  to this state in a  case
 of elephanlia.  A  similar change  may occur
 after fractures, the muscles nearest the frac-
 tured  part being partially converted to a fibro-
cartilaginous,  a  cartilaginous, and  osseous
structure successively.   Tavernier and  An-
dral have observed ossification of  muscles to
 a great extent.  In most ofthe cases in which
 it has been seen it has been limited to the cel-
 lular tissue between the  larger fasciculi of
 fibres, or dipping into  them from the fibro-serous
 expansions  and aponeuroses, beneath  which
 the ossific matter is deposited.  As the osseous
 change  proceeds the muscular fibres become
 atrophied, and ultimately disappear.   Earthy or
 phosphatic concretions are sometimes  met with
 in  the same situation, and  in the cellular sub-
 stance between the muscles, especially in gouty
 persons.
   31.  e. Tubercular degeneration is very rarely
 seen in muscles, and is met with only in the
 vicinity of scrofulous disease of the knee joint,
 or  of  tubercular masses in the neck, armpit,
 mediastinum, &c.
   32. /. Malignant degenerations of muscles are
 observed only  secondarily.  Scirrus is  thus
 met with, changing the  muscular structure to
 a dense, whitish, fibrous* substance, which sub-
 sequently runs into malignant ulceration.  Can-
 cer, in  the  carcinomatous state, and  medullary
 sarcoma  or  fungo-hamatoid  disease, are some-
 times found to invade the muscles, particularly
 the pectoral,  to a  considerable  extent.  Me-
 lanoid formations are  also observed, but chiefly
 in the connecting cellular tissue.
  33. g. Simple cysts, cysts containing hyda-
 tids, and others containing  small worms, have
 been found  in the substance of muscles.  The
 former have been observed by Werner,  Lob-
 stein, Cruveilhier,  and others ; the last  by
 Mr. Owen—the trichinia spiralis—who  found
 this worm in subjects who  had died  of differ-
 ent diseases, of a low character.
  34. h. Fluids are sometimes effused between
 the muscular fibres.   These  consist: 1.  Of a
 watery serum, in some cases of dropsy and leu-
 cophlegmasia.   2. Of a gelatinous matter, infil-
 trated between the fasciculi  and around the
 muscle, in acute rheumatism.   3. Of puriform
 or  sanious matter,  infiltrating the fasciculi  of
 muscles, found  only in rare instances, and  in
 cases where puriform or ichorous fluids  have
 been carried into the  circulation from a distant
 situation ; and,  4. Of  blood. This last  has  been
 met with in various proportions, and has pre-
 sented various  appearances—fluid, semifluid,
 and dark, or almost black—in small specks,  or
 ecchymoses, or  in larger deposites.   The  effu-
 sion of blood between the muscular fibres has
 very rarely  caused rupture of them.  To this
 alteration, the term muscular apoplexy has been
 applied by several French pathologists.   It  is
 very rarely  met with in the voluntary  mus-
 cles, unless  in  scurvy and purpura haemorrha-
 gica.  It is  sometimes seen in the involuntary
 muscles, and  even in  the  heart itself,  after
 death from  malignant, putrid, or pestilential
 fevers.
  35. i. Inflammation  and obliteration  of blood-
vessels are often followed by marked alterations
of the muscles, which the  diseased vessels
supply.   Thus, Cruveilhier and  others  have
traced phlebitis from one of the principal veins
of a limb to the branches proceeding from a
muscle ;  purulent  matter infiltrating it,  and
numerous small abscesses  being interposed
between its fasciculi.  Obliteration ofthe blood-
vessels is generally followed by gangrene, and
particularly when the  arteries are obliterated,
unless a collateral circulation is formed.   The 
998                                NERVES—Diseases or.
gangrene following  ergotism is  chiefly occa-
sioned in this way,  although some  change  is
also early produced  by the morbid food on the
nerves  of the  part.   Ulceration  rarely takes
place in  muscular structures,  and  chiefly  in
consequence  of the  pressure of tumours.  In
the involuntary  organs it sometimes  extends
to and invades the  muscular structure, in  its
progress from adjoining parts in  which  it has
originated.   Malignant ulceration, softening, and
destruction are  often met with consecutively
upon local malignant maladies, particularly  in
the pectoral  muscles, and in the face.
  36. k. The physical and mechanical  changes  to
which muscles  are liable consist  of rupture of
their fibres, rupture of the aponeurotic envelopes,
or luxations of muscles, wounds,  contusions, &c.
The consideration of these does not  fall within
the scope of my work.   I  may,  however,  re-
mark, that the continuity  ofthe muscular tissue
may be destroyed by external violence various-
ly applied, by spontaneous rupture after  ante-
cedent softening, by suppuration and ulceration,
and by violent involuntary contraction.   When
these accidents  are  not  the  result of previous
organic change, they are generally repaired by
means of a reddish jelly-like substance, poured
out at the point of separation.   This substance
changes into a  vascular and reddish cellular
tissue, becomes subsequently compressed, of a
lighter colour,  more solid  and less  vascular,
forming  the  medium of  union between the di-
vided parts, and restoring  the  continuity and
functions of the injured muscle,  but itself not
consisting of true  muscular tissue.
   37. I.  Rupture of the fibres of a  muscle gener-
ally occurs upon any sudden, involuntary, or un-
conscious and violent contraction of it;  is at-
tended by extreme pain, sometimes  by a crack
or  noise, and by inability to contract the mus-
cle, each attempt to  do so remarkably augment-
ing the  suffering ;  and is  followed by  some
swelling, and occasionally by ecchymosis.  The
treatment of these accidents consists of con-
stant relaxation ofthe muscle,  favoured by po-
sition, and of suitable bandaging  of the part or
of  the limb, continued until reparation has ta-
ken place.
  Bibliog. and Refer.—Leuwenhoeck, Microscopical Ob-
serv. on Muscles,  in Philosoph. Trans., vol. xxvii., p. 529,
1712.—Pouteau, Mem. sur la Luxation des Muscles, &c. ;
dans Melanges de Chirurg. et (Euvres  Posth., t. ii.—R.
Whytt, An Essay on the Vital and other involuntary Mo-
tions of Animals, 8vo.   Edin., 1751.—T. Simson, An  In-
quiry how far the Vital and Animal Actions can be account-
ed  for independent of the Brain, &c, 8vo, p. 10.  Edin.,
1752.—A. Haller, De Partibus Corporis humani Sensibili-
bus et Irritabilibus, 4to.  Goet., 1753 ;  et in Oper. Mm., t.
i.—Lieutaud, Hist. Anat., <fec, t. ii.,4>. 346.— F. Fontana,
in Traite du Venin de la Vipere, t. ii.,  p. 239, 1781—/sen-
fiamm, De  Musculorum  Pathologia, 4to.  Erlang., 1774.—
A. Ypey, Observat. Phys. de Motu Musculorum Voluntario
et Vitali, 8vo.  Frank., 1775.—Ploucquet, De Myositide et
Neuritide, 8vo. Tub., 1790. — Schallhammer,  De Morbis
Fibr<c Muscularis, <&c, 4to. Halze, 1799.—Dumas, in Journ.
Gener. de Med.,  t. xxiii., p. 61.—Emmanuel, in Ibid., t.
xxiv., p. 5.—A. Humboldt, De l'lnfluence du Galvanisme
sur l'lrritabilite des Muscles, dans Mem. de la Soc. de Med.
d'Emulation, t. i., 1797. — Portal, Anat. Medicale, t. ii., p.
412.—Beclard, Addit. a l'Anat. Gen. de Bichat, p. 214.—M.
Baillie, Works, edit, by Wardrop, vol. i., 8vo.   Lond., 1625.
—J. Thompson, On Inflammation, &c, p. 152.—Lobstem,
Compte rendu, &c.,p. 32. Strasb., 1&20 ; et TraittS d'Anat.
Pathol., t. ii., p. 353.—Otto, Sclt. Beobach., p. ii., p. 40.—
 Ouvrard, in Nouv. Journ. de Med., Dec, 1622; et Rostan,
in ibid., t. vii., p. 280.— Wardrop, in  Trans, of Med.  and
 Chirurg. Soc. of Lond., vol. vii., p. 278.—Flaubert, in  Re-
 port. Gener. d'Anat. Patholog., &c, t. iii., p. 124.—V". N.
 ab  Hildenbrand, Institutiones Med. Pract., t. iii., p. 34.—
 Andral, Precis d'Anat. Pathol., t. i., p. 220 ; t. ii., p. 571.—
Tytler, in Trans, of Med. and Phys. Soe. o( Calcutta, toL
i., p. 117— J. Kennedy, in Lond. Med. Repos . No. 124.—
A.N. Gendrin, Hist. Anat. des Inflammations, 2 tome»r8TO.
Paris, 1826 ; t. ii., p. 188 (Gives the best account of changes
produced by Inflam. of Muscles).-Craigie,  Memento of
Gen. and Pathol. Anatomy, p. 486.  Edin., 1WK-CW
Iter, in Lond. Med. and Phys. Journ.^vol. ly.,p. 95.—Tad-
dei de  Gravina, in Ann. de MW. A'Omodn, 1B36, t. Ixxr.,
p. 4'Jl.— W. C. Henry, in Edin. Med. and Surg. Journ., vol.
xxviii., p. 240.—Cruveilhier, Diet, de Med. et Chirurg. Prat.,
t. ii., p. 568; et Anat. Pathol., livr. 2 et 17.—Rayer, in
Archiv. Gener. de  Med., t. i., p- 493.—Prevost et Dumas,
in Ibid., t. iii., p. 88.— Wright,  in Ibid., t. xxi., p. 562.—
Ollivier, in Diet, de Med., 2d edit., art. Muscles.
  NERVES—Diseases  of.—The various af-
fections and structural  lesions of nerves have
been  insufficiently  investigated;  and the  ex-
isting state of knowledge respecting them is
without precision, even as respects those which
are the most  frequently observed.   Sciatica is
a proof of this want of precise knowledge ; for
information is still required as to the state of
the nerve in  this affection.  Cotugno, one of
the earliest investigators of this complaint, im-
puted  it to inflammation.   This  opinion  was
considered incorrect  by later writers;  and now
it has been demonstrated that certain  states of
sciatica actually proceed from inflammation of
the sciatic nerve.   In cases of morbid sensibil-
ity also of other nerves, it has not been shown
whether the affection be functional  merely, or
whether it be really  inflammatory, or depend-
ant upon  alteration of structure.   And it is oA-
en  difficult to determine how far the trunk of
the nerve is implicated, or whether or not the
affection  proceeds entirely from disease at the
origin of the nerve in which  it is manifested.
These remarks apply also to impaired or abol-
ished  function and sensibility of  nerves.  The
real mischief may be seated  at  or  near their
origins, in their trunks, or in parts closely con-
nected with  either;  and  the  same  species of
lesion  which  in either situation may induce
exaltation of sensibility  or spasm,  or convul-
sive actions of the  muscles supplied by them,
may, in a higher grade, produce loss of sensa-
tion, and in a still higher grade occasion loss of
motion, or loss of either,  or of both functions,
according to the nature and precise  seat of le-
sion.   Since the researches of Sir C Bell have
appeared, some light has been thrown upon this
department of pathology; still the light has been
sufficient only to render our darkness more vis-
ible.   In the  brief account about to be given of
diseases  of nerves,  I shall notice, first, the le-
sions of structure observed in them ;  secondly,
inflammations  of nerves;  and, thirdly, morbid
exaltations of sensibility, or  neuralgic  affec-
tions ; certain  other disorders of nerves being
comprised  under different appellations, as pa-
ralysis, &c.
 I.  Structural  changes of Nerves.
     Classif.—IV. Class, III. Order (Author).
   1.  There are few parts of the animal  body
less subject to organic lesion than the nerves,
 particularly those of voluntary motion ; and the
 lesions most frequently observed in them are
 chiefly the results of inaction, or of disease in
 parts connected with their origins, or of inflam-
mations of some portions of their trunks.
   2.  A. The size of nerves  varies  materially,
 and the change  may be either original or ac-
 quired.—a. Congenital or original smallness  is
 not infrequent, either in a simple  state, or con-
joined with other morbid changes.   It is gen-
 erally connected with absence or imperfection 
NERVES—Struct
of the organ lo which the nerves thus affected
belong.   In internal dropsy of the head and hy-
drencephalocele,  the  cerebral  nerves,  while
within the skull, are often very thin, as are the
spinal nerves in the vicinity of the tumour  in
spina  bifida.—b.  True atrophy of the nerves,
wasting or acquired smallness, is generally met
with in particular nerves ; it is seldom or nev-
er general, excepting in a very slight degree, in
general emaciation, or in very old persons.   In
hemiplegic and paralytic persons, the nerves of
the paralyzed parts are seldom very remarkably
smaller  than those which  are  capable of con-
veying volition.   The nerves, however, of the
organs of sense waste, shorten, or  lengthen,
&c, as the cause and consequence of diseases
impairing or abolishing the functions of these
organs.   This has  been most commonly  re-
marked  in respect of  the optic nerves, which,
alone, or with the optic beds and quadrigeminal
bodies, have been found atrophied.  Wasting
of nerves frequently arises from pressure of
any kind, as  that of tumours and collections
of fluid,  &c, and is sometimes connected with
neuralgic and epileptic affections.  Wasting of
the trunks of the nervi vagi has been observed
in consumption, and of the ganglial  nerves sup-
plying the organs of generation some time af-
ther the disappearance of the menses.
  3. c. Irregular increase of the  size of nerves is
rarely congenital; but is sometimes  met with
as a consequence of inflammation, dropsy, can-
cer.  In such cases, single nerves  are only af-
fected ;  but the  increase of size is sometimes
three or four  fold.  The ganglia and sympa-
thetic nerves are  not  infrequently  enlarged.
Laumonier,  Pinel, Romberg,  Lobstein, and
Duncan  have found them unusually large  in
idiots, hemicephalic monsters, and diabetic pa-
tients ;  but Meckel and Otto, in their dissec-
tions after death from those diseases, have not
observed this appearance.  [Lobstein has often
noticed  the thoracic ganglia and  semilunar
plexus very much  engorged with blood, and
florid from inflammatory congestion  ; and Dr.
Cartwright, of Natchez, Miss., frequently ob-
served disease of the thoracic and abdominal
portion of the great sympathetic, in the yellow
fever which prevailed in that place in  1823.
Seventeen out of twenty yellow  fever subjects
presented intense congestion and inflammation
of the semilunar ganglia  and plexuses; and
the cardiac and pulmonary plexuses were often,
also, in the same pathological condition, though
the latter were less frequently and extensively
affected than those of the other viscera.   In
connexion with  these appearances, there was
generally more  or less  lesion of the cerebro-
spinal axis, the  duodenum, stomach, lungs, or
liver.  (Am.  Med.  Recorder, vol. ix., p. 37.)]
Dr. R. Lee has  demonstrated the remarkable
enlargement of the uterine nerves upon concep-
tion and during pregnancy.   (Philos. Trans.,
1842.)   Thickening of the  nerves is not  an un-
usual  consequence of chronic inflammation  of
their sheath and the cellular tissue connecting
their fibrils.   In  several cases of this descrip-
tion, the nerve assumes a yellowish or grayish-
yellow colour ($ 4).
  [The  sympathetic nerve is  often  found en-
larged, sometimes to six or eight times its nat-
ural diameter.   A case of this kind is recorded
by Cruveilhier (Path. Anal.), in which  all the
ural Changes of.                       999

cervical ganglia of the left side were enormous-
ly enlarged, especially the middle, which was
two inches and a half in length by one inch in
thickness.  They were of a grayish-white col-
our, of a  very  dense, compact consistence,
creaking very sensibly under the knife.   They
were evidently fibrous, so arranged as to form
a large number of cells, filled with a sort of ge-
latinous  substance; the  component  nervous
filaments were  completely atrophied, the only
part left  being  their  neurilemmic covering.
The nervous cords  between the diseased gan-
glia, as well as  those which passed off from
them, were very much enlarged, of a pale gray-
ish colour, and abnormally firm in their consist-
ence.  (Gross.)]
  4. B.  The nerves may also present anomalies
of form, position, and ramification.   These are
too numerous, in respect of every nerve, to ad-
mit  of particularizing  them.—a.  Their colour
varies with their structural  changes.  When
atrophied  or  softened, they usually lose  their
gloss and whiteness, become somewhat opaque,
gray, or yellowish,  or  grayish-yellow.   Con-
tused or inflamed nerves are more or less red
throughout,  or  spotted or  streaked with  red.
In ulcers and gangrened parts, they are usually
more or less discoloured.   In complete atrophy,
or near a cancerous part, they present various
shades of brown or rust-colour.  In jaundice,
they very seldom participate in the general dis-
coloration.
  5. C. The consistence of nerves is sometimes
either diminished or increased.—a.  Diminished
consistence is most  common: instead of  being
firm and elastic, the nerve becomes soft,  with-
ered, or shrivelled,  easily torn, and appears  as
if macerated.  In some instances, their sheaths
are of their  natural firmness, but their  fibrils
seem loosened, and somewhat separated from
each other.   In  other cases, the medullary part
of the nerve is  remarkably softened  and dis-
coloured, appearing as if it had been dissolved
by a solution of a fixed alkali; and, in the more
extreme cases,  so completely disorganized  as
to run out upon  the division ofthe nerve  like a
jelly, or even like water.   This state is analo-
gous to that described under the name of pulpy
disorganization  of the medullary structure  of
the brain, and proceeds from the same causes,
one of the chief being a high degree of inflam-
mation.  Softening of the  nerves may also  be
conjoined to atrophy.   The nerves,  in  some
parts, are sometimes entireiy deprived of me-
dulla,  the  hollow  sheaths alone  remaining.
This occurs chiefly within the skull and  spine
in children, with imperfect development of the
brain and water in the head, or with hydren-
cephalocele, and spina bifida.
   6. b. Induration of nerves is a rarer occur-
rence than softening, and  seems to be chiefly
attributable to a state of chronic inflammation,
causing the deposition of a plastic lymph in the
cellular tissue connecting their fibrils  and glu-
ing them  more firmly together.   Induration
may also be conjoined  either with atrophy  or
with hypertrophy of the nerve.  The medullary
substance is never actually converted into car-
tilage or bone.
   [c. The fatty degeneration of nerves, or, rath-
er, a deposite of fat within the neurilema, has
been noticed in some instances.  A case of this
kind is  recorded in the Lond. Med.  Gaz., Aug. 
1000                        NERVES—Structural Changes ot.
26, 1842, from Muller's Archives, in a man af-
fected with  anasarca and  ulcers  of  the leg.
Portions of  the  saphenus  nerves, and other
large branches of the ischiatic, in the neigh-
bourhood of  the diseased part, were enlarged,
and appeared as if composed of mere fat.  On
examination  with the microscope, an extraor-
dinary quantity of fat was found deposited be-
tween the  sheath and the fibres of the nerve,
which increased  in  irregular gradations  as  it
was traced downward, till it constituted the
whole structure of the nerve.  The fat globules
appeared to be arranged concentrically on the
inner surface ofthe sheath, into which the prim-
itive fibres  could be seen running.   They grad-
ually disappeared lower down, till at length no
trace  of them could be found, the fat globules
having entirely taken the place of the primitive
nervous fibres.]
  7. D. The  continuity of nerves may be broken,
as in  external injuries, wounds, &c., by which
they may be partially divided,  torn  asunder,
contused, their fibrils forcibly separated, &c.—
a.  If they be  stretched gradually, as by soft tu-
mours, swellings, &c, they often yield remark-
ably without  their functions being destroyed.
But when  suddenly and forcibly extended, as
by hard tumours, aneurisms, dislocations, &c,
they may be torn, although this can rarely hap-
pen without  breach of continuity  in the sur-
rounding or  more superficial parts.—b. When
a considerable nerve is wounded, neuralgic and
sympathetic affections sometimes arise in  addi-
tion to the  necessary paralyzing  of the part
which it supplies, and to the usual phenomena
proceeding from such injuries, as redness, swell-
ing, effusion  of coagulable lymph, and reunion.
If a nerve be completely divided, both extremities
swell, particularly the upper ; the more distant
or separated portion of nerve becomes some-
what thinner, and the lymph effused between
the divided ends unites them both into a more
or less large  and solid knot, consisting of cel-
lular  tissue,  into which new and irregularly-
disposed nervous  threads are produced  after
some time.   There is no part of the soft solids
which are more disposed to unite than nerves,
even  although the division has been made with
loss of a considerable portion of the nerve, or
their ends have been far removed; but the union
is  always made through the medium of a cellu-
lar tissue produced from the divided ends, into
which medullary fibrils shoot irregularly some
time  afterward.  Even  after amputation, the
divided extremities of  different  nerves  will
unite in this manner, forming a loop.  When
union does not take place, the divided ends cic-
atrize with a permanent swelling, with loss  of
motion and  sensation of the part supplied by
the divided nerve.   [When a portion of nerve
is removed,  the divided  extremities, in the
course of twenty-four hours, become enlarged
and vascular, and the surrounding cellular tis-
sue, taking on inflammation, pours out coagu-
lating lymph, which finally encloses  and ce-
ments them together.   After some time, vary-
ing according to the thickness of the nerve and
the distance between the divided ends, the mat-
ter thus effused is organized, assuming a whi-
tish, gristly appearance, and the function of the
organ is either partially or wholly re-established.
Sensibility commonly returns more quickly than
voluntary motion.   Mr. Mayo found  that the
sentient nerves, when thus mutilated, general-
ly began to regain their functions early in the
third week, while the motor nerves did not re-
cover any of their powers till after the fourth.
It is proper to observe, that if the interval be-
tween  the divided extremities is very great, as
from one to two inches, the union is either ex-
tremely imperfect, being effected solely by con-
densed cellular tissue, or, what is  more com-
monly  the case, nature entirely fails in her ef-
forts, and the function  of the part is thus for-
ever destroyed (Gross).]   After amputation,
the ends of the nerves appear swollen,  infla-
med, spotted, or  red,  from  the blood  effused
between their fibrils  at the divided surface.
This state subsides  into a grayish, thick, firm,
and fibrous-like knob, from which delicate ner-
vous fibrils proceed, serving as nervous ramifi-
cations to the surface and divided parts.*
  8. c.  Contusion of a  nerve is  followed by ef-
fects varying  with the severity of the injury.
When  the contusion is slight, extravasation of
blood in the cellular tissue connecting the ner-
vous fibrils is the chief consequence; if  it be
more  violent, the fibrils themselves may be
crushed.  In  the  first  case, severe pain  and
numbness in the  course of the injured nerve,
and temporary or partial paralysis, are the re-
sults, which generally cease after a time.  In
the second the effects are more severe, and the
palsy more permanent.
  9. d. Punctures are  among the frequent in-
juries to which nerves  are liable.  They occa-
sion extreme  pain, which is often  protracted
long after  the infliction of the  injury, is ex-
tended in the course of the nerve, and is some-
times accompanied with spasms, tremours, or
convulsive motions  of the  muscles supplied
with the punctured  nerve.   Cases illustrative
of this lesion have been recorded by Sabatier,
Wilson, Swan, Bosquillon, and others. Punc-
tures often occasion a circumscribed swelling
of the  nerve, with slight effusion  of blood in
the cellular tissue  connecting the  fibrils, and
in the enveloping neurilema.  It has been shown
by Wolff,  Descot, and Beclard  that, when
the acute inflammatory symptoms  consequent
upon this injury have  subsided, and when the
effused fluids  are absorbed, there still remains
in the  situation of the puncture a hard, opaque,
and circumscribed enlargement, of a fibrous
consistency, formed  by a thickening of the cel-
lulo-fibrous tissue of the nerve. This change
in the  part  may occasion severe pains of the
nerve,  which may not be  subdued until the
nerve is divided in the situation ofthe puncture.
   10. e. Section of a  nerve may give  rise to se-
vere suffering, whether it be complete or in-
complete.   When the division is  incomplete,
severe  pains,  as in cases .of puncture, are felt,
and are remarkably increased  by attempts to
contract the muscles supplied with  the partial-
  * [These tumours always exist on the ends of divided
 nerves, and are not  necessarily productive of pain in the
 stump, except when exposed to pressure, when  partially
 implicated in a firm cicatrix, or when thinly covered, and
 thus exposed to the effects of atmospheric changes, or othei
 external causes.  But when thickly covered with soft parts,
 they seldom give rise to painful symptoms, though of large
 size.  These neuromatous tumours are generally composed
 of a dense, white substance, of cartilaginous consistence,
 which, examined by the microscope, is found to be made up
 of numerous bands of fibres, enclosing an amorphous struc-
 ture ;  these bands being composed of numerous filaments,
, interlacing each other, and terminating often in loops.] 
NERVES—Inflammation of.                           1001
ly divided  nerve; perfect  repose, appropriate
bandaging,  and, if these fail, complete division
of the nerve, being the chief means of relief.
Complete division of a nerve may occasion se-
vere pain,  which, however, is generally much
less violent or prolonged than when  the nerve
is punctured  or partially divided.   When  the
section is complete, the acute pain attending it
is instantly followed by insensibility and  loss
of motion of the parts  supplied by the  divided
nerve, the  divided ends  of the nerve under-
going the changes described above (y 7).
   II. f. A ligature drawn tightly around a nerve
instantly produces effects analogous to division
of it.  After a time, the  ligature  occasions
swellings above and below it, and close to it,
that above  being  the greater.   When  the  lig-
ature causes  division of the nerve the ends re-
main in  contact, surrounded by the inflamed
cellular tissue, and by coagulable lymph, which
soon becomes organized.   Union takes place,
as after division  from  a wound; but the  en-
largement,  especially that which was  above  the
ligature, still  continues more or less.  Ligature
of nerves sometimes occasions very severe or
even  violent  effects, but not so  generally as
commonly  supposed.
   12. g. Wounds, even when very small, occa-
sion most  severe effects when a portion of a
foreign  body remains  imbedded in  a nerve.
Very interesting cases of this description have
been  published by Denmark, Jobert, Descot,
Jeffreys, dec, in the works referred to in  the
Bibliography. These effects are especially se-
vere when  the wound has cicatrized, the for-
eign substance lodged  in the nerve  occasion-
ing the  most  painful irritation in the  course of
the nerve and its ramifications, or violent neu-
ralgia, with spasms ofthe muscles supplied by it.
In some instances, tetanus  has been  the result
   13. h. A nerve may be involved in a cicatrix
following a wound, amputation, or  burn, and
become the  seat of intense pain or irritation,
owing to its exposed, or insufficiently protected
state.   The actual or potential cautery—the lat-
ter even when performed with a caustic alkali
—may,  either previously  or subsequently to
the cicatrization of the part, occasion very se-
 vere effects when the branch of a nerve is in-
volved in the injury.   M. Frere (Revue Med.,
Mai, 1839,  p. 207) has recorded an instance of
an issue made  by the caustic potash having
thus  been  followed by  severe local  effects,
which terminated in fatal tetanus.   But this is
a very rare, if not a singular occurrence.
   14. E. Lesions of nerves of a malignant nature
have not been satisfactorily observed, nor have
they been  found  to form primarily in  nerves.
Otto and others  have remarked, that the me-
dulla has appeared more  or less diseased in
the  vicinity  of carcinomatous  or  cancerous
swellings or  ulcerations, the nerve  being dis-
coloured in parts, hardened, swollen, and knot-
ty, and degenerated in its structure to a great-
er or less extent throughout, both in its sheath
and medulla.
II. Inflammation of Nerves.—Svn. Neuritis,
   Nervorum  Inflammatio ; Neurite,  Fr.    Die
   Nervencntzundung, Germ.
    Classif.—HI- Class,  I. Order  (Author).
   15. Defin.—A  violent,  sharp, lacerating  pain
in the situation of a nerve, with a feeling of numb-
ness, increased by slight pressure, and often at-
    II.              126
tended by greater fulness than natural, sometimes
by redness, in the course of the nerve, and by in-
flammatory or irritative fever.
  16. Inflammation of nerves  has been gen-
erally passed over by writers on practical med-
icine.  Boerhaave remarks : " Nemo forte un-
quam vidit inflammationem in nervo ; haec vero
si contingat, in sola  tunica vaginali haeret."
(De Morb. Nerv , p. 265.)   That the inflamma-
tion is seated chiefly in the neurilemma cannot
be doubted ; but it is  not the less  an affection
ofthe nerves, and that it is, in a most demon-
strable shape, a not very  infrequent disease,
will  be  acknowledged by most  experienced
pathologists.  Although it is not manifest that
several affections of nerves, such as  neuroma,
cramps, partial  loss of sensation, or of motion,
sciatica, and the severe attacks of pain usually
termed neuralgia, proceed  from inflammation
implicating a trunk or branch  of a nerve, yet
there is much reason  to  infer that such is ac-
tually the case in some  instances, and more
frequently than has been  admitted, although
the inflammation  may not  be seated or mani-
fested exactly as it is in the more  unequivocal
instances ofthe disease to  which the term has
been generally conceded.   It was contended by.
Cotugno, with much reason, that the trunk of
the sciatic nerve is always more or less  in-
flamed in sciatica ; and I will endeavour in the
sequel to show  that neuroma, or painful tuber-
cle, is the consequence of a chronic inflamma-
tion  of the sheaths of the nervous fibres, and
of the connecting cellular tissue.
  17. i.  Acute Inflammation  of  Nerves.—
Neuritis  acuta;  Neurilemmas,  neurilitis, Auct.
Neurilemmatitis, Hildenbrand.—Acute neuritis
is rarely met with  in a  primary or  idiopathic
form, or  independently of  wounds or external
injuries;  but not  so rarely as was very gener-
ally  supposed.  The researches of Martinet,
Gendrin, and Duges have shown that the chan-
ges in the nerve, in the idiopathic and traumatic
forms of the disease, are the  same ; and that
these changes are not limited to the neurilem-
ma, but extended to the  nervous substance it-
self, which was found in several  cases (Mar-
tinet's 4th, 5th, 6th, and 10th cases) of a dark-
red  colour, softened, and  even " injected by
very manifest  vessels."   Indeed,  as M. Olli-
vier has remarked, there is no  reason that  the
nervous  substance  should  be  less capable of
inflammation in its finer ramifications than in
its  central  masses.  However, it cannot be
disputed that the chief marks of inflammatory
action are seated in the neurilemma.  The dif-
ferences in the  symptoms caused by inflamma-
tion  limited to the one, from those  produced by
inflammation extending to the other, have not
been shown ; although Hildenbrand supposes
that when the  pulp or substance of the nerve
is affected—neuromyelitis—the symptoms  are
less  acutely and distinctly evolved  than in neu-
rilemmatitis, and are attended by nervous symp-
toms indicating more acute  sensibility, and
greater disposition to spasm.   This distinction
is, however, extremely doubtful and imperfect;
careful post-mortem  investigation is required
to elucidate this  subject, but opportunities of
determining it are very rarely afforded the pa-
thologist.*
  * [M. Gendrin  has shown,  by his " Researches," that
inflammation of a nerve, when artificially induced, always 
1002
NERVES—Inflammation of.
   18. A.  The symptoms of acute neuritis are a
lacerating, sharp, or lancinating pain in the sit-
uation of a principal nerve or branch of a nerve,
attended by a sense of numbness, generally fol-
lowing the course of the nerve affected and of
its branches ; exacerbations of the pain after
slight  and variable remissions, and upon  the
slightest touch or pressure, or upon moving the
muscles supplied  by the affected  nerve;  and,
in some cases,  numbness,  or  partial or even
complete palsy, of parts below the  seat of pain,
which in  these  also may be acute, remitting,
and lancinating.  Even when  the  pain is most
continued, the slightest touch  may exasperate
it; while very  firm pressure  above,  but  not
upon, the affected part of the nerve,  will as-
suage it.  When the nerve  is superficial, as in
the extremities, a longitudinal swelling or hard-
ness may be detected in the seat and course
of the nerve.  The heat of the part is  increas-
ed, and a burning sensation is also often felt in
it.  The usual phenomena of symptomatic in-
flammatory or of irritative fever are generally
present, in varying grades, according to the in-
tensity  of the local affection,  the size of the
nerve implicated,  and  the temperament, habit
of body, and visceral conditions of the patient.
   19. Neuritis sometimes occurs  in the puer-
peral  state—Neuritis Puerperalis—and  attacks
chiefly  either of the lower extremities soon
after parturition.  M. Duges (Rev. Med., Aout,
1824) first directed attention to the disease as
it appears in this state ;  and since that time I
have seen three or four cases of it.  The first
of these I attended in 1825, with my friend Dr.
John Da vies, now of Hertford.   It was compli-
cated with  both phlebitis  and  artereitis, and
terminated in fatal gangrene of the whole limb;
the nature of the  disease being farther shown
by the examination after death.  M. Duges has
endeavoured to distinguish five varieties of puer-
peral neuritis.   1. The simple or circumscribed.
2. The oedematous.  3. The phlegmonous.  4.
The cedemato-phlegmonous  ; and,  5. The gan-
grenous.  It is evident that these varieties are
chiefly the result of the association of neuritis
with inflammation of either  the veins, the lym-
phatics, or  the  arteries; my own experience
proving that these associations are even more
frequent in the  puerperal state than the  sim-
ple form of the disease.
   20. M. Duges attributes the first  or simple
variety of puerperal neuritis to  the pressure of
the gravid uterus  on the pelvic nerves.   It is
usually seated in the sciatic nerve, and  occa-
sions acute lancinating pain ;  and in the more
severe  cases, partial  palsy of the  limb.  M.
Duges states that this variety is readily re-
moved by warm baths; but the slighter cases
which are thus remedied cannot amount to ac-
tual inflammation,  or to anything  beyond con-
gestion of the vessels of the  nerve, or of the
parts surrounding it.  The presence of fever in
connexion with  the pain in the nerve is not, in
the puerperal state, sufficient  proof of the ex-
istence of inflammation, as in nervous and irri-
table females in this state, febrile commotion
is often readily excited by pain.
has a tendency to excite inflammation in the organ to which
it is distributed. Thus, inflammation of the fifth nerve will
produce ophthalmia ; ofthe eighth  pair, gastritis, but, what
is remarkable, not gastritis. The  reverse of this probably
sometimes occurs, the  inflammation beiug propagated from
the organs to the nerves.—(Gross.)]
  21. The phlegmonous variety of M. Dices is
in all respects the same as the common form
of the disease already described (Y 17).   He
characterizes  it, in the puerperal state, nearly
as follows : 1. The pain follows the direction
ofthe nerve, particularly the crural, or the more
superficial nerves ofthe lower or upper extrem-
ities, and  is more acute and insupportable than
in other  inflammations.  2. The swelling as
well as the pain proceeds in the direction of
the nerve, is dense, unequal, and precedes any
external redness.  3. The pain and swelling in
the seat of the nerve are of  longer duration
than in common phlegmon;  the pain  always
precedes the swelling, and the chills and rigours
accompanying their commencement are of long-
er duration, and more severe, and the conse-
quent fever is more intense.
  22. The varieties of neuritis which M. Duges
has denominated the edematous, the edemato-
phlegmonous, and the gangrenous, are complica-
tions, as I have above suggested, of neuritis,
with either  phlebitis or artereitis, or both.   In
the case already alluded to ($ 18), neuritis was
associated with inflammation of both the veins
and arteries.
  23. B.  The diagnosis of acute neuritis from
neuralgia is  often difficult.  Some authors have
supposed  that the  latter depends upon inflam-
mation of the  nerve ; and it is not improbable
that, in some  of the cases characterized by a
more or less persistent pain in the nerve, and
by a limitation of the pain to a single nerve or
its ramifications, some degree of inflammation
may exist in a part of it, or at its origin.  Gen-
erally,  however, the presence of fever, of fixed
and constant pain in the situation or course of
a nerve, of tension, dense swelling, and tender-
ness on pressure, of partial palsy of, and in-
creased pain on contracting the muscles sup-
plied with the affected nerve, &c, indicate in-
flammation ; while the absence of fever,  the
erratic and  intermittent character of the pain,
its subsidence upon firm pressure, mark its de-
pendance  upon irritation  in  a  related part, or
upon some other cause.
  24. C. The appearances in fatal cases consist
chiefly of redness, more or less marked, of the
affected nerve, proceeding from injection of the
capillaries of the neurilemma, or of the cellular
tissue connecting the fibrils ; of minute  puncti-
form and  numerous ecchymoses ; of sero-san-
guineous, or even of puriform, infiltration of
the fibro-cellular envelope.  In addition to  one
or more of these changes, the size ofthe nerve
is increased, most frequently without any ap-
preciable  change of consistence, but  occasion-
ally with more or less softening of the affected
part.   Bichat found numerous small varicose
dilatations of  the veins in the sciatic nerve of
a person  who had experienced severe pain in
this  nerve ; and Van de Keer found the sciatic
softened to a deliquescent  pulp, of a grayish,
dirty red  colour, in  the  midst of which were
hard granulations.   The neurilemma was thick-
ened, red interiorly, opaque and white exter-
nally, but  granulated and more or less injected.
These  changes were manifestly  consequent
upon inflammation,  and confirmatory  of  the
opinion of Cotugno, who attributed, too exclu-
sively, sciatica to inflammation ofthe nerve.
  25. ii- Chronic Neuritis—Neuritis diuturna
—in certain of its conditions or results, has not 
"vERVES—Chronic Inflammation of.—Neuroma.
1003
 been satisfactorily elucidated.  Neuroma, or the
 tumour which is  sometimes found in a nerve,
 is undoubtedly a consequence of chronic inflam-
 mation of the tumefied part, inasmuch as the
 changes  observed in it  are similar to those
 which result from chronic inflammation in other
 parts of a like structure.   Ulceration may also
 be adduced; but it is very rarely  observed,
 never,  perhaps, limited to a nerve; and only
 when a nerve participates in the ulceration of
 surrounding parts.  When this is the case, the
 suffering thereby occasioned may require the
 removal ofthe diseased portion of nerve, or its
 excision, as advised by M. Ollivier ;  and, in
 some extreme cases, when the bone becomes
 affected, or adjoining parts much disorganized,
 even the amputation of a limb may be rendered
 necessary, as in a case adduced  by Mr. Swan,
 in which the popliteal  nerve and surrounding
 parts were extensively ulcerated, excision of a
 portion of the nerve having  been found ineffi-
 cacious.
   26. A.  The only form,  or  result, of chronic
 neuritis that has been satisfactorily investiga-
 ted is neuroma, or painful tumour of a nerve.
 Numerous writers have noticed this  kind of
 tumour, and, among  others, Camper, Boer-
 haave,  Gooch, Home, Spangenberg,  Petit,
 Chaussier,  Delpech, and  Meckel.   But  J.
 Frank,  Aronssohn,  Descot, and  W. Wood
 have more fully investigated its nature than
 other writers.  M. Odier, of Geneva,  applied
 to it the term neuroma.  A modification of the
 same disease, or painful tumours of the  sub-
 cutaneous or smaller nerves, has  been fully
 described by Mr. W. Wood, under the name of
 "painful sub-cutaneous tubercle."  These  tu-
 mours, whether formed  upon  small sub-cutane-
 ous nerves, or upon large or small nerves of
 the extremities or of the trunk, are essentially
 the same, but vary in structure, size, and  ap-
 pearance, with the activity or grade of vascu-
 lar action which produced them, and with  the
 particular tissue of the nerve that  has been
 principally affected.  The tumour is sometimes
 round, but more frequently  oval or elliptical.
 Its size  varies from that  of  a pea or bean to
 that of a turkey's egg, but  it rarely exceeds
 that of a hen's egg.  More than  one  tumour is
 often found in the same case.  It is met with
 at all ages ; but of sixteen cases, four were in
 persons above forty-six years of age, and twelve
 in persons under that age.  Of twenty-four ca-
 ses, fifteen  were  stated to have occurred  in
 men,  and six  in women.  The disease is met
 with chiefly in the trunks or larger branches of
 the nerves of the extremities, particularly the
 upper, and near the elbow-joint.  It  occasion-
 ally occurs in the internal parts  of the body;
 and, if these parts, and the size and distribution
 ofthe nerves supplying them,  admitted as read-
 ily of examination as the extremities, it might
 be found more frequently in them, constituting
 the cause of some painful  internal complaints.
 Of the cases  adduced by Mr. Wood, sixteen
 were seated in the upper, and five in  the lower
 extremities;  one in  the neck, one in the tho-
 racic cavity, and one in several parts.   When
 once formed,  the tumour generally  increases
 more  or less rapidly, and is rarely much influ-
enced by  treatment,  but  it seldom  attains a
very considerable size under two or three years.
It  may, however, remain stationary, as to bulk,
 for a very considerable time.  The sub-cutane
 ous tubercle is particularly slow in its growth,
 rarely attaining  a greater size  than  that of a
 bean, and often remaining without increase of
 bulk for several years.
   27. a.  The diagnosis of neuroma, when su-
 perficial, is not difficult.   The tumour is most
 frequently hard and firm to the touch, occasion-
 ally elastic, and  admits of motion in a lateral
 direction, but not upward or  downward, or in
 the direction of the nerve.   The skin is movea-
 ble over it, and is natural in appearance.  When
 it is very large, the cutaneous vessels, particu-
 larly the veins,  are enlarged, and the skin is
 somewhat livid in rare instances.  The tumour
 is extremely painful on the slightest pressure ;
 the pain extending to the parts supplied by the
 nerve—to the ring and little  finger when  the
 ulnar nerve is the seat  of the  disease.  If a
 blow is received on it, the pain darts through
 different parts ofthe body.  In three cases, re-
 ferred to in the references, epileptic fits were
 distinctly caused by these tumours, and were
 cured in two of them when the  tumours were
 removed.  In some instances the pain is  not
 severe when the  parts are kept at rest;  but, in
 most, tickling or tingling, creeping or numbing
 sensations, or a combination of these are  felt
 in parts near or below  the tumour;  and,  in
 many, a most excruciating pain, independent
 of, but much increased by pressure, exacerbated
 at intervals, is complained of at a distance from
 it, but in the direction of the trunk  or branches
 of the nerve affected.  The powers of sensa-
 tion and of motion are,  however,  seldom im-
 paired, but motion aggravates  or brings on  the
 pain ; and prickling, accompanied or alternated
 with  numbness, is felt in the limb, and severe
 pains dart  in the direction  of the  nervous
 branches.  In the smaller forms of the disease,
 which Mr. W.  "Wood denominates "painful sub-
 cutaneous tubercle," paroxysms of pain occur
 often without any  apparent cause, and after
 irregular intervals, occasionally of some weeks'
 duration.  In  most instances, the  severity of
 pain produced by pressure, the extension of it
 in the course of the nerve, the lancinating pains
 associated with  numbness, and  the increased
 suffering caused  by attempting motion  of the
 tumour in the direction of the  nerve, of which
 it does not admit, are sufficiently diagnostic of
 the nature ofthe  disease.
  28. b. Tumours of the nerves,  when careful-
 ly examined after death, or after removal by op-
 eration, present different  appearances in differ-
 ent cases, owing probably to  the  originating
 seat of the disease, and to the state and prog-
 ress of it.  Mr. W. Wood remarks that it is
 often difficult to determine in  what particular
 tissue the diseased action had commenced.  In
 some cases this action appears to have  begun
 in  the cellular tissue in the proximity of the
 nerve, to which it had gradually extended, so
 that, in its progress, the  nerve and its cover-
 ings had  become completely involved in  the
 disease ;  but, unless tumours which commence
 externally to the sheath of the nerve shall im-
 plicate the nerve itself, they cannot be consid-
 ered as cases of neuroma.   I believe, however,
that  the  diseased action  under  consideration
commences most frequently in the neurilemma,
forming the external sheath of the nerve or its
connecting cellular tissue, or  in the minute 
1094               NERVES—Chronic Inflammation of—Causes, kto.
processes of neurilemma sent off from the gen-
eral sheath to envelop the  several  nervous
fibrils which  form the nerve.   In rare cases,
the tumour consists chiefly of a cyst contain-
ing a fluid; in other cases, it is  partly solid
and partly  fluid;  but much more frequently it
is solid throughout.  The solid part  assumes
different degrees  of consistency, and  presents
a different  colour and appearance in  different
cases, and  even in  different parts of the same
tumour.  In some,  the whole mass is firm, of
a whitish or yellowish colour,  and of a fibro-
cartilaginous appearance, very much like nerve,
but harder, and somewhat more shining ; the
fibres running  either in a serpentine or parallel
manner with interlacing fibres.  In others, one
part is  firm and of a reddish colour, and anoth-
er part is cellular, the cells varying in size, and
some being empty, and other scontaining a fluid
or a soft medullary-like substance.   Others,
again, consist of a number of small lobes, close-
ly pressed  and connected  with the diseased
nerve.   Some are fatty, or tubercular, or con-
sist chiefly  of coagulated albumen.  Nearly all
present the appearance of having a firm, dense
sac, shining externally, and seemingly formed
of the  altered neurilemma.  This covering is
either loosely or  very intimately  attached to
the contained parts  by cellular tissue.
  29. The nerve is  sometimes  sound  as it en-
ters, or emerges  from, the tumour ; but it  is
oftener  more or less diseased  for a little dis-
tance above and below, being somewhat redder
than natural, and thickened.   The nerve can
be traced distinctly  to the diseased part, where
the fasciculi, being  separated from each other,
run into the  substance  of the  tumour, where
they are either lost, or traceable through it, or
near its surface.  When, however, the tumour
is very large,  the nervous fibres  often cannot
be traced through it, they being so completely
altered, or atrophied, or entirely  removed by
the morbid deposition, or hypertrophy of cer-
tain elementary parts ofthe mass.   Some wri-
ters have considered this tumour of nerves as
being of a  scirrous  or cancerous nature ; but
that such is not the case is proved by the cir-
cumstances, 1. Of its not invading the adjoining
tissues nor implicating the skin, however large
it may be, or however long it may have exist-
ed ; 2. Of the complaint not returning when the
tumour has been removed.
  30. B. These tumours sometimes closely re-
semble  the oval tumours which often form on
the extremity  of a  nerve after  amputation.
These  latter  tumours are frequently  three or
four times as large as the nerve on which they
form, but of the same colour, of a firmer con-
sistence, and of a different structure.  The tex-
ture of the tumour  is fibro-cellular, and dense,
in which the nervous filaments lose themselves
or become indistinct, probably by being wasted
in proportion  to the hypertrophy  and indura-
tion of  the cellular  tissue of the affected part
of the  nerve, manifestly the result of chronic
irritation or inflammation.
  31. C. In some cases, consequent upon chron-
ic inflammation, the cellular tissue forming the
nervous sheath,  and connecting  the nervous
fibrils,  has  been found infiltrated  with  serum,
lymph, or sero-albuminous or sanguineous fluid,
and rarely with purulent matter unless in acute
or sub-acute cases.   These changes have been
 observed chiefly in the ischiatic and other large
 nerves.  Bony and earthy concretions have, in
 rare instances, been found in  the cellular tis-
 sue  connecting the  nervous fibrils, but  exte-
 rior to  the  medullary matter.  These  have
 probably resulted from a  state of chronic  in-
 flammation, or have been the residua after par-
 tial absorption of morbid deposites.
   32. D. Inflammation and its consequences
 may occur in either the cerebro-spinal or the
 ganglial or soft nerves, probably in the latter
 more frequently than in the former, but, owing
 to the situation of the ganglial nerves, and the
 marked peculiarities of their structures, either
 escape detection, or give  rise to different phe-
 nomena and  to different lesions in them  from
 those observed in the cerebro-spinal  nerves.
 When the ganglial nerves are inflamed, they
 are generally enlarged, of a lively or deep red ;
 sometimes softened, and  occasionally firmer
 than natural.  These  are  the only changes in
 this particular class of nerves which I have ob-
 served.
   33. iii. The causes of acute and chronic neu-
 ritis are chiefly those productive of inflamma-
 tions of other tissues and organs.  The cir-
 cumstances which predispose to the disease have
 not been fully elucidated,  owing to the infre-
"quency of it, and to its being confounded with
 other maladies,  as with rheumatism,  neural-
 gia, &c.  My own observation induces  me to
 infer that all  lowering influences, copious haem-
 orrhages, prolonged  pressure, and vicissitudes
 of temperature, humidity,  and electrical states
 ofthe air, both favour and more directly produce
 it, particularly when  aided  by the application of
 cold in any form, by wet or damp clothes, by
 sitting or lying on the ground, or on cold stones,
 or on  damp  seats or couches,  by exposure to
 malaria, or to foul air, or  other contaminating
 agents, by inordinate exertion, by suppression
 of accustomed discharges,  by injuries, wounds,
 bruises, contusions, sprains, or operations, and
 by any local source of irritation.  The idiopath-
 ic form of neuritis is occasioned chiefly by the
 same causes that give rise to rheumatism.  The
 puerperal state certainly favours the develop-
 ment of it, in its severest forms; the circum-
 stances  which are most efficient in causing it
 being then frequently in concurrent operation,
 particularly soon after delivery, when it may be
 complicated with phlebitis, and even also with
 artereitis, as in the case above alluded to (18).
   34. iv. The prognosis  in neuritis depends
 chiefly upon  the  circumstances in which it oc-
 curs.  In the puerperal state, or when asso-
 ciated with inflammation of either of the cir-
 culating systems, it is a serious and even dan-
 gerous disease ;  the latter chiefly on  account
 of the  complication,  and  the  exhausted  or
 otherwise diseased state of the patient.  The
 prognosis should be equally unfavourable if it
 occur in the  course of fevers, or in connexion
 with other maladies, or even in a bad  habit of
 body, in all which circumstances it is most apt
 to appeal.  In a large proportion of the cases
 recorded by MM. Martinet, Duges, and others,
 the  disease,  in its acute  form, terminated  fa-
 tally when it thus appeared ; the inflamed por-
 tion of nerve  being either injected, enlarged,
 red, softened, or infiltrated with serum or with
 puriform matter ($ 23).  The simple or uncom-
 plicated disease, occurring in  a previously 
NERVES—Bibliography and References.                      1005
healthy person, and the  chronic  form, espe-
cially in the  state  of neuroma, and  admitting
of an operation, is most frequently removed by
judicious treatment.
  35. v. Treatment.—a.  My own experience
leads me  to agree with the remark of Hilden-
brand, that acute neuritis is never resolved by
a recourse to blood-letting and antiphlogistics
alone.  That local blood-letting—much more
rarely general  blood-letting—is required, ac-
cording to the circumstances of the case and of
the patient, is admitted ; but additional  means
are also required, and should be adapted to these
circumstances.   Local depletions and fomenta-
tions ; the more chologogue purgatives,  as cal-
omel, &c.;  and anodynes, particularly opiates
with calomel  and camphor, or with the acetate
of  lead, or  with  the  oxide  of bismuth, are
most applicable to  the more  sthenically acute
cases; but when the disease is associated with
other serious maladies, or when it occurs in a
cachectic state of the frame, or with asthenic
characters, actively restorative agents are gen-
erally then required, even while local depletions
and anodyne fomentations are being employed ;
and, in some cases, they should  be  most en-
ergetically prescribed in order to be successful,
and be combined with the most powerful nar-
cotics, the functions of the several emunctories
being at the same time duly promoted, and mor-
bid  or effcete matters  eliminated from the cir-
culating fluids.
   36.  b. If the disease  pass  into, or primarily
assume  a chronic  state,  alteratives  conjoined
 with tonics,  as the  preparations of  cinchona
with alkaline carbonates or the  liquor potassae,
and iodide of potassium ; camphor with-opium,
or with the extract of aconite ; blisters in the
course of the  diseased nerve, if  it  be deep-
seated, and  kept  discharging for  some time,
and stimulating  and  alterative embrocations
(F. 296,311), appear to be most successful. To
some of these  chronic cases the treatment ad-
vised for neuralgia may be of service.
   37. c. In cases of neuroma and  painful sub-
cutaneous tubercle these  means will  generally
fail, and even the narcotic alkaloids applied lo-
cally are not more serviceable.  In these cases,
the extirpation of the tumour becomes neces-
sary; and even, in certain circumstances, am-
putation of a limb may be required.  Mr. Wood
states, that in  twenty-four cases of  neuroma,
the following were the results : in eight cases
the tumour was successfully  excised; in two,
the patients died after the operation  ; in four,
amputation  was  successfully  performed;  in
three, no operation was attempted ;  in three,
the tumours were accidentally met with on dis-
section ;  in two, the disease  was seated in in-
ternal parts  of the body ; in one, the  tumour
was laid open in order to bring on suppuration,
but  the patient died of quotidian intermittent;
and in one, the disease was cured by destruc-
tion of the nerve by caustic.
   38.  III. Lesions of  sensibility and func-
tion constitute the third class into  which the
disease of nerves may be divided.   As the prin-
cipal part of alterations of sensibility,  or that
consisting of morbid exaltation  of  sensation,
has very  generally had the  term  neuralgia im-
posed upon it, and as this morbid  condition has
been usually discussed under  this name, it may
be considered in a  separate article, without the
relation between it and  other diseases of the
nervous system being  in any way interrupted
by this mode of treating it.   And as those pain-
ful  affections  of the nerves  which have been
considered to exist independently of inflamma-
tions, and to  which the  name neuralgia  has
been given, are somewhat diversified in char-
acter and severity, the more general appellation
of Neuralgic Affections may be  applied to
them.   The disorders  of function   to  which
nerves are liable, especially losses of the pow-
ers of transmitting sensation and volition, and
their  agency  in producing spasms, &c., being
more advantageously treated of in connexion
with other and very intimately related lesions,
are therefore  comprised  in those  articles that
are devoted to the consideration of diseases
which are thus characterized, and which  chiefly
consist of losses, and of exaltations of sensation,
and of muscular contractions, or of impairment
or irregularity of sensation and motion.  See
art. Paralysis, Chorea, Convulsions,  Irrita-
tion,  Hysteric Affections, &c.)

  Bibliog. and  Refer. — i. Inflammation of Nerves.—
Bocrhaave,  Prslect. Academ. de Morb. Nerv.,  2 vols., 8vo.
Venet.,  1T62. — Cotunnius, De Ischiade Nervosa, 12mo.
Vien., 1770.—Ploucquet, De Myositide et Neuritide. Tub.,
1790.—Nasse, De Neuritide, 4to.  Hate, 1801.—Bichat,
Anat. Generate, t. i., p. 177, edit. 1801.—Bettoli, in Giorn.
della Soc.  Med.  Chirurg. di Parma, vol.  ii., p. 256.—E.
Home, in Transact, of Society for Improvement of Med. and
Chirurg.  Knowledge, vol. ii., art. ii.—Reil, Fieberlehre, b.
iv., p. 56.—D. Pring, A View of the Relations of  the  Ner-
vous System in Health and Disease, 8vo, p. 168. Bath, 1815.
—Martinet, Memoire sur I'lnflammation des Nerfs. Paris,
1824 ; and in Revue Medicale, t. ii., p. 329, 1824.—Duges,
Sur le Neurite Puerperale, in  Ibid., t. iii., p. 157, 1824.—
/. Swan, On the Treatment of Morbid Local Affections of
Nerves, 8vo, 1820 ; and On the Anatomy, Physiology, and
Pathology of the Nervous System, 8vo. Lond., 1822 ; and
Treat, on Dis. and Injuries of Nerves, Svo. Lond., 1834.—
Lobstein, De Nervi Sympathetici Fabrica, Usu, et Morbis
Comment.,  p. 55.   Pahs, 1823.—Descot, Sur les Affections
locales des Nerfs, 8vo.  Paris, 1825 — V. N. Ab  Hildenbrand,
Institut. Practico  Medicse, &c, t. iii., p. 18.—Van de Keer,
Sur Neurilemitis, in Joum. Univers. des Sc. Med., t.  xxv.,
p. 64;  et t. xxx., p. 328.—A. N. Gendrin, Histoire Anatom.
des Inflammations, t. ii., p. 142.—Olivier, in Diet,  de Med.,
2d edit., art. Nerfs.—Cruveilhier, Anat. Patholog., livr.—
Brown, in Glasgow Med. Journ., vol. i., p. 132.—P. Jolly,
in Diet, de  Med. et Chirurg.  Pratique, art. Neurite.
  ii. Lesions of Consistence, Continuity, &c.—Galen, Me-
thodus Medendi, 1. vi.—Paulus Mgineta, 1. iv.. c. 54.—Ori-
basius, Synopsis, 1. vii., c. 22.—Avicenna, Canon., 1. iv.,
fen. iv., tract. 4, cap. 1.—Scultetus,  Observ., No. 64 (Tere-
binthina et  Cera pro punct. nerv.).—Morgagni, De Sed. et
Causis Morb , Epist. Iii., 31.—Monro, On the Structure and
Functions of the Nervous System, p. 81, 83.—Cruickshanks,
Experiments on the Nerves, Philos.  Transact., 1795, p. 120.
—Haighton, in Ibid., p. 190.—Michaelis, Ueber die Regen-
erat. der Nerven.  Kussel, 1795.—Autenreith, Observat. in
Hydrothor.  Viror.  Tub., 1809.—Lobstein, Opus Citat., p.
165.—Denmark, in Transact, of Med. and Chirurg. Soc. of
London, vol. iv., p. 48.— Wardrop, in Ibid., vol. xii., p. 205.
—C. Bell, Exposit. of the Natural Order of the Nerves of
the Hum. Body, 8vo.   Lond., 1824; and the Nervous Sys-
tem of the  Hum.  Body, as explained in Papers read before
the Roy. Soc. of London, with  Cases, dec,  8vo. Edin.,
1836.—Breschet, art. Cicatrice, in Diet, des Sciences Med.,
t. v.—Mayer, in Reil's Archiv. f. d. Physiol.,  b. ii., p. 449.
—Jobert, Etudes  sur le Systeme Nerveux, p. 547-634, 8vo.
Paris, 1838.—Prsvost,  Annal.  des  Sc. Natur., 1827.—P.
Flourens, in Ibid., 1823, t. xiii., p. 113 ; et Journ. des Pro-
gies des Sc. Med., t. xii., p. 268.—Pigne, in Journ. Hebdom.
de Med., &c, Ann. 1832, t. vi., p. 309—Hortcloup, in Journ.
des Connaiss. Med. Chirurg.,  Jan., 1835,  p. 144.—Descot,
Opus Cit., p. 98.—Jeffreys, Archives G6ner. de Med., t. ii.,
p. 293.  Paris, 1823.—Galenzowski, in Ibid., t. xxiii., p. 26.
—F. Tiedemann,  in Journ. Complem. des Sc.  Med., t. xii.,
p. 289.
  iii. Atrophy and Hypertrophy of Nerves.—Vesalius, De
Corporis Humani Fabrica, 1. iv., c. 4.—Morgagni, Epist. ii.,
36; xiii., 9, 10 ; Ixiii., 6. — Lieutaud, Hist. Anat. Med., 1.
iii., obs. 188-191.—Wenzei, De  Pemtiori Cerebri Structura,
p. 116-126.—Haighton, in Mem. of Med. Soc. of Lond., vol.
iii., p. l.—Rudolphi, Grundriss der Physiolog., b. ii., p. i.,
p. 220.—Otto, De Morbis ab Intumescentia  et Pressione
Nervor. per Foramina Ossium  egred., dec.  Erf., 1799; et 
1006
NEURALGIC AFFECTIONS—General Characters of.
 Anat. Patholog., p. 445.—Biermayer, Museum. Anat. Path-
 ol. Vind., p. 134, 1816.—J. F. Meckel, Archiv. f. d. Physiol.,
 b. iii., p. 196.—Jeffrays,  in Lond.  Med. Repos., ed. by /.
 Copland, April, 1822.— Ward, in Ibid., Sept., 1823.—Hard,
 Traite des Maladies de  l'Orielle,  8vo. Paris, 1821.—Ko-
 reff, in Magendie's Journ. de Physiol., t. iv., p. 374*.—B4-
 cUrd, in Ibid , t. v., p. 17.—Serres, in  Ibid., t. v., p. 233.—
 Esquirol, in Diet, des Sciences Med., t. viii., p. 291.—Rom-
 berg, Ziitschrift fur die Anthropologic, 1823, P. iii., p. 224.
 —Bellingieri, in Annali Universali de Med.  Mar., 1827.—
 Pinel, Nouv. Journ. de Med., t. iv., p.  40.
   iv. Neuromata, or Tumours of Nerves.—Sandifort, Mus.
 Anat., vol. iii., p. 148.—A. Portal,  Cours d'Anatom. Med.,
 t. iv., p. 247.—Spangenburg, in Horn's Archiv. f. Med. Er-
 fahrung., b.  v., p. 306.—Odier,  Manuel de Med. Prat., 8vo,
 p. 278. Geneve, 1803.—E. Home,  Op. cit., vol. ii., p. 192.
 —Alexander, Dc Tumoribus Nervorum, 4to.  Lugd. Bat.,
 1810.—Neumann, in  Von Siebold's Summl. Chirurg. Bro-
 bachtungen, b. i., p. 54.—Adelmann, in Ibid., b. iii., p. 177.
 —Mojon et  Coverceli, in Ibid., b.  i., iii.—Pring, Op. Cit.,
 p. 151.—Descot, Op. Cit., p. 257.—Otto, Selt. Beobachtun-
 gen, <fcc., p.  i., p. 83.—Aronssohn,  Sur les Tumeurs devel-
 oppees dans  les Nerfs, 4to.  Strasb., 1822.— Wishart,  in
 Edin. Med.  aud Surg. Journ., July, 1822.— W.  Wood, On
 Painful Sub-cutaneous Tubercle, in Ibid., vol. viii., p. 283,
 429; and in  Trans, of Med. and Chirurg. Society of Edin.,
 vol. iii , p. 317; and on Neuroma, in Ibid., vol. iii., p. 367.
 —Ollivier, Traite  de la Moelle Epiniere, t. i., p. 492,  3d
 edit.; and in Diet, de Med., art. Nerfs.—/. Frank, Praxeos
 Med. Univers. Praecepta, vol. iii., p. ii.—Abercrombie, On
 Diseases of  the Brain, &c, p. 414.—Cruveilhier,  Anat.
 Pathologique, livr.  i., pi. 3.—(See, also,  numerous other
 references of less importance in Ploucquet's Medicina Di-
 gests, and in Otto's Anat. Pathol.)
  [Ad. Bibliog. and Refer.—M. Hall, in  Ed. Med. and
 Surg. Jour.,  vol. xi., p. 466; and Principles and Theo. and
 Pr. of Med., Am. ed., by Bigelow  and  Holmes.—J. Elliot-
 son,  in Cycl. of Pract. Med., art. Neuralgia;  and Pract.  of
 Med., Am. ed., by Stewardson.—Andral, Cours  de Eathol-
 ogie  Interne.—6'. D. Gross, Elements of Path. Anat., 2d ed.
 Phil., 1845.—Cartwright, in Am. Med.  Recorder, vol. ix., p.
 37.—Lobstein, Treat, on Struct. Functions and Diseases  of
 the Human Sympathetic Nerve, translated by J. Pancoast.
 Phil., 1831.—B. C. Brodie, Clinical Lectures on Surgery,
 delivered at  St. George's Hospital,  Am. ed. Phil., 1846.—
 /. Hope, Path. Anatomy, with coloured Engravings, ed. by
 L. M. Lawson.  Cincinnati and Lexington, 1 vol., 8vo, 1844.
 —Oke, in Prov. Med. and Surg. Jour.,  July 24, 1844 (Case
 of reunion of divided Nerve).—M. Foville, Traite complet de
 1'Anatomie, de la Physiologie, et de la  Path, du Syst. Ner-
 veaux, Cerebro-Spinal, &c.  Paris, 1844. — F.  A. Langet,
 Anat. and Phys. of Nervous System,  dec. Paris, 1842, 2
 vols., 8vo.—Gunther and Schon, in  Am. Journal Med. Sci.,
 vol. iii., N. S.,from Arch. General.—Bennett, On Neuroma-
 tous  Tumours in Stumps, in Am. Journal Med. Sci., N. S.,
 vol. vi., p. 223.]

 NEURALGIC  AFFECTIONS  —Syn.  Neural-
   gia (from vcvpov, a  nerve, and alyeu, I suf-
   fer pain).  Neuralgia faciei, Prosopalpia, Swe-
   diaur. Hemicrania idiopathica ; Trismus max-
   illaris, Auct.   Trismus   dolorificus,  Sauva-
   ges.   Rheumatismus  spurius  nervosus, Most.
   Autalgia dolorosa, Young.   Dolor Faciei cru-
   cians,  Fothergill.   Dolor  Faciei Fothcrgillii,
   Auct.  var.  Neuralgia,  Chaussier, Good, and
   others.   Neuralgic, Tic Douloureux, Fr. Ner-
   venschmerz, Nervbses Reissen, Antlizschmerz,
   Gesichtsschmerz, Germ.  Neuralgia, Ital.  Ex-
   cruciating nervous pain.
     Classif.—IV.  Class, II.  Order  (Good).
       II. Class,  III. Order (Author).
   1. Defin.—Violent pain seated in the trunk or
branch of a nerve, occurring  in paroxysms of ir-
regular duration, and after  either  irregular or reg-
ular intervals.
   2. Neuralgic affections were  confounded by
the  ancient and older writers with toothache,
rheumatism, gout, &c., according  to the seat
of suffering.   Cotugno,  Fothergill,  Andre,
Pujol, Fortsmann, and Chaussier were among
the first  who  directed attention to these affec-
tions with  precision, and distinguished them
from the  disorders with  which they had been
formerly confounded.   Since the  commence-
ment of the present century several writers in
this  country and on  the Continent of  Europe
 (see Bibliog. and Refer.) have advanced still
 farther our knowledge of this subject.   At first
 the study of neuralgia was confined to the oc-
 currence  of it in the nerves of the  face and
 lower extremities, and the terms neuralgia and
 tic  douloureux were  applied  only to the most
 excruciating states of pain experienced in these
 parts; but  more recently these  terms, or a
 qualitative  one, implying very close resem-
 blance, as neuralgic affection,  &c., have been
 extended to all morbid  exaltations of sensibil-
 ity  in parts  not manifestly  inflamed ; so that
 they have been  made to comprise, by French
 pathologists in particular, disorders formerly
 very differently named, and seated in internal
 viscera.
   3. That morbid exaltations of sensibility, in-
 dependent of inflammation, in  a  recognisable
 form, occasionally affect internal  organs, can-
 not be doubted, and  that they are quite as often
 seated in the ramifications of the organic or
 ganglial nerves as in the cerebro-spinal nerves,
 is equally evident  to the close  observer,  al-
 though their characters may vary with the dif-
 ference of seat;  and that they actually do thus
 vary in character is  well known.   The pain ex-
 perienced during a  paroxysm of  neuralgia  in
 one ofthe branches of the fifth pair of nerves,
 however excruciating, is  not attended by that
 intolerable feeling approaching almost to vital
 extinction, which characterizes those pains  in
 internal or vital  organs, that  have been  more
 recently  termed  neuralgic, that formerly had
 different   names  imposed on them, but that,
 however named or  described, undoubtedly be-
 long to  the category  of neuralgic  affections.
 Therefore, I shall comprise under this head, as
 succinctly as may be compatible  with a due
 discussion of the subject, all those very pain-
 ful disorders, wherever seated, which are ap-
 parently  unconnected with  inflammation, and
 which are not the result of some important  or
 recognisable lesion.
   4.  According to this view,  as well as to the
 mode of considering the subject  adopted by
 some recent writers, several disorders, partic-
 ularly toothache, headache, the different forms
 of  colic,   certain  manifestations  of hysteria,
 &c,  might  with  propriety  be  considered as
 forms of visceral neuralgia ;  but  these disor-
 ders, as  well as some others, which have ac-
 tually been thus viewed  by a  few of these wri-
 ters, are generally so intimately connected with
 some more  tangible or  recognisable mischief,
 and so dependant upon it, that the propriety of
 retaining  the old appellations, while  we ac-
 knowledge the pathological relation they have
 insisted  on, remains unaffected by  the  more
 partial view entertained  by them.   In  naming
 and  arranging,  as well as in discussing  these
 and   other  disorders,  prominent   phenomena
 should not alone be noted, to the  neglect  of
 other important,  although more latent, morbid
 relations, but all sides of the subject ought  to
 be duly viewed.
  5. I. General Characters of Neuralgia.—
 The pain  of neuralgic affections sometimes  is
slight and obtuse at  its commencement, and
 augments in violence with more or less rapid-
ity, becoming sharp, lacerating, darting or lanci-
nating, and being attended by excessively acute,
constrictive, or plunging sensations, which  at
short intervals  dart  through  the pained  part: 
NEURALGIC AFFECTIONS—Special Notices of.
1007
the fulgura doloris of Cotugno.  More frequent-
ly the pain is sudden in its accession, and it is
occasionally preceded by an itching or heat in
the part, or by numbness and pricking  sensa-
tions, or by slight and fugitive pains, either or
most of which may recur during the remissions
between the more violent paroxysms.  In some
cases, the  attack of neuralgia is preceded by
nausea and general disorder, with more  or less
of derangement of the digestive and biliary or-
gans ; and in others, by anxiety at the praecor-
dia, by slight dyspnoea, or  by slight chills  fol-
lowed by heat.  At the  commencement  the
pain is  attended by numbness or torpor,  and
formication ;  and it is commonly lancinating or
darting, although sometimes pulsative, or acute-
ly smarting or burning.  Whatever character
the pain may assume, it is  often instantaneous
in its  occurrence  and disappearance,  resem-
bling a  shock of electricity.  It  is frequently
confined to the trunk of the nerve, but as often
it extends itself to the ramifications, and even
to the terminations of the nerve.   More rarely
it extends  from the ramifications to the trunk.
Sometimes it affects only a few ofthe branch-
 es, or even one or two merely of the fibrils.
Accompanying the pain, especially during its
greatest intensity, other  phenomena are  ob-
 servable : tremours, spasms, cramps, or convul-
sive motions of the muscles connected with
 the affected nerves ; general exaltation  of sen-
 sibility, with  restlessness and agitation ; some-
 times a tetanic rigidity of the muscles ;  and
 more rarely an  inability of contracting them,
 with loss  of sensibility towards the surface.
 Generally, neither redness, heat, nor swelling
 of the part can be detected. Occasionally, how-
 ever, the arteries  in the vicinity pulsate more
 strongly, and the veins are somewhat distend-
 ed.  M. Ollivier  states that he has observed,
 in a few instances,  where  the nerve was su-
 perficial, that its  volume  was  somewhat in-
 creased.  These were doubtless cases  of  neu-
 ritis, which has very generally been confounded
 with neuralgia, and to which the latter is prob-
 ably more frequently owing than is generally
 supposed, or than can well be demonstrated ;
 for neither swelling, heat,  nor redness  attends
 neuralgia,  but they all accompany and indicate
 neuritis ;  still, they are so limited in extent and
 amount, when inflammation is confined to a
 nerve, as  hardly to admit of  appreciation or
detection during an examination of the  surface
of the part affected.
   6. The duration and return of the paroxysms
are extremely variable.  Sometimes the affec-
tion is intermittent,  at other times only remit-
tent, the attacks occurring after irregular, and
much more rarely after regular intervals. Some
authors have supposed, from this latter circum-
stance,  and certain of them, even although the
intervals may be of  irregular or prolonged du-
ration, that the disease is a local or masked
ague, originating  in such cases in malaria.
Often when the paroxysms become more  fre-
quent, they  become  also  more violent,  and
sometimes of longer duration.  "When the at-
tack is very sudden  it frequently continues
without abatement for an  indefinite, but gen-
erally short period, and then as suddenly ceas-
es   The  most intense attacks are often of
the shortest  duration, but  generally they vary
from two or three minutes to several hours.
When  they  continue much longer,  the  inten-
sity of the pain varies, and slight remissions,
with acute, lancinating, constrictive, or lacera-
ting  pangs dart through the  part like  shocks
of electricity, occasioning irregular  spasms or
twitchings of the muscles, and intense suffer-
ing.  A critical evacuation, as haemorrhages,
particularly   epistaxis, menorrhagia,  haemor-
rhoidal discharges, salivation,  cutaneous erup-
tions, an abundant general or local sweat, or a
copious discharge of the lochia or of urine, bil-
ious  or mucous diarrhoea, the formation of an
abscess, discharges from the  ear or from  its
vicinity, or a regular attack  of gout or rheu-
matism, or prolonged exertion, attended by a
copious and sustained perspiration,  sometimes
are observed, and serve to account for the sud-
den or even for the more gradual cessation of
suffering.
  7.  The accessions of the attack often cannot
be attributed to any appreciable cause ; but
more frequently they are occasioned by over-
loading the stomach ; by neglect of the biliary
functions, and of the states of the bowels ; by
excesses  in  the  use  of  intoxicating  liquors ;
by exposure  to cold, damp, humidity, or mala-
ria;  by injurious over-exertion, &c. ; or by any
of the remote  causes of the complaint acting
even slightly or inappreciably.
  8.  In comparatively few cases  is the health
quite restored at the end of the paroxysms, or
during the interval; for more or less disorder
of the digestive or biliary organs may be  de-
tected in the great majority of them,  with  im-
paired tone ofthe organic nervous system, and
general lassitude or  debility, although the  pa-
tient may seem quite well in  the intervals, and
be able, with few interruptions, to pursue his
usual avocations.  In many,  more  or less  un-
easiness, numbness, prickings, soreness, smart-
ings, or sudden but momentary pangs, are  felt
at times in the part between  the more  severe
paroxysms;  and in some the  general health, or
the digestive organs, betray more or less marked
disorder.
   9. As to the duration of the disease, it is  im-
possible to state  anything with precision.   A
person  who has once suffered an attack is  lia-
ble to a return of it, although he may have
been completely restored ; and a return or re-
turns of it may take place in a short time, or
not till after many months or even  years.   As
respects the paroxysms, it is an acute malady ;
but as regards  the repetition  of them, the  lia-
bility to their return, or  even their actual  re-
currence, it is generally a chronic and most pro-
longed  disease.
   10. II. Special Notices  of  Neuralgia.—
Neuralgia may affect the nerves of the head,
trunk, or extremities, particularly those which
are  seated superficially, or are most exposed,
and  surrounded by loose cellular tissue ;  it may
affect  also the visceral nerves, as  the nerves
of the  heart, of the  diaphragm, of the liver,
spleen, stomach, bowels, uterus, kidneys, &c,
giving rise to those affections which have been
usually named angina pectoris, syncope anginosa,
gastralgia, gastrodynia,  colic,  ileus,  hepatalgia,
nephralgia, certain states of  hysteria, of hypo-
chondriasis,  &c,  all which are noticed either
under their  specific  appellations  or under  the
viscera in which they appear to be chiefly seat-
ed.  Of all the special forms  or seats of neural- 
ONS—Special Notices of.
1008                NEURALGIC AFFECTS

gia, those affecting the face and head are the
most severe, frequent, and important.
  11.  i. Facial Neuralgia.—Neuralgia Faciei.
—Tic Douloureux.—It is more easy to say what
this affection is not than what it is.  It is not,
as M.  Berard has remarked,  acute neuritis,
nor chronic inflammation, nor any  structural
change of the nerve;  and, although various
lesions have been  detected  in connexion  with
this affection, these have rarely been observed
in the nerve itself, and are neither so constant
in occurrence nor so uniform in character as to
account for it.  The pathological and symp-
tomatic phenomena of the complaint can only
be stated in connexion with  the morbid exalta-
tion  of sensibility which constitutes  it; and
this lesion of sensibility cannot be  otherwise
defined than as a pain varying in its character,
always excessive, generally intermittent, returning
sometimes at regular intervals, but more frequently
after irregular periods; sealed in one of the branch-
es of nerves of the face, and extending  in various
directions through certain of  their ramifications;
existing without evidence of inflammation or of fe-
ver ;  and, although occasionally connected with or-
ganic  changes in some part related to the affected
nerve, yet as often occurring without such morbid
relations, or without any obvious connexion with
them in some cases where they are found to exist.
  12.  a. Although  tic douloureux  was  not de-
scribed by the ancients  as a distinct affection,
it was certainly known to them, but  confound-
ed with various forms of headache;  and  as
such it was  described  by Aret^eus (see De
Caus. et Sig. Diuturn., 1. i., cap. 2).  It was first
described  as a distinct affection, and the name
" tic  douloureux" given to it, by M. Andre, of
Versailles.  Very soon afterward, Dr. Fother-
gill published an  account of it in the Medical
Observations and Inquiries.   Since then it has
received the various appellations above stated
as synonymes of neuralgia  in the generic ac-
ceptation  of the word.   That  tic  is an  affec-
tion of a nerve,  numerous considerations and
proofs sufficiently  demonstrate ; and that it is
seated in some one or more of the ramifications
of the trifacial or  fifth pair, is  also proved by
the seat, direction, and phenomena  of the af-
fection.  The researches of Sir C. Bell, Shaw,
Magendie, Mayo, &c, have shown this nerve
to be chiefly,  if not entirely, a nerve of sen-
sation ; and  the  ramification of its  principal
branches from a large ganglion, the Casserian,
farther proves this to be its  chief function, and
demonstrates  its  relations  to  the ganglionic
system.  That a morbid exaltation of sensibil-
ity should, therefore, more frequently occur in
the more  superficial ramifications of  a nerve
whose office it is  to transmit sensations from
the face to the brain, these ramifications being
the most exposed of any to vicissitudes of tem-
perature, weather,  &c, than in any other nerve,
may be readily admitted, and explained by this
circumstance.  The experiments of Professor
Riberi on the frontal  branch of this  nerve far-
ther illustrate this fact, and prove that the fa-
cial or seventh pair of nerves is not the seat of
this affection.  Not only is this shown by the
seat ofthe pain, but by the experiments of the
physiologists just  mentioned, and  by  those
made by Fodera,  Burdach, Schospf, Bucker,
and Eschricht.
  13. Admitting, therefore,  that the ramifica-
tions  of the  trifacial nerve are  generally the
seats  of tic, or neuralgia of the face, the ques-
tion may still be asked, are the branches of the
facial or seventh pair ever similarly affected?
The free inosculations of  the branches of the
one nerve with those of the other, and the con-
sequent extension  and direction  of suffering,
render it very difficult to prove an affection of
the latter nerve.  Still, although pure tic may
never be seated in the facial or seventh pair of
nerves, inflammation, or any powerful source
of irritation, may excite a most intense pain in
the trunk and principal branches of  this nerve
closely resembling  tic, although more  closely
allied to the more diffused neuralgic pains oc-
casionally affecting other  situations.   Halli-
day  and  Chaponniere  have  adduced  cases
which they believe  to be neuralgia of the sev-
enth pair ; and within a few months  of the pe-
riod in which this  was  written, I attended a
patient suffering  neuralgia  of this nerve,  the
pain extending to the whole side of the face,
and to the neck and  occiput.  The affection was
evidently seated in  this nerve, but was consid-
ered as inflammatory, and treated by local de-
pletions and blisters  to the nape of the neck,
which permanently removed  it.  M. Berard
has seen neuralgia ofthe second cervical nerve.
I have been, during  the last few years, consult-
ed respecting three remarkable cases of neu-
ralgia of the nerves of one side of  the head,
extending from the  occiput to the forehead and
vertex: one  was sent to me from Mons, and
another from St.  Omer.  It was difficult to de-
termine, in these cases, which  of the nerves
supplying this part was the seat of the disease ;
but the facial and branches of the first and sec-
ond cervical were considered  as chiefly impli-
cated.   In these the attacks continued, on each
occasion, from two or three to  several hours,
with  the  most agonizing  exacerbations, and
were  ushered in, in one case, with  vomiting,
by horripilations,  and a free discharge of pale
urine.   In another case, the attacks  frequently
commenced in the night or early in  the morn-
ing, and were kept  off during many months by
the treatment about to be recommended.
   14.  b. The symptoms of tic are chiefly the in-
tensity and paroxysmal nature ofthe pain con-
stituting it.   The pain occurs, or is  exacerba-
ted, in fits;  the  succession of a various num-
ber of fits constitutes an attack, which may be of
uncertain duration,  and leave the patient com-
paratively well in the intervals, which also are
of uncertain  continuance.   The  accession of
the fits is generally  sudden, but is often prece-
ded by various indications of its approach, as
itching of the  nose,  sneezing, tickling, pricking
or coldness, creepings or formication, &c, in
the part about to be affected.   In some cases
it is preceded or attended by an abundant dis-
charge of urine, by  horripilations or  pandicula-
tions, especially when the  complaint assumes
a  regular or periodic character.  After these
precursors, or independently of them, the pain
darts  through one  or more ramifications  of
nerves, and  either  instantly, like a shock  of
electricity, or very  rapidly, acquires  its  utmost
intensity.  The  pain is  most acute, burning,
tensilive, pungent,  stabbing, lacerating, &c. (<")
5), and so poignant as to excite the agonizing
cries of the patient.  The pain has been so  in-
tolerable as to cause the patient to  terminate 
NEURALGIC AFFECTIONS—Special Notices of.                1009
his existence (Duval).  The suffering is gen-
erally referred  to one of the branches of the
trifacial nerve, and darts along the minute ram-
ifications, but it is not  always so limited to a
branch or fibril as to admit of its precise seat
or source being indicated.  It sometimes radi-
ates in several directions, and seldom is con-
centrated in one point without extending in the
direction of the  smaller branches.   In the great
majority  of instances, tic douloureux is limited
to one or other of the three branches of the fifth
pair of nerves, but it occurs probably more fre-
quently in either the ophthalmic or the superior
maxillary branch than in the inferior maxillary.
When  it is seated in the first or ophthalmic
branch, the frontal ramification of it is oftener
affected  than the lachrymal or nasal;  but in
rare cases it extends to  two or all  of these ram-
ifications in the same case ; and often, when
the frontal nerve  is  affected,  an  abundant se-
cretion of tears takes place, or pain is felt in
the eye, and sometimes uneasy sensations are
experienced in  the side of the nose, with dry-
ness, itching, &c.
   15. When the second or superior  maxillary
branch of the trifacial is the seat of suffering,
the infra-orbital is the part most commonly af-
fected, although the  pain  may extend more or
less to the other ramifications of the maxillary.
Generally the pain is referred to the infra-or-
bital nerve as it  passes from the foramen, or
proceeds from it to be expressed  upon the  up-
per lip, ala of the nose, and gum.   It sometimes
affects the posterior  dental  ramification, and
resembles a severe  attack of toothache.   It
more rarely is seated in the extreme branches
supplying the pillars of the fauces and adjoin-
ing parts, in which, however, I have observed
one instance.
   16. Tic douloureux of the third branch is gen-
erally seated in the  inferior dental nerve, and
particularly its  mental  portion as it emerges
from the mental foramen, extending to  the in-
ferior lip.  In some instances the pain  affects
the branch which the inferior maxillary branch
sends to the seventh pair; and  when  this is
the case  the affection appears to  implicate the
latter nerve.  In others, the tic is seated in the
anterior  auricular branch, the pain extending
to the temple in the course of the temporal ar-
tery.  In very rare instances it is seated in the
lingual branch  of the inferior maxillary.   Of
this variety I have met  with one  case, in a fe-
male about fifty years of age.
   17. c.  Neuralgia faciei may thus  be divided
into frontal, infra-orbital, and mental,  according
to its common seat, the other ramifications of
the three principal branches of the fifth pair be-
ing much more rarely affected.  Whatever va-
riations  the complaint may present, the pain
rarely or  never passes from one side of the face
to the other ; and seldom  has it been observed
to exist in both  sides at  the same  time :  of this
latter occurrence, however, Frank, in  his  ex-
tensive experience, met with two  instances.
During the neuralgic paroxysm, the muscles of
the face are often contracted, so as to give the
countenance most singular expressions ;  but
the muscles of the unaffected side are rarely or
never similarly affected.   The least motion or
noise  occasionally aggravates the  pain, and
when the ophthalmic branch is the seat of the
complaint, a strong light has generally the same

    II.               127
effect.  On examining the seat of suffering, lit-
tle or no alteration can be detected beyond a
slight  blush occasionally of the surface,  or a
little redness ofthe conjunctiva, when the first
branch is affected, and a somewhat stronger or
fuller pulsation of the arteries going to the af-
fected parts ; but there is no febrile commotion
of the  system, nor acceleration of pulse, which
often beats slower than usual during the fit.
   18. d. The duration ofthe fit varies from less
than a minute to  one, two, or several minutes,
or to a quarter or half an hour, or even longer.
The severer the complaint becomes the longer
are the attacks.   The termination of the fits
are often as sudden as the commencement, and
sometimes more  so; and in  some cases, par-
ticularly of frontal neuralgia, a copious  dis-
charge of tears or of mucus from the nostril at-
tends  it, and seems to be critical;  but occa-
sionally the fit subsides more gradually.  Some
cases of tic are irregular, or atypetic,  in respect
of the intervals between the paroxysms, while
others are periodic, and resemble a masked in-
termittent.  The  most trivial circumstance, or
the slightest vicissitudes of temperature, amor-
al emotion, or exposure  to the air, &e, will
often suffice  to bring on a fit.  According to
Frank, the attack takes place more frequently
during the day than night.
   19.  e. The whole duration of  the  complaint
may be very long.  It may cease for months or
even years, and return in a more severe form
than before, generally in  the  same  branch of
the trifacial as before, but sometimes in anoth-
er branch of this nerve.  In some instances the
fits become more frequent with the duration of
the complaint.  An increased severity or fre-
quency of the attacks is generally followed by
a failure of the general health, and by more or
less emaciation, owing to want  of sleep, anx-
iety, and dread of the recurrence of the fits, and
impairment of the digestive, assimilating, and
excreting functions.
  20. ii. Toothache.—Odontalgia.  Dolor Den-
tium.   Odontalgic, Douleur de Dent, Fr.   Der
Zahnschmerz, Germ.   Odontalgia, Dolor di Den-
ti, Ital.—Toothache is undoubtedly a variety of
neuralgia, although it may be more frequently
referred  than  any other variety of the  com-
plaint  to  some source of irritation  in one or
more  teeth, or in the gums or antrum.  Yet,
even without these obvious causes,  and often
when they very prominently exist, an attack of
toothache is often brought on by the same caus-
es as those which produce the other forms of
neuralgia (t) 52, et seq.), the local sources of ir-
ritation being often insufficient to develop this
morbid effect, until aided by other agents or in-
fluences.
  21.  Odontalgia may be divided into, 1st.  The
inflammatory, or that  caused  by inflammation
of one or more of the  constituent structures or
tissues of the teeth; 2d. The ulcerative or ca-
rious, or that caused by ulceration or caries of
a tooth, and consequent exposure or irritation
of a nervous fibril;  3d. The nervous, or neural-
gia of the nerves supplying the teeth and gums,
independently  of  inflammation or caries of a
tooth—neuralgia  dentalis.   Besides  these va-
rieties, toothache may proceed from inflamma-
tion or abscess of the gum or in the antrum,
from caries of a  portion of the  alveolar  pro-
cesses, or of  the upper  or lower jaw;  from 
1010         NEURALGIC  AFFECTIONS—Neuralgia of Neck and Trust*.
fungus,  exostosis, or other  growths,  on the
root of a tooth ; from retention of one of the
first set, and from a wrong direction being given
to one or more of the second set.   It may af-
fect, moreover, the gouty or rheumatic diathesis,
and thereby assume a modified or more ex-
tended form ;  and  it may be  developed  by ex-
posure to cold, malaria, &c., and be character-
ized accordingly.
  22.  There can be no doubt that, even when
the most energetic of these  sources of irrita-
tion are present, little or no pain or uneasiness
is sometimes felt, until disorder of the digest-
ive organs  occurs; until the functions  of the
stomach, duodenum, or  intestines are  deran-
ged, either  by improper  ingesta, or by morbid
secretions poured into or accumulated in them ;
or until bile collects to an injurious amount in
the gall-bladder  and ducts, and depresses the
organic  nervous influence.   When, however,
these  disorders of the digestive organs occur,
the affection of the dental nerves is developed,
particularly in those parts more  immediately
irritated; and as soon as those disorders are
removed, or  morbid matters evacuated, the
pain subsides, even although the local source
of irritation remains; still, as  long as it  re-
mains, toothache recurs whenever local or con-
stitutional causes of neuralgia occur to develop
its effects.
  23.  The  attacks of toothache vary much in
character and intensity, according to the na-
ture of the  local mischief, to  the states  of the
digestive organs, and the temperament and di-
athesis of the  patient.  In some the paroxysm
is most acute and intense, but of short dura-
tion ;  in others it is much less severe, but con-
tinues a much  longer  and  a  very indefinite
time,  it being of an  aching kind with occasion-
al exacerbations.   In many, the pain, whether
most  acute or more chronic, is limited to the
seat of local mischief, or even to the tooth it-
self;  in others the pain extends to the whole
jaw, or to the  cheek, or even  to the whole side
of the face, particularly  when the upper jaw is
the seat  of irritation, and after exposure to a
current of air or to cold.  In those states of the
complaint  which have, by some writers, been
called catarrhal, rheumatic, and gouty, the pain
often  extends  to a great part of the same side
of the face, and it is often difficult to localize it
with much  precision.
  24.  iii. Neuralgia of the Neck and Trunk.
—A. M. Itard has  described, under the name
of otalgia, a neuralgia of the ear, seated chiefly,
as he  supposes, in the chorda tympani and acous-
tic nerve.   It  is sometimes associated with
neuralgia of the face.   The pain in the ear is
very acute, is sudden in  its accession and dis-
appearance, and is independent of any indica-
tion of inflammation of the ear.  It is often at-
tended by noises in the  ear,  and by temporary
deafness (see art. Ear, y 6).
   25.  B. Neuralgia of the cervical nerves  is very
rare.  M. Bosq.uili.on met with a case which
was apparently caused  by the puncture of  a
nerve in bleeding  from the jugular vein ; and
M. Jolly has  alluded to another which appear-
ed to be produced by the application of leeches
to  the side  of the neck.  A  less severe  or
chronic form  of neuralgia of certain  of these
nerves, resembling  rheumatism  in many re-
spects, but attended by spasm or contractions,
 more or less permanent, of some of the ma*.
 cles, sometimes occurs in connexion with ca-
 ries or other disease of, or in the vicinity of the
 upper cervical vertebrae.  Of this  state of the
 complaint I  have seen two or three cases, but
 in neither was the pain so intolerable as in the
 most acute cases of neuralgia.
   26. C. Neuralgia of the thoracic  or intercostal
 nerves, and painful affections ofthe other nerves
 of the  trunk, have been described by Siebold,
' Nicod, Jolly, Allnatt, Valleix, Tkale, and
 Brown as neuralgic;  by Parrish,  Darwall,
 Griffin, Ollivier, and Bennett  as resulting
 from spinal  irritation; and by Tate,  Addison,
 and others in connexion with hysteria and uter-
 ine irritation.   That  these  painful affections,
 whether amounting to neuralgic acuteness, or
 hardly  exceeding a rheumatic aching, may de-
 pend, in some  instances, upon vascular con-
 gestion of a portion of the spinal cord, or of its
 investing membranes, or upon inflammatory ir-
 ritation, or some other morbid state of the cir-
 culation in  these  parts, is  very  probable, al-
 though the exact state of these structures has
 not been satisfactorily demonstrated in connex-
 ion with these affections.  Still, cases not  in-
 frequently occur of neuralgic or painful states
 of the  thoracic and abdominal nerves, without
 any evidence of congestion or irritation of the
 spinal cord ; while, on  the other hand, proofs-
 of these states of spinal disorder are often fur-
 nished to the close observer, without any pain-
 ful expression of it in those particular nerves.
 When  treating  of the  painful manifestations
 of Hysteria (see that article, y 14, et seq.), I had
 occasion to  remark, that disease of the spinal
 chord or of  its membranes is not necessary to
 the production of these  painful affections; and
 that  when such  disease is observed in connex-
 ion with them, it is to  be viewed rat lie i as a
 contingent result of the same irritation as pro-
 duced  them, or as  an associated complaint,
 rather than as the primary and necessary source
' of these affections (Hysteria, y 23-61).  A sim-
 ilar view  may be entertained respecting the
 connexion of neuralgia of the nerves of the
 trunk with spinal irritation, in cases whero no
 evidence of hysteria exists.
    27. That  neuralgia of these nerves is often
 connected with hysteria, as often with eviden-
 ces of  disorder, congestion, &c, in a corre-
 sponding  portion of the spine, and often also
 without one or other of these, and even with-
 out both,  I believe to be nearly the truth.  The
 much greater frequency of the affection in fe-
 males  tends to prove the first of these posi-
 tions.   Thoracic neuralgia commonly occurs
 about  the union of the seventh, eighth, and
 ninth ribs with their cartilages, and chiefly on
 the left side.  The pain often extends from
 this point, in the  course of the  nerve, to the
 spine, and sometimes it associates itself with a
 similar pain in the mamma of the same side.
 It generally darts in the course of the nerve ;
 and, although it has little influence on the state
 of the organic functions, it sometimes embar-
 rasses  the  respiration.  It is occasionally as-
 sociated with pain in the epigastrium or in the
 bowels, or with hysterical colic, or with pain
 in the region of the uterus or ovaria.  These
 neuralgic pains may be distinguished from rheu-
 matism by the latter being accompanied with
\ soreness  of the muscles on pressure, and on 
NEURALGIC AFFECTIONS—Neuralgia of the Extremities.         1011
contracting them ; while the former are attend-
ed by extreme sensibility ofthe skin and parts
supplied by the affected  nerve.  These pains
sometimes occur coetaneously on both sides of
the chest,  rarely successively, and often  they
are periodic.   They are frequently independent
of any evidence of disorder in the spinal  cord
or its coverings.
   28. Intercostal neuralgia is a frequent com-
plaint.  The  greater number  of cases usually
denominated  pleurodynia  ought to be classed
under this  head.  It chiefly affects females : of
 148 cases noticed by Messrs. Griffin, 26 were
males, 49 married women, and 73 girls.   It is
most frequently observed between the ages of
15 and 50 years, and occurs  in all  tempera-
ments,  particularly in the nervous  and  san-
guineo-nervous.   Residence in low, damp cell-
ars  and localities,  or in close, ill-ventilated
apartments; laborious vocations, and poor diet;
watchings and night work, are among its most
influential causes.  It is sometimes associated
with other neuralgic affections, or with  sup-
pression or irregularity of the  catamenia.
   29. This affection occurs much more fre-
quently in  the  left  than  the  right side.  Ac-
cording to the researches of M. Valleix, of
all the  intercostal spaces, the sixth,  seventh,
eighth,  and ninth are its  common seats.   He
has never observed it in the eleventh and twelfth
spaces, and very rarely in the first and tenth.
The pain is generally much increased on press-
ure ; but not  in all parts of the course of the
nerve.  There  are usually very limited points
where the  pain is felt  acutely; and these are
separated by intervals, where pressure is not
painful.  These points are situated:  1st. A lit-
tle from  the spinous  processes, and corre-
sponding to the point where the nerve passes
frord between the vertebrae.   2d. At the ante-
rior part of the intercostal space, and near to
the sternum  or epigastrium ;  and, 3d. About
the middle of the  intercostal  space, where,
however, the pain is much less frequent  than
at either extremity.  At these points, the pain
is often so  acute as to occasion the most mark-
ed indication of extreme suffering when the
linger is passed over them ;  and it is generally
increased, on a full inspiration, by cough, and
sometimes even by the movements of the arm
or side; but  it presents  this  peculiarity, that
inspiration  excites pain in one point, and other
emotions in a different point.
   30. The  pain may be  either  dull, aching,
sore, and continued, and felt chiefly in one or
other ofthe points just specified ; or it may be
sharp, darting, poignant, and  recurring at in-
tervals of short, but of various duration.  Gen-
erally both kinds of pain are felt, the latter
being superadded to the former.  The acute,
lancinating pains commonly proceed  from ei-
ther  of the points which  are painful on press-
ure, and dart in the course  of the nerve    In
connexion with this pain, there is no indica-
tion, upon auscultation or percussion, of inflam-
mation of either  the lungs,  pleura, or pericar-
dium ;  and there are  also  febril symptoms.
The digestive organs are, however, commonly
more  or less  disordered, this  disorder mam
festly depending  upon the same  pathological
state as gives rise  to  the neuralgia, viz., im-
paired energy and irritation  of some portion of
the oiganic nerves.
  31. The course of this affection is often ir-
regular.   The pain usually increases gradually,
and subsides in the same way ; but it is much
influenced by the states and  vicissitudes of
season, weather, and temperature.  It is com-
monly most severe in  cold or snowy weather.
In many the affection  assumes a regularly in-
termittent form, and it  is then of long duration.
  32. d. Neuralgia ofthe lumbar nerves has been
mentioned by several writers, but true neural-
gia is rarely observed in this situation.  Most
ofthe cases which have been thus termed have
evidently been instances of severe pain, symp-
tomatic of irritation  in  the kidneys, ureters, or
urinary bladder, or in the uterine organs.  MM.
Chaussier, Richerand, and Delpech have de-
scribed cases of neuralgia, which they have re-
ferred to  the anterior branch of the first lum-
bar nerve, and in which the  pain has extended
from the  loins  and crest of the  ilium to the
groin and labia of the vulvae of the female, and
to the chord and scrotum, or testicle.  The
pain was  very acute, and recurred daily, with
retraction of the testicle, but without any dis-
order of  the urinary  excretion.   Somewhat
similar cases have been noticed by MM.  Bar-
ras and Campaignac ;  but  in these  the  pain,
affecting chiefly females, was experienced near
the neck of the bladder and vulva, and was un-
attended by any disorder of the urinary func-
tions.  Sir Astley Cooper has adduced some
cases, in his work on the Testis (p. 110),which
he believed " to be seated in the nerves, and to
be ofthe nature of tic douloureux."  In these,
the pain darted in the direction of the spermat-
ic chord ; and  one  of them seemed to  have
been caused by an injury received some tirr|e
previously on this part.   Sir Astley states that
the affected testis hung lower  than  the unaf-
fected, and he adds, that he dissected all the
testicles which he had removed for this  com-
plaint, but there was  no apparent structural
change in any of them.
  33. Certain states  of lumbago are more near-
ly allied to  neuralgia than  to rheumatism, in
respect  not  only of the characters of the pain
and of the accompanying, but  also of the ag-
gravating and alleviating circumstances  and
agents.   Even in those cases where the pain is
evidently seated in the  lumbar muscles, it is
nevertheless to be referred to some change in
the circulation in that portion of  the spinal
chord, or in the roots of the nerves supplying
these muscles.   (See articles Rheumatism and
Spinal Chord.)
  34. iv.  Neuralgia of the Extremities.—
Neuralgia Membrorum.—Neuralgic  des Membres,
Fr.—Neuralgia is comparatively  rare in the
upper, but not infrequent in  the lower extrem-
ities.—A. In the former situation, cubito-digital
neuralgia, as it has been termed by Chaussier,
or neuralgia of  the  cubital  nerve, is  oftenest
met with.  It is geneially seated  in that por-
tion ofthe nerve which passes between the in-
ternal tuberosity of the humerus  and the ole-
cranon,  from which it  darts in the  course of
the nerve.  Sometimes it appears below the
armpit, following the inner margin of the fore-
arm, and extending to the cutaneous branches
of Ibis  nerve, and to those sent  to  the  little
and ring finger.   In reeent attacks  the  tem-
perature of the arm  is  occasionally increased
during the paroxysm, which frequently occurs 
1012
NEURALGIC AFFECTIONS—Sciatica—Muscular Neuralgia.
during the night.  In very severe  fits the pa-
tient  experiences  much anxiety, often holds
the arm up,  and grasps it forcibly  with the
other hand.  Besides neuralgia of this nerve,
M. Martinet has mentioned neuralgia of the
supra-scapular and  external musculocutaneous
nerves.  In both these  the pain is seated in,
and extends more or less to, the ramifications
of the nerve.   In these three different seats of
suffering the  complaint presents similar phe-
nomena.
  35. B. Sciatic Neuralgia.—Neuralgia Sci-
atica.  N. fimoro-poplitee, Chaussier.   Sciatica,
Auct.  var. Ischias nervosa postica, Cotugno.
Ischias, Sciatica, dolor ischiaticus, Ischiagra, Ma-
lum ischiadicum,  &c—This form of  neuralgia
was  formerly confounded with all painful affec-
tions of the hip and adjoining  parts, whether
inflammatory or rheumatic, primary  or symp-
tomatic ; and  the pain was referred to the joint,
to the muscles, to the bones, to the tendons, to
the nerves, &c, according  to the views of the
writers.   Hence, among the synonymes of the
complaint we find  Morbus  Coxendicus, Morbus
Coxarius, Dolor Coxa,  Coxagra,  &.C., names
which belong to different affections.   Sciatica
has also been viewed as a variety of rheuma-
tism, until the comparatively recent writings
of Chaussier and others have shown that, al-
though often very closely allied to certain states
of that disease, it is essentially a form of neu-
ralgia.  It is a  common disease in  advanced
age ; it is very rare in infancy and childhood ;
and  it is somewhat more frequent in females
than  in males, particularly in females during
the puerperal states.  It attacks in preference
the  nervous  temperament, and the rheumatic
and gouty diathesis.  It is most frequent in cold
and  wet seasons, during stormy and changea-
ble weather, and in low, humid,  clayey, and
marshy localities.   It is common among fisher-
men, sailors,  soldiers, and all those who are li-
able to wear wet clothes, or who are exposed
to currents of damp air or to cold.   Owing to
the state of weather, season, locality, and oc-
cupation, I have observed it assume  an almost
epidemic frequency.
   36.  An  attack  of sciatica generally  com-
mences with acute pain in the sciatic slope or
curve between the great trochanter and the is-
chium ; and the pain follows the course of the
great sciatic,  or femoro-popliteal nerve, extend-
ing sometimes upward to the sacrum, but gen-
erally downward along the  posterior surface of
the thigh to the popliteal space, and often along
the nerves of the leg to the foot.  It is some-
times very severe in the tibial nerve.  The ac-
cession of pain is occasionally sudden, but it is
often preceded  by painful  pricking or tingling
along the thigh, by slight numbness, or by chills,
formication, &c. Usually  one limb only  is af-
fected, and very rarely  both.  The motions of
the extremity are extremely painful and diffi-
cult.   During the exacerbations some patients
suffer most in the  sciatic slope, others in the
posterior part of the thigh, and others in one
or both of the popliteal or  tibial nerves.   The
pain is in every respect similar to that felt  in
other kinds of neuralgia.   Exacerbations of it
occur generally in the  evening or during the
night, and cease in the morning;  but several
may take place during the day, with remissions
more or less complete, during which the pain
is more dull, and is attended by numbness and
pricking or tingling.  The slightest cause may
bring on the exacerbation, as  motion or exer-
tion* the heat of bed, or mental  excitement.
The duration  of the  exacerbations of pain,  as
well as the frequency of their recurrence, is
very various, and  differs but little from other
forms of neuralgia.  The  continuance of  the
attack is equally uncertain ; the causes of the
complaint, the constitution of the  patient, and
various other circumstances, influencing it.   In
some cases, the accessions of suffering are fol-
lowed  by convulsive or trembling movements
of the limb, by slight numbness, or partial pal-
sy ;  and an attack generally  leaves  the limb
emaciated, flabby, and weakened.   When the
attack has been very severe, or of long contin-
uance, lameness, a dragging of the leg; great
emaciation of the limb; a weakened or partial-
ly paralyzed state of the muscles ;  and disorder
of the digestive  organs,  are  experienced  for
some time  afterward.
   37. C. Femoral or  Crural Neuralgia—
Neuralgia Cruralis—Ischias nervosa antica, Co-
tugno—Neuralgic femoro-pretibial, Chaussier—
occurs much less frequently than  sciatic neu-
ralgia.  It may affect any portion of this nerve.
from the groin downward.  It often commences
in, or a little below, the groin, and extends along
the anterior and internal aspect ofthe thigh and
leg to the foot, and even to the sole.   In a case
of neuralgia  seated in this nerve, in  a gentle-
man from South America, at present under my
care, the pain is experienced chiefly in the mid-
dle of the thigh and of the leg, and in both ex-
tremities.  The pulse is somewhat frequent and
irritable, and the bowels disposed to be costive.
The muscles are soft and  flabby, and the spirits
depressed.  The complaint has been of long
duration,  and  the intermissions  few and of
short duration, since his arrival in England.
   38. v. Neuralgia  of  muscular and mem-
branous structures has  been noticed by sev-
eral modern writers ; and, adhering to the defi-
nition of neuralgia (y 1), and to the circumstance
of the occurrence of severe pain in these struc-
tures independently of fever, it may be viewed
as often allied to  neuralgia, although passing,
in its characters and in its various morbid as-
sociations, in some cases  into chronic rheuma-
tism or gout, and in  others into hysteria.—a.
But in true neuralgia of the muscles the pain is
much  more acute than in rheumatism, recurs
in frequent exacerbations, and  is rarely or never
altogether absent  in a dull or numb form.   In
all the cases I have seen, the remissions were
attended by  weakness or partial  palsy of the
muscles affected ;  and the complaint was symp-
tomatic of organic lesion  in either the brain or
spinal chord; apoplectic,  epileptic, or paralytic
attacks  generally  occurring  after  longer  or
shorter periods.   A lady  from Gravesend con-
sulted me  a few years since for neuralgic pain
of the muscles of one side, and particularly of
those  of the  shoulder and arm of that side.
After many months of suffering, maniacal de-
lirium  and palsy  supervened.  Several large
tubercular formations were found in  the brain
after death, similar to those  described in the
article Brain (y 111).  Indeed, as Dr. Seymour
has very justly insisted, those severe  neuralgic
pains in the muscles or  limbs should always
lead to suspicion of the existence  of  softening 
NEURALGIC AFFECTIONS—Visceral Neuralgia.               1013
or other organic lesions or formations in the
substance of the brain.  In two cases, when
the muscular pains were most  acute in the
thighs, and were attended by occasional cramps,
and were followed by weak and irregular action
of them on volition, amounting to partial paral-
ysis, extensive organic change was found in the
spinal chord and its membranes.  (See Spine
and Spinal Chord.)
  39. b. The painful affections ofthe periosteum,
attributed to  syphilis or to mercury, as Dr. T.
Thomson has suggested, are in many respects
neuralgic.  The painful affections noticed so
fully in the article Hysteria (v 14, et seq.) dif-
fer from neuralgia chiefly in the  seat of irrita-
tion causing them—in the affection ofthe uter-
ine organs.   A  neuralgic affection of the  skin
has been noticed by some writers, and its con-
nexion with herpes and other cutaneous erup-
tions pointed out.   In some states of hysteria
the sensibility of the 6kin is often most painful-
ly increased. ' The epidemic fever that prevail-
ed in Paris in 1828, and in some of the West
India Isles, was attended by pricking and severe
pains in the skin and upper and lower extremi-
ties, alternating with  numbness.  But these
symptoms  were accompanied with  so many
others, which often  predominated, that they
cannot be viewed as constituting a form of neu-
ralgia, although  illustrating certain manifesta-
tions and morbid associations of this affection.
   40. vi. Visceral Neuralgia.—It is unneces-
sary to notice, otherwise than by enumerating
the several visceral affections which, if not truly
 neuralgic, are in many respects related to neu-
 ralgia.  Most of these  have been duly  consid-
ered in the several  articles or sections of arti-
cles devoted to them.—a. Certain forms of head-
ache, particularly the nervous forms, and those
which are limited to one part, or  which are at-
tended by violent shooting pains, or are remit-
tent or intermittent, are closely  allied  to neu-
ralgia, and are generally aggravated  and alle-
viated by the same agents and influences as it.
In these cases, the pain is to be referred to the
state of some portion  of the ganglial  nerves
supplying the brain,  in connexion with some
change in the state of the cerebral circulation.
Indeed, visceral  neuralgia, with few exceptions,
which will be noticed, may be referred to the
ganglial nerves,  or may be termed ganglial neu-
ralgia;  a seat of those  complaints pointed out
by me as early as 1821  and 1822, in the works
noticed in the references to this article.
  41. b.  Ganglial neuralgia most frequently oc-
curs in delicate  constitutions, and in nervous,
melancholic,  or  lymphatic  temperaments.  It
is more frequent in females than  in males, and
is caused by all the moral  and physical influ-
ences which powerfully impress the  nervous
system.  As in external, so in visceral neuralgia,
the course of the affection is  intermittent or
remittent;  but the recurrence of the  attacks
are less regular in the latter than  in the former.
And in the visceral  as well as the external
complaint, it  may be presumed  that more or
less of vascular determination or fluxion fol-
lows the excessive exaltation of  sensibility, at
least in some cases.  Visceral or ganglial neu-
ralgia may thus be followed  by increased secre-
tion  or by other evidences of increased vascu-
lar reaction or determination.  It is also apt to
perpetuate itself, or is more prone to return or
to continue after having once appeared ; and it
seldom leaves after it, or presents upon the ex-
amination  of fatal  cases, lesions sufficient to
account for the amount of suffering experienced
during life.
  42. c. The chief special forms of visceral neu-
ralgia which present themselves in practice are,
1st. Neuralgia of the heart, and particularly that
form of it which has been termed angina pecto-
ris ;  2d. Gastrodynia or gastralgia, and its vari-
ous morbid associations ;  Colic and ileus, more
especially lead  colic ;  4th. Hepatalgia and  sple-
nalgia; 5th. Nephralgia ; 6th. Hysteralgia ; and
7th.  Mastodynia. These are all fully noticed
either in the articles devoted to them especial-
ly, or in sections of the articles  on the diseases
of the  organs in which they are seated; and
their pathology is still farther illustrated in the
article on Irritation and its sympathetic rela-
tions.  The subject of nephralgia (see Kidneys,
y 249) is well exemplified in the case of inter-
mittent neuralgia of the kidneys described  by
Dr. Macculloch, in  which the secretion  of
urine was greatly increased.  In some slighter
states of this affection,  occurring in hysterical
females, and generally  associated  with more
or less of  hysteria, this influence of morbidly
exalted sensibility of the nerves of the organ
upon secretion  is also fully shown.
  43. d. Many  of the cases of hysteralgia,  or
irritable uterus,  as it has been  most commonly
termed in this  country, may be considered as
neuralgia of the uterus, although it  is ascribed
by some writers to congestion of  this  organ.
Doubtless cases sometimes occur  of severe
pain in the uterus, depending upon, or at least
associated  with, congestion or  chronic inflam-
mation of the  neck and mouth of the womb;
but there are others of a more truly neuralgic
character,  which may be discriminated from
these by a due exercise  of tact and observation
(see art.  Uterus,  Painful  affection  of),  and
which are most successfully treated, according
to the principles of cure recommended for  neu-
ralgia.
  44. e. Neuralgia of the vagina has been no-
ticed by a few  writers.   It has been variously
described by patients as a most acute burning,
or lancinating,  or lacerating, or plunging pain.
It is usually of short duration, and of frequent
recurrence; but it  is sometimes attended  by
a more continued  aching or  soreness;  and
the attacks are after intervals of various and
sometimes of very long duration.   In its idio-
pathic  form there is no appreciable lesion  of
the vulva, vagina, or uterus, but it is occasion-
ally symptomatic of organic lesion ofthe womb,
and the patient is usually fearful of cancerous
or other serious mischief being present.   It
has been imputed to cold or astringent injec-
tions for the cure of leucorrhoea, to sitting  on
cold or damp  seats, and on stones or on the
ground; to excesses in coition, and to othei
causes of neuralgia;  but certain of these are
matters rather  of inference than of ascertained
occurrence.
  45. vii. Neuralgia  of Nerves of Associa-
tion.—a. It is extremely probable that several
anomalous  painful affections, occurring in  par-
oxysms of extreme agony, which  cannot  be
referred with precision  to a single  part or or-
gan, but which affect the diaphragm, stomach,
heart, and their  vicinity,  or either of them more 
1014                  NEURALGIC AFFECTIONS—Diagnosis or.
or less prominently, are actually instances  of
neuralgia of these nerves, and the ramifications
of them, particularly of the pneumogastric and
phrenic  nerves.  Several of these affections
have been  considered  as instances of angina
pectoris ; but, although nearly allied to that af-
fection, they are more  correctly instances  of
neuralgia of these nerves, the phenomena char-
acterizing individual cases  varying with the
ramifications especially affected, and with the
associated affection of ganglial nerves frequent-
ly accompanying them.   Many of the cases  of
these neuralgic affections occur in persons who
have experienced  either regular or irregular
attacks of gout, and have hence been viewed
as occurrences  of retrocedent  or misplaced
gout, both from this circumstance and from the
immediate relief consequent upon the develop-
ment of that disease in the extremities.   Still,
some of these cases occur either without any
previous manifestation of gout, or without any
attempts subsequent to their appearance  to
develop the  gouty attack.  In a case long at-
tended by Dr. Roots and myself, in which the
attacks of extreme agony were referable to the
diaphragm, heart, and stomach, but sometimes
to one of those situations more than to the
others, there has been  no  regular  manifesta-
tion of gout  ; and in another occasionally seen
by me for twelve  or thirteen years, there has
been no attempt to develop a paroxysm of that
disease  since the  first  occurrence of the vis-
ceral neuralgia, although treatment was  often
prescribed  with this intention.  In  this case
the violent  attacks of pain  in the praecordia,
and sometimes also in the stomach, with mark-
ed disorder  of the  heart's action,  were  often
alternated with the most  acute pain of the
head, generally of some hours' duration,  or
even longer.  Notwithstanding the  extreme
suffering these two patients have  endured for
many years—in one case about 10 or 12, in the
other for 14 or 15—the general health has not
suffered, and no farther change beyond that de-
pending upon advancing age can be observed.
   46. b. Many of the more  severe sufferings
aften complained of by hypochondriacal and hys-
terical patients, and which are very generally
viewed  as  either imagined  or remarkably ex-
aggerated,  owing  to the general health  being
but little impaired, and to the little disturbance
evinced by the organs  of circulation and loco-
motion, may be considered as forms of neural-
gia affecting chiefly the nerves of organic life
or of association.  In many cases of hypochon-
driasis and hysteria, the most distressing pains
are referred to the stomach or to  the bowels,
to the heart, and to various other viscera; and
in some  these pains are said either to change
their seats from time to time, or to affect sev-
eral organs, or even to assume different fea-
tures.  The circumstance of these  sufferings
engaging the entire attention of  the patient,
and the apprehensions  and despondency often
attending them, being usually viewed in con-
nexion  with very slight appearance  and evi-
dences of ailment, often lead to a belief in their
 want of reality; while they should be viewed
as evidence of greatly  impaired energy of the
ganglial system of nerves, or even of more se-
rious disorder of these nerves ;  of asthenia of
this part of the nervous system, associated with
a morbid exaltation of its sensibility, and not
infrequently with either functional or structu-
ral lesion of one  or more  important organs,
particularly of  the  organs subservient to the
perpetuation  of organic life.   I  have had  al-
ready frequent occasion to remark upon the
efforts made  by nosologists  and  systematic
writers to point out differences, and to manu-
facture genera and species as if they were deal-
ing with the distinct objects of natural history,
while they ought, at the same time that they
mark differences and modifications of morbid
action, to show obvious connexions and inti-
mate alliances—such as are so frequently ex-
hibited by hypochondriasis,  hysteria, and  neu-
ralgia, and more especially visceral neuralgia.
  47. III. Diagnosis  of Neuralgia.—A fully-
developed case  of neuralgia is  characterized by
the  remarkable severity and  frequent recur-
rence of darting or plunging pains, and by the
intermittent or remittent forms of the attack.
The situation of the pain  in  the course  of a
nerve serves to indicate the  nature  of it, in
the less violent cases, while the  ease caused
by pressure, and the absence of fever, of ten-
derness on firm pressure, of hardness or swell-
ing, and of heat in  the seat of the nerve, dis-
tinguish these cases from neuritis.  This dis-
tinction, however, does not always hold, for I
shall hereafter  have to show that some cases
of neuralgia depend upon a congested or slight-
ly inflamed state of the origin  or some portion
of the nerve.   In all cases both of internal and
external neuralgia, the effect produced by  firm
and  continued  pressure aids  the  diagnosis ;
for where pressure gives ease  or is well borne,
the neuralgic character is thereby indicated ;
and  where the neuralgia  is  associated with
congestion or  inflammatory action, pressure
will indicate their existence.
  48. a. When  the nerves of the face are affect-
ed  in the extreme manner characteristic of
tic, the  disorder cannot be mistaken  for any
other.  Even when it is attended by spasm or
twitchings, &c, of the muscles of  the face, it
cannot, owing to the seat and violence of the
suffering,  be  confounded with  trismus ; and in
even the less severe cases, the recurring na-
ture of the pain sufficiently marks it from the
continued pain, increased on the action of the
muscles, constituting rheumatism  of the face,
which also is sometimes attended by swelling.
  49. b. In neuralgia of the nerves of the trunk,
the chief object of the diagnosis is to deter-
mine the existence  or non-existence of inflam-
matory action or congestion in the spinal chord,
or in its membranes.  This can be ascertained
only by attention to  the  history of the case,
and by a careful examination of the spine.  It
is of importance also to ascertain whether or
not the pain is dependant upon disease of a vis-
cus near or related to the nerves affected,  or to
the  seat of pain; and this  object is to be at-
tained only by careful examination, and by the
aids of percussion  and auscultation, with due
attention to the constitutional and symptomatic
phenomena.
   50. c.  The  same intentions as the above
should guide our inquiries in forming a diagno-
sis of visceral neuralgia from  inflammation  or
congestion, or even from organic disease ofthe
viscera, to which the patient's sufferings are
referred ; and  in these, as  well as in others,
the  continued and persistent character of the 
NEURALGIC AFFECTIONS—Causes.
1015
pain and other symptoms, tenderness on press-
ure, heat, swelling, or distention, febrile com-
motion, the state  of the pulse, of the secre-
tions and excretions, and of the tongue, coun-
tenance, and skin, will indicate the presence
of inflammation, or  of active vascular deter-
mination ; and in plethoric patients, of conges-
tion ;  and will point out the treatment which
should be adopted, while the intermittent, re-
mittent, or periodic pain, the marked intervals
of ease, the  history of the  case, and  the cir-
cumstances increasing or ameliorating the pa-
tient's sufferings, will demonstrate the neural-
gic character.
  51.  d. Neuralgia of the extremities can hardly
be confounded with any other  disease, unless
when the ischiatic nerve is  affected.   Sciatica
may be mistaken for disease ofthe hip joint, or
of the vertebrae  in connexion with inflamma-
tion or abscess of the psoa muscles, extending to
adjoining parts ; or these affections may be mis-
taken  for sciatica, the  ischiatic nerve, or  the
nerves contributing  to  form it, being often in-
flamed or  irritated, or  pressed  upon  in  the
course  of  these  maladies.   In psoas  abscess,
the pain in the loins, the tenderness in that
situation and anteriorly, the acute hectic fe-
ver, the continued form ofthe disease, the ob-
vious tumour and the consequent fluctuation,
the direction which the tumour takes, either to
the groin or to  the loins near the sacro-iliac
juncture, &c, suffice to distinguish it from true
sciatica.  In hip disease, or even in spontane-
ous dislocation of the hip, the situation of the
pain,  the alteration  in the direction and posi-
 tion of the trochanter, and the lengthening and
 subsequent shortening of the  limb, show the
 nature of the disease.
   52.  IV.—Causes.—.A. Predisposing. — Neu-
 ralgia is most frequently observed in the ner-
 vous and melancholic temperaments ; in per-
 sons   of a  hypochondriacal, hysterical, rheu-
 matic, and gouty  diathesis ; and in adult  and
 aged  subjects.   Sex has no very  marked in-
 fluence upon its frequency, although certain of
 its forms are more frequent in  females than in
 males, while other forms are more common in
 males.  It is oftener met with in females about
 and after the cessation of the  menses  than at
 any other period; and it is more common in
the wealthy  or easy classes of society than in
 the poor and laborious.  It is more common in
cold  and humid,  than in warm and dry cli-
 mates.  Chronic or prolonged debility, the ex-
 haustion consequent upon acute diseases, and
 prolonged or neglected dyspepsia;  the puerpe-
 ral states, exhausting discharges, and prolong-
 ed or improper lactation; excessive venereal in-
dulgences, menstruation, &.C., anxiety of mind,
 &c, are among the most influential predispo-
sing causes.
   53.  B. The exciting causes are  not always
 clearly ascertained in practice, for while some
 cases are chiefly referable to  physical causes
acting either upon the brain or upon the nerves,
 others can be attributed only to some pre-ex-
 isting disorder, or pathological condition, which,
however, when more closely viewed, often ap-
pears as much an associated effect of some an-
 terior morbid state as an efficient cause of this
 affection.-*. There can be no doubt that mora
 emotions of a powerful kind, prolonged mental
excitement  or  anxiety, habitual  exertions of
the intellect, prolonged watchings, and other
circumstances which affect nervous power and
the state ofthe cerebral circulation, particular-
ly when aided by other exciting causes, will be
more or less influential in producing certain of
the varieties  of neuralgia,  more  particularly
those seated in the nerves of the head or face.
Bellingieri met with two cases  of tic which
were caused by fright.
  54.  b. Of all the causes whose operation is
well ascertained, there are none more efficient
in  producing  these  complaints,  particularly
when seated in the extremities, than exposure
to malaria  and to damp and cold in any form;
to any of them singly, and more especially when
they are conjoined.  One of the most important
services rendered to  medical science in modern
times is to be found in the exposition of the
causes and morbid relations of neuralgic affec-
tions by Dr. Macculloch.   Until that work ap-
peared, the influences  of malaria  in causing
the several forms of neuralgia, especially when
aided by damp and  cold  states of the atmo-
splvere, were hardly acknowledged, and the im-
portant connexions of neuralgic affections with
other diseases were  entirely overlooked.  But,
even without  any probable operation of mala-
ria, cold and damp, particularly when the ex-
posure to them has been prolonged or frequent;
vicissitudes of season and weather, especially
in respect of humidity and electrical conditions;
the partial abstraction of animal heat by  cur-
rents of air, by wet clothes or shoes, or by sit-
ting on cold or damp seats, standing or sitting
on  cold  floors, and exposure  of  the  face to
cold and  wet, or to a  snow-storm, especially
when outside a carriage, have no mean influ-
ence  in producing neuralgic  complaints.   Re-
siding in low and damp cellars  or houses;
sleeping on the ground or on the  ground floor,
or in the open air; low, damp, and miasmatous
localities  and a clayey soil,  are often so pro-
ductive of these complaints as  to impart to
them an endemic character; and when to these
are superadded wet and cold seasons, the prev-
alence of rains and stormy weather, and elec-
trical vicissitudes ofthe atmosphere, they may
even assume  an epidemic appearance.
   55. Of the  influence of local injury ; of for-
eign substances lodged near to  or between the
fibrils of a nerve ;  of bruises, wounds, &c. ; of
overstretching a nerve by great efforts; and
of  undue or prolonged pressure of a nerve, in
the production of both neuralgia  and chronic
inflammation, notice has been taken in the ar-
ticle  Nerves  (§ 20).  These produce  or  per-
petuate irritation  and inflammatory action or
congestion in the portion of nerve thus injured.
Indeed, some of the pathological  causes about
to be noticed  have a similar effect.
   56. c.  The pathological causes  and associations
of neuralgia are of much importance as respects
the obvious indications of cure which they sug-
gest.  Certain of these causes act directly upon
the nerves affected, and some  even upon the
part which is the source and  centre of pain,
while others  exert  a more distant or sympa-
thetic,  and not infrequently a doubtful  influ-
ence.   The same causes as were stated to oc-
casion inflammation of a nerve (y 33) may pro-
duce neuralgia, and any of the  organic lesions
of nerves (y 2, et seq., 24, 26) may have a sim-
 ilar effect.  Various structural changes seated 
1016                     NEURALGIC AFFECTIONS—Causes.
 at the origin of a nerve, or in the nerve itself,
 or in contact with it, or so near it as indirectly
 to implicate it, may occasion either  pain  or
 spasm, or both, or palsy, according to the man-
 ner in which they either irritate the fibrils de-
 voted to sensation or to motion, or entirely in-
 terrupt one or both of these functions.   Hence
 the intimate connexion existing  between neu-
 ralgic, spasmodic, or convulsive,  and paralytic
 maladies.
  57. The pathological causes which occasion-
 ally give rise to neuralgic affections  in some
 one or other of their seats are very numerous,
 and may be divided into, 1st, those which are
 hyperamial, or consist of congestion or inflam-
 mation in some portion  of the nerve,  or in its
 origin ; 2d, those which are anamial, or which
 consist of a deficiency of blood ; 3d, those which
 occasion irritation in some portion of the trunk
 or ofthe ramifications of a nerve, or even of or
 near to its origin ;  and, 4th, those which  con-
 sist of irritation or other similar disorder of re-
 mote  but  related organs or parts.  Several  of
 the pathological  conditions  comprised under
 these four categories are probably, on some oc-
 casions, mere accidental  morbid associations
 resulting from pre-existing disorder; but they
 are, with equal probability, in other cases, the
 active agents of the neuralgic affection.  Oth-
 ers of them are concurring or aiding influences
 in developing the  effects of more energetic
 causes.
  58.  (a) Hyperemia in any  form,  general or
 local,  congestive or inflammatory, may, either
 at the origin or in the course of a nerve, occa-
 sion this affection.   Evidence of this  is to be
 found in the appearances observed in some ca-
 ses after death ; in  the termination of  several
 in apoplexy or palsy ; and in the symptoms and
 the effects of treatment  in other cases.   I  was
 consulted several years ago by  a  gentleman
 about fifty years of  age, suffering neuralgia of
 the head  and face: the  symptoms indicated
 active determination of blood to the brain, and
 he was treated accordingly, and the neuralgia
 disappeared.  Two  years afterward he  experi-
 enced  a return of  the  affection; and  he  had
just arrived in the vicinity of London from the
country to consult  me, when he was  seized
with apoplexy, and soon afterward died.  I was
called to a lady about fifty years of age, suffer-
ing neuralgia referred to inflammatory conges-
tion  or similar change within  the cranium.
Cupping in  the nape of the neck, with other
means appropriate  to these viewrs, were pre-
scribed.  She was relieved ; but the complaint
soon afterward returned.  Her friends then re-
quested a consulting surgeon to  see her;  and
he prescribed large  doses of the carbonate of
iron.  She immediately  became maniacally de-
lirious, afterward hemiplegic, and she soon af-
terward died.   The  family surgeon informed
me that the appearances after death indicated
intense vascular congestion, with signs of pre-
vious  inflammation.   A gentleman from  the
country very recently came under my care for
chronic diarrhoea of seven years' continuance.
He had experienced two attacks  of phlebitis of
the femoral veins consequent upon  having ta-
ken the extract of logwood, this medicine hav-
ing  restrained, but not arrested the diarrhoea.
A cautious alterative and derivative treatment
was therefore prescribed, and the diarrhoea was
 slightly abated and the stools improved ;  but a
 violent attack of neuralgia supervened, the pain
 being seated chiefly in the right side of the oc
 ciput and in the frontal branch of the fifth pan
 of nerves of the left side.  The increased ac
 tion of the carotids induced me to prescribe lo
 cal blood-letting, a blister to the nape of the
 neck, a blister on the abdomen, <&c., and the
 attack entirely ceased in a short time; but a
 few days afterward the phlebitis returned foi
 the  third time, but in a less severe form, re
 covery from  it taking place after some days,
 but the diarrhoea was only moderated.
  59.  That cerebro-spinal neuralgia is some
 times owing to venous congestion or inflammato-
 ry action in a limited portion of the spinal chord
 or its  membranes, or even of the theca verte-
 bralis and the vicinity of the inter-vertebral fo-
 ramina, cannot  be  doubted, inasmuch as  it is
 sometimes observed in connexion  with, and
 manifestly depending upon, these lesions.  In
 two cases, both  of them males between  fifty
 and  sixty years  of age,  the neuralgic pains,
 sometimes associated with spasm  of the ab-
 dominal  and femoral nerves and muscles, of
 which they complained for several years, and
 which ultimately terminated in paraplegia, were
 ascertained by post-mortem examinations to
 have arisen from these changes.  These cases
 were frequently seen by the  author and other
 physicians, and the nature of the malady  rec-
 ognised from the first.   It is  not unusual lo ob-
 serve,  associated either  with these  affections
 ofthe spinal chord and its membranes, to which
 the term spinal irritation has been recently ap-
 plied, or  with inflammation of the constituent
 structures of the spine, or with caries  of the
 vertebrae, intense neuralgia,  or marked pain,
 generally of a remittent or intermittent kind,
 in one  or more of the spinal  nerves  more  im-
 mediately related to  the seat of these lesions.
 When the vertebrae and their connecting struc-
 tures are unaffected in these cases, the disease
 in the spinal chord and its membranes may not
 be evinced by tenderness  on  pressing the  spi-
 nal processes, or by manual examination of the
 spine, especially in adult or aged males.
  60. It is almost unnecessary to add; that in-
 flammation of the nerve itself, a congested or ,
 varicose  state of the vessels supplying the cel-
 lular tissue forming  the sheath or connecting
 the fibrils of  the nerves, and the usual conse-
 quences of inflammatory action, as the effusion
 of lymph, or of puriform matter, either  in the
 connecting cellular tissue or around  the nerve,
 &c, will sometimes give rise to  neuralgia, or
 to pain similar to neuralgia, particularly when
 the larger nerves of the lower extremities are
the  seat  of these changes.   This cause,  first
 contended for by Cotugno, has been fully con-
 firmed by Cerillo, Bichat, Siebold, Swan, and
 others.   However, it must be admitted, as will
 be shown more fully hereafter, that inflamma-
tory changes in the neuralgic nerve are observ-
ed only in a small proportion of cases of  this
complaint; and in most, even of these, the at-
tendant pain is more permanent, the intervals
of ease shorter and less complete, than in those
cases of neuralgia where these changes are not
discovered.
  61. (b) Anemia is  much  less  frequently a
cause than a complication of neuralgia ;  and
 its influence is more predisposing than exciting. 
NEURALGIC AFFECTIONS—Causes.
1017
The  same remark equally applies to plethora.
But it is not unlikely that great  deficiency of
blood may so  affect  a  portion of the cerebro-
spinal axis as to  occasion acute pain in some
one of its nervous ramifications.  But whether
a cause or a complication, it is not unusual to
meet with evidence of  anaemia in  some instan-
ces,  or  of general plethora in  others, in con-
nexion with neuralgic affections.  In hysterical
females, or in those subject  to menorrhagia,
more or less deficiency of blood is  sometimes
associated  with  these affections, particularly
with visceral neuralgia.
   62. (c) The dependance of neuralgia upon ir-
ritation  of a portion  of the trunk or ramifica-
tions of the affected nerve may be admitted as
having been proved in some instances.  Sir H.
 Halford, in his Classical Essays, has adduced
 several  instances of  the dependance of  the
 complaint  upon  a preternatural deposite of
 bone, or upon diseased bone.   Among the most
 frequent of the former are exostosis in  some
 part or throughout the frontal sinuses ; thick-
 ening or bony deposites in this situation, or in
 the  ethmoidal and spheroidal bones ; ossific de-
 posites in the falciform process or  other parts
 of the dura mater;  and exostosis from a fang
 of a tooth.  Thickening or  exostosis of the
 frontal bone, or  ossific deposites in the  dura
 mater, may occasion the complaint by affecting
 extreme ramifications  ofthe nerve  affected, or
 of some other nerve intimately related to it;
 but in these cases the connexion between the
 presumed cause and the disorder is not so ob-
 vious as in some cases of exostosis or other
 disease ofthe fangs of a tooth, or caries, exfo-
 liation, or ofthe  alveolar processes, or disease
 of the jaw, antrum, &c.  Various kinds of tu-
 mours  have been found in the close vicinity of
 the trunks as well as the terminations of neu-
 ralgic nerves; and ossific deposites in the ad-
 joining vessels, membranes, &c., have likewise
 been found.   That the  former may affect the
 sentient functions of a nerve is very probable ;
 and that the  latter  may be a  consequence as
 much as a cause of neuralgia, in some instan-
 ces, is  also likely.   We cannot with logical
 precision assign  all, or even the majority of le-
 sions found after death as the immediate caus-
 es  of suffering.   Some of them are effects of
 that suffering, and others are either associated
 results, or merely coincidences,  in the varied
 course it has taken, or effects merely of the
 intercurrent disorders by which that course has
 been modified.
   63. The irritation or similar affection of the
 cutaneous extremities of the affected nerve,
 either by chronic eruptions, as herpes zoster,
 &c., by superficial  injuries, punctures,  leech-
 bites, and cicatrices, has individually occasion-
 ed neuralgia.  In these cases, as well as those
 caused by diseased teeth, caries, and exfolia-
 tions of bone, &c, the connexion of cause and
 effect has been  fully  proved by the disappear-
 ance of the  effect  upon the  removal of the
 cause.   Thus, the removal of diseased bone or
 teeth has often cured  the neuralgic complaint;
 and suitable applications to a cicatrix, to which
 a cure of neuralgia was attributed, removed he
 Dain (Bright)   In  many of the cases  which
 ePv3ently defend upon irritation in these pre-
  L si nations" theaffecuon may be seated at
 a considerable distance from its local cause, or

     II.                I28
it may commence in the very seat of irritation,
and suddenly dart to a remote part.   Thus, as
in  the cases  adduced by Mr. Bell and M. Pi-
orry, the pain may commence in a  tooth, and
suddenly pass to the arm, or even to the neck
and trunk ; and upon the removal of the tooth
all disorder may cease.
  64. (d) The cause of neuralgia may consist
of irritation of an organ or part at a distance
from, but more or  less related to, the seat of suf-
fering.   In  several articles in  this work, and
more fully, and with reference to other articles,
in that on Irritation, I have shown that disor-
ders of various internal organs or parts may so
affect not only other distant internal organs, but
also Temote  external parts,  or  those  supplied
by cerebro-spinal nerves, as to occasion con-
vulsions,  spasms, and  morbid  exaltations of
sensibility.   It has  been supposed by many
that disorders of the  digestive organs may give
rise to  neuralgic  affections in  various situa-
tions ; and I believe that such disorders, wheth-
er consisting of irritation caused by hurtful in-
gesta or by the accumulation of acrid or other-
wise vitiated secretions, may have  this effect,
not only in these  organs themselves, as in gas-
tralgia or gastrodynia, enteralgia or colic, but
also in remote but related organs, as the heart,
diaphragm,  &c, and even in  one or more of
the nerves proceeding from the cerebro-spinal
axis.  The  disorders of the digestive  organs
act, in some of these cases, as a predisposing
cause, and in others as an exciting, or, at least,
as a concurring cause, or in aiding to  develop
the  operation of  other causes, some of which
may have escaped detection, and hence it may
itself appear as the  sole efficient agent in pro-
ducing the neuralgic affection.  In estimating
the  influence of disorders ofthe alimentary ca-
nal  in producing this affection, too much has
been imputed to it  by some, and too little by
others.   Montfalcon  and Elliotson believe
that they have no influence in causing the com-
plaint.   This is, however, too extreme an opin-
ion.  Doubtless  some  of the  cases in which
these disorders  are very prominent,  and in
which the  neuralgic suffering subsides upon
their removal, may be viewed as associated
effects of a pre-existing morbid condition, prob-
ably ofthe ganglial nervous system.  But, that
disorders of the digestive organs are without
 any influence in  causing or developing neural-
 gia is not consistent  with the evidence  fur-
 nished by Swan, Brodie, Andral, and others,
 and by my own experience.  That paroxysms
 of the complaint are cured by cathartics, is an
 admitted fact; but Dr. Alison believes that this
 circumstance proves nothing as to the influence
 of these disorders upon the complaint, for ca-
 thartics may produce  a beneficial  effect upon
 it by deriving the blood from the brain and spi-
 nal chord.   Yet, admitting this effect of ca-
 thartics, still these  disorders are not without
 some influence, and the fact is much too impor-
 tant to be disregarded in practice, however  it
 may be  attempted to  account for  it.   I have,
 both in the article Irritation and in other arti-
 cles and works, attempted to  show that disor-
 ders of the digestive organs, and even of other
 organs,  as of the urinary, &e, may be directly
 extended by means of the ramifications of the
 ganglial system  to  distant internal organs  in
 some cases, and be there  expressed  by spas- 
1018           NEURALGIC AFFECTIONS—Terminations and Prognosis.
modic action  or morbidly-excited sensibility ;
or to the roots, or even to the ramifications, of
cerebro-spinal nerves;  in other  cases, giving
rise to similar morbid manifestations of muscu-
lar motion  and sensation.  I have met with
several instances in which faecal accumulations
in the caecum  and sigmoid flexure of the colon,
and internal haemorrhoids, have been attended
by severe neuralgia of the lower  extremities ;
and as soon as these have been removed, this
affection has ceased.   (See  Notes and Appen-
dix to M.  Richerand's Elements of Physiology,
by the author (p. 546, 562, et passim), and article
Irritation,  passim.)
  65. (e) Diseases of the urinary organs some-
times give rise to severe neuralgic pains, gen-
erally in the  extremities.   Instances  of  this
cause of the complaint have  been  furnished by
Sir B. Brodie, Dr. Rowland, and  others.  Mr.
Swan mentions a case where severe  pain  of
the backs of the fingers was  induced by evacu-
ating the bladder when once distended.  A sim-
ilar case was observed by the  author, the pain
being most  severe under the nails and along
the backs of the fingers.  I have seen stricture
of the urethra apparently the cause of slight
aguish attacks, and of intermittent nervous af-
fections of a painful and spasmodic nature.
  66. (/)  That irritation of the extremities of the
nerves will occasion neuralgia in  some of the
branches of the same, or of intimately-connect-
ed nerves, appears to be proved not only by the
occurrence of this affection after superficial in-
juries and cutaneous eruptions (y  63), but  also
by the circumstance of severe frontal neuralgia
having been caused by the larvae  of insects in
the frontal sinus, a case of which occurred in a
member of my own family;  the larva escaped
after a severe fit  of sneezing, and the pain im-
mediately ceased.
  67. V. Complications.—Several of the path-
ological states just adduced  as causes of neu-
ralgia may be  considered with equal propriety
as complications, or as associated results of*
some anterior disorder, particularly affecting
the ganglial  nervous system, as I  attempted to
show many years ago.   The most common of
these associations are irritation, congestion, or
other disease of the spinal chord or of its mem-
branes ; caries or inflammation of the inter-
vertebral substance or vertebra; hysteria, and
uterine disorders; epilepsy  and other convul-
sive affections;  disorders of the digestive or-
gans ;  faecal accumulations  in the caecum  or
sigmoid flexure of the  colon, or disease of the
rectum ;  ague, rheumatism,  and catarrh ;  par-
alytic affections ; internal abdominal and pelvic
tumours;  disease of the hip joint, and psoas
abscess.   There are occasionally other compli-
cations of neuralgia met with in  practice, but
these are chiefly accidental,  or at  least  less in-
timately connected than the  above with  this
affection.
  68. A.  The connexion subsisting between
neuralgia and many of the disorders now enu-
merated is very obvious : certain of them, al-
though frequently the  primary affection, are
sometimes consecutive, and more of them are
merely consequences  of pre-existing  morbid
conditions, one or other appearing earlier or in
a more  prominent manner  in some instances
than in others.   Diseases of  the spine, or of the
hip joint, psoas abscess,  and facal accumulations,
 &c, in the large bowels, are generally a path-
 ological cause of neuralgia, although often also
 associated results  of previous  disorder.   The
 same remark applies also to other derangements
 of the digestive organs, to hysteria, and to spinal
 irritation or congestion, although they are more
 frequently pure complications  than the fore-
 going.   The occasional complication of ague,
 rheumatism, or catarrh, with neuralgia—compli-
 cations not infrequently observed—are merely
 the associated effects produced by malaria, cold
 and wet, and currents of air.  I have seen neu-
 ralgia conjoined with obscure or irregular  at-
 tacks of ague, and  as the former became less
 violent the true character of ague was  more
 distinctly and  regularly developed.  In cases
 of sciatica,  the rheumatic character is often
 very prominent, or rheumatism of other parts
 sometimes alternates or is associated with the
 sciatic affection.  The same is occasionally also
 remarked in respect of toothache and rheuma-
 tism of the face.
   69. B. Epilepsy and convulsive  or spasmodic
 affections are often the external manifestations
 of the same lesion which  occasions neuralgia,
 the one  alternating with, or to a certain extent
 accompanying  the other.   Indeed, the same lo-
 cal lesion which produces intense pain may, in
 a different grade, or  as it extends to the nerves
 of motion, occasion  spasm or convulsion ;  and,
 in a  still more advanced grade, loss of sensation,
jot of motion, or of both functions.  Of this, I
 have met with several instances, when the pri-
 mary lesion was seated within the cranium  or
 spinal canal.   In some cases, severe pain has
 been experienced in different parts of the  low-
 er extremities; afterward the  pain has been at-
 tended by cramps in the  muscles of these ex-
 tremities, or of the abdomen; these have re-
 curred at intervals,  and have  been followed by
 weak, imperfect, and irregular action of these
 muscles, giving the patient an  unsteady and
 partially paralyzed  gait, in some cases resem-
 bling paralysis agitans, in others chorea, or an
 intermediate state.
   70. That neuralgia and epilepsy may be as-
 sociated  effects of the same lesion, the latter
 appearing consecutively on the former as the
 primary lesion increased, was demonstrated  to
 me many years ago in the case of a composi-
 tor in a printing office, who complained of most
 severe neuralgic pains in the left hand, which
 generally originated in the situation where the
 metal composing-stick pressed most during his
 work.  As the intensity of the pain increased,
 regular attacks of epilepsy supervened, but dis-
 appeared with the removal of the local affec-
 tion and its cause.   Painters* colic may be con-
 sidered  as a form of visceral  neuralgia, and
 this  affection I have seen associated with epi-
 lepsy on two or three occasions.
   71. VI. Terminations and Prognosis.—Neu-
 ralgic affections terminate, 1st. In health; 2d.
 In some other disease ; 3d. In death.—A. A  re-
 turn to health is a most frequent termination of
 neuralgia of the nerves  of the lower extremi-
 ties,  while  neuralgia of the face and head  is
 most liable to prove obstinate, to return, or to
 terminate unfavourably.   The result, in all ca-
 ses  and seats  of the affection, depends upon
 the  exciting cause  of it.  When  it proceeds
 from malaria,  or from cold and wet, or  from
 any of the more passing and external physical 
NEURALGIC AFFECTIONS—Nature of.
1019
causes, it is generally soon removed by decided
means early  prescribed.  Yet, even  in these
cases, a first attack leaves behind it a predispo-
sition to return upon exposure to the exciting
causes, although those causes may be less en-
ergetic than those which first occasioned it.
  72.  B. When neuralgia cannot be imputed to
these causes; when it  is occasioned by  less
manifest causes ; when there is reason to  sup-
pose that some organic lesion exists within ei-
ther the cranium or spine, a protracted disease
may be expected, and the supervention of anoth-
er malady, generally resulting from the progress-
ive increase  of the  primary  lesion, and of a
still more  fatal tendency, may be  anticipated,
although at a more or less  remote period.  In
a very large majority of these cases, neuralgia
terminates in some related malady—in a convul-
sive, epileptic, apoplectic, or paralytic seizure.
From either of these the patient may recover
partially, rarely completely, and be again at-
tacked, but he seldom experiences the neural-
gic affection, or at  least in the  same form or
degree of  severity.   Of the several maladies
into which neuralgia passes, palsy,  generally in
the form of hemiplegia, sometimes in that of
paraplegia, when the lower extremities  have
been  the seat of the affection, has been  that
most frequently brought  under my own obser-
vation.  Next to this, apoplectic, or apoplectic
conjoined with convulsive seizures, have been
noticed.
  73. C. It is chiefly, if not entirely by passing
into the apoplectic, epileptic, or convulsive, or
the universally paralytic states, that this affection
terminates in death, such termination sometimes
taking place more  or less suddenly, upon the
occurrence of the first seizure, or not until after
two or more  recurrences or exacerbations of
the seizure.  A gentleman from the country con-
sulted me for facial  neuralgia.   He continued
tolerably free from the  affection during near-
ly two years,  when a severe attack occurred,
followed by convulsions, which rapidly passed
into apoplexy and death.  Another  experienced
an attack of apoplexy attended by convulsions,
that supervened upon neuralgia.  I found him
partially recovered  from this attack.  He had
been very largely blooded, and the pulse indi-
cated an excessive loss of blood ;  yet another
attack took place nevertheless, within 48 hours,
and speedily terminated life.   Whether or not
he could have recovered from the first attack
without the large depletion is difficult  to deter-
mine.  Still, as I have remarked in the articles
Apoplexy and Convulsions, I have rarely seen
large blood-lettings beneficial, more frequently
I have observed them prejudicial, in seizures
attended by convulsions.  In these cases, it is
better to wait, or to employ other measures less
likely to be prejudicial, than to bleed largely with
the view of recovering the patient from the seiz-
ure, which  cannot always be arrested at once,
or recovered  from  under some time after hav-
ing been developed.  Time, I may here remark,
is a necessary element in the process of recov-
ery ; and if due time be not allowed for the pro-
cession of phenomena terminating in a return
to health, but disturbing, officious,  or  exhaust-
ing measures be adopted to hasten what admits
not of being accelerated, serious mischief may
accrue.
  74.  VII.  Thr appearances observed in fa-
tal cases, particularly of neuralgia ofthe face,
have  been the  majority of those found  in the
membranes  and substance of the  brain, and
bones ofthe cranium (see art. Brain and Cra-
nium), more especially  tumours, and ossific de-
posites in the dura mater, and near the base of
the brain or cranium ; exostosis, great thicken-
ing, and even caries of some parts of the cra-
nial bones in the vicinity ofthe affected nerves ;
and many ofthe structural lesions already men-
tioned as  pathological  causes of the  affection
(y 62, 63).  Various changes of structure found
both in the  brain and  membranes,  and  in re-
mote  viscera,  may be only coincidences  or
the effects  of  protracted suffering upon the
circulation in the brain.  Softening of parts of
the brain, effusions of blood, and even ossific
deposites in the membranes, or in the coats of
the arteries, sometimes observed in cases ter-
minating in apoplexy  or palsy, may  be alto-
gether or partly consequences of the  repeated
returns of the neuralgic affection; morbid sen-
sation exciting  or otherwise changing  capillary
action in related portions  of  the brain and its
membranes.  Still, such cases as have been re-
corded by Sir H. Halford, Tyrrell, Mont-
ault, and others, where bony deposites, fungous
tumours ofthe  dura mater, &c, implicating the
fifth pair of nerves, compel our belief that these
lesions have been concerned in  causing the af-
fection.   In some cases of neuralgia ofthe low-
er extremities,  signs of chronic inflammation
of the trunk of the nerve, or the  more  usual
consequences of this state of vascular action,
particularly  injection and  enlargement  of the
capillaries of the nerve, thickening, discolora-
tion, &c, of the connecting cellular tissue, have
been remarked  by Cotugno, Cirillo,  Siebold,
Bichat, Rousset, and  Swan; while,  in  other
cases, no,  change could  be detected in the
nerves themselves by Dessault, Wardrop, Bi-
chat, Andral,  and others ;  nor even in the
nervous centres, when the patient did not die
of any ofthe diseases of these parts just men-
tioned as frequent terminations of neuralgia.
In cases  of visceral  neuralgia, inflammatory
changes have been remarked in the ganglia by
Lobstein, Swan, and others ; but it is difficult
to estimate the morbid amount of vascularity
of these parts of the nervous system, as it va-
ries very much in this  respect even in health.
  75. VIII. The nature of neuralgia must
necessarily  be  estimated, 1.  Partly from the
general character of the local and constitution-
al symptoms attending it; 2. Partly from the
appearances observed in fatal cases ;  3.  Partly
from  its relation to other maladies, into  which
it often  passes  ; and, 4. Partly  from the  influ-
ence exerted upon it by medicinal agents.—(a)
That  the local and constitutional symptoms ac-
companying neuralgia are different from those
of acute  neuritis have  been shown both  in the
article Nerves  ($ 23, 27), and  above (y 5). Still
there may exist, in some ofthe more persistent
and continued,  or even in the merely remittent
states of neuralgia, chronic inflammation  at the
origin, or in some part of the trunk, ofthe nerve
affected.   The  absence of fever and of tender-
ness on firm pressure,  although  indicating the
absence of inflammation in the majority  of ca-
ses, still should not be  estimated as precluding
the existence ofchronic inflammatory  action in
all of them.  The absence of fever, &c, is no 
1020                   NEURALGIC  AFFECTIONS—Nature of.
proof of the absence of the  slighter states or
more chronic forms of inflammation of the af-
fected nerve or parts intimately related to  it.
In those cases where there is most reason  to
suppose that the complaint is independent of
inflammation, the pulse  even  falls in frequency
during the severity of the paroxysm.  The ab-
sence, however, of all appearances and conse-
quences of inflammation in some  of the fatal
cases proves strongly that neuralgia is  at least
occasionally independent of this state of vascu-
lar action.  The nature  ofthe exciting causes,
and the characters of the other diseases with
which  it is often allied, or into which  it occa-
sionally passes, indicate that neuralgia varies
in its nature in different cases ; that it may
proceed from chronic inflammatory irritation
about the  origin, or in the course of the nerve
in some instances ; and from a state of partial
or slight pressure on the  nerve in others.  That
it may even  arise from a deficient or interrupt-
ed circulation of blood  at the origin or in the
trunk of the nerve, is merely a supposition that
hardly admits of positive proof.   The circum-
stance of neuralgia terminating so frequently
in palsy is no evidence of this being its imme-
diate cause, for palsy proceeds more frequently
from the consequences of inflammatory action
in portions of the nervous centres related to
the paralyzed part;  from disorganization or
organic lesion : from inflammatory softening,
sanguineous effusion, &c, than from deficient
or interrupted  circulation of blood, although
this state  of the circulation in parts of the ner-
vous centres probably causes  palsy in some in-
stances.
  76.  Those  cases of neuralgia which  are un-
equivocally caused by malaria, which are com-
pletely intermittent, and which are devoid of
febrile commotion, or of tenderness ofthe nerve
upon firm pressure, may be viewed as  non-in-
flammatory ;  but it may be asked, what, then,
is the nature of the affection 1   Does the dis-
order, in these cases, proceed  from slight press-
ure of the nerve at its origin or in its  course,
or from a supposititious state of irritation, of
which irritation we know as little as of the na-
ture of the pain of which it is assigned as the
cause 1  Is it merely a disturbance of function 1
The effect of treatment  furnishes no very con-
clusive evidence of the nature of the affection,
not even of its inflammatory or non-inflamma-
tory character.   For even in those cases where
evidence of the existence of  inflammatory ac-
tion is the strongest, even there an energetic
exhibition of tonics,  as of camphor, quinine,
iron, &c,  will often effect a cure.   We know,
at least I have fully satisfied myself, and I have
shown in  this work, that these  remedies will
often cure inflammations ofthe circulating ves-
sels ;  and we may, therefore, infer that they
may prove equally serviceable in neuritis; al-
though we may find them still more beneficial
in neuralgia of a purely non-inflammatory char-
acter.
  77.  Concluding, therefore,  that those affec-
tions, to which  the name  neuralgic has been
applied, may be viewed  as more or less inflam-
matory in some instances, and non-inflamma-
tory or functional in  others, and that great ad-
vantages will accrue  in practice from  the sci-
ence and  acumen which enable the physician
to distinguish between  these, or  to estimate
how much of either character may be present,
it will next be inquired, having found a certain
palpable condition to which the disease is to be
imputed only in some cases, to what is it to be
attributed in those other instances where that
condition is supposed not to exist 1  Now those
other instances have been said to proceed from
irritation, altering the sensibility of the nerve,
which either is  the seat of this irritation, or
manifests it from an intimate relation to the
irritated part.  In these cases, the violent pain
is often the chief, if not the only cognizable dis-
order.  Its dependance  upon inflammation is
not entertained for the reasons above assigned,
in  connexion with its sudden occurrence, and
as sudden cessation—phenomena hardly to be
explained by assigning inflammation as their
cause.  The affection has been viewed as func-
tional in such circumstances as morbid exalta-
tions of sensation, as the result of irritation of
the nerve or of parts related to it.   This, how-
ever,  is merely a play upon words, a confession
of our ignorance ;  for, to say that intense pain
is a morbid exaltation of sensation, is a conse-
quence of  irritation, is  merely a nervous dis-
order or affection, and so on, is explaining noth-
ing, is merely substituting terms for  the con-
cealment of our  ignorance, or with the vain
hope that we are  evincing our knowledge.
  78.  Considerable practical knowledge of neu-
ralgic  affections  has  suggested the following
inferences:  1. That "these affections often pro-
ceed from chronic  inflammatory action in some
part of a nerve, or of a part intimately related
to it.   2. That the exciting causes of the affec-
tion should be kept in view when we estimate
the inflammatory or non-inflammatory charac-
ter of it.  3.  That, even in those cases which
present no inflammatory character, some pre-
existing affection or disorder of related parts,
especially of the nervous centres and internal
viscera, should be suspected and searched after.
4.  That, in the non-inflammatory  cases espe-
cially, the neuralgic disorder should be gener-
ally viewed as an external  manifestation of
some latent internal disorder, which a patient
investigation of the case,  with due  acumen,
will frequently detect, and which, when once
detected, will suggest  the only permanently
successful  and safe indications  of cure.  5.
That  the  connexion of these affections with
gout,  rheumatism, hysteria, &c, should not be
overlooked; nor the tendency they often evince
to  terminate in palsy, epilepsy, or  apoplexy be
neglected, in estimating the morbid relations
and nature of individual cases, and in determin-
ing the indications of cure  most appropriate to
each.  6.  That the one-sided views published
of the subject, the vaunted success of certain
remedies for the cure ofthe affection, the pub-
lication of successful cases, to the neglect of
the unsuccessful;  and the  silence as to the ul-
timate result of many cases, or as to  the dis-
eases  which  appeared at some  period  after a
supposed cure, which has been preserved, have
all tended  to mislead the inexperienced as to
these  affections.   7. That  the  suppression of
the neuralgic affection by powerful tonics and
stimulants, or by the more  energetic narcotics,
without due reference to, or an accurate esti-
mate of, the states of the most important vis-
cera, has sometimes proved injurious ; and that,
although the neuralgic affection has apparently 
NEURALGIC AFFECTIONS—Treatment of.                  1021
ceased altogether, and for a considerable time,
still some severe visceral disease, or an apo-
plectic, epileptic, or paralytic seizure not infre-
quently supervenes, and endangers, or carries
off, the supposed case of cured neuralgia.
  IX.  Treatment of Neuralgic  Affections.
  79.  A.  From what has been advanced above
as to  the physical and pathological causes and
associations of neuralgia, it is obvious that our
first and  most strenuous endeavours should be
directed  to  ascertain  and  to remove  these.
When the symptoms are such as indicate,  or
even to render very probable, the existence of
an inflammatory state of the nerve, more espe-
cially  in young, robust, or plethoric subjects,  or
when  the disease has appeared after suppressed
discharges, or the disappearance of eruptions,
&c.;  the treatment in the first instance  should
be that advised for Neuritis, more especially
local  blood-lettings, derivatives, and counter-irri-
tants.   I  have seen  recent attacks of neuralgia,
with these characters, removed by these  means
alone, in a very short time.  When  any evi-
dence is  furnished  of disorder in the nervous
centres, or in any important viscus, the  treat-
ment  suited  to such disorder should be deci-
dedly and promptly prescribed before the more
common  neuralgic  remedies are had  recourse
to; and  in all complications, as well as in all
instances caused by  pre-existing disorder  or
lesion, the associated affection should receive
immediate attention, and the means afterward
directed  for the removal of the neuralgic affec-
tion ought to be such as may either not endan-
ger a return  of the complication, or may tend
to its permanent  removal.   In  such circum-
stances  blood-letting,  cautiously  employed,  is
often extremely  beneficial, and renders the
means subsequently prescribed much more ef-
ficacious.  The same remark applies to cholo-
gogue and alterative purgatives when thus early
and appropriately prescribed.
   80. B. Having removed the  causes,  as far
as this intention can be accomplished, and had
 recourse to such antiphlogistic  means  as the
 state  of the case and of the patient permitted,
the morbid associations of the affection  having
received  due attention, in the use of these and
 other remedies, the treatment may be directed
 more especially t&  the neuralgia, according to
the characters it may present, and to the  diathe-
sis of the patient.  In the distinctly intermit-
 tent form of the  affection, and  if there  be  no
determination of blood to the head, or no active
visceral  disease, the preparations of iron, or of
bark,  or  quinine,  conjoined with such other
remedies as  the  peculiarities  of the case will
suggest,  may be given, or other remedies, about
to be  noticed, may be tried.  At the same time
that tonic, antispasmodic, anti-periodic, and
narcotic  medicines are being administered  in-
ternally,  various external means maybe applied,
according to the  seat, character, and duration
ofthe affection.   In the cases caused by mala-
ria or cold and  humidity,  quinine, cinchona,
camphor, arsenic, &c, are especially appropri-
ate.   In  the more strictly nervous or hysterical,
and in cases connected with a deficiency  of
blood, the  preparations  of  iron, of opium,  of
belladonna,  &c, are  most  suitable.   In the
rheumatic and gouty diatheses,  the fixed alka-
lies and  alkaline  earths with colchicum and
ammonia, aconite with camphor, &a, are most
successful, especially after  biliary  and other
secretions  have been evacuated by an  active
exhibition of chologogue purgatives.
  81. C. When neuralgia appears to proceed
from disease within the cranium, or near the
origins of the  affected nerves, as in the cases
observed by myself and others, and already re-
ferred to, a seton or issue should be established
in a situation selected with reference to the in-
ferred lesion, and an alterative course of treat-
ment, aided by narcotics, ought to be preferred,
such as the  iodide of potassium with  liquor
potassae, Plummer's pill with soap and opium,
the iodide of mercury with stramonium or bel-
ladonna.  In some of these cases, the applica-
tion of a few leeches behind  the ears, or to the
spine, when the latter is the seat of irritation.
or a  small cupping in the same  situations, and
the repetition of these according to circum-
stances, will prove of service.
  82. D. Cases will  occur  of  the  failure of
means directed according to the principles now
stated; the utmost care  in ascertaining the
physical and pathological causes and morbid
associations of neuralgia, and our best endeav-
ours to remove  them, being altogether unsuc-
cessful.  In these, we must have recourse  to
more empirical measures, yet even these meas-
ures must not be blindly, but rationally prescri-
bed.   This brings me to the consideration of
the principal remedies which have been employ-
ed against this  complaint, according  either to
rational views and principles of treatment, or
to a  vague empiricism.  In noticing, therefore,
these remedies, I shall mention the states  of
the disorder in which I believe each of them to
be most appropriate, and  the combinations in
which my experience has shown them to  be
most efficacious.
  83. a. Evacuants are  more  frequently re-
quired in neuralgic affections  than has  been
generally  inculcated; but not so much on ac-
count  of any general fulness of the vascular
system, as of local congestion, or an  irregular
distribution of the blood, owing to  impaired
tone of the vital energies  generally, and to de-
ficient or impaired secretion and excretion.—a.
The propriety of having recourse to blood-letting,
and  particularly to local blood-letting, and  even
the repetition of it in some  instances, and the
circumstances requiring this treatment,  have
been already  noticed (y 79).—b. Emetics  have
very rarely been advised in neuralgic disorders,
and  yet cases  occasionally are met with in
which an  emetic proves a  good  initiative reme-
dy, particularly in  promoting the  removal  of
vitiated secretions from the biliary passages.
Emetics are indicated chiefly in neuralgic affec-
tions of the trunk, or where there is  evidence
of congestion and impaired  function of  any  of
the abdominal viscera.
   84. c. Purgatives  have  been very generally
recommended.  They are beneficial not only as
evacuants of morbid secretions  and faecal accu-
mulations, sometimes the primary source  of
irritation, but also  as derivatives, particularly
when the more drastic purgatives are prescri-
bed.  They, moreover, promote secretion and
excretion, and  remove visceral congestions.
Sir C. Bell and Dr. Allnatt have praised the
decided exhibition  of croton oil  as a purgative,
and  some more recent observers have noticed
its good effects, and have  viewed it  as exerting 
1022                  NEURALGIC AFFECTIONS—Treatment or.
 an alterative effect similar to that produced by
 colchicum upon the urinary functions.  I gave
 it many years ago in a case of neuralgia of the
 right pillars ofthe fauces and side ofthe tongue,
 and the patient continued free from the disease
 for more than a year, when an attack occurred
 and  proved much more obstinate than the for-
 mer, the means which were formerly success-
 ful failing  on this  occasion.   Chologogue pur-
 gatives  are often preferable to any other when
 prescribed with decision,  and  aided  by ano-
 dynes.  In 1820 I treated a case of infra-orbital
 neuralgia, and in 1821 a sciatica, as follows :
  No. 296.  ft Calomelanos,  gr. xij.;  Pulv. Ipecacuanhs,
 Pulv. Opii, &a, gr. ij.; Mucilag., q. s. M.  Fiant Piluls iij.,
 hora somni sumendie.
  No. 297. ft Infusi Senns Comp., f vss.; Magnesis Sulph.,
 § ss.; Magnes. Carb., 3ss.; Vini Colchici, 3jss.; Tinct. Senns
 Co., 3»ij.; Tinct. Cardamom. Co., 3ij. ; Tinct. Opii, 1t|,xv.
 M.  Fiat Mist,  cujus capiat  partem tertiam ter  in die.
 (Hora 7a A.M., hora 11a A.M., et hora. 3tia P.M.)
  85. In these cases the complaint was remov-
 ed in four days, alleviation of suffering being
 apparent in both within  twenty-four hours after
 the first  dose of pills.  Rahn, Wilson,  and
 many others have recommended cathartics, and
 when there is little or no visceral obstruction
 or congestion, any of the more active and cer-
 tain purgatives may be  prescribed, particularly
 when a derivative operation merely is desired
 to be produced.  In neuralgia, however, of the
 lower extremities, I have preferred equal parts
 of spirits of  turpentine  and castor oil (?ss.  of
 each) taken  on  the surface of mint water or
 milk,  containing some  calcined magnesia, to
 other purgatives, calomel with colchicum  and
 ginger, or calomel with ipecacuanha and opium,
 being given occasionally at  night when  visceral
 obstruction or congestion was present.  Purga-
 tives are more particularly indicated in neural-
 gia of the lower extremities, which is not infre-
 quently induced  by faecal accumulations in the
 colon and sigmoid flexure ofthe colon.  Their
 good effects are often promoted by an occasion-
 al enema with ol. terebinthinae and castor oil.
  86. /3. Alteratives and deobstruents  are
 especially indicated when neuralgia appears to
 depend  upon  visceral obstruction or structural
 change  near the origin or in the course of the
 affected nerve, and in cases of visceral neural-
gia.  Under this head may be  comprised va-
rious  substances,  whose beneficial operation
may be  differently explained.  The alteratives
most frequently employed are the preparations
of mercury, of iodine, and of arsenic, variously
combined.—a. Dr. Corkindale prescribed calo-
mel with opium,  and Loebenstein-Loebel, cal-
omel with  the golden sulphuret of antimony
and opium, until the gums became affected.
 Hildenbrand and Herrmann often pushed mer-
curials to the production of salivation.  Schle-
 sier preferred the bichloride of mercury, two
grains of it being dissolved with three grains
of the extract of stramonium in an ounce and
a half of distilled water, and from thirty to fifty
drops being taken every second hour.
  87. b.  I have given the preparations of iodine,
particularly the iodide of potassium, with liquor
potassae and narcotics, the  iodide of mercury,
and the iodide of iron.   The first and second
of these  preparations  are most appropriate
when the complaint appears to  depend upon
organic  change within the cranium or spine;
the last where it is more strictly nervous, and
 where it is connected with uterine obstruction.
 In  some  neuralgic affections referable  to  the
 diaphragm, heart, and stomach, or passing
 from the one  to  the other, and presenting a
 gouty character, the  iodide of potassium, with
 liquor potassae and opium, was extremely ben-
 eficial.
  88. c. The preparations of arsenic are more
 strictly alteratives and antiperiodics than ton-
 ics.  They have been very generally prescribed
 for  neuralgic  complaints.   They have been
 much confided  in by Nesse-Hill, Bassedow,
 Bedingfield, Halliday, and Rowland.   They
 are most  successful in the  more  functional
 states ofthe complaint, particularly when they
 are caused by malaria  and exposure to cold.
 They are also  serviceable in those forms of it
 which are intimately allied to hysteria, and are
 associated with congestion of the  uterus  or
 with disordered menstruation.   They may  be
 conjoined with  any of  the narcotics hereafter
 noticed (y 96, et seq.).
  89. d. Spirits  of turpentine, as  usually given
 for the cure of neuralgia, acts  more  as  an  al-
 terative than as a  stimulant, diuretic, and ape-
 rient, in all which ways it exerts considerable
 influence.  Dr. Home (Clin. Experim. and Hist.,
 p. 247) remarks, that having found, in one  of
 Dr. Cheyne's philosophico-medical works, a re-
 ceipt composed of oleum terebinthinae and hon-
 ey for the cure of sciatica, he tried it and found
 it to succeed ; and that he has used it for many
 years, and found it " an efficacious and valua-
 ble medicine."   Dr. Darwin (Zoonomia, vol. ii.,
 s. iii., c. 2) also had recourse to  oil of turpen-
 tine, both in this form of neuralgia and in lum-
 bago.  It was afterward prescribed by myself,
 and the results  of my experience of it in neu-
 ralgia and many other diseases, published  in
 the  London Medical  and Physical Journal for
 August, 1821.   M. Martinet  also about the
 same time recommended it for sciatica.   Pit-
 cairn, Cheyne,  and Home, who first employed
 this substance against sciatica, usually gave it
 in doses of about fifteen or twenty drops  in the
 form of linctus with honey.   At first  I prescri-
 bed it as follows in neuralgic affections, but I
subsequently varied the dose and the modes of
exhibiting  it,  with the  circumstances of the
case, seldom giving less than half a drachm for
a dose.
  No. 298. ft Olei Terebinthins ; Tinct. Guaiaci Ammo-
niata, aa, Jiij.; Mellis Opt., fij. ; Olei  Cajuputi, Dlxii.;
Olei Limonis, Hlvi.  Misce ul fiat Linctus ; Cochleare unum
minimum bis terve de die sumendum.
  This medicine, although recommended chief-
ly for sciatica, is frequently of great service, if
 not equally beneficial, in other  forms of neu-
ralgia ; for all which it may be employed in va-
rious forms, as with calcined magnesia, on the
surface  of milk, or of an aromatic water, &c.
 When the  eructations,  &c., after taking it are
 unpleasant, magnesia is often  of service, and
 moreover promotes its  operation on  the  bow-
els.   Sometimes a large dose of the turpentine
—from three to six drachms—taken at once,
or with half an ounce of castor oil, on the sur-
face of rnilk or mint water, almost immediate-
ly removes the complaint.  In neuralgia  ofthe
lower extremities  enemata containing  it are
often beneficial.  Cheyne recommended equal
parts of spirits of turpentine and alcohol to  be
distilled together, and from one to four drachms 
                       NEURALGIC AFFEC

of this compound to be taken daily.  He sup-
posed that in this manner  the turpentine was
deprived of many of the inconveniences attend-
ing it in other forms.   Turpentine has  lately
been much employed, particularly in sciatica,
in France and Germany, where it has received
the praises of Elgenstierna, Cloquet, Lar-
boque, Dufaux, Piorry, Trousseau, Most, Du-
crois, and others.  A strong recommendation
of this  medicine  is to be  found in its  being
equally  appropriate  to the  inflammatory and
non-inflammatory states of the affection; and
in the fact of relapses or a  return of the com-
plaint being less frequent after the use of it
than after any other remedy.
   90. «. The use of cod-liver oil may be noticed
at this place.  It has been  long recommended
for rheumatism and sciatica, and more recent-
ly for  the several  forms  of neuralgia.   As
usually  prepared and  kept, it  is a nauseous
medicine; and I doubt much its efficacy over
the oil procured  from the livers of several oth-
er fish.  That obtained from  the liver of the
skate is equally beneficial;  and that yielded by
the liver of the ling superior to both.  But the
oil from the liver of the torsk, or the gadus
brosma,  a  remarkably fine fish caught only on
the coasts of Shetland, Faroe, and  of  some
parts of Norway, is  esteemed much above all
others by  the inhabitants of these parts, and
is much employed by them as a domestic med-
icine, the  fresh liver and oil being considered
an article of great  delicacy  when  cooked  in
such a way as to prevent, as much as possible,
the separation of the oil from the liver.*   The
quantity of these  oils which may be taken for
neuralgic  and rheumatic complaints is as much
as the stomach will tolerate.
   91. y. Stimulants, Tonics,  and Antispas-
modics.—There  is scarcely a substance which
may be ranked  under this  head that has not
been tried against neuralgia.—a. The prepara-
tions of cinchona and  the sulphate of quinine
have been very generally used ;  the latter, how-
ever, has  recently superseded  the  former, al-
though not always with justice.  The more en-
ergetic  preparations  of cinchona,  conjoined
with very full doses of the  alkalies or alkaline
carbonates, or with opium, as advised by Schenk
and Kerrison, or with the  sulphuric aether,  as
prescribed by Lassere, have succeeded in some
  * Of the oil from the livers of the torsk, ling, and cod, I
can speak from experience.  When obtained from the fresh
livers, and used before it becomes rancid, it is not unpalata-
ble, and does not offend the stomach.  The fishermen in
the parts above mentioned  usually employ it as the only
sauce to either of these fish ; and I have very frequently
partaken of it in this manner, and esteemed it above any
other sauce.  But the livers of these fish (that of the torsk
more especially, it  being prized much above the others),
when prepared in the following way, are admirable articles
of diet for the complaints under consideration, as well as
for rheumatism and some others.  The  stomach of the fish
is well washed, two parts filled with the fresh liver, and
firmly tied  at each end, so as not to allow any of the oil to
escape while being  boiled.  When ate  quite warm, with a
little salt and  spice, the liver still containing the greater
part of its oil, this  is very palatable.  The fresh livers of
these fish, and also of the young coal fish and haddock, are
prepared in various other ways as articles of diet, or they
enter into the composition of several dishes much relished
in  the countries I have mentioned. I may add, that they
often served me as  articles of diet very many years ago ;
and that I now would as soon partake of them as of turtle
or venison, although no  lukewarm admirer of these admira-
ble articles of diet, which, when excellent of their kind,
gratify the palate, humour the stomach, and harmonize all
the organic function*.
riONS—Treatment or.                  1023

 cases where quinine has failed. The sulphate of
 quinine  has, on  the other hand, been said  to
 succeed when  cinchona in decoction or powder
 has been unsuccessful.  When,  however, the
 bark has been given as just advised, or with
 serpentaria, capsicum, camphor,  or ammonia,
 or with  chlorate of potass, much more depend-
 ance may be  placed on its  efficacy.   I  have
 rarely trusted to  quinine alone in this affection,
 but  have prescribed  it with  the sulphate   of
 iron, camphor, capsicum, and extract of co-
 nium or henbane, after the bowels have  been
 freely evacuated by suitable purgatives.  In a
 most severe case  of sciatica, of which a sur-
 geon retired from service in India was  the sub-
 ject, this latter combination proved very quick-
 ly and permanently efficacious.  Both bark and
 quinine  are  most  successful in cases caused
 by malaria, or by wet or cold, and when the
 affection is  intermittent or is  chiefly functional.
 They often fail  when the  complaint presents
 remissions  only, when it appears to  depend
 upon chronic inflammatory action or upon a
 permanent  source of irritation.  If employed
 at all in these cases, local  blood-lettings and
 active purgatives should precede  them, the lat-
 ter being given from time to time during their
 use.
   92. b. The preparations of iron have obtained
 great reputation for the cure of neuralgia, es-
 pecially since the sesqui-oxide was recommend-
 ed for it by Dr. Hutchinson, and given in large
 doses by Elliotson and others.  The full effi-
 cacy of this substance may be obtained in do-
 ses  of from half a drachm to a drachm, three
 or four times a day, conjoined with an aperient,
 or a smart purgative being given occasionally.
 This and the other preparations of iron are  in-
 dicated  chiefly in the  same  circumstances  of
 the  complaint  as have been  just stated to  re-
 quire cinchona or quinine, and when  there is
 a deficiency of  blood, or  at  least  no  general
 plethora or inflammatory action.  The sulphate
 of iron is often not less beneficial than the car-
 bonate,  and it  may be prescribed with other
 medicines as above stated (y 91).  The hydro-
 cyanate  of iron has been  used by MM. Dupuy
 and Jolly in the following form :
   No. 299.  H: Hydrocyan. Fern, gr. xviii.; Quininae Sulph.,
 gr. xii. ; Extr. Opii, gr. i.; Conserv. Rosae, q. s. ut fiant Pi-
 lulas xii.   Capiat unam 2dis vel 3tiis horis.
   93. c. The preparations of zinc have been pre-
 scribed  for neuralgia, but chiefly in  combina-
 tion with some  one of the narcotics  about  to
 be  noticed.  The sulphate  was  preferred  by
 Meglin, and the  chloruret or chloride by Hanke,
 who directs one grain of it to be dissolved  in
 two drachms of chloric aether, and from five  to
 ten  drops of the  solution to be  given every
 fourth hour in  sugared water.  The chlorate of
 potash has been  praised by Helmenstreit and
 Meier, who gave it in doses of from  three  to
 five grains  every fourth or fifth hour.  I have
 prescribed it in somewhat larger doses in the
 decoction of bark or infusion of valerian.   It
 is not devoid of efficacy in the rheumatic and
 hysterical states of the disease.
   94. d. Nux vomica and strychnia  have lately
 been suggested in the treatment of neuralgia.
 Linn.£:us gave the former in  gastralgia; and I
 have prescribed  the alcoholic extract of it in  a
 few instances—in  one or two with decided ser-
 vice, but in others with doubtful advantage. 
1024                  NEURALGIC  AFFECTIONS—Treatment  of.
 This preparation is in many respects preferable
 to strychnine, both in this and in paralytic af-
 fections ; but it is not suited to the more con-
 tinued  and inflammatory stages  of this disor-
 der.  The same remark applies  to phosphorus,
 which  has been  employed  by  Loebenstein-
 Loebel, dissolved in oil, of which, however, I
 have had no experience.
   95. e. Of camphor, given  in tolerably large
 doses, with opium or some  other narcotic,  or
 with quinine, or sulphate  of iron, I entertain a
 favourable opinion, as well as of valerian and
 guaiacum, the ammoniated tincture of these be-
 ing the preparations I have preferred.  Schnei-
 der employed the oil of valerian  both internal-
 ly and  externally  by friction.   The prepara-
 tions of guaiacum with colchicum, or with acon-
 ite, and the alkaline carbonates,  are most use-
 ful in the rheumatic forms of neuralgia.  Musk
 has  been  prescribed by  Beaumes,  and by  J.
 Frank conjoined with calomel and antimony.
   96. 6. Narcotics and  Sedatives.—a. The
 several preparations  of opium, and more re-
 cently the salts of morphia, have been prescri-
 bed in this class of affections, in various com-
 binations, and with different effects.   I have
 found them of service in  full doses with calo-
 mel, camphor, and ipecacuanha, particularly  in
 sciatica, after  the bowels  have been  freely
 evacuated ; and in toothache, opiates with cam-
 phor, creasote,  and capsicum, applied to  the
 gums, or to a carious tooth,  often affords re-
 lief.   Recamier advises the following pills  in
 neuralgia:
  No. 300.  ft Pulv. Opii puri ; Pulv. Ipecacuanhae, 53, gr.
 iij.; Camphorae ; Ammoniae sesquicarb., aa, gr. xij. ; Muci-
 lag. Acaciae, q. s. M.  Fiant Pilula? xx.  Capiat j. ad iij.
 2dis vel 3tiis horis.
   97. b. Aconite was first prescribed in neural-
 gia by Murray ; but it was previously used  in
 rheumatism.  More recently it has been much
 employed in neuralgic affections by Jahn, Tea-
 lier, Hufeland, Turnbull, and others.  Spiel-
 mann advises it to be given with the golden sul-
 phuret of antimony ; Rademacher with the de-
 coctions of guaiacum and sassafras ; Wildberg
 with the succinated spirit  of ammonia, the gal-
 banum plaster with opium being  employed ex-
 ternally ;  and Fritze with the boracic  acid.   I
 have  prescribed it with the  biborate of soda.
 The preparations of aconite that  are chiefly to
 De depended upon are, the alcoholic extract and
 the tincture, both for internal and for  external
 use (y 110);  but they are most quickly effica-
 cious when applied externally.  Aconite  has
 succeeded in several cases in my practice, but
 it failed very recently in a case of femoral neu-
 ralgia.  It is, however, a very valuable remedy,
 particularly in the rheumatic forms of the com-
 plaint, and in neuralgic affections of the heart
 and diaphragm, as well as of the  nerves  of the
trunk and extremities.  It is not indicated in
the inflammatory states of the disease ;  and  it
should not be given in these until local deple-
tions  have been resorted to.  The modes of
exhibiting it advised by Hufeland  and Jahn
deserve notice:
 No. 301.  ft Extr. Aconiti ; Calomelanos, 55, gr. ij.; Re-
 sinae Guaiaci, Jss.;  Sulphureti Antimonii Aurei,  gr. ij. ;
Olei Valerianae  jEtherei,  fllij.; Sacchari Albi, 3j.  M.
Fiat Pulvis. Capiat dimidium mane nocteque.
 No. 302. ft Extr. Aconiti, 3ss. ; Extr. Conii ; Res. Guai-
aci ; Asafoetidae, 51,  3j.; Calomelanos, gr. xv.  M.  Fiant
 Pilulae sing. gr. iij.   Capiat iij. ad vj.  ter quotidie.
   [Dr. Fleming, in his recent work on aconite
 (An Inquiry into the Physiological and Medicinal
 Properties ofthe Aconitum napellus, Lond., 1845,
 Svo, p. 160), has given a table of 40 cases treat-
 ed by this remedy, of which  27  were perma-
 nently cured, and 13  only temporarily relieved.
 In some of them the  medicine was used  inter-
 nally, in  others  externally;  sometimes both.
 Dr. Fleming suggests, that if the  neuralgia de-
 pends  on  inflammation either in the painful
 part ofthe nerve or farther up in its course, or
 in sympathetic irritation, the internal use is
 more likely to be beneficial; if from local func-
 tional irritation,  the  topical application.   We
 should prefer to depend chiefly on its external
 use, as we do not regard its internal use as free
 from danger.  Dr. F. states that he  has  met
 with several  cases of neuralgia in which the
 individuals had, for weeks or  months, been in
 the habit of procuring sleep,  and a  tempora-
 ry cessation  of pain, by opiate draughts, and
 who, on  using the aconite, obtained permanent
 relief of the disease.   Dr. F. has tried  it in
 40 cases of toothache,  by rubbing the gums with
 a few drops  of the tincture, or by introducing
 a  piece of cotton, soaked with a  drop or two,
 into the  carious tooth.  In 7 of these cases it
 failed ; in 6 it succeeded only for a short time ;
 in the rest the relief was complete.]
   98. c.  Belladonna has been very generally pre-
 scribed in neuralgia.   I have given it with cam-
 phor and sulphate of  quinine,  and  at the same
 time applied it externally, as about to be noticed
 (y 111).   In some instances I have found it oc-
 casion stupor and malaise,  without materially
 relieving the pain.  M. Trousseau has advised
 the extract of it, in doses of a quarter of a grain,
 to be given every hour until it causes vertigo,
 and then it is to be taken at  longer intervals.
 He also has given it  with sulphate of quinine,
 or with preparations of iron ;  or he has exhib-
 ited these after the narcotic effects of the bel-
 ladonna had become manifest.  Siebold, Thomp-
 son, and Deleau have recommended it to be
 employed both internally and  externally.  Pe-
 reira considers  it inferior to aconite in this
 disorder.
   [We regard belladonna as one  of the most
 successful remedies for the relief and cure of
 this obstinate class of diseases.  In a very ag-
 gravated case of neuralgia at Geneva, New-
 York, which  had  resisted a  great variety of
 treatment for twelve  months, during which the
 patient suffered the most excruciating agony,
 a perfect cure was accomplished by the use of
 a pill composed of three grains of pil. hydrarg.,
 and one grain of extract of stramonium.   One of
 these was  ordered to be taken every night at
 bedtime,  until the gums were a little  affected;
 then to  leave off* for  a few days, and resume.
 In two weeks a cure was effected.  Whenever
 threatened with a return of the complaint, the
 same remedy always  prevented it (Bost.  Med.
and Surg. Journ., vol. xviii., p. 178).   In the
same journal, vol. xix., p. 77,  is contained  an
account  of a very severe  case of neuralgia
cured by the  repeated use of emetics.
  The following formula will prove exceeding-
 ly efficacious in many cases of obstinate neu-
ralgia : R Extr. Belladonna, fss. ;  Opii. Pulv.,
3ij. ; Adipis Suis, fss. ; Olei Thymi, lUvj.   M.
A portion of this ointment as large as a hazelnut
is to be well rubbed upon the affected part two 
NEURALGIC AFFECTIONS—Treatment of.
1025
or three limes a day, or whenever the  parox-
ysms of pain are sivere.  The rubbing  should
be continued for eight or ten minutes at a time,
until the ointment is quite absorbed by the skin ;
a little saliva may be added now and then, to
promote the absorption.  If the sight becomes
affected, or any unpleasant symptoms  super-
vene, it should be suspended for a while.  This
application is peculiarly well adapted to  cases
of facial neuralgia.]
  99. Stramonium has also been extensively
used in neuralgic affections.   Lentin prescri-
bed it in the  form either of tincture or  of ex-
tract.  It has  been  favourably mentioned by
Marcet, Trousseau, Begbie, Vaidy, Richter,
and  others.  It is advantageously given with
camphor and ipecacuanha. Dr. Rowland found
it to  succeed only in three  cases out  of ten,
and  in these three, partially in two, and com-
pletely in one.  Dr. Elliotson considered it
most useful in enteralgia.
   100. d.  Conium was strongly recommended
by Fothergill for this affection.  It afterward
fell into disuse ; but  it has since been favoura-
bly mentioned by Chaussier,  Dumeril, and
Rowland.   The  reputation of hyoscyamus  is
probably equal to that of conium in  the treat-
ment of neuralgia.   Breitung prescribed the
extract of it with calomel; and  Herison the
tincture, with the tincture of guaiacum.  It en-
ters into the composition of the pills of Meglin,
which have  obtained some notoriety  in this
complaint.
  No. 303.  ft Extr. Hyoscyami; Extr. Rad. Valeriana; ;
Oxydi Zinci, 55, 5j. M. et divide massam in Pilulas lx.
Capiat j. vel iij. 2dis vel 3tiis horis.
   101. /. The Rhus toxicodendron  has been  ad-
vised for neuralgic affections, but it has never
come into general use.  Anderson gave three
grains of the powdered  leaves three times a
day ; and Goeden prescribed the  resin of guai-
acum, the powdered leaves  of the toxicoden-
dron, and calomel in the  form of pills.
   102. g. Colchicum has not been so generally
employed in  this class of affections as  it de-
serves ; and it has not proved so  successful in
some of the cases in which it has been prescri-
bed as it might have been if it  had been given
in those forms and  combinations in which I
have found it beneficial in these affections.  In
some persons, especially in those  subject to
visceral neuralgia, it is very liable to occasion
remarkable depression of nervous power.   It
should, therefore, be exhibited with much cau-
tion, and in conjunction with stimulants or ton-
ics.  Accumulated faecal matters and  morbid
secretions should be  evacuated before it is  ta-
ken.   I have found it most  serviceable when
given with  ammonia, or camphor, or with cin-
chona and an  alkaline carbonate ; the powder
of the cormus, or the extract with sulphate of
quinine and camphor, or with sulphate of iron
and powdered capsicum,  in the form of a pill;
the tincture or wine, with  the decoction, and
the compound  tincture  of cinchona, and the
sesquicarbonate of ammonia, or the carbonates
ofthe fixed alkalies ;  or any ofthe preparations
of this plant with magnesia, and appropriate
stimulants  and restoratives.   I prescribed, in
1820, for a lady in Walworth, suffering a most
acute attack  of facial  neuralgia, colchicum,
with the decoction  and compound tincture of
cinchona, the sesquicarbonate of ammonia, and
     II.              129
the tincture of capsicum, after the bowels had
been completely evacuated by means of cholo-
gogue purgatives.  The removal of the attack
was rapid, and the patient did not experience a
return of it for some years.  Some years after-
ward I had recourse to  the same combination
for neuralgia of the muscles of the arm, in a
young gentleman who had experienced a very
severe epileptic seizure, for which he had been
largely blooded and much reduced.  It was con-
tinued during a few days, and was aided by act-
ive purgatives.  The neuralgic affection ceas-
ed ; but some months afterward he was again
seized with epilepsy;  a physician saw him in
my absence,  and directed blood-letting, which
was followed immediately afterward by anoth-
er attack of epilepsy and paralysis of the arm,
formerly the seat of neuralgia.
  103.  h. Hydrocyanic acid is  often of service,
but chiefly in cases of visceral neuralgia, more
particularly gastralgia and enteralgia.  I have
found it successful in some cases in which col-
chicum  produced remarkable depression.  It
may be given with camphor, the sesquicarbon-
ate of ammonia, or with other stimulants and
restoratives, or with carminatives.   When vis-
ceral neuralgia is complicated with  anaemia, it
may be  prescribed at the  same time with the
salts of iron.
  104.  e. Sialagogues and Errhines were for-
merly much employed in painful affections of
the head and face;  and in some forms and ca-
ses of facial  neuralgia they may still be em-
ployed  with some hopes of benefit.  When it
is considered that the  substances  which are
used locally as errhines or as sialagogues act di-
rectly upon branches of the trifacial nerves—
upon ramifications of the  very nerve which is
generally the seat of the affection—the modern
neglect of these  means is deserving of remark.
—a. Errhines, however, should  be  used with
caution when there is reason to infer any seri-
ous affection of  the encephalon, or active de-
termination of blood to, or congestion in, that
organ.   As respects the choice  of substances
which may be used in this way, those which
most efficiently promote a discharge from the
pituitary membrane are the  most  efficacious.
Sugar, in a fine  powder with a small quantity
of black pepper or capsicum  intimately mixed
in it;  the various kinds of snuff"; and powders
containing a small proportion of veratrum or of
asarum, may be employed, according to the cir-
cumstances ofthe case.
  105.  b. Sialagogues and  masticatories may be
used without  any risk in all cases.  Tobacco is
the common local sia'agogue among sailors,
and the community of  the United  States of
America, and is  probably both a  cure and pre-
ventive  of facial neuralgia  and toothache  in
many instances,  particularly of the latter form
of the disorder.  But the continued or frequent
use of this substance as a masticatory proves
injurious to the digestive organs,  and to the or-
ganic nervous energy, owing to the quantity of
saliva imbued with the juice of it which is swal-
lowed.   When it is desirable to  use any of the
warmer substances as a masticatory, horserad-
ish, ginger, mezereon, pellitory of Spain, or cap-
sicum may be selected.   If a tonic and antisep-
tic be preferred,  the betel nut, catechu, myrrh,
the astringent barks,  &c., may  be  employed.
If a refrigerant  be indicated, camphor,  alum, 
1026                   NEURALGIC AFFECTIONS—Treatment or.
sal ammoniac, &c, may be used.   For tooth-
ache several substances have been employed as
masticatories or as sialagogues with advantage,
and various combinations of them with narcot-
ics, or with antiseptics, have  been resorted to.
Thus camphor  dissolved  in  the tinctures of
opium and capsicum, creasote  being added to
the solution, acts both as a sialagogue and as
an anodyne in this complaint, when applied by
means of a piece of lint or cotton to the gums
or to a diseased tooth.
  [In the treatment of tic douloureux, we  are to
bear in mind that it originates from a great va-
riety of causes,  as, 1st. From some peculiarity
of constitution or  neuralgic habit ;  2d.  From
dyspepsia ; 3d.  From  dyspepsia complicated
with congestion of the liver and other viscera;
4th. From anaemia; 5th. From morbid action
in the spine ; 6th. From disorder of the uterus;
7th. From disease  of the brain; 8th. From lo-
cal mechanical causes, as decayed teeth, exos-
tosis, tumours, &c.; 9th. From malaria.  Each
of these  different forms will be best treated by
adapting our remedies to remove the original
pathological  condition  on  which the disease
depends.   For information  on these points the
reader must consult the appropriate articles,
which he will find scattered through thework.]
  106. f.  External modes  of medication have
been resorted to in neuralgic affections,  in al-
most endless variety.—A. Of local blood-letting
notice has already been taken,  and  the propri-
ety of it vindicated  in  many  instances,  and
wherever a chronic state of inflammation of the
nerves  is inferred to  be  present.  Various
modes of employing galvanism, electricity, and,
more  recently,  electro-magnetism,  have  been
adopted  by Andry, Thouret, Lebreton, Bal-
ly, Harris, and  Harles*  Acupuncture  has
been recommended by Recamier, Bergamaschi,
Sachs, Churchill, and others,  especially in
sciatica.   Of these means  I have  had no expe-
rience.   The affusion of cold water, the  shower
bath, and  cold salt-water bathing have been sev-
erally advised;  but they may be  hurtful more
frequently than  beneficial  if they be not  pre-
scribed with discrimination, and if they be not
immediately followed by  frictions   and  other
means to secure reaction, t
  * [Dr. Thomas Harris, now chief of the Medical Bu-
reau of the United States Army, has reported several cases
<>f neuralgia successfully treated by galvanism, applied af-
ter the manner recommended by Mansford in his work on
epilepsy.—(See Am. Jour. Med. Sci., vol. xiv., p. 384 and
311.)  We have known repeated instances where  the ap-
plication of the horseshoe magnet, in neuralgia, toothache,
&c.,has almost instantly afforded relief.  For several cases
uf this kind successfully treated by the magnet, at St. Thom-
as Hospital, Lond., see Am. Jour. Med. Sci., vol.  xiii., p.
247.  Neuralgia is often relieved by the manipulations of
animal magnetizers  ; on what principle is  not as yet fully
established.]
  t [Electro-puncture in Neuralgia.— M. E. Hermel (An-
nates Medico-Psychologiques.  Pans, Janv., Mars, and Mai,
1844.—Jour, des Connaiss.  Paris,  Julliet, 1844, p. 27-8),
as an evidence of the successes which electro-puncture has
had iu his hands in the treatment of some of the severest
forms of neuralgia, almost all of them lumbo-sacral  and sci-
atic, accompanied in some instances with partial paralysis,
gives  eight cases in which perfect cures were speedily ef-
fected by electro-puncture, when all the usual modes of de-
pletion, purgation, <fcc, were of no avail.  He says nothing,
however, of the still more formidable and distressing forms
of neuralgia, known  as tic douloureux.  Nevertheless, he is
inspired with full confidence in the value  of this remedy,
and while he promises lo supply fresh evidence  thereof,
meanwhile comes to these conclusions:  1. That  electro-
puncture is applicable  to idiopathic or essential neuralgias.
2. The violence  of the pains is not a counter indication to
   107  B  The strictly local applications to nenv
ralgic parts are numerous.^ They may be ar-
ranged into, 1st. Those which arc intended to
alter the sensibility of the affected nerve, with-
out  causing  vesication  or  suppuration ;  2d.
Those which, by causing vesication or suppu-
ration, in addition to the local excitement, may
thereby more permanently impress and change
the  morbid affection  ; 3d.  Those which  may
still more powerfully affect the seat of disorder,
by being applied more  immediately to the nerves
and  capillaries in the  vicinity, and after the cu-
ticle has been removed ; or those which admit
of  being  endermically prescribed ; and,  4th.
Those which  interrupt the communication  be-
tween the seat of the affection and  the senso-
rium, and  which may remove the  cause of irri-
tation in the part affected.
   108. a.  Those applications which are intended
to alter the sensibility of the affected nerve without
causing vesication or suppuration consist chiefly
of compresses, epithems, cataplasms, pomades,
and  ointments, frictions with ointments, or lin-
iments, embrocations, and plasters.—(a) Com-
presses and epithems of various kinds have been
prescribed by Ricotti, Mondiere, and others;
and  the chief of these are compresses moisten-
ed with cold water, or with a solution of prus-
sic acid, or with laurel water.  Epithems with
a solution  of corrosive sublimate  (4 grs. to ?j.
of distilled water)  have even been resorted to
by  Wedekind and  Fleischmann.  Hufeland
advises compresses moistened with equal parts
of laurel water, Goulard's lotion, and rose wa-
ter,  or with  this  last  somewhat in  excess.
Trousseau recommends an epithem of a de-
coction of stramonium (5J. of the plant to Ibj. of
water).
  [The hydrocyanate of potash is one of our most
efficient local remedies in  this disease.   We
have known numerous cases of tic douloureux
relieved by it.  It  should be dissolved in  dis-
tilled water, in the proportion of from 10 to 30
grains to jiv., or, in bad cases, even stronger,
and  applied by friction over the affected part.—
(See Bost. Med. and Surg. Journ.,  vol. v.)]
   109. (b) Cataplasms, or poultices, containing
various  active  substances  have sometimes
proved beneficial.   The powdered leaves of hy-
oscyamus, of conium, of tobacco, and of the
solanum nigrum, have been made into poultices
with linseed meal and decoction of poppies, and
applied to the  affected  part.  Poultices con-
taining one or more of these, and some stimu-
lating or irritating substance, as capsicum, mus-
tard, &c,  so  as to conjoin  a narcotic with an
irritant or rubefacient effect, have likewise
been advantageously applied.
   110. (c) Various pomades and ointments, with
or without friction, have  been recommended:
those containing the  extract of belladonna, or
the acetate of morphia, by Lambert, Bartels,
Lesieur,  &c. ; those  containing the iodides of
mercury, by Thompson and Scott, or the iodide
of potassium;  those  containing  the  sub-car-
bonate of lead, by Ouvrard;  and those with
veratria, aconite, &c, by Tuhnbull, Rowland,
and  others.  Several of these are more service-
able when applied by friction, so as to occasion
the employment of this therapeutic agent ; they have never,
in any case, been aggravated by its use. 3. The paralysis
which supervenes in the progress of idiopathic (essentielles)
neuralgias yields to the same treatment.—(Velpeau.)J 
NEURALGIC AFFECTIONS—Treatment of.
1027
 considerable rubefacient effect, as those with
 the iodides of mercury or of potassium, or with
 veratriaor aconite.
   [ Veratria and aconitinc are two of our most
 important topical remedies in the treatment of
 neuralgia.  An ointment composed of twenty
 grains of veratria to one ounce of lard may be
 rubbed over the part affected, from time to time,
 with the best  effects.   The usual strength in
 which we have employed it is from ten to twen-
 ty grains to the ounce of lard, or simple cerate;
 or the alcoholic tincture, which is a neater prep-
 aration,  may be used.   When used internally,
 which we  do not recommend, the veratria may
 be given in doses of one sixth of a grain, with half
 a grain of extract of hyoscyamus, three times a
 day, obviating costiveness by the use of rhubarb
 and blue mass.  (See Dr. Turnbull's Essay on
 the Medical Properties ofthe Natural Order Ranun-
 tulacea.)  We prefer the internal use of extract
 of belladonna to that of veratria, delphinia, or
 aconitine, which are too powerful  to be em-
 ployed with safety.
   Veratria may be applied very successfully in
 these cases by dipping the point of a  lancet in
 a saturated solution of the alkaloid, and making
 a number  of punctures over the part  affected.
 Each puncture will become at once the seat of
 a sharp pain, similar to that caused by the prick
 of a fine needle.  This lasts but for a few min-
 utes ; ten  or twelve punctures should be made
 night and  morning,  and  continued till the dis-
 ease  yields.]
   111. (d) Frictions with stimulating liniments or
 with  strong solutions of narcotic substances, or
 with both conjoined, have been employed.  Col-
 ville found frictions with tar of service ; and
 Todd derived advantage from friction with a
 strong solution of extract of belladonna (31J. of
 extr. in  fj. of water). I have had recourse to
 friction of the affected parts with narcotic and
 rubefacient substances conjoined, and frequent-
 ly prescribed the following with marked benefit:
   No.  304.  R Linimenti Camphorae Co.; Linim. Terebin-
 thins, Si,  f jss. ^ Olei Olivae, jijss.; Olei  Cajuputi, 3jss. ;
 Extr. Belladonna; (vel Tinct. Alcohol. Aconiti), Jiij. Misce,
 ut fiat Linimentum.
   112. (e)  Embrocations  with various  substan-
 ces have proved equally serviceable with any
 of the foregoing applications.   Warm flannels,
 or several  folds of  cotton  made warm, and
 thoroughly imbued with any of the liniments re-
 ferred to in the Appendix (F. 295-314), or with
 the liniment just prescribed, and then closely
 applied to  the  affected part, and covered by a
 warm napkin, or by oiled silk to prevent evap-
 oration, are often of essential service in  most
 of the varieties of neuralgia, particularly when
 renewed  from time to time, or according to the
 effect produced.
   113. (/) Plasters of various kinds have like-
 wise  been placed on the part,  and some  of
 them  have been intended to produce a rubefa-
cient, in  addition to their other effects. Those
plasters which  contain belladonna, or both this
narcotic  and camphor, have usually been pre-
ferred.   M. Trousseau has employed the ex-
tract of stramonium in this  manner.   The fol-
lowing plaster  has been  frequently applied  in
sciatica:
  No. 305.   R Cera: Albas ?j.; Olei Terebinthins, Jss.,
leni igne colliquefactis, adde Pulvens Euphorbia, 3J.-3SS.
M.  Fiat Emplastrum.
   114. b. Various means of producing vesication,
pustulationy or suppuration have been  resorted
to for this complaint.—(a) Blisters applied, and
even repeated, in the course ofthe nerve, have
been praised by Cotugno, Magendie, and oth-
ers.  Moxas have likewise been recommended
by  Bontius, Cotugno, Larrey, Barras,  and
Walther.   Compresses  moistened  with  a
strong solution of tartarized ointment, and ap-
plied until redness or pustulation is produced,
has been prescribed by  Magri ;  but  an oint-
ment containing the tartar-emetic, or mercu-
rial ointment with it (3J. of ant. tart., and ?j.
of the oint.) as used by Scott, is more"imme-
diate and certain  in its effects  than  the solu-
tion.  Issues and setons have been employed in
the more obstinate or chronic cases.   For sci-
atica they may be placed near the trochanter
major, and, in  cases of facial  or occipital neu-
ralgia, particularly when there  is  reason  to
dread organic lesion near the base of the cere-
brum or cranium, they may be inserted in the
nape ofthe neck, or somewhat higher, or even
in the occipital scalp.
  115. c. Applications to  the affected  part after
the  cuticle has been removed from the surface—or
endcrmic medication, as  it has been  termed—
have been  frequently  tried in neuralgia, and
recommended by Trousseau, Ricotti, Bonnet,
Ansiaux, Radius,  and others.   Various  nar-
cotic substances have  been thus employed ;
but the acetate of morphia, sprinkled over the
surface thus  denuded of its cuticle, or  ten
grains of the acetate intimately mixed in from
one to two drachms of an ointment, a portion
of this being applied to  it, and  an ointment
with a small portion ofthe extract of belladon-
na, are the means  most frequently selected, al-
though various other substances may be simi-
larly applied.
  116 d. The affected nerve in some instances
has been divided above the  seat of pain, in order
to interrupt  the communication  between  the
seat and the  sensorium; but there are very
few cases on record in which this measure has
succeeded beyond a  short period, or given per-
manent relief.  When  there is reason  to infer
the existence of any irritating substance in the
nerve or part affected, the removal of it, if this
be at all possible, should be attempted ; and,
when the affection seems to proceed from the
exposure of a fibril of nerve in a cicatrix, or
from the irritation of an eruption, the  applica-
tion of a caustic  to the former, suppuration
being afterward promoted, and of appropriate
means to the latter, according to its nature, is
chiefly indicated.
  [M. Berard has seen (Malgaigne's Manuel
de Med. Operat., 4th edit., Paris, 1843, p.  130)
an infra  orbitar neuralgia return after having
exsected three inches (nine millimetres) of the
nerve ; and Swan has seen the two ends of a
nerve in  a horse reunite (76.) after having ex-
sected a segment  near nine inches long!   M.
Maloaigne suggests (76.) whether it might not
be advisable, after dividing the  nerve, to de-
tach both  ends by dissection, and  fold them
back on the trunk so as to form a noose, or to
interpose between  the ends a small fleshy flap
from the immediate  neighbourhood, the better
to intercept, when  the cicatrization is comple-
ted  over  this, the continuity of nervous influ-
ence.   M. Bonnet, of Lyons, proposes in the
frontal nerve to divide  it freelv down to the 
1028                  NEURALGIC  AFFECTIONS—Treatment or.
bone by a  sub-cutaneous  incision—(lb., 151,
152.)   M.  Malgaigne, for  the  infra-orbitar
nerve, prefers also the sub-cutaneous section
on the groove of the nerve in the  floor of the
orbit; after which  he tears out the divided
fragments from its  groove by means of a for-
ceps applied to the portion of the  nerve laid
lure, and divided a little below the orbit (76.,
p.  155).   M. Bonnet makes only a sub-cutane-
ous division of the nerve.—(76.—Townsend's
Velpeau, vol. ii., p. 435.)
  Dr. Mott was one  of the  first surgeons in
this country who treated  neuralgia by exsec-
tion of a portion ofthe nerve ; but after exten-
sive  trials  he  laid the operation aside,  as he
found the disease very certain to return as se-
vere as ever.  In that form of neuralgia which
results from an injury or wound  of the nerve,
Dr. Mott  has in  several instances effected a
cure by exsecting  the cicatrix,  in which will
generally be found a nervous fibrilla.  (See Lec-
ture on Neuralgia, in the N. Y. Lancet, Feb. 12,
1842, No. 7, vol. i.)
  Dr. J. C. Warren,  of Boston, has reported
several cases  of tic douloureux cured by the
division and removal of a portion of some of the
facial nerves.—(Boston Med. and Surg. Journ.,
vol. i, p. 1.)  In one  very aggravated case of
a man  aged 70, who had been affected for 14
years with  severe pain in the side  of the  face,
beginning near the ear, and thence darting into
the lower and upper  jaw, lips, eye, forehead,
and scalp, and who had previously undergone
three operations, with only  temporary relief,
viz.,  two  on  the  sub-orbitar nerve and  its
branches, and a third on the nerve of the low-
er jaw,  where it comes out on  the chin, Dr.
Warren proceeded to divide the facial nerve,
between the parotid gland and the mastoid pro-
cess, with  the effect  of removing the pain in
the upper part of the  face, while  that in the
lower was as acute as ever.  A portion of the
submaxillary nerve was then exsected by tre-
phining  the lower jaw beneath  the masseter
muscle and near its angle, when the pain en-
tirely ceased, and the  disease did not return.—
(Loc. cit.)
  In another case, neuralgia of a branch ofthe
plantar nerve, which caused  convulsions in a
female, and which was occasioned by including
a nerve in  the ligature of a small vessel, was
perfectly cured by making an incision in the
sole  of the foot, behind the  interstice of the
fourth and fifth toe, and dividing the internal
plantar nerve going to the fourth and fifth toe,
of which a portion, one inch in length, was re-
moved.   But one spasmodic attack occurred
after the operation, and the patient speedily re-
covered her usual health.
  The observations of Dr. Warren on the va-
rious forms of neuralgia, with numerous  illus-
trative  cases, as contained in several numbers
ofthe Boston Med. and Surg. Journal, are  high-
ly  valuable, and well worthy the  attention of
the practitioner.  Amputation has been had re-
course  to,  but without any benefit, however,
in  cases, for  example, where the  little finger,
from a mere blow, has, without any external le-
sion, been followed by severe neuralgic  pain,
and finally wasted away.  Dr. Wigan, in a case
of this kind in a lady who struck her little fin-
ger against a garden roller, amputated it; but
finding the distress continue in two others, am-
putated them also, with a like unsuccessful re-
sult.  Neuralgic pain in every part ofthe body
came on, and the patient died a martyr.—(/ ro-
ccedings of the Med. Society of London, March,
1845;  London Lancet,May 3, 1845, p. 505.) Mr.
Crisp proposes,  in such cases (76., loc. cit.), the
possible  advantage of removing a portion  of
the nerve, from the  remarkable  effect known
from this kind of operation on the lame foot of
horses. According to Mr. Pilcher (lb., loc. cit.),
the nerves ofthe organ of sense,  as ofthe eye,
may become paralytic by pure concussion, i. e ,
by a blow, without any ecchymosis or change
of structure.  M. Dendy, however (76., loc. cit.),
has known a family, the  members of which
were so delicate  that slight pressure on the
surface produced a kind of  thrombus.  It  is
difficult, however, to determine how  far neu-
ralgic and paralytic diseases  of the nerves are
dependant on the influence ofthe nervous cen-
tres, or on local  causes. Surgery, in most such
cases,  seems to have  less resources  than in-
ternal  constitutional treatment  and  external
applications.—(Dr. Townsend's Velpeau, vol. ii.,
p. 435.)
  The cold dash  is a powerful remedy in many
cases  of neuralgia.  We  lately  succeeded in
curing two severe cases of sciatica, which had
resisted  blue pill, belladonna, and  the whole
routine of ordinary treatment, by turning cold
water upon the hip and leg from a pitcher ele-
vated some feet above  the  patient.  The great-
er the shock the  more advantageous did the
remedy prove, and the speedier relief did  it
bring.  Dr. La Roche, of Philadelphia, has also
succeeded in allaying and completely removing
the pain of acute and protracted sciatica, which
had resisted various remedies, by the applica-
tion of ice  over the affected part.  Dr. Bell
also speaks favourably of the same application.
Numerous cases of neuralgia of the face have
been cured by extracting decayed  or wisdom
teeth,  a  remarkable  instance of which is re-
corded by Dr. Post, of New-York, in the 6th
vol. of the New- York Journal of Med. and Coll.
Sciences.}
  117. C. The  diet and regimen  for neuralgic
patients must necessarily depend upon the pe-
culiarities, causes, and  complications of indi-
vidual  cases.   In most instances, however,
regular and  abstemious living ; due exercise in
the open air; the avoidance of all depressing
physical and mental causes; and a pure, dry,
and moderately warm air, avoiding all injurious
exposures, night air,  dews, and  crowded as-
semblies,  are most conducive to recovery, and
to the prevention of those recurrences of the
complaint to which all  are subject who  have
once been tormented by it.  Above all, the pre-
disposing and exciting causes (<$ 52,  et scq.)shou\6
be guarded against; the stomach preserved in
good humour ; and all  the  secretions and ex-
cretions healthily promoted, without being in-
ordinately increased, or increased so as to oc-
casion debility.   In some  instances, a course
of chalybeate or  alkaline mineral waters proves
of service, after  appropriate medical treatment
has ceased ;  and when the complaint has been
caused by malaria, cold, and other physical in-
fluences, these  are often extremely beneficial
when the state of the digestive organs receives
due attention.
  Bibliog. and Refer.—Arelttus, De Morb. Diuturn.,lih. 
BIBLIOGRAPHY  AND  REFERENCES.                         1029
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 Trans,  of London, vii., p.  522.—Vaidy, in Journ. Comple-
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 de Med., Dec, 1825.—Lasserre, in Joum. Univers. des Sc.
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 de Therap., t. ii., p. 280.—Wolff, in Journ. des Progrcs des
 Sc. Med., t. iii., p. 237.—Stokes, Amer. Journ. of Med. Sc,
 No. xxxiv., p. 496.—Nicod, Nouv. Journ. de  Med., t. iii.,  p.
 247, Ann. 1818 (On Thoracic or Intercostal Neuralgia).—
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 p. 246.—Marcet, in  Ibid.,  vol. viii., p. 551. —  Elliotson,
 in Ibid., vol. xiii.— Yeats,  Hist, of severe Case of  Neuralg.,
 8vo.  Loudon, 1822.—L. Martinet, Mem. sur l'Emploi de
 l'Huile de Terebinth,  dans la Sciatique, 8vo.  Paris, 1823.
 —Ribes, Observ. de Neuralg. du Nerf Facial.—Magendie's
 Journ,  de Physiol., t. ii.,  p. 219.—Author,  in Lond.  Med.
 and Physical Journ., vol.  xlvi., p.  193; and  London  Med.
 Repos., vol. xvii., p. 374.—Montfalcon, Diet, des Sc. Med.,
 t. xxxv., p. 500.—Andral, Clinique Medicale, t. ii. and t. v.;
 and Precis  d'Anatomie Pathologique, t. ii.—C. Bew, Opin-
 ions on the  Causes and Effects of Tic Douloureux, 8vo.
 Lond.,  1824.—M. Duparque, in Nouv. Biblioth. Med., t. iii.,
 1826— P. Jolly, in  Ibid., t. i. et t. ii.;  et Diet, de Med.  et
 Chirurg.  Prat.,  art. Neuralgic.—Abercrombie, Pract.  and
 Pathol. Researches on Dis. of the Brain and Spinal Chord,
 8vo, p. 324.— T. Tyrrell, in  hrs edit, of A. Coopers Lectures
 on Surgery, vol.  ii., p. 407.—C.  Scudamore,  A Treatise on
 Rheumatism and  Neuralgia, 8vo.  Lond., 1827.—Brown, in
 Glasgow Med. Journ., 1828.—Campaignac, Sur les Neuralg.
 des Organs  Genito-Urinaires et de l'Anus, in Journ. Heb-
 dom. de Med.,t. ii., p.  396, Ann. 1829.—Bardsley, Hospital
 Reports, 8vo.  Lond.,  1830, p. 101— T. P. Teale, A Trea-
 tise on Neuralgic Diseases, &c, 8vo.  Lond., 1829.—Rev.,
 in Johnson's Med. and  Chirurg. Rev., No. xxiii., p.  112.—
 G. Strombio, Giorn.  Analitico di Med.  Milano, Settemb.,
 1828.- Barras, Traite sur les Gastralgies et les Enteralgies,
 8vo.  Paris, 1829, 2d edit., 2 tomes.—/. Macculloch,  An Es-
 say on Remittent  and Intermittent Diseases,  including gen-
 erally Marsh Fever and Neuralgia, &c, and treating of Tic
 Douloureux,  Sciatica,  Headache, Ophthalmia, Toothache,
 Palsy, <fec, 2 vols., 8vo.  Lond., 1828, vol. ii.—Dupuy, Rev.
 Med  t. i., 1829.—Gardner, Lond. Med. and Phys. Journ.,
 IHSo'—Halliday,  Consid. Prat, sur les Neuralgies  de la
Face  8vo    Paris, 1832.—Herison, Journ.  de Pharm. et
des Sc. Access.. Mars.  I832.-r0«, Archiv Gen  de  Med
Juill  1832 —P. A. Pwrry, Clinique Med. de la Hop. de la
Pltie'p  293.  Paris, 1833.—Deleau, Mem. sur l'Emploi des
Uataplasmes de Belladonne  dans les  Neuralgies, 8vo. Paris,
 1833.—Elliotson, in Cyclop, of Pract. Med., vol, iii., p. 165.
 —H. Halford, Essays and Orations, read aud delivered  at
 the Roy. Coll. of Physicians, p. 34, 3d edit., 8vo.  Lond.—
 /. Scott, Cases of Tic Douloureux, 8vo.  Lond., 1834.—/.
 Swan, A Treat, on Dis. and  Injuries ofthe Nerves, p. 1, 2d
 edit., 8vo.   London,  1834.— Thompson, Cases  of Tic Doul.
 and other Forms  of Neuralg., 8vo.   Loudon, 1834.—Bellin-
 gen, Annal. Univers. di Med., Avril,  1834.—Ricotti,  in
 Ibid, Juill., 1829.—Biett, in Diet, de  Med., t. viii., p. 15,
 2d edit.—Harris, American  Journal of Med. Sci , August,
 1834.—Roots, in  Lond. Med. and Surg. Journ., 1834.—Ben-
 net, North  American Archives of Med. and  Surg., April,
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 Nov., 1837 ; and in Brit, and  For. Med. Review, p. 276, Jan ,
 1838.—C. Bell, in Medical  Gazette.   London, 1825.—4.
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 — Trousseau et Pideaux,  Traite de Therap., &c, t. i., Svo.
 Paris, 1836.—Most,  Encyklop. Wortub., t.  ii., p.  142.-R.
 Rowland, A Treatise  on  Neuralgia, 8vo. London, 1838.—
 Theophilus Thomson, in Library of Medicine, vol. ii., p. 262.
 — Valleix, De la Neuralg.  Dorsale, on Intercost., in Ar-
 chives Gener.  de Med.,  t. vii., 3d  series, 1840.—Ollivier,
 Diet, de Med., 2d edit., art.  Neuralgic; et Traite  des Mal-
 adies de la Moelle Epiniere, &c, t. ii., p. 209, 3d edit.—R.
 H.  Allnutt, Tic  Douloureux, or Neuralgia Facialis, and
 other Nervous Affections, their Seat, Nature, and Cause,
 with Cases, <fec,  8vo.  Lond., 1841.—(See, also, Bibliog.
 and Refer, to art. Nerves.)
  [Ad. Bibliog. and Refer. — /. C. Warren, Cases of
 Neuralgia, Bost.  Med. and  Surg. Journ., vol.  i., p. 1 ; vol.
 xi., p. 97,113, 129, 145, 177, 209.—Job  Wilson, Bost. Med.
 and  Surg. Jour., vol. ii., p.  133.—F. Tiedemann,  On Re-
 generation of Nerves, Bost. Med. and Surg. Jour., vol. vii.,
 P- 171.— S.  D. Townsend, Bost. Med. and Surg. Jour., vol.
 xi.. p. 197.—/. Bennet, West. Journ. Med. and  Phys. Sci.,
 1830  (Case of imitative Neuralgic  Affection). — Andrew
 Nichols, On Irritation of the Nerves,  Address  before the
 Mass. Med. Soc,  25th May,  1836, Bost. Med. Jour., vol. xv.,
 P. 46.— W. A. Gillespie, Cases of Neuralgia,  Boston Med.
 Jour., vol. ix., p.  349.—Luther V. Bell, in Bost. Med. Jour.,
 vol. xiii., p. 343.—George Calmer, in Am. Jour. Med. Sci.,
 vol.  v., N.  S.,  p. 248.—James Duncan, On Neuralgia  of
 Stump, in Am. Jour. Med. Sci., vol. ix., N.  S., p. 484.—M.
 Levrat, in Am. Journal Med. Sci., vol. iii., N. S., p. 209.—
 Golding Bird, On Abdominal Puerperal Neuralgia, in Am.
 Jour. Med Sci., vol. vi.,N. S., from Prov. Med. Jour., 1843.
 —/. Young, Cases of Nervous Affections, in Am. Journal
 Med. Sci., vol. xxv., p. 61.—G. B. Fundenberg,  On Facial
 Neuralgia,  in  Am. Journ. Med. Sci., vol. xxvi., p.  509.— G.
 Bird, in  Lond. Lancet, April 25, 1840 (Abdominal Neural-
 gia).—C. C. Hildreth, Observations on the Neuralgiae, Am.
 Jour. Med.  Sci., vol.  xviii., p. 77.— W. Stokes, in Am. Jour.
 Medical  Sci., vol. xvii., p. 497.—W. A. Gillespie,  Cases of
 Neuralgia, &c.,Am. Journal Med.  Sci., vol. x., p.  115.—N.
 Chapman, On  Tic Douloureux, in  Am. Journal Med. Sci.,
 vol. xiv., p.  289.—T. Harris, Cases of Neuralgia treated by
 Galvanism,  Am.  Journal Med. Sci., vol. xiv., p. 384.—M.
 Nelaton, Tubercles in the Nerves, Am. Jour. Med. Sci., vol.
 xiv., p. 219.—R. H. Allnatt,  On Tic Douloureux, and  oth-
 er Nervous  Affections, <tc, 2d edit.  London, 1843, 8vo, p.
 224.—Herman Klencke, Physiologie der  Entziindung  und
 Regeneration in den Organischen Geweben.  Leipzig, 1842,
 8vo, p. 230.—James H. Miller, in Am. Jour. Med. Sci., vol.
 xiv., p. 321.—M.  Civiale, On Neuralgia ofthe Neck of the
 Bladder ; Traite Prat, sur les Maladies des Organes Genito-
 Urinaires.—R. Macleod, On Rheumatism, &c.  Lond., 1842,
 p. 164.—M. Hall, On the Diseases and Derangement ofthe
 Nervous  System,  1 vol., 8vo.  Lond., 1841 ; Princ.  of Diag-
 nosis ; Am. edit,  by /. A. Swett, 1  vol., 8vo.  New-York,
 1843.—/. H. Griscom, On Spinal  Irritation, in  New-York
 Med. and Surg. Jour., 1842.—/. Harrison, An Essay towards
 the correct Theory  of the  Nervous System, 1 vol., 8vo.
 Phil., 1841.— W.  C. Henry, A Report on the Physiology of
 the Nervous System, 1 vol., 8vo.   Phil., 1841. — V. Mott,
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 Dissertations for  the Years  1836 nnd 1837.  Boston, 1838,
 p. 378, 8vo. — H.  Green, Case of Neuralgia of lower Jaw
 successfully treated by a  Surgical Operation, in New-York
 Jour, of Med. and Coll. Sci., vol. xi., p. 324.—M. Lafarque,
 An  Account of Inoculation  of Veratrine in Neuralgia, in
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 Med. Rev., vol. xiii.,  p. 138.—i/. Hunt, On the Nature and
Treatment of Tic Douloureux, Sciatica, and other  Neural-
gic Disorders.   Lond., 1814, Svo, p.  192 ; and Brit, and For.
Med. Review, July, 1844.—Elliotson, Hall, Watson, Eberle,
 Hosack, Dunglison, Bell and  Stokes, Dickson, and various
other writers on the Theory and Prac. of Medicine]

NIGHT-BLINDNESS AND  DAY-BLIND-
  NESS.—Nyctalopia  and Hemeralopia.—Syn. 
1030      NIGHT-BLINDNESS AND  DAY-BLINDNESS—Phenomena—Causes.
  Nyctalopia, vvKralwirta (from vvt;, night, and
  uf), Hippocrates, Galen.  Nyctolopia, Pliny,
  Linnaeus, Vogel.   Visus diurnus, Boerhaave.
  Amblyopia crepuscularis, Sauvages.  Paropsis
  noctifuga, Good.   Dysopia, tenebrarum,  Cul-
  len.   Aveugltment  de nuit, vue de jour, Fr.
  Nachlblindheit, Germ.  Cecila di  Nolle,  Ital.
  Night - blindness, Day - sight,  Hen - blindness,
  Guthrie.
Hemeralopia (from r/ptepa, day, and u^», eye).
  Amblyopia meridiana, Sauvages.   Visus noc-
  turnus, Boerhaave. Photophobia, Plenck. Dy-
  sopia luminis, Cullen.  Visas acrior, Darwin.
  Paropsis lucifuga,  Good.  Oxyopia,  Luscitio,
  Auct.  Homeralopie,  vue  de  nuit,  Fr.  Tag-
  blindheit, Germ.  Cccita di giorno, Ital.  Day-
  blindness.  Night-sight.
    Classif.—IV. Class,  I. Order  (Cullen).
      IV. Class, II.  Order (Good).—I. Class,
      III.  Order (Author).
  1. Defin.—Obscuration or loss of vision  by
night only (Nyctalopia); or by day only (Heme-
ralopia).
  2. It has been justly remarked by Dr. Forbes,
that the two terms, nyctalopia  and hemeralopia,
have been inextricably confused, by being taken
respectively by different authors to mean the
same thing;  one terming night blindness nyc-
talopia, and another hemeralopia, while day-blind-
ness has been equally designated by both terms.
He has, therefore, assigned the meaning which
he would attach to each of them, and conform-
ably with  what appears to him, and not unrea-
sonably, as their derivation, he defines nyctalo-
pia to  be  vision obscured by day but good at
night, and hemeralopia to  be  vision obscured
by night and distinct by day.  These meanings
are opposed to those which I have assigned to
the terms  in question, and which are those most
generally  received ; the " a " in the middle  of
each of the words being manifestly viewed as
privative.
  3. Of the two disorders of vision about to be
noticed, night-blindness is the  most frequently
observed,  and the most generally  functional.
Day-blindness, when  at all  marked, is sympto-
matic of vascular irritation, or inflammatory ac-
tion in the more interior or posterior textures
of the eye.  Still, in  its slighter states, it  may
depend  upon  similar  pathological  causes  to
those which occasion night-blindness, but cases
of this kind are extremely rare.
  4. i.  Phenomena.—In  persons suffering un-
der this complaint, vision  becomes gradually
indistinct  as the light  of day disappears,  until
it is entirely suspended.  The blindness  con-
tinues  during the night, and ceases with the
return of daylight; but its degree varies in dif-
ferent cases, and in the same case with the du-
ration of  the disorder.  At first, or in slight
cases, the blindness is  partial, and objects may
be seen with a strong artificial light; but, as
the complaint advances, vision becomes so im-
paired  that the moon  or stars cannot be dis-
cerned, nor even the light of a candle placed at
a short distance :  more frequently, however, an
artificial light may be discerned, but  not the
bodies  in  its vicinity.  In the  more prolonged
cases, blindness is sometimes so complete, that
an object  cannot be  seen after sunset  in  the
brightest artificial light.  Generally the sight is
restored as daylight  returns, and it again be-
comes  perfect when  the sun has risen above
the horizon ; blindness and vision continne in
this to correspond with  the setting and rising
of the sun.   The  approach and  remission of
the paroxysms at sunset and sunrise are gen-
erally gradual, but, in some cases, more or less
sudden.  If the disease be allowed to continue,
the eyes may ultimately become so weak during
daylight, that the direct or reflected rays of the
sun cannot  be endured without much uneasi-
ness and indistinctness of vision ;  a certain de-
gree of hemeralopia thus  following obstinate or
prolonged nyctalopia.   In some, also, of these
severe cases, and even when this irritable state
of the eye has not been induced, the patient is
incapable, when  placed in an obscure situation,
of distinguishing objects by day as by night.
  5.  Usually no uneasy sensation or  visible
alteration of the eye is present.   The state of
the pupil is variously described  by authors.
Some say that it is immovable and contracted,
others that  it is  dilated.   This  discordance
probably arises from the pupil having been ob-
served at different stages of  the complaint or
at different periods, at night or during day only.
Mr. Bampfield is  not always consistent with
himself, when noticing this symptom. He states
that, after the disorder is far advanced, the pu-
pil is  often contracted, and the patient evinces
painful irritation of the eyes when exposed to
a vivid light or when looking upward ; and that
it is considerably dilated both by  day and night,
in the proportion of about one case in twelve ;
and at night it is often dilated, and neither con-
tracts nor dilates  when exposed to the moon
or to  artificial light.   My own recollections of
the few cases which I had an opportunity of
seeing many years ago admit not of my offering
any remark on this  point; but they are suffi-
cient  to confirm my  belief that, although  the
complaint is in some respects  local—is depend-
ant upon the state of the nervous  apparatus of
the eye in part—yet  this local disorder itself
depends  upon more  general  or constitutional
derangement; and this must  especially be the
case when the  nervous systems and digestive
organs are particularly affected, as observed in
many cases of this affection.   Indeed, very  few
cases will be found,  in which  the  functions of
these systems and organs are not more or less
impaired.   That the brain is somewhat affected
in some instances, is evinced by headache or
vertigo, which may, however, equally with the
nyctalopia, be symptomatic of impaired organic
nervous energy and disorder of the  digestive
organs.   The complaint continues  for a very
various period.   It sometimes disappears with-
out the aid of medicine.   In temperate climates,
it generally assumes a milder  form than in hot
countries.  In the former it usually continues
from one month  to six or seven weeks.  In the
latter it is often  prolonged to four, six, or nine
months, and  even  much above that period in
some  instances.
  6. ii. Causes.—Nyctalopia is very rarely seen
in this country;  but in the most southern parts
of Europe, and in countries within the tropics,
it is not infrequently met with.  It is said to be
endemic in some  places within  the tropics ;  and
even in some parts ofthe south of Europe,  and
of China : it has occasionally, also, assumed an
epidemic form even in temperate climates, and
in northern  countries, where  the sun in sum-
mer  is  long above  the horizon.   Thus,  Dr. 
NIGHT-BLINDNESS—Pathology—Prognosis—Treatment.
1031
Guthrie observed it very prevalent in the Rus-
sian troops in Finland, during the spring, ow-
ing to the short absence of the  sun, and the
strong reflection from the snow.   M. Richer-
and states that nyctalopia is both endemic and
epidemic  in  northern regions from  the  same
causes, and that artisans who exert their sight
in an  intense artificial  light are occasionally
affected with it.  Within the tropics, the influ-
ence of season in producing this complaint  is
not so evident as in very cold climates.  Dr. J.
Grant remarks that nyctalopia is not infrequent
in soldiers and seamen  in the East  and West
Indies; and that on the eastern shores of the
Mediterranean, and  in the islands of the  Adri-
atic, it is at times very prevalent.  It has also
sometimes become epidemic in parts of France,
Germany, Poland, and Europe.   Wherever  it
occurs, it  preserves the same characters, vary-
ing only in the severity of its attack and length
of its duration, in individual cases,  according
to the constitution of the patient and the inten-
sity and combination of the causes.
  7. Nyctalopia seems to have been congenital
in  rare instances,  according to  Haller  and
others, or at  least to have  appeared at a very
early age, and to have continued subsequently.
It has occurred in three persons in one family ;
and it has been said to  be  hereditary in some
cases.  Europeans  residing within the tropics
are more  liable to  it than the native inhabi-
tants ; and those who have been  attacked are
prone  to a return of it, if they remain in the
same  climate.  It  is  very rarely observed  in
children;  and it is more  frequent in males than
in females.   The colour or appearance of the
eyes has  no  influence in favouring  its occur-
rence.  It rarely affects the upper classes, but
is most frequent in those exposed  to  fatigue,
watching, and debilitating influences, and whose
diet is poor or unwholesome.  Venereal excess-
es and manustupratio are also influential  caus-
es of it.   Nyctalopia has been ascribed also  to
sleeping in the sun, to poisonous vegetables,
and to the use of bread in which darnel is pres-
ent.  The ancients believed the lolium to  be
hurtful to the sight; and the observations and
experiments of modern physicians have proved
this opinion to be correct.   It is  not improba-
ble that the  Cannabis Indica, or Indian hemp,
which is so much used in the East for the pur-
poses of excitement and  intoxication, has also
considerable influence in producing this disease.
Its probable dependance in  some degree upon
exhaustion of nervous power and weakness  of
the digestive functions, has already been no-
ticed (y 5).
  8. iii. Pathological States.—In most  in-
stances, this  affection depends  upon the  over-
excitement, and consequent exhaustion, of the
nerves of the eye by the brilliant  sunshine and
light, in warm and arid countries, and in snowy
regions, when the light of day is of long contin-
uance, the retina and nerves being thereby re-
duced  to a state incapable of being excited  by
the feeble light remaining after sunset, and  of
perceiving objects  in that light.  In the  more
extreme  cases, the torpor  of the  retina and
nerves seems to be  so great as  not to be over-
come  by  even a bright  artificial light.  It  is
possible, also, that the rays ofthe sun combine
with them so much  of electro-motive agency  as
to favour  distinct vision, and an artificial light,
not possessing this property, is accordingly less
influential than they in exciting vision.  The
same causes which exhaust the sensibility of
the nervous apparatus  of the  eye, at the same
time tend, particularly when energetic and pro-
longed,  to occasion a  congested, or a sub-in-
flammatory  state of the retina  and posterior
parts of the organ, and the attendant contrac-
tion of the pupil.   It is manifest, also, that all
the circumstances which  produce  exhaustion
of nervous energy, particularly many ofthe re-
mote causes above enumerated,  or congestion
of the venous circulation,  or both nervous ex-
haustion and vascular congestion, will also fa-
vour  the development  of  nyctalopia when its
more efficient exciting  causes are in operation.
The connexion between impairment of the di-
gestive  functions and  this affection, so  very
generally observed, is a necessary result of ex-
haustion of  nervous power; for, when the  or-
ganic nervous  energy  is  much  reduced, the
functions of sense are  readily exhausted, and
are soon proportionately weakened.
  9. iv. The prognosis of nyctalopia is gener-
ally favourable.  As it occurs in temperate or
northern climates, it very frequently undergoes
a spontaneous cure with change  of the season
and circumstances in which it originated.   Dr.
I. Grant states that it has occasionally  been
removed by the  occurrence  of diarrhoea,  of
haemorrhage from  the  nose, and of abscesses
and eruptions about the head  and face.  I met
with a case many years  ago which was removed
almost immediately by copious discharges of
morbid bile consequent upon the exhibition of
stomachic purgatives, the  inordinate  accumu-
lation of bile in the gall-bladder and biliary ducts
having been intimately connected with the de-
velopment of this affection. Bontius, Senner-
tus, Ettmcller, Boerhaave,  and some others,
however, have formed  a much more unfavour-
able opinion ofthe complaint than that just now
expressed ; and as it appears in warm climates,
particularly  when affecting persons addicted to
intoxicating liquors, to  the use of opium, or of
the cannabis indica, nyctalopia is much more
difficult to remove than in other circumstances,
and sometimes long resists treatment.  Much,
however, depends upon the existing states of
the nervous  system generally,  and of the digest-
ive organs, upon the habits of the patient, and
upon the continuance or interruption of the ex-
citing causes.   In these more  unfavourable cir-
cumstances, total loss  of  sight may ensue, as
remarked by Bampfield and  others; but  this
result rarely occurs unless internal inflamma-
tion ofthe eye supervenes, or is  neglected.
   10. v. Treatment.—The humoral  patholo-
gists, believing that nyctalopia depended upon
inspissation  and congestion ofthe humours, had
recourse to bleeding, attenuants, and deobstruents,
with purgatives, sternutatories, and sialogogues,
and  as  these often removed  fecal  accumula-
tions and morbid secretions from the prima via
and  collatitious  viscera, advantage  frequently
resulted from this treatment.   In some instan-
ces an emetic was premised with  benefit.  The
exciting substances,  by which the  senses  of
smell and taste were  thus roused, sometimes
tended,  by nervous connexions, to remove the
torpor of the nerves of the eye.  Both the an-
cients and the moderns, in places the most re-
mote from each other, have  had recourse to 
1032                       NIGHT-BLINDNESS—Treatment.
the livers of various  animals, of bullocks, he-
goats, sheep, pigeons,  black cocks, black swine,
&c., for  the cure of nyctalopia; these  being
eaten as an article of diet, or the vapour from
them being used  as a fumigation for the eyes.
Dr. I. Grant states that he has repeatedly seen
a cure apparently produced by fumigating the
eyes with  the vapour of bullock's liver.   The
disease occurred in persons who were in some
degree affected with scurvy, and various meas-
ures had previously been resorted  to without
benefit; two or three fumigations having cured
the complaint.  The same writer remarks, that
the vapour from  the  heated liver was applied
to the  eyes; at other times  the viscus  itself
was given to the patient to eat;  in both cases,
after it had undergone the most complicated
preparations, particularly  with  various  stimu-
lating substances.  A recent German writer,
Dr. Meissner, gives a similar account  to  the
above ofthe liver-cure  of nyctalopia.  He states
that, in a small town of Podolia, he met with
more than  a hundred cases of the  complaint.
It was then the time of the Greek fast, when
the inhabitants use  no animal  food, but live
chiefly on  bread  and  grits prepared with  oil.
He was assured that,  at the same period every
year, a great many people are seized with nyc-
talopia ; but that when Easter came they ate
the liver of a black cock, or black  swine, and
were cured in a few  days.  He examined, by
day and by night, several of those affected by
the disorder, but could perceive nothing partic-
ular in their eyes, except great immobility of
the  pupils.  In other respects,  they were in
perfect health,  and would submit to no  other
treatment,  assuring  him  that they should be
free from  their malady within  fourteen days
without any medicines.   On Easter day they
began to eat liver and animal food, and two of
those he had examined saw as well as ever on
the third day, and on the  following Sunday all
were completely cured.  In  these  cases,  the
application of heated vapour; the aroma and
vapour  from various stimulating substances
added to the liver; the use of a much more ex-
citing diet, after a protracted  fast,  which had
been more or less influential in  producing  the
affection ; the influence of the imagination, and
still more probably, the fact of the chief causes
ofthe complaint having ceased to be in opera-
tion, serve  to explain  the effect,  without  impu-
ting any peculiar virtue to the particular vis-
cus in question.
   11. It  is very  obvious  that  this complaint
should be treated upon rational principles, and
if the application of these to each case fail in
any one, these empirical means may be resort-
ed  to,  according  to  the  weight of evidence
which may exist in its favour.  The^r*^ inten-
tion of the physician should be to ascertain the
predisposing and exciting causes, and  to re-
move them; the  second, to observe the  exact
states of the eye, and of the head, particularly
with reference  to the presence of congestion,
or of an increased or diminished determination
of blood to  the brain, eyes, &c., and to prescribe
means appropriate to whichever of these states
may be present;  and the third should  be  to
determine  the modes  in which  the  several di-
gestive, assimilating,  and excreting functions
are being performed.
   12. The  first of these requires no remark;
but the second demands most careful observa-
tion of each case, and involves very different
if not opposite modes of cure, according to the
results which each case furnishes  to such ob-
servation.   If vascular plethora, or active con-
gestion of,  or determination  of blood  to, the
brain be present, then depletions, according to
the peculiarities of the case, are requisite.   If,
on the other hand, the vascular system indicate
insufficiency of blood, and the state of the head
a diminished flow of blood to the brain, a nour-
ishing diet, chalybeate medicines, and  tonics,
with due attention to the several digestive func-
tions, are thereby indicated.  Emetics, stomach-
ic and deobstruent purgatives alternated with
vegetable  bitters and tonics; the sulphate of
quinine or of iron with camphor; the infusion or
decoction, and the compound tincture of cin-
chona, are generally beneficial when employed
appropriately to  the  indications furnished by
each case, and ought not to be omitted, even
although the indications  of  internal disorder
may be slight.   Due regard  should  be  had  to
the state of nervous power both generally and
locally ; and while torpor of  the nerves of the
organ should be  attacked  by the application of
stimulants and irritants to the vicinity of the
eye, or even to the eye  itself, exhaustion of
nervous power should be removed by means of
the more permanent and diffusive restoratives
just mentioned,  or by others of a similar na-
ture.   With this intention the extract of mix
vomica or strychnine, or the tincture or spiritu-
ous extract of aconite, may  also be severally
but cautiously prescribed, either singly or con-
joined with vegetable bitters and tonics, or with
stomachic aperients.
  13. Of the local means, blisters applied to the
temples, and renewed according to their effects,
as advised  by Mr. Bampfield, are  among the
most efficacious ; but other  local  stimulants
may be prescribed, more particularly the warm
vapour of camphor, or of  ammonia ; embroca-
tions or liniments with  ammonia, camphor,
tincture of  capsicum, are applied on the tem-
ples, and warm collyria to the eyes themselves.
Besides these, electricity  and galvanism have
been resorted to, and with more or less benefit.
It is not improbable that an ointment contain-
ing either of the most irritant of the narcotic
vegetable alkaloids, particularly veratria, strych-
nine, aconitina, &c, may  be of service  when
applied to the temples, and the effects carefully
watched.  Errhines  and sialogogues may also
be tried.
  14. II. Hemeralopia, according to the mean-
ing which I have attached to the word (y 1),
namely, day-blindness, or imperfect vision in the
day, particularly  in sunshine, and more  perfect
or natural vision  in the  twilight, is rarely ob-
served, even in connexion  with night-blindness,
unless the latter  has  gone on to inflammation
of the inner coats of the  eye, or is associated
with inflammatory action  in the brain, or with
incipient opacity in the crystalline lens, or with
other diseases of the eye, of which affections
some degree of day-blindness is often  symp-
tomatic.  Indeed, whenever the sensibility of
the retina  is naturally acute, as in albinos (prob-
ably owing  in them to the deficiency of dark
colouring matter in this part), or is morbidly in-
creased, owing to disease  of more or less inti-
mately  related  structures, particularly  to  in- 
NOSTALGIA—.Etiology.                            1033
flammatory states of the brain, or of its mem-
branes, or  to the  more  temporary excitement
consequent upon an excessive use of spirituous
or other intoxicating liquors, then more or less
of hemeralopia is often complained of, especial-
ly in the light ofthe sun, or in any other strong
light.  Hemeralopia,  like  nyctalopia, may  be
symptomatic also of intestinal worms, and even
of hysteria. In these circumstances, it may be
viewed as  a consequence chiefly of a morbid
sensibility ofthe retina and nerves of the eye,
and generally independent of inflammatory ac-
tion.
   15. i.  The treatment of day-blindness must
necessarily depend upon the state of disease of
which it is  symptomatic.   If it proceed from in-
flammatory action, vascular depletions, and the
antiphlogistic  treatment,  cold  shower  baths,
purgatives, diaphoretics, and sedatives, are gen-
erally required, aided  by cooling  and anodyne
collyria.   If it proceed from morbidly increased
sensibility unconnected with inflammatory irri-
tation, an opposite treatment, as tonics, chalyb-
eates, and restoratives, with antispasmodics,
anodynes, and  anthelmintics, is required, with
change of  air and  attention to diet and  regi-
men.
  Bibliog. and Refer.—Hippocrates, De Morb. Vulg., 1.
vi., sect. 7.—Plautus, Miles  Gloriosus, act. ii..sc iii., v. 50.
—Celsus,L. vi.,c. 6.—C. Plinii Secund., Nat. Hist., 1. xxiii.,
63 ; 1. xxviii., 47 ; 1. xxix., 38 (Treated by the liver and blood
of goats, the ashes from the dung of fowls, &c).—Avicenna,
Canon., I. iii., fen. iii , tract, iv., cap. 3, p. 561.—F. Plater,
Praxis Med.,  t. i.,cap. 6, p. 193.—Forestus, Opera Omnia,
I. xi., obs. 38.  Franc. 1634. — D. Sennert, Opera, t. iii., 1.
i., p. iii., sect, ii., c. 44, p. 25fi.—Bontius, De Medic. Indor.,
I. iv., p. 32.— Ettmuller, Opera Omnia, 1.  ii., art. i., p. 33,
ed. London, 1701.—Boerhaave, De  Morb.  Oculor., 8vo, s.
158.—Got., 1750.—Haller, Disput., toin. i., disp. xxii., sect.
2. Laus., 1750.—Chamseru, Hist, et Mem. de la Soc. Roy.
de Med., Ann. 1780.—Flemmtng, in Hufeland, Journ.  der
Pr. Heilk., June, 1810, p. 'Z.—Bampfield, in Trans, of Med.
and Chirurg. Soc, vol. v., p. 39.—Guthrie, in Edin. Med,
Comment., vol. xix., p. 288.—Scarpa, Malatie degli Occhi,
p.252.  Pavia, 1801.—Forbes, Edin. Med. and Surg. Journ.,
vol. vii., p. 419.—Richerand, Elements of Physiology, by J.
Copland, Svo, p. 650.  London, 1829.—Demours, Diet, des
Sc. Medicales, t. xxxvi., p. 549.—Radii, Scriptor. Ophthalm.
Minor, vol. iii., p. 176-193.  Lips., 1830— E. Meissner, Be-
merk. aus  dem Taschenbuche eines Arzes,  <fec   Halle,
1819 ; and Encyclopadisches Wtirterbuch, <fec, b. v., p. 338,
Svo.  Berl , 1830.—A.  Simpson, Observations on Hemera-
lopia or Nocturnal Blindness, 8vo.  Glasg., 1829.— Ratge
Delorme, in Diet,  de Med , 2d edit., arts. Hemeralopie et
Nyctolopie.—/. Grant, in Cyclop, of Pract. Med , vol. iii., p.
184.—(Lawrence, Travers, Mackenzie, Little, &c, On  the
Eye.]

NOLI ME TANGERE.   See Lupus.
NOSTALGIA.—Synon. Nostalgia (from vooror,
   a return  home, and alyor-, sorrow), Sauvages,
   Cullen, and others.   Nostrassia, Nostomania,
   Auct. var.   Pathopatridalgia, Zwingler.  Phi-
   lopatridomania,  Harder.   Maladie du  Pays,
   Nostalgie, Fr.  Das Heimweh, Germ.  Malat-
   tia del paese, Ital.   Mother-sickness, Home-
   sickness; a morbid longing for home.
     Classif.—General Pathology ;  ^Etiol-
       ogy ; Special  Pathology.
   1. Nostalgia  is rather a cause of disease than
a disease in itself.  It has, however, been de-
scribed by several writers as a form of melan-
cholia, from which, however, it is quite distinct.
I  shall briefly  consider it, first, as a cause of
disease ;  and, secondly, as a disease  superindu-
cing still more serious disease.
   2  I ^Etiology.—If  we associate the sug-
gestions or memory of our native home or place
wrth those of many of the pendant occurren-
ces  and  the moral emotions and affections of

   '  II.               I30
which home has been the scene, what numer-
ous sources  of misery or happiness are often
thereby called into existence, more especially
if they be made subjects of contemplation or of
mental rumination in different, opposite, or less
happy circumstances than  when  they  made
their  first impression on  the mind.  How fre-
quently is the early happiness of life made the
means  of heightening present  wretchedness,
especially by the uncultivated and ill-regulated
mind, or by the  mind that is unable to  repose
upon other and more  fortifying resources.  The
suggestions of memory, in continually haunting
the mind of him who  has removed, for the first
time, from the scenes of varied enjoyments and
strong excitements, to  places remote, not only
from these, but from all other attachments, par-
ticularly if he be doomed to different avocations
from those to which he had become accustom-
ed, are among the most distressing of the nu-
merous ills that  imbitter the destiny of man.
They are less, or perhaps but little, felt by him
who becomes a voluntary exile in pursuit of
gain ;  but even he has his melancholy remi-
niscences, "when he  would not, if he could, be
gay ;" especially after the exciting delusions of
hope have lost a portion of their witching influ-
ence ;  and he, at times, with the compelled ex-
ile, experiences   those  emotions  which the
scenes of early  life and of early attachments
suggest.  The person  who  leaves his  native
abode, particularly if  it be endeared to him by
simple joys and warm affections—if it  posses
scenery of wild sublimity, or seas of stormy
grandeur ;  if he  have been accustomed to gaze
upon the one, while borne furiously along upon
the other ; if he have repeatedly escaped from
the imminent dangers of either, in order again
to experience the exciting pleasures they af-
ford ; however far, or in  whatever manner re-
moved from  such scenes and such enjoyments,
he constantly reverts to them, not only in  his
waking, but  also  in his sleeping hours.  Vis-
ions of former bliss or of former dangers haunt
him by night and  by  day.  His sleep is broken
or disturbed ; his appetite fails him; his healthy
looks vanish ; and a gradual blight overtakes
him.   In this manner persons have been known
to wither gradually, sometimes without any or-
gan evincing disease of a prominent kind ; while
more frequently some particular part, owing to
various concurring causes, experiences danger-
ous disease, to which this maladie du pays has
predisposed, and rendered almost or altogether
irremediable. Numerous examples ofthe effects
of continued longing for the scenes of early life
occur to the  medical practitioner ;  but they are
most common among the natives of the high-
lands, as those of Switzerland and of Scotland,
when they migrate to the low countries, where
this feeling is heightened by the influence of a
more depressing air upon constitutions formed
in the pure and cold atmosphere of more eleva-
ted regions.   Nor are the natives of richer and
more fertile countries, and those abounding in
peaceful occupations, without an inward pining
after the  scenes of early enjoyments and ten-
der associations when removed  at a distance
from them.   Indeed, suggestions of these haunt
the minds ofthe expatriated, whether the will-
ing or  the compelled,  and,  with an attraction
of indescribable sweetness, will not allow us to
forget our native  soil. 
1034               NOSTALGIA—Definition—Symptoms—Treatment.
   " Nescio qua natale solum dulcedine captos
       Ducit, et immemores non siuit esse sui."
  3.  Nostalgia is  most frequent among those
who have removed at an early age from the en-
dearments of near and affectionate relatives,
and from the simple pleasures of a country life,
more especially when disappointment, fatigue,
privations, and sickness overtake  them soon
after  their  removal.    It  is common  among
young soldiers and sailors who are subjected
to privations and  fatigue  in foreign climates,
particularly  if these climates be unwholesome.
The endemic influence of these climates, by de-
pressing the vital energies, both favours  and in-
creases this desire of return to the place of na-
tivity.  Campbell  has  beautifully  illustrated
this  feeling  in  the " Soldier's Dream,"  while
sleeping on the field of battle,  in  which  the
joys  and endearments of home appear to him,
and  sorrow returns to  him with waking con-
sciousness.   Home-sickness  is  also  frequent
among young persons of both sexes, who have
been  unaccustomed  to painful  impressions,
when they remove to  large cities, and are sub-
jected to the confinement  or rigorous duties of
servitude. It is rare among persons advanced in
years, and particularly among those who have
experienced the frowns or vicissitudes  of for-
tune.   Nostalgia,  although more correctly a
cause of disease than a disorder of itself, still
may be viewed in the latter sense ;  as a disor-
der consisting at first of a  morbid exaltation of
those instinctive and  moral feelings, in which
recollections of home  and of tender attach-
ments are associated with  sentiments of regret
at the loss of the endearments which those at-
tachments afforded. These feelings, when in-
ordinately exerted or long  indulged, depress,
or even further disorder the  digestive, assimi-
lating, and  circulating  functions, through  the
medium of the organic  nervous system, until
ultimately disease  of the  organs  performing
these functions, or of the  brain  itself, accord-
ing to their individual  predisposition, is pro-
duced.
II. Nostalgia.—Nostomania; Nostrassia; Home-
  sickness.
    Classif.—I. Class, IV. Order (Author).
  4.  Defin —The desire of returning to one's na-
tive country immoderately or morbidly indulged, or
recollections of home and its  endearments made the
subject of unavailing regret,'to the neglect of other
considerations and objects,  and to the injury of
health.
  5.  A. Symptoms.—The earliest signs of nos-
talgia are  unusual reserve, sadness,  distaste of
amusement and of occupation, a continual recur-
rence to the various circumstances connected
with home, and expression of regret at removal,
with a  desire  of  returning,  and of enjoying
those pleasures which the imagination is con-
stantly  presenting  in  more  glowing colours
than are real.   After some time the complex-
ion becomes pale and  anxious ; the appetite is
much impaired; the strength sinks, and  the
body emaciates. The usual enjoyments of life
and the society of  friends  or acquaintances af-
ford no distraction  from  the constant and pain-
ful rumination in which  the patient is engaged.
As the bodily functions become impaired by  the
continual  indulgence of regret, and of the  de-
pressing feelings associated with it, the mind
is more and more unable to resist a  recurrence
to the subject of distress, or to break off the
train of painful ideas.   The patient nurses his
misery, augments it until it destroys his nightly
repose and his daily peace, and ultimately de-
vours, with more or less  rapidity, his vital or-
gans.
  6. In some cases, nostalgia assumes a more
acute form and rapid progress—nostomania—
with cerebral irritation or excitement, present-
ing inflammatory characters.   The ideas con-
nected with home present an unreal form or a
state of  exaltation amounting  almost to delu-
sion.   The head Becomes hot; sleep entirely
departs; the pulse is accelerated ; and headache
is complained of; and ultimately somnambu-
lism,  or  more complete mental derangement,
may supervene.  After this state has continued
for some time, or in various grades of excite-
ment or modification of phenomena, more or
less complete collapse of the functions of the
brain and of the powers of life  may take place,
and the patient die in the course of a few weeks,
as in cases described by M. Larrey.  In some
instances the patient sinks into a state of ma-
rasmus, with symptoms of low nervous or of
hectic fever ; and in others the complaint pass-
es into phthisis, disease of the lungs being de-
veloped during the continuance of the nostalgia.
  7. When nostalgia occurs during the prog-
ress of other diseases, the complication ren-
ders the  state of the patient often very critical,
heightening the severity of the primary com-
plaint, and either opposing or entirely prevent-
ing convalescence.   In these  circumstances,
indulgence of the hopes of return to the scenes
of early  happiness becomes necessary to the
prevention of fatal results.      «
  8. B.  The diagnosis of real from feigned nos-
talgia is  sometimes  required.  The former is
attended not only by sadness, moroseness, va-
cuity, or absence of mind and love of solitude,
but also by remarkable pallor ;  by a rapidly pro-
gressive  emaciation and  debility, and by in-
creased heat of the  forehead.   If accidental
mention  is made ofthe place or persons ofthe
patient's attachment, his countenance becomes
suddenly animated ;  his cheeks assume a tem-
porary flush, and his eyes are brilliant.
  9. C. The appearances after death from nostal-
gia are stated by M.  Begin to  consist of signs
of vascular irritation in the superior and ante-
rior parts of the  brain, and more particularly in
the pia mater and  arachnoid covering them.
These signs generally consist  of injection of
the capillaries of these parts ;  the effusion of
an opaline serum in  the meshes  of the mem-
branes ;  slight  induration or softening of the
cerebral substance, and effusion of serum in the
ventricles.   These changes are constant; but
other viscera also often betray disease, espe-
cially the lungs, the digestive  canal, and the
heart; and, in some cases, one or other of these
organs present the chief alterations.
  10.  D. Treatment.—Nostalgia requires more
of moral than of medical treatment.  Kindness,
encouragement, and exciting hopes of soon re-
visiting the scenes for which the patient longs,
are generally of the  greatest service.   Varied
amusement, pleasant occupations,  and every
means which may distract the mind  from the
indulgence of feelings of regret, should be re-
sorted to.   Music, dancing, gymnastic exer-
cises, theatrical amusement, exercise  in the 
OBESITY—Definition of—Characters.
1035
open air, hunting, coursing, &c, may be em-
ployed  according  to  circumstances.   All  allu-
Bions which may suggest the subject of the pa-
tient's  misery should be avoided ; but the  soci-
ety of persons from the same place may be en-
couraged, as the  griefs of the patient may be
allayed by the encouragements and the happi-
ness of his  associates.
   11. If indications of cerebral excitement ap-
pear, the tepid douche,  and subsequently the
cold affusion on the  head, or the shower  bath,
and the promotion of the several secretions and
excretions,  should be  recommended.   If the
above  means fail, and  when a return to home
can be accomplished,  this most certain of all
remedies should not  be neglected.   It will suc-
ceed even when death is apparently approach-
ing,  provided that the lungs  have not under-
gone structural  change.  In the cases of young
soldiers,  even  a  temporary  return to  their
homes, or leave of absence from their corps,
has been productive  of a salutary influence.
   Bibliog. and Refer.—/. Harderus et /.  Hoferus, in
Halleri, Dissert, ad Med. Pert., 4to, vol. i. ;_Pensees d'un
Allemand sur la Nostalgie, <fcc, 8vo.  Jense, 1754.—R. Ham-
ilton, in Edin. Med. Commentaries, vol. xi., p. 343.—Guer-
bois, Essai sur la Nostalgie, 8vo.  Paris, 1803.—C. Castel-
nau, in Journ. de Med., t. xii., 8vo. Paris, 1806.—Therrin,
 Euai sur la Nostalgie, 4to.  Paris, 1810.—/. L. Paugnet,
 Dissert, sur la Nostalgie,  4to.  Paris, 1815.—Percy et Lau-
 rent, Diet,  des Scien.  Med.,  t. xxxvi , p. 271. — /. Zaugerl,
 Ueber das Heimweh, 8vo.  Wien., 1824. — Begin, Diet, de
 Med. Prat., t. xii.,  art. Nostalgie.
 OBESITY.—Syn. Obesitas.  UoZvaiipnia (from
   irokv,  much,  and  cup',  flesh).  Corpulentia,
   Pliny.   Polysarcia, Sauvages, Vogel, Sagar.
   Polysarcia adiposa, Sauvages, Good.   P.  fa-
   ginosa, Forestus.   Phanigmus plelhoricus ;
   Empymelium  polysarcia, Young.   Obisite, cor-
   pulence, embonpoint excessif,  Fr.  Fette, Vollei-
   bigheit, Germ.   Obcsita, Ital.  Obesity, Cor-
   pulence, Morbid fatness.
     Classif.—III. Class, II. Order (Cullen).
       VI.  Class, I. Order (Good).   I. Class,
       IV.  Order (Author).
   1. Defin.—An accumulation of fat under the
 integuments, or in the  abdomen, or in both situa-
 tions,  to such an amount as to  embarrass the sev-
 eral voluntary functions.
   2. I. Characters.—A certain degree of  fat-
 ness is quite compatible with health, especially
 in some persons  of the sanguine temperament.
 Other persons, also, as  well  as these, may be
 lean or fat, at  different epochs of life, without
 any marked difference in their states of health.
 As long, however,  as their  general health is
 not impaired, and the  fatness does not amount
 to a morbid pitch—to absolute obesity—nor im-
 pedes the functions of life and volition, it can-
 not be viewed  as a morbid condition.   Obesity
 may occur  at  any period of life ; it may even,
 in a slight degree, be congenital.  Infants often
 are remarkably fat while they are at the breast,
 the fat being deposited chiefly under the integu-
 ments ;  but after two  or three years of age they
 become  gradually  thinner, owing to the exer-
 cise they are then enabled to take.   Obesity in
 childhood is often the result of overfeeding and
 of hereditary  predisposition; and  in «•">"»-
 stances  it  continues  to m*^*™"*™?
 through the several periods of childhood    It is
 unnecessSry to  adduce remarkable  instances
 of obesity in childhood and early life.  Several
 such cases are noticed by Mr. Wadd, M. Kaigl
 dTlorme  and  Dr. Williams.  They present no
very remarkable phenomena, excepting an un-
usual degree of muscular strength for that age,
the obesity of youth differing in  this from the
obesity of advanced life.
  3. With the progress of age, and as the gen-
ital organs are  developed, the youthful plump-
ness of the body is diminished, the activity of
these organs  increasing all the nutrient and ex-
creting functions,  more  particularly  in males.
The absence  of the testes in eunuchs, and,  in-
deed, castration of any of the lower animals,
has a remarkable influence in favouring obesi-
ty.   As age advances, especially after the for-
ty-fifth or fiftieth year, when the genital organs
lose much of their activity, the tendency to an
inordinate accumulation  of fat in  the  ceconomy
is most remarkably evinced ;  although various
circumstances, as impairment of general tone
and vigour, confinement, and want of exercise,
the states of the locality and climate, may hast-
en it, and opposite circumstances delay or pre-
vent it.  After the fortieth year, the  indulgen-
ces of the appetite for food are more frequent,
and active physical exertion is either diminish-
ed or in a great measure laid aside.  Many of
the active  pleasures of early life are then, or
soon afterward, superseded by other  duties, or
by the sedentary occupations of  life ; while in
females, the peculiar functions they have to dis-
charge, the changes to  which they  are liable
with the advance of age,   and  the  various
changes  contingent on child-bearing  and suck-
ling, tend remarkably to produce obesity.
  4. The situations in which  fat  is most liable
to accumulate  to  an  inordinate amount are in
the  subcutaneous tissue, in the interstices be-
tween the muscles, in the omentum and mesen-
tery, under the pericardium, around and under
the kidneys, in the mediastinum, and around
the mammary glands.  In cases of the more
sthenic forms of obesity (t) 9), the deposition of
fat is general, or presents a certain relative pro-
portion in these and other places where it usu-
ally accumulates; and,  unless  the accumula-
tion is excessive,  the functions of the body, ex-
cepting those of volition, are not materially im-
peded.  But when obesity becomes truly great
even in these,  and still more remarkably in the
asthenic  form,  and in  more cachectic or leuco-
phlegmatic habits, volition, respiration, and cir-
 culation are  remarkably embarrassed, especial-
 ly upon attempts at physical exertion, and upon
 mental emotion ;  the digestive, assimilating,
 and excreting functions being both primarily
 and consecutively impaired.
   5. In  many  cases, particularly of morbid ac-
 cumulations of fat, the obesity is partial. This
 is  most frequently observed in  the  omentum,
 giving the appearance termed a pot-belly, in the
 mammae, neck, in the abdominal parietes  and
 nates, or haunches of females, and around the
 kidneys.   In a very remarkable case of fatness
 in a female between fifty and  sixty years of age,
 and in  which death occurred  from  internal
 strangulation of the intestines,  under the care
 of Mr. Jones  and the author, remarkable  col-
 lections of fat into bag-like masses or tumours
 were  observed to be attached to, or rather to
 hang  down from  each axilla ; the fat under the
 abdominal parietes being about six inches deep.
 Instances of partial fatness of a strictly mor-
 bid kind are met with also in other  situations.
 The  most remarkable,  and  at the  same time 
1036
OBESITY—Causes—Description—Asthenic.
 the most dangerous of these, is the accumula-
 tion of fat in the parietes of the heart, where
 it occasions atrophy,  softening,  pallidity,  and
 weakness ofthe muscular fibres, favouring pass-
 ive dilatation and even rupture of the cavities.
 (See art. Heart, $  227, et seq)
   6. The amount of obesity varies remarkably ;
 and  it is often difficult to draw a line between
 the fatness consistent with health, and that
 which may be viewed  as morbid.   The transi-
 tion from the one to the other is gradual,  and
 the progress to the latter, as well  as its more
 unequivocal existence, is characterized by im-
 paired vital energy and tone, as manifested par-
 ticularly by the digestive and assimilating func-
 tions.   The  fat usually  found in the healthy
 body  has  been estimated at various amounts,
 from one tenth to one  fifteenth of the weight of
 the body.   In extreme cases of obesity, the fat
 may constitute two thirds or four fifths of the
 entire weight.  Mr. Lambert weighed 52 stone
 11 lbs. ; and in his case, probably  the propor-
 tion of fat to the other parts  of the body was
 even greater than that just assigned.
   7. In the  medical consideration of obesity  it
 is requisite  to view the accumulation of fat as
 merely a part—a part more or less prominent—
 of functional disorder, and even sometimes of
 more serious and extensive disease.  The ex-
 ternal and physical characters which the obe-
 sity presents, and the  various phenomena and
 functional aberrations  with which it is associ-
 ated, will generally indicate not only its path-
 ological sources, but  also  its probable  conse-
 quences ;  and point out the kind and extent of
 professional interference, and of personal man-
 agement it may require, as either an incipient,
 an advanced, or even  an almost irremediable
 constitutional mischief.
  8. There  are several points to which atten-
 tion should  be directed in estimating the char-
 acter,  tendencies, and probable consequences
 of obesity, as furnishing the basis of a rational
 treatment of it.   These are the evidences fur-
 nished ofthe states  of vital power as manifested
 chiefly in the digestive,  assimilating, and  ex-
 creting functions ; of the conditions of the res-
 piratory and  circulating organs,  and of  the
 blood ; ofthe muscular structures and actions,
 and  of the  general surface and appearance.
 The pathological conditions and tendencies of
 a case are indicated by them ; and in propor-
 tion as these are impaired, so is the health de-
 teriorated, whatever may be the amount of obe-
sity.   According to the states of these func-
tions and organs, obesity has been divided into
sthenic and asthenic, the transition from the ex-
treme of the former to  the extreme of the lat-
ter being gradual, and presenting no break.
  9. a. When the organic or strictly vital func-
tions are not materially  impaired ; when the res-
piratory and circulating actions proceed without
material disorder, unless  upon physical  exer-
tions which  obesity may embarrass  or impede;
 when the blood is  not apparently deficient in
quantity or quality ;  when the muscles are not
 emaciated nor deficient in firmness or power;
 and when the countenance and general surface
 retain their usual appearances or a healthy hue,
 the sthenic character is  present; and in propor-
 tion as these evidences are furnished, in like
 proportion this state of vital manifestation ex-
 ists.   It is  of the  utmost  importance,  as re-
spects not only obesity itself, but also the treat-
ment of diseases  which occur in fat  persons,
that the states of vital power, and of the circu-
lation, particularly  as  regards the quantity of
the blood, should be correctly estimated.
   10. b. In proportion to  the departure  from
these states of healthy function, as the vital
powers become impaired ; the respiration short,
puffing, or asthmatic ; the circulation  embar-
rassed ;  the blood deficient, watery, or dark;
as the muscles are weak, flabby, or emaciated,
and the  fatty accumulations soft  or leuco-
phlegmatic ; and as the countenance becomes
bloated, the surface sallow, or of an unhealthy
hue, so obesity, however great it may be, should
be viewed as being asthenic, and more especial-
ly morbid as regards its existence and its con-
secutive states.  In this form of obesity, inter-
current visceral or internal disease  often pur-
sues a rapid and unfavourable course; and the
inexperienced  practitioner, misled by the  fat-
ness and apparent  vascular  fulness  of  the pa-
tient, is often induced to take away a part of
the already deficient blood.  I have  on several
occasions met with such  occurrences, the re-
markable deficiency of blood being evinced, on
dissection after death, by the blanched state of
the viscera and structures.   In all cases of as-
thenic obesity, lowering or depletory measures
are not well endured, even in the treatment of
acute diseases affecting subjects thus  circum-
stanced ; or. if at all  adopted, they  should be
aided by derivative and restorative means.
   11. II.  Causes.—The causes of obesity are
chiefly predisposing, for, unless the predisposi-
tion be strong, the exciting causes are generally
inoperative.—a. The  predisposing causes  are,
chiefly, a peculiar  diathesis, temperament, or
habit of body hereditarily transmitted ;  inactiv-
ity, indolence, and quietude of body and mind ;
a lively, happy, and sanguine disposition;  sed-
entary occupations, and a heavy or insufficient-
ly pure or renewed air.   Where the  hereditary
predisposition  is strong, moderation  in both
food and drink will not prevent obesity, unless
very active exercise be taken, or even great or
continued exertions may be  made in the open
air; and where no such predisposition exists,
large quantities of  food and  drink may be ta-
ken without any change from a state of lean-
ness. The constitutional predisposition  to obe-
sity  varies  much   in its  character, with the
state of the powers of life, and with the con-
formation of the  frame.   Persons  of  strong
conformation, of the  sanguine  temperament,
and  of good health, if fully and richly fed—if
they partake of much oily and carneous food,
and  of malt or vinous liquors—often  become
fat, although they  take much exercise, espe-
cially when they advance in age, or live in the
close air of towns ; and if  these persons, after
having had the advantage of active exercise in
the open air in early life, are  obliged to forego this
advantage, and are devoted to sedentary occu-
pations, obesity sooner or later overtakes them
—sometimes with  great rapidity,  if they live
thus fully and richly. But in them obesity gen-
erally presents more or less of the sthenic char-
acter, unless their general health has been pre-
viously injured, or their confinement to an in-
sufficiently renewed air has been close or pro-
longed.   Others, who take considerable exer-
cise, enjoy good health, and eat heartily of nu- 
OBESITY—Pathology.                             1037
tritious  food, become fat, although not in  re-
markable excess ; and in them obesity always
presents the sthenic  character.
  12.  In persons of a weak or lax fibre, of a
leucophlegmatic temperament, and weak vital
or constitutional powers, obesity  is frequently
hereditary;  and is apt to  occur, even without
this predisposition, if they enjoy in abundance
the necessaries and luxuries of life ; but it al-
ways  assumes an asthenic or atonic form.  In
these, the appetite is generally much  greater
than the powers of complete digestion and as-
similation ; the pulse is soft, languid, and weak,
and the excretions are scanty.  Obesity often
occurs in  those who have been  weakened by
excesses,  by long  confinement in a close  at-
mosphere, or by disease, and is frequent in  the
advanced periods of life, and in those of a  ca-
chectic  habit of body.   It occasionally is con-
sequent upon torpor and chronic disease ofthe
liver, and  upon protracted dyspepsia; and in
some instances it  is attendant  upon scanty
menstruation, partial  anaemia, and slight chlo-
rosis  in young females.  In these cases more
particularly, the muscles are pale, flabby, and
wasted, in proportion to the  accumulation of
fat, which is soft, flabby, or semifluid.
   13. b. The more immediate or exciting causes
of obesity are sufficiently obvious ; is generally
a full and rich diet, and a life of ease ; the par-
taking of food and liquors beyond what is requi-
site for the  waste and wants of the economy,
for the amount of exercise which  is  taken.
Soldiers and sailors  do not become obese  du-
ring a campaign ; but change their duties, give
them plenty of rest, or make them landlords of
inns,  butlers, butchers, &c, and more than one
half of  them would soon  be corpulent.  It is
the quantity more probably than the quality of
the food which  fattens ; still, many substances,
particularly  such as are oily  and saccharine,
promote obesity more remarkably than others.
Fat  meats,  butter, oily vegetable substances,
milk, saccharine, and farinaceous substances
are the most fattening articles of food ;  while
malt  liquors, particularly rich  and sweet  ale,
are of all beverages the most conducive to the
same end.  The fattening  effect of figs  and
grapes,  and  of  the  sugar cane, upon  the  na-
tives  of the countries where  these are  abun-
dant, are well known.   In various countries in
Africa and the East, where obesity is much ad-
mired in females, warm baths, indolence,  and
living upon saccharine and  farinaceous arti-
cles, upon dates, the nuts from which palm oil
is obtained, and upon various oily seeds,  are
the means usually employed  to  produce this
effect.  Among the Asiatics, farinaceous arti-
cles, sugar,  sweetmeats, milk, butter,  and ve-
getable  oils, are chiefly indulged in with this
object.
  14. Many years ago  I  was consulted by a
lady who, at the early age of about thirty-six
years, had become excessively corpulent;  and
the circumstance of her having diminished the
quantity of her food to the utmost extent, her
obesity  still  increasing notwithstanding,  had
rendered her more anxious respecting it   Af-
ter various  inquiries  respecting her modes of
living, it appeared that she partook of very lit-
tle ofthe usual articles of food, and of none of
fie fermented  or  distilled beverages,  but  she
lie  veryTarge quantities  of white sugar, to
which she had taken a great liking.  The cause
was  now  obvious, as was the cure.  The in-
fluence  of malt liquors, particularly  such as
abound most in saccharine matter, is very man-
ifest.  Instances in proof of this influence, cal-
culated  more to amuse  than  to  instruct, have
been adduced by Wadd  and others.
  15. Rest, indolence, ease of mind and body,
too much  sleep, sleeping after a full meal, too
much food, and indulgence in any  kind of vi-
nous, spirituous, or malt liquor, are the  chief
causes of  obesity, the predisposing and consti-
tutional causes ($11) imparting to  it the dis-
tinctive  characters of sthenic and asthenic above
assigned to it.
  16. III.  Pathology.—I  have  briefly stated
the nature of obesity in the article  on the pa-
thology  of the Adipose  Tissue  (t) 3); and my
views, there exhibited, are in accordance with
those since published by  Liebig, in some  re-
spects,  but different from them in  others, as
he imputes too much to chemical affinities or
actions, and keeps out of view  the  controlling
influence of vitality.   The abnormal condition,
according  to  Liebig, which occasions the de-
posite of fat in the animal body depends upon
a disproportion between the quantity of carbon
in the food, and that of oxygen absorbed by the
skin  and lungs.  In the normal condition, the
quantity of carbon given out is exactly equal to
that which is  taken  in  with the food, and the
body acquires  no increase of weight from the
accumulation of substances containing much
carbon and no nitrogen.  If we increase the
supply of highly carbonized food, then the nor-
mal state  can be preserved only on the condi-
tion  that by exercise  and labour the waste of
the body is increased, and  the supply of oxygen
augmented in the  same proportion.   The pro-
duction  of fat is always  a consequence of a de-
ficient supply of oxygen,  for  oxygen  is  abso-
lutely indispensable for the dissipation of the
excess  of  carbon in  the food.  Liebig farther
argues that, since  in  all fatty bodies there are
contained, on  an average, only 10 equivalents
of oxygen for 120 equiv.  of carbon, and  since
the carbon ofthe fatty constituents ofthe ani-
mal body  is derived from the  food,  seeing that
there is no other source whence it  can be de-
rived, it is obvious, if we suppose fat  to be
formed  from albumen, fibrin, and caseine, that,
for every  120  equivalents of  carbon deposited
as fat, 26  equivalents of oxygen must be sep-
arated from the elements  of these substances.
And farther, if we conceive fat to  be formed
from starch,  sugar, or sugar  of milk, that for
the same  amount of carbon there must be sep-
arated 90, 104, and 110 equivalents of oxygen
from these compounds respectively. There is,
therefore, but one  way in  which the formation
of fat in the animal body is possible, and that
is, a separation of oxygen from the  elements
of the food.   Thus he  infers that the surplus
of oxygen, or the oxygen disengaged during
the conversion of food into fat, goes to the sup-
port of respiration, and to supply, in  part, the
oxygen  which is too sparingly furnished by res-
piration.
   17. There may be much  truth in these views ;
they are probably true in part; but Liebig does
not  sufficiently estimate  the influence of the
vital power in producing and  controlling the
combinations  of the animal elements,  while 
1038                              OBESITY—Treatment.
these  elements  and  their  combinations  are
within the sphere of this influence.   The va-
rious changes which the food undergoes from
the moment of its mastication are produced by
this influence, aided by the secretions poured
into the alimentary canal, in the first instances,
and by the oxygen of the atmosphere  subse-
quently, when the  product of digestion is con-
veyed into the circulating system.
  18. But Liebig states, that " the most deci-
sive experiments of physiologists have  shown
that the process of chymification is independent
of the vital force ;  that it takes place in virtue
of" a purely chemical action, exactly similar to
those processes of decomposition or trans-
formation which  are known  as putrefaction,
fermentation, or decay."  Now we have  here
to take M. Liebig's word for the decisiveness
of the experiments to which he refers ; for he
has  neither  adduced  nor  referred to  any of
them.  The  fact  is,  that  these  experiments
prove the converse of  his  proposition ;  and
common  sense and observation prove it  still
more strongly, for we  have,  from  all these
sources, every reason  to infer  that the quanti-
ty,  and probably also the quality of the  gastric
juice, are influenced by the states  of vital and
organic  nervous  power.  That the  action of
the gastric juice upon the  masticated food is
identical, neither with fermentation, nor with
putrefaction, nor with  decay, is most probable;
that it is somewhat similar to each, or to all,
may be admitted ;  but that it  is purely chemi-
cal, as  inferred  by Liebig, requires  farther
proof.  That the gastric juice  exerts a  certain
degree of action when it is removed from the
system,  is no  proof that this  action  is either
purely chemical, or entirely independent of vi-
tal influence ;  for  it is  sufficiently shown  that
all  the recrementitious secretions possess a
certain emanation or endowment of vitality,
which is  soon  dissipated ; and as soon  as it is
dissipated, decomposition supervenes.   That a
transformation takes place in  consequence of
the admixture of the gastric  juice with the
food  is all that we know ; that  this transforma-
tion  may be  fermentive, or  putrefactive, or
chemical, as respects certain of  its  aspects,
may  be  admitted; but that it is  neither the
one nor the other  altogether, that it is peculiar
in many respects, and that  it  is influenced by
the states of vital and organic nervous power,
are  sufficiently manifest on a comprehensive
view of the Subject.  That the gastric juice
acts to a certain extent upon food enclosed in
perforated balls, or even when entirely removed
from the  stomach, so as even  to give the food
the appearance of chyme, may even be conce-
ded ; but that the  change is complete, or alto-
gether such  as  it would have been if it had
been subjected to the vital influence  of the
stomach and duodenum, in the natural process
of digestion, is not proved.*

  *  Cit is well known  that MM. Liebig and Dumas differ
in opinion on this subject ; for while  the former believes
that graminiverous animals produce fat out of sugar and
starch, the  latter considers  it a fixed rule  that animals, of
whatever kind, produce neither fat nor any other alimenta-
ry substance ; that they receive from the vegetable kingdom
all  their aliments, whether it be sugar, starch, or fat.
The French committee on gelatin, he  states, have proved,
beyond all  doubt, that the  animals which  eat  fat are the
only ones in which fat is found to accumulate in the tissues.
There can  be no dispute, however, that, as Liebig main-
tains, the food which has a decided influence in the forma-
  19. IV.  Treatment.— The  indications  and
means of cure are, in many cases, very obvious
and easily  prescribed ;  but they are rarely even
partially adopted, and still more rarely adopted
in all their parts by the patient.   Temperance in
eating and drinking, and active exercise in the
open  air, the  avoidance of the chief causes of
obesity,  are easily insisted  on ;  and proofs of
the efficacy of the  recommendation are suffi-
ciently strong.   But the patient, however well
he may  be convinced  of the propriety of this
advice,  has seldom  strength of resolution to
adopt it, particularly as respects the curtail-
ment of those pleasures furnished by the palate,
the indulgence of which become only the more
inveterate as  we advance in age, and which are
the last  of the sensual gratifications which are
relinquished.
  20. A. In the more  sthenic forms  of obesity,
all articles abounding in fat or oil should be re-
linquished, and lean and white  meats, the light-
er kinds of fish,  brown or rye bread, turnips,
greens, and others of the less  nutritious vege-
tables, ought  to constitute the chief diet; and
even these   should  be  taken  in moderation.
Active  exercise,  particularly on foot, or on a
rough trotting horse,  gymnastic amusements
and  exercises, and the shower or cold bath,
followed by  active frictions of the limbs and
trunk by the  patient himself, are also most im-
portant  parts of the treatment.  Early rising
and  exercise  before breakfast, and a moderate
indulgence in sleep, avoiding it after dinner or
during the day, ought also  to be enforced.  The
treatment of  this form of the complaint is alto-
gether  regimenal, little  or  no  medicine being
requisite  beyond what  may be  necessary to
preserve the  secretions and excretions free, or
to control injurious local determination of blood
as it may occur.   It  has, however, been rec-
ommended to impair the appetite by giving the
patient nauseating doses of antimony, of squills,
or of ipecacuanha.  The  last of these is the
safest, and it only should be employed if a  re-
course to  this  indication be determined upon.
But  it is much safer to trust altogether to tem-
perance and  exercise  than to other  means,
tion of fat in animal bodies is that which is richest in starch,
sugar, and other  substances of a similar constitution.  Thus,
rice,  Indian  corn,  pease, linseed, potatoes, beets, dec, ara
used in husbandry in large quantities, with great effect, for
fattening, that is, for the increase of flesh and fat.  Beer,
which is  known to have a fattening effect, according to
Liebig, contains no oil.  Rice contains from 0-13 to 1*05
per cent, of  oil; pease, about 1 per cent.; potatoes, yWxir
of their weight;  hay, nearly 2 per cent of fatty matter, &c.
Liebig has  undertaken to show that  hay ought to contain
7 per cent, of fat, to account  for the amount of butter which
is often obtained  from milch  cows ; whereas, M. Dumas un-
dertakes  to  show that the  ox which  is fattened, and  the
milch cow, furnish a smaller quantity of fatty material than
the fodder contains.—(See  Pereira, On Food and Diet,
Am. ed., p. 273.) "In regard to the  principle of M. Du-
mas," says Liebig (Ed. and Lond. Phil. Mag., July, 1843,
p. 25-6), " that  the organism of an animal is not able to
produce any substance serving as food, it is equivalent to
saying that the organism produces nothing, but transforms
it; that no combination takes place in its body, when the
materials  are not present by means  of which the meta-
morphosis originates. Thus, the  formation of  sugar of
milk in the bodies of carniverous animals cannot take place,
for dog's milk, according to Simon, contains no sugar of
milk.  Thus, also, fat cannot be  produced in their organ-
ism, because, besides fat, they do not consume  any non-ni-
trogenous food.  But starch, gum, and sugar contain, even
with  this large  quantity of oxygen, all the ingredients of
fatty bodies ; and the formation of butter in the body of the
cow,  and of  wax in that of the bee, leave hardly any doubt
that sugar, starch, gum, or pectin furnish the carbon for
the formation of  the butter or of the wax."—(Loc. cit.)l 
CEDEMA—Definition—Passive.                          1039
which may be productive of disorder.  If the
appetite be  painfully craving in the  intervals
between  meals, the patient  may  take a cam-
phor lozenge or chew a small piece of camphor
with advantage ; but smoking cigars or tobac-
co of any kind, although often efficacious, is
ultimately injurious to  the digestive functions
and nervous system.  It is preferable to endure
hunger for a time:  after some days this sen-
sation will become less urgent, and abstinence
be more easily tolerated.
  21. A recourse to acids, whether mineral or
vegetable, in order to reduce or to prevent obe-
sity, is generally injurious, especially if persist-
ed in for  a period sufficiently long to produce
this  effect, and is apt not only to injure the di-
gestive  organs, but also to  favour the occur-
rence of  disorders of the urinary organs,  and
of rheumatic  and gouty  affections.   The  em-
ployment of soap and  alkalies, as advised by
Dr.  Flemyng, is,  upon the  whole, safer than
the use of acids, particularly in the gouty and
rheumatic diatheses.   But the prolonged  use
even of these is liable to induce chronic disor-
ders of the kidneys and bladder.
  22. B. The treatment of*asthenic obesity should
depend mainly upon the disorders of the digest-
ive  and assimilating organs, with  which it is
often associated and as often the result.   In
females this form  of obesity  is frequently com-
plicated with disorder of the uterine organs,
and  hence attention ought to be paid to  this
circumstance.   In this state of the complaint,
also, temperance and exercise in the open air
are  the most important parts of the treatment.
When the  liver is torpid,  the  nitro-muriatic
acids may  be prescribed,  or Plummer's pill
with soap, the bowels  being duly regulated by
means of stomachic aperients or purgatives.
The same means may be employed if the liver
should be inferred to be enlarged or  obstruct-
ed,  or the iodide of potassium  may be taken
with liquor potassae, and the compound decoc-
tion of sarza.  In some cases the preparations
of iron may be given, particularly the tincture
of the sesquichloride, or the alkaline prepara-
tions of iron.   In  most  instances  of asthenic
obesity, change of air,  travelling, and a course
of mineral waters suited to the peculiarities of
the case,  as the alkaline, the chalybeate, or the
saline, as circumstances may require, should
be recommended, and aided by suitable diet and
regimen.
  Bibliog. and Refer.—H. Hoffmann, Thesium Medico-
rum  Semicenturia de Pinguidine, 4to.  Altd., 1B74.—Ett-
muller, De  Corpulentia nimia, Opera, 4to.   Lips.,  1681,
Pars, ii., p.  878.—/. E. Schapper, Epist.  de Obcsitate ni-
mia,  Opera, 4to.  Rost., 1701.—Kuehn, Nova Act. Academ.
Natur. Curiosor., t. i.,p. 225.—Fr. Hoffmann, Opera, Suppl.,
t. ii., p. 537, fol.  Halae, 1718— T. Short, Discourse on Ihe
Causes and Effects, Prevention and Cure, of  Corpulency,
Svo.  Lond., 1727.—/. C. Pohl, in  Halleri, Disput. Anat.,
I. iii.  Laus., 1734.— M. Flemyng,  A Discourse on the Na-
ture,  Causes, and Cure of Corpulency, Svo.  Lond., ""60.-"
G. Baker, in Med. Transact, of Coll. Phys., vol. n., p. 259.
-W. X Jansen, Abhandlung von dem Thienschen Fette,
Bvo.  Hala), 1786.—/. Tweedie, Hints on Temperance and
Exercise in the  Case of Polyscarcia, 8m  Lond., 1,99 -
Dupuytren,  in Journ. de Med., &c, Oct., 1806, t. x.i., p. 262.
-L. Maclean, Inquiry into Hvdrothorax, <&■*»];> Svo^ Sud-
bury,
Paris
bury, 1810.-A. Maccary, Traite sur la Polysarcie, 8vo.
Paris 1811 —Cursory, Remarks ou Corpulency, by M. K. C
5K?  W  Wadd), Svo.  London, ItilZ.-Percy et Laurent,
in L^c  .^s Sc Med., t. xxxvii., p. 1.-^. Wadd Cursory
Remarks on Corpulency or  Obesity, Svo.  London 1822 ;
and  Comments on Corpulency, Lineaments of Leanness,
Ac, 8v...  London, l82<i.-Raige-Delorme, D ct. de M6de-
cne, t. xvi., art. Polysarcie.-Willtams, Cyclop,  of Pract.
Med., vol. ii., p- 189.
CEDEMA —Syn.  Oidnua (from oideu, I  swell),
  Dioscorides.  (Edema, Sauvagas, Vogel, Sa-
  gar, &c.  Leucophlegmatia, Plater.   Ecphyma
  adematicum, Young.   (Edeme, QHdematie, En-
  flure, French.  Geschwulst, Wassergeschwulst,
  (Germ.  Edema, Ital.   Puffing,  watery swell-
  ing, &c.
    Classif.—IV. Class, IV. Order  (Author).
  1. Defin.—A swelling occasioned by the effu-
sion or infiltration  of water or serum in cellular
structures.
  2. Although the sub-cutaneous cellular tissue
is most frequent, it is not the only seat of cede-
ma.  Slight effusion of serum is also occasion-
ally observed in the sub-mucous and sub-serous
cellular tissue, and in the cellular parenchyma
of the viscera.  CEdema of the sub-mucous or
sub-serous cellular tissue  seldom gives rise to
symptoms of sufficient importance to point out
the nature of the lesion.  (Edema, however,
of certain of the most important organs, may
be recognised during the life of the patient, es-
pecially cedema of the glottis (see  art. Larynx,
t) 67)  and cedema of  the lungs (see art. Lungs,
$ 166).   (Edema ofthe brain is not so readily
recognised,  and is  of much rarer occurrence
than that of the lungs, and is chiefly  observed
in the insane, particularly  in  the subjects of
general insanity, in  its more chronic  and apa-
thetic states.   In whichever situation cedema
may occur,  it presents  either a passive or an
active character.
  3. A. Passive cedema—the cold cedema of some
authors—proceeds from the retardation or sus-
pension  of the circulation either of the veins
or of the absorbents, or from impaired or im-
peded action of the heart, and consequent in-
terruption ofthe venous circulation.—a. It may
arise  from obstruction or obliteration  of one or
more veins ; from a  varicose state ofthe veins;
from  preserving for  too long a period  the same
position,  the physical  overcoming the vital in-
fluence, as in standing for a long  period ; from
a weak action of the  heart; from want  of ac-
tion of the muscles, whereby the venous circu-
lation is unaided, as observed in cases of palsy,
which is often attended by oedema; from a thin,
watery, or morbid state of the blood, often con-
nected  with deficient  tone of the organic ner-
vous system, as in  chlorosis, scurvy, &c.; or
from the superabundance of water in the blood,
as  in granular and  other diseases of the kid-
neys, and in suppression of the cutaneous per-
spiration.
   4.  b. On examination after death, the volume
of the part is found  increased by the exhalation
of serum in the meshes of the cellular tissue.
The  surface  of the swollen part is  generally
pale ; and,  upon  incising the  part, the  serum
escapes in a fluid state ;  but sometimes, partic-
ularly when the serum is albuminous, it is re-
tained  in the cellular meshes, and presents  a
gelatinous appearance.   The  same characters
are observed in all cases of passive cedema of
the cellular,  sub-cutaneous, sub-mucous, and
sub-serous  cellular tissues.  Passive  cedema
of parenchymatous organs increases the bulk
of these  organs, but in other respects presents
the same appearances as those just mentioned.
The  structure of the oedematous organ is some-
times  a  little  discoloured, and  when  firmly
 pressed by the finger  it retains the impression,
as observed  in  cedema of  the sub-cutaneous 
1040              CEDEMA—Treatment—Bibliography and References.
cellular tissue.   When incised, the divided sur-
face permits the escape of the effused serum in
drops;  but when the serum is pressed out, the
parenchyma of the organ  presents no farther
lesion than rarefaction by the evacuated fluid.
  6. c. The symptoms of passive  or cold  otdcma
readily distinguish it from  active or warm cede-
ma  (v 6).  The pallor and coldness of the sur-
face, the depression following the pressure of
the finger, the state  of the pulse, and the ab-
sence of febrile action, are sufficient to point
out the  passive  form  of this lesion.  The na-
ture of the  obstruction causing the cedema is
sometimes  indicated by  the  appearances pre-
sented by the  cedematous part: thus, when the
obstruction is in the veins in the  vicinity of the
part, the superficial veins are often distended.
When the obstruction is remote or central, or
when the cedema is produced by the state of
organic  nervous power,  or of the blood, this
condition ofthe  superficial veins is not observ-
ed,  and the  surface is generally pale.  The seat
of the oedema, also, often points out the obstruc-
tion occasioning it:  thus, cedema of the face,
commencing  generally in the eyelids, is com-
monly caused by obstruction to the circulation
through  the  heart, particularly its  left side,
and is frequently consequent upon hydrothorax,
caused by this lesion, and upon congestive in-
flammation of both lungs.  (Edema of the low-
er extremities most commonly follows obstruc-
tion in the right side of the heart.  (Edema of
the upper extremities generally  precedes that
of  the lower, in cases  of hydrothorax; and
sometimes  cedema occurs in the  side  of the
face, and in the hand corresponding with  the
side of  the chest in which the effusion exists,
when one cavity only is the seat of effusion.
(Edema ofthe face and ofthe extremities may
occur equally, or about the same time,  in dis-
ease of the kidneys,  with superabundance of
serum in the blood,  or with other alterations
of this  fluid.   (Edema of  the lower extremi-
ties may proceed from the pressure of the grav-
id uterus, or of pelvic tumours, or of accumu-
lated faeces in the caecum  or colon,  or  of en-
largement of an undescended testes (Author),
or of enlarged glands, and  from disease  of the
veins or absorbents,  as well as  from obstruc-
tion in the right side of the heart.  (Edema of
the male genitals proceeds from the same le-
sions as occasion cedema of the lower extrem-
ities ; but it may also arise from strangulation
by  the  prepuce, or from urinous infiltration.
(Edema of the female genitals is usually caus-
ed by pregnancy.
  6. B.  Active, or warm  adema, is not  so fre-
quent as the former  variety—a. It is  some-
times connected  with inflammatory action in
the  part, or in the vicinity, especially with as-
thenic inflammation, or that weak state of in-
flammatory action which occurs  in weak, ca-
chectic, or  leucophlegmatic  persons, or lym-
phatic constitutions, and which has been term-
ed by some hydro-phlegmasia.  It attends, in a
more or less remarkable form, certain  states
of Erysipelas—the cedematous especially—and
diffusive inflammation of the cellular tissue.
It is in every respect a state or form of in-
flammation of the cellular tissue.   The surface
is not only swollen, but is also warm, and gen-
erally coloured, sometimes with various shades
of deepness.   It is often somewhat firmer to
the touch, and does not pit  from pressure so
readily as in the passive form.
  7. b. Upon dividing  the cedematous part, the
effused fluid  is frequently different from that
found in the passive variety.  It is often sero-
puriform ; occasionally the serum is sanguine-
ons, sanious, or sanguineo-puriform.  It is also
sometimes purely serous, of a yellowish tint.
The predominance of either serous or puriform
characters differs much in different cases.  The
same  appearances are often  observed in  the
vicinity of inflammation of parenchymatous or-
gans,  as  in  cedema of the lungs  occurring in
the vicinity of inflamed parts ofthe organ.
  8. b. The  diagnosis of active oedema is easy.
The increased temperature ofthe part, the oc-
casional  redness  of the surface, and pain or
tenderness from pressure, the state of the  cir-
culation, and the general febrile commotion suf-
ficiently distinguish active from passive oedema.
The former usually appears more suddenly, and
proceeds more rapidly, than the latter; and is
often consequent upon deep-seated suppuration,
or upon the presence  of irritating matters in
the circulation.   In this latter  case, the fluid
effused is generally of an irritating and con-
taminating nature, inducing  unhealthy suppu-
ration  or  sloughing of the cellular tissue  in
which it is effused, or through which it extends.
  9. c. The  prognosis  is important in respect
both ofthe constitutional and ofthe local rela-
tions of cedema.   In the passive form, the oede-
ma indicates a most serious, and even danger-
ous, condition of the circulating system, or of
the kidneys.   In the active  state, the  danger
may not be so  great, particularly when the cede-
ma is associated with inflammation in its vicin-
ity ; but even  then it should  suggest the pres-
ence of inflammation of either the veins or ab-
sorbents, or even of both, or, at least, pressure
upon, or interrupted  circulation through,  the
trunks of veins.   When cedema is connected
with a morbid state of the circulation, with ir-
ritative fever,  or is symptomatic of deep-seated
suppuration,  &c.  ($ 8), it  should be  always
viewed as indicating  great danger, if  not in-
creasing it.
  10.  d. Treatment.—It is unnecessary to enter
more  fully into the treatment of oedema than
to remark, that the means of cure should be
directed to the pathological condition or cause
of which  cedema  is merely a  symptom, and
that the principles and  means  of cure which
have been advised for  anasarca (see art. Drop-
sy, () 132,  et seq.) should be employed for  it.
When  the cedema is  consequent  upon deep-
seated suppuration, or is  erysipelatous, then
the constitutional and local means prescribed
for the cedematous and gangrenous states of
Erysipelas  (see  that art), or for diffusive in-
flammation of the Cellular Tissue (y 35), or
for Asthenic  Inflammation (v 236),  are  the
most appropriate, the  various physical  or me-
chanical causes which  may operate in particu-
lar  cases being removed.
  Bibliog. and  Refer.—/. G. Knelm, Von den WSsser-
igten Gcschwuelstcn und dcren L'ehandlung, 8vo, 1793 —
L.E.Bruht, Essai sur l'CEdeme,4lo.  Paris, 1804.—Merat,
in Diet, des Sciences Med., t. xxxvii., p. 132.—Bateman,
in Edin. Med. and Surg. Journ., vol. iii.—/. Bouillaud, in
Diet, de Med.  ct Chirurg.  Prat, t. xii., art. OH,leme.—J.
Darwall, in Cyclop, of Pract. Med., vol. in., p. 196.—(r'. F.
Most, Encyklopathie  der Gesammteu Medicineh. u.  Chi-
rurg. Praxis, t. ii., p. 517.—(See, also, Bibliog. anu Ref-
er, to art. Dropsy.; 
(ESOPHAGUS—Diseases of the—Structural Chanoes.             1041
  {ESOPHAGUS,  DISEASES  OF  THE —
(Esophagus (from otot, ot<w, fut. oiou, I carry,
and jayu, qtayoc:, I  eat, &a).   (Esophage, Fr'
Die  Spciscrbkre,  der  Speisentr'dger,  Germ.__
There  are two portions of the alimentary ca-
nal the diseases of  which  have been very gen-
erally overlooked by systematic and practical
writers in this country, and which have receiv-
ed but an imperfect notice from foreign authors
I allude to the oesophagus and cacum.  The for-
mer  is, perhaps, less frequently  diseased than
any part  of the canal; the latter is, as I have
shown in the article Cecum, one of the most
liable of  the organs of the body to functional
disorder  and organic  change.  Through the
one, the passage ofthe ingesta is rapid, and on
it their effects are  slight  or transient, unless
when they are of a most irritating and noxious
kind.   Through the other, the passage of ali-
mentary and faecal matters is remarkably slow,
and liable to interruptions, and hence injurious
impressions are made on  the containing parts
by morbid or irritating states of the contained
substances ; and hence, probably, is partly ow-
ing the less frequency of diseases of the oesoph-
agus compared with those ofthe cacum.  Still,
the diseases of the  oesophagus are much more
common than have been supposed, the little at-
tention which  has  been paid  to them having
been  the cause of their  being  overlooked  in
many cases in  which they were actually pres-
ent.   And when we consider the frequency of
diseases of the pharynx and throat on  the one
hand, and of diseases of  the  stomach on the i
other, we can hardly infer that the cesophagus
 should escape participating in them so gener-
ally as has been supposed.
   2. In discussing the diseases  of the cesoph-
agus  I shall, first, give a rapid  sketch of the
structural changes which this canal occasionally
 undergoes in the course of diseases in which  it
is implicated; and I shall  next consider in suc-
cession the most important ofthe maladies which
occasion these changes, with the consequences
 which they usually produce, the symptoms  by
which they are indicated, and the treatment they
require.
 I. Structural Changes of the  QEsophagus.
     Classif.—IV. Class, I. Order (Author).
   3. The cesophagus presents organic lesions
less frequently than the  mouth and pharynx,
and still less so than the lower parts of the di-
gestive canal.—a. The epithelium covering  its
mucous surface is sometimes eroded, softened,
or even  destroyed, at its inferior part.   This
 is often  met with in children  at the period of
weaning, and  in those who have been imper-
fectly or improperly nourished.   M.  Andral
has found the epithelium remarkably thickened.
   4. b. The mucous membrane of the cesophagus
 is but seldom  inflamed or congested with blood
compared with other parts of the digestive
canal, unless consecutively upon eruptive dis-
eases, particularly  scarlatina.   It is generally
injected  or congested with black blood in rabies,
especially its  upper portion.  It is sometimes
thickened either generally  or in parts.  Its folli-
cles  are  occasionally enlarged and apparently
congested and obstructed, particularly in young
subjects and in mucous or gastric fevers.  1 e-
getations or excrescences,  of various sizes  and
forms, have been found to shoot from it, nar-
rowing  the passage and most  seriously ob-

      II              131
structing  deglutition.  Cases  of this descrip-
tion are mentioned by Schneider (in Haller's
Collect. Dissert., viii., No. 258),  Dallas  and
Monro (Edin. Essays and Observ., v. iii), and
Baillib.  Ulcers are, perhaps, less frequently
observed in this part ofthe digestive, tube than
in any other.   I have, however,  met with sev-
eral cases of this lesion, which  is not infre-
quent in children.  Ulcers in this  situation have
been described  and delineated  by Sandifort
(Museum  Anatomicum, tab. civ.,  tig.  3)  and
Baillie (Series of Engravings, &c, fasc. iii.,
pi. 3 and 4); but notwithstanding that Brunner
had described ulceration of the  cesophagus as
commencing  in its mucous follicles, this form
of  ulceration  has been  overlooked by those
pathologists.   I shall, therefore,  notice this le-
sion more fully in the  sequel.  Agglutination
of the opposite  parietes  of the oesophagus, by
coagulable lymph thrown out upon its mucous
coat, has been said to  have been  found in a
fatal case of smallpox (Bartholinus, in Act.
Hafn., t. i., obs. 109).   This  is, however, an
extremely  rare occurrence.  Exudations  of
lymph, forming a false membrane upon the mu-
cous surface of the canal, is  not rare, and is
found generally in  the upper part of it, in cases
where this exudation is thrown out over the
tonsils and pharynx (see § 23).
  [Dr. Gross states (Path. Anat., 2d ed.,  p.
534) that he  examined,  in  1838, the stomach
and cesophagus of a boy,  13 years old, who sud-
denly expired in convulsions after an illness of
three days.   The  patient complained of severe
pain in the fauces, and had great difficulty of
swallowing ;  every attempt of the kind being
followed by  spasm  of the throat,  especially
when the substance was of a fluid nature.   On
inspecting the  cesophagus,  it  was found lined
throughout with a thin layer of  lymph, closely
adherent  to the natural  mucous  coat, which
was itself highly injected, and of a bright red
colour.  The stomach was perfectly sound, the
inflammatory appearances terminating abruptly
at the cardiac orifice.  The adventitious mem-
brane was also traced around the mouth of the
larynx, and over the whole of the fauces.  Dr.
G.  states that these membranes rarely become
organized.  When the inflammation  subsides,
they gradually  lose their  moisture, together
with their adhesive properties, and  are either
vomited up in small tubular fragments, or swal-
lowed and digested, or passed by stool.  Andral
relates an instance where an  exudation  of
lymph lined  the cesophagus of a new-born in-
fant for about a third of its extent.—(Loc. cit.)]
   5. £. The  sub-mucous  cellular tissue of  the
canal  is sometimes inflamed  or  congested, in
 the same circumstances  as those just mention-
 ed : infiltrations  of serous, sero-puriform,  or
 sanious fluids are also observed in it as conse-
 quences of inflammation.  It may also become
 thickened and indurated,  particularly after pro
 tracted  inflammatory irritation.  It may  be
 transformed into a fibrocartilaginous substance,
 or into scirrous structure, thereby narrowing,
i even  nearly to complete  obliteration of  the
 tube.  Instances of scirrous degeneration ofthe
 tube passing into the ulcerative or carcinoma-
 tous state are not rare, especially in the extrem-
 ities of it; but simple thickening and induration
 caused  by chronic inflammation  have  often
 been  mistaken for scirrus.  Transformation 
1012                     ffiSOPHAGUS—Inflammation  of thk.
of a portion of the tube into a cartilaginous state
has been  observed  by Morgagni, Haask,  and
others.  This canal may be partially or entire-
ly obstructed also by abscesses  formed in its
parietes or even exterior to them;  or by the
growth of tumours in  its vicinity : thus slowly
increasing difficulty of swallowing attends upon
aneurism of the aorta, or upon a mass of ob-
structed  lymphatic  glands pressing upon the
cesophagus.   Bleuland  has  seen this  effect
produced by exostosis of the body of a vertebra.
The dysphagia, however, which proceeds from
these causes is seldom so urgent or distressing
as that which depends upon disease of the coats
of the tube.
  6.  d. Softening and attenuation of the cesoph-
agus are occasionally met with, and these states
may even  go on to spontaneous perforation,
presenting all the anatomical characters which
this lesion evinces in  the stomach.   Gangrene
of the tube is very rare.   I agree with M. An-
dral in considering the majority of cases of
this  occurrence recorded by authors as pulpy
softening of the part, which is not uncommon
in infants  and children.  It,  however, some-
times occurs, especially near the pharynx  in
malignant scarlet fever.
   7. e. Perforation of the cesophagus generally
is followed by effusion  into  the thorax.   M.
Andral states that the perforation  in all the
recorded cases has taken place in the thoracic
portion of the canal near the cardiac orifice ;
and  the surrounding  part of the parietes has
sometimes been  found  altered  and softened,
and at other  times without any appreciable al-
teration.  There are, however, cases on record
in which the perforation bad taken place about
the middle and upper part of the tube.   The
perforation in a case attended by me was above
the middle of it; and similar instances are pub-
lished  by  Kade  (De  Morbis Ventriculi, &c,
Halae, 1798), and by Reil (Memorab. Clin., fasc.
i., p. 13),  who met with it in cases of typhus
fever.
   8. Perforation of the cesophagus occurs at all
ages.  M. Veron met with it  in an infant just
born.  M. Guersent  observed it in  a child of
seven years of age.  M. Bouillaud found  it in
an adult, in whose  stomach  four perforations
also existed.  I have seen it in a child.  It oc-
curs more frequently at the periods of infancy
and  childhood than at  any other.  In some
cases, the perforation  is stopped by the aorta
or trachea, so that no effusion takes place.  In
other cases,  a double perforation occurs, and
the canal of the cesophagus communicates with
that of the trachea  or  even of the aorta.  In-
stances of the communication of the cesophagus
with the trachea in this manner have occurred
to Zeviani (Memorie de Fisicadi Verona, t. vii.),
Monro  (Morb. Anat. of the  Gullet,  &c, 8vo,
1830, p. 373), and to myself.   In the majority
of cases of perforation, the ulceration appears
to commence in one of the follicles  (see v 37).
   9. /. Purulent and  tubercular  matters  have
sometimes been found underneath the mucous
membrane of the cesophagus.   Albuminous ex-
udations also  form, either in patches,  or to such
an extent as to form  false membranes, as al-
ready noticed ($ 4, 23).  M. Guri found a lay-
er of whitish firm matter adhering closely  to
the mucous surface in  a new-born infant;  and
Hi'.denbrand states that its formation is not
infrequent, but that it generally separates and
passes into the stomach, being rarely excreted
upward.   This agrees with what I  have ob-
served in some  cases of epidemic croup and
scsrlpt flfiVGT"
  10. g.  Dilatation of the gullet seldom occurs
unless, as remarked by  Portal (Anat. Med., t.
v., p. 204), from stricture of the cardia and of
parts ofthe tube below the dilatation.   In some
cases the dilated part forms a  large sac, a por-
tion  of which falls lower than  the seat of stric-
ture, constituting a kind of diverticulum.   Ca-
ses of this  description  have  been noticed by
Isenflamm and Sandwort (Med. Anat.,t.  i,p.
242).
  11. h.  Polypous excrescences  have been found
shooting from the internal surface of the gullet,
narrowing the passage and obstructing degluti-
tion, but they occur less frequently in  this  situ-
ation than in the  pharynx.  They present the
same appearances as in other situations, and
have been noticed by Pringle, Monro (Edin.
Essays and Observ., vol.  iii), Baillie, Graeffe,
and  Schneider  (see Haller's  Coll.  Dissert.,
vii.,  No.  257).  They often grow from  a pedi-
cle sufficiently long to permit of their rising into
the pharynx upon efforts to vomit.
  12. i.  Cartilaginous and osseous degeneration
of the cesophagus are observed in rare instan-
ces,  and generally confined to a small portion
of the tube, forming a kind  of ring.   Gyser
(De  Fame Lethali  ex Calloso (Esophagi Angus-
tia, 4to,  Argent, 1770) found a cartilaginous
ring restricting the canal, so as to prevent the
passage of a sound.   Similar  cases have  been
recorded by Becker, Bang, Baldinger, Andral
(Anat. Pathol, t. i., p. 276), and others.  Carti-
laginous degeneration of the gullet in  its whole
extent  has been said  to have occurred to
Sampson  (Miscell.  Curios., &.C., Ann. 1613),
Garnia  (Morgagni, De Sed.  et  Caus. Morb.,
epist. xxviii.,  15), and Desgranges (Journ. de
Boyer et Corvisart, &e, t. iv., p. 203).   Os-
seous and cretaceous deposites are also very  rare-
ly met with in the parietes  of the gullet.   In-
stances,  however, have occurred to the elder
Monro, Abrahamson (in Meckel's Archiv., b.
i., st. iii., p. 16), and to  Walther (Mus. Anat.,
b. i., No. 278).
  13. k.  Rupture of the cesophagus  has  been
very rarely  observed.  Instances of its occur-
rence after vomiting and muscular efforts  have
been published by Boerhaave, Zeisner (Disser.
de Raro QHsophagi Morbo. Regiom., 1732), Sedil-
lot  (Recueil Periodique, t. vii., p. 194), Meier
(Baldinger's  Magazin, b. iii., p. 399), Guer-
sent (Bulletins de la Faculti de Med.,  Z. 1), by
Bouillaud (Archives Gentr. de Med.,  t. i., p.
531), and by Mr. W. King (Guy's Hasp. Rep.,
part xv).   In all these the parietes of the oesoph-
agus have been either ulcerated, rupture taking
place in the seat of ulceration, or softened and
attenuated in the manner already described  (Y4).
II.  Inflammation of the Oesophagus. — Syn.
  Oesophagitis ;  Inflammatio   Oesophagi ;  Jnf
  Gula,  Auct.   QHsophagite, Fr.   Entziindung
  der Speiserohre, Germ.
     Classif.—III. Class, I.  Order^ujJIot).
  14. Defin.—Pain between the shoulders, or be-
hind  the trachea or  sternum, augmented  by deglu-
tition, which is rendered  more or less difficult or
even  impossible, with symptomatic fever,  &c.
  15. Inflammation of the cesophagus occurs 
CESOPHAGUS—Inflammation of the—Causes—Symptoms.
1043
more frequently in a complicated and consecutive,
than as a simple and primary disease.  It varies
as to its intensity and form or character, and as
to the particular tissues of the canal in which
it  may  occur.  It may be acute, sub-acute, or
chronic; it  may be limited to the mucous sur-
face, or it may extend to the more external
coats, through  the  medium of the  connecting
cellular tissue ; it may even affect only the mu-
cous follicles of the canal, the internal mem-
brane being either entirely exempt, or affected
only in the immediate vicinity of the follicles.
   16. A. Causes.—a. Oesophagitis is most fre-
quent during infancy and childhood, but  it is
occasionally also observed during middle  and
advanced  age.   Long-continued and  severe
dyspepsia, constipation, the abuse of spirituous
liquors, the habit of wearing too warm clothing
around the neck and throat,  the use of tightly-
laced corsets, the strumous diathesis, and san-
guine and  plethoric habit of body,  predispose
to it.
   17. b. The exciting causes are  chiefly those
physical agents which act  directly upon  the
canal, and diseases of adjoining organs or parts
which  extend  to  it, either in their course, or
upon their disappearance in their original seats.
The former are draughts of cold  fluids, or the
ingestion of ices,  while the body is overheated
or perspiring ;  the  deglutition of too large a
mouthful, or of too warm fluids or substances ;
or of hard, irritating bodies ; the abuse or in-
cautious use of irritating medicines, as iodine,
squills, ammoniacum, ammonia, &c.; exposure
of the  neck and chest of  females ;  the use of
highly-seasoned or spiced articles of food;  the
accidental or intentional ingestion of acrid or
corrosive poisons, as the mineral acids, the bi-
chloride of mercury, preparations of arsenic,
&c.; acrid and septic animal poisons, particu-
larly those developed in preserved  or smoked
meats,  mushrooms,  &c. ; and the  injudicious
exhibition of acrid  emetics.  Oesophagitis is
often caused in young children  by sore nip-
ples, and by an unhealthy state of the milk of
nurses.
   18. This disease may also occur upon  the
disappearance of cutaneous eruptions, or after
the suppression of accustomed secretions  and
discharges.  It may appear in the gouty or in
the  rheumatic  diathesis,  and thus  assume a
modified form ;  but it is very rarely a conse-
quence  of suppression or metastasis of either
of these diseases.  It most frequently occurs
during the progress of some diseases, and as
a sequela or extension of others, particularly
of eruptive fevers,  aphthae,  erysipelas,  pertus-
sis, inflammatory affections of the  fauces  and
pharynx, and  of the internal surface of the
stomach.
   19. Oesophagitis is, moreover, not only caused
by, but also often complicated with, one or oth-
er of the foregoing diseases, particularly scar-
latina,  smallpox,  erysipelas,  aphthae,  gastric
and mucous fevers, inflammation ofthe fauces
and pharynx, or inflammation of the stomach.
In nearly all these  associations  the inflamma-
tion  of  the cesophagus is a consecutive affec-
tion  • but, although arising from the extension
of the inflammatory action chiefly by continui-
ty of surface it is not the  less important as re-
spects i 1 consequences.   Inflammation ofthe
fnSrnafsurface of the cesophagus may also be
complicated with spasm of some part, or of the
whole of the canal.  In this case, the irritabil-
ity of the muscular coat of the tube is so inor-
dinately increased in consequence  of  the in-
flamed and  sensible state of its mucous  sur-
face, that  it becomes spasmodically and pain-
fully contracted upon the passage of substan-
ces along it.  The disease is also occasionally
complicated with chronic laryngitis, this latter
affection being consecutive upon the  former.  A
case of this  description lately came  before me.
The laryngeal affection, which,  owing to the
paroxysms of suffocation and cough  accom-
panying it, was the prominent  complaint, and
attracted the chief attention,  was removed after
the treatment had been appropriately directed
to the primary disease.
  20. ii. Symptoms.—A.  Of Acute Oesophagitis.
—Pain in  some form or other is always com-
plained of, and is usually accompanied with a
sensation  of heat.  It extends in general be-
hind the trachea,  from the middle ofthe throat
to between the shoulders, and the ninth dorsal
vertebra.  This burning pain varies in  degree,
is sometimes  chiefly felt about  the bottom  of
the pharynx, and behind the glottis; at other
times, behind  the sternum and xyphoid carti-
lage ; and is occasionally accompanied with the
sensation of a foreign substance in  one of the
above situations.   In some  instances the  pain
is dull and slight, and in others attended by the
feeling of a cord extending in the course of the
canal.  In all cases, the pain or  uneasy sensa-
tion  is greatly augmented  by deglutition ;  so
much so, on some occasions, that the  patient
either obstinately refuses to swallow, particu-
larly liquids, or experiences an  instant regur-
gitation of  them.   Sometimes, in  the  more
acute cases, the  matters thus thrown  up are
ejected  forcibly  through the nose,  or  irritate
the glottis so as  to occasion violent and suffo-
cative fits of coughing.   Independently of the
regurgitation of matters attempted to be swal-
lowed, there  is  frequently  an  expuition  of a
glairy fluid, secreted from the pharynx  and up-
per part of the cesophagus.   The patient is gen-
erally tormented with thirst and singultus. This
latter symptom  is seldom wanting when the
lower  part  of the tube  is  inflamed.  In this
case, the  more  consistent  substances  which
are swallowed are arrested by spasm of the in-
flamed part, occasioning great  pain, generally
referred to  the  space between the shoulder
blades, and  are afterward ejected or vomited,
with a considerable  quantity of mucus, some-
times streaked with blood.
  21. In  children, oesophagitis,  in  its more
acute states, is not infrequent, particularly du-
ring infancy ;  and in them the diagnosis is dif-
ficult.  The child generally refuses drink,  or
drinks little, cries, and regurgitates  the inges-
ta.  Hiccough is almost constant, and frequent-
ly vomiting, which does not  often occur in the
adult from  this  disease.  When the  milk  is
thrown up unchanged, we should always  sus-
pect the  existence  of  inflammation  of the
cesophagus.
  22. Besides the  foregoing,  there are  also
many of the usual signs of symptomatic fever,
generally  of the inflammatory  type, but  fre-
quently of a remittent  form.  The tongue  is
red at its point and edges, sometimes through-
out ; at other times  it is loaded and furred  in 
1044
(ESOPHAGUS—Inflammation of the—Terminations.
the middle and base.  The fauces are red and
injected, or natural; the uvula is generally re-
laxed.   The  bowels are confined ; the urine
scanty and high-coloured.
  23. iii. Terminations.—Acute inflammation of
the cesophagus may terminate (a) in  resolu-
tion ; (b), in suppuration ; (c), in softening of
the coats of the canal, or (d), in gangrene, or
(e), it may pass into a chronic state of disease.
—A. Resolution takes place generally with  a
gradual subsidence of the acute symptoms, and
a more copious discharge of mucous or muco-
purulent fluid ; or with critical evacuations, as
hypostatic urine, copious perspiration, &c.  It
occurs chiefly on the fifth, seventh, ninth, or
eleventh day ; and occasionally with the exu-
dation  of an  albuminous  substance,  the  dis-
charge of which disposes to a resolution ofthe
inflammatory action.  This substance is secre-
ted on the internal surface of the tube, as in
croup,  forming a  false membrane, sometimes
extending upward to the pharynx  and fauces.
As the inflammation subsides, this false mem-
brane is thrown off from the mucous surface,
the secretion of the mucous follicles gradually
detaching it from  its adhesions to this surface,
and it is passed with the ingesta into the stom-
ach.
   24. B. Suppuration sometimes occurs in one
or other of two forms :  1st. The purulent mat-
ter may be discharged, in consequence of vio-
lent inflammation, from the whole internal sur-
face of the tube ; this, however, seldom takes
place unless oesophagitis is occasioned by very
irritating  ingesta.  I was  called some years
ago to  a  case of this description  by a practi-
tioner  in Westminster.  The patient, a robust
young man, had  attempted to poison himself
with laudanum.   In order to procure the evac-
uation of the poison, a considerable quantity of
mustard, mixed with warm water, was exhibit-
ed.  This  produced full  vomiting,  after the
other means had  failed.  Inflammation  of the
cesophagus, however, in its  most  distressing
form, supervened, and in the course of two or
three days was followed by a most copious and
entirely purulent  discharge regurgitated from
the cesophagus.   The quantity discharged be-
tween each visit, and collected  in  the vessel,
was surprising.  He nevertheless  recovered,
and without any affection of the nervous  sys-
tem, as is often observed after poisoning from
opium.   2d.  Suppuration more commonly oc-
curs when the inflammation attacks a part only
of the tube, and implicates all its coats.  A dis-
tinct abscess usually forms in this  case, most
frequently in the  cellular tissue connecting the
mucous with the  muscular coat.  It occurs in
neglected cases of the disease, and  in scrofu-
lous habits ;  and  is generally indicated  by the
complete stop put to deglutition, by great thirst,
excessive pain, and by a sense of fulness, and
of pulsation in the situation of the oesophagus.
In most of the cases on record the  abscess has
burst into the canal, either spontaneously upon
efforts at deglutition  or vomiting, or upon in-
troducing a bougie or probang along the pass-
age ; and the patient has obtained instant re-
lief. Interesting cases of this description have
been published by M. Bourguet  (Gazette de
Santi, 1823, p. 221), and by M. Barras (Archives
Gen. de Med., t. x., p. 134).  Recovery general-
ly takes place rapidly after the matter  is dis-
charged ; it either passes into the stomach or
is ejected upward.
  25. C. Gangrene occasionally terminates in
inflammation of  the  cesophagus, but not  so
often as is  stated by some writers.  It occurs
chiefly after oesophagitis  complicating scarla-
tina, or following  that  disease, in which cir-
cumstances I have observed it on several oc-
casions, generally, however, associated with
gangrenous pharyngitis.  I have, likewise, seen
it after oesophagitis  caused  by poisonous  in-
gesta, particularly the animal poison generated
in  preserved or spoiled meats.  Although it
may commence previously to dissolution, yet
the morbid appearances usually  described  as
constituting this change are somewhat increas-
ed after death.  When the inflammation ter-
minates, the sphacelus is chiefly confined to the
internal surface of the tube, which  presents
more or less, along its whole extent, soft, tu-
mefied patches, of an irregular form, of a dark
gray or slate  colour, and  emitting a peculiar
foetid odour.
  26. The  symptoms  indicating this change da-
ring the life of the patient are not always man-
ifest.  Two cases of this  mode of termination,
occurring  independently of poisoning, and  of
complication with scarlatina, have  come  be-
fore me  in practice, and were  recognised du-
ring life, and verified by an examination after
death.  The one occurred in a child, the other
in an  aged female.   In both,  great tumefac-
tion and tenderness of the lateral and anterior
parts of the neck ; a deeply-incrusted tongue,
with a dark sordes ; a feeble, small, unequal,
and intermittent  pulse ;  singultus,  and fre-
quent foetid eructations; great prostration  of
strength, with leipothymia, and  cold  clammy
perspirations,  were remarked.   There was  no
vomiting ;  but in one of tlie cases a small quan-
tity of an  offensive, sanguineous mucus was
occasionally regurgitated upward shortly before
death.
  27.  D. The changes of structure  most com-
monly observed in fatal cases of acute oesopha-
gitis  are injections in patches, stria?, or gen-
erally of the mucous surface, with partial  de-
struction of its epithelium, particularly  in in-
fants.   This surface is usually reddened, the
tint, however, varying from a rose hue to a
reddish-brown.   The  mucous membrane  is
commonly  tumefied, its subjacent cellular  tis-
sue  thickened, injected, infiltrated with  a  se-
rous or sero-puriform or sanguineous fluid, and
both the one and the other softened and more
easily torn than natural.  Sometimes they are
reduced to  a nearly pulpy state, and are of a
reddish-brown  or purple  colour.  The  sub-
mucous cellular tissue sometimes presents mi-
nute  collections  of  a puriform matter, which
elevate the internal  surface  into pustular em-
inences.   The whole parietes of the canal are
softened, sometimes cedematous, injected with
blood, and  more lacerable than  usual.  In rare
cases, purulent  collections form exteriorly to
the muscular coat.   Ulceration seldom occurs
after this state of inflammation : it is more fre-
quently met with after that hereafter to be de-
scribed.  When, however, it does occur, the ul-
cerated part generally varies in size and in
depth, the parts in its immediate vicinity being
very much softened, inflamed, and somewhat
thickened or tumefied. 
OESOPHAGUS—Stricture of the.
1045
  28.  E. The changes produced in the oesoph-
agus after  the  ingestion of strong acids are
generally of a disorganizing nature in the more
rapidly fatal cases.   The mucous surface  is
eroded, and of a brownish, or brownish-black
hue, and the tube generally more or less con-
stricted.  The erosion  or  partial solution  of
the internal surface sometimes extends to the
connecting  cellular tissue, so that the muscu-
lar coat  may be readily denuded, as by rubbing
a sponge firmly along the exposed surface.
  29.  iv. Sub-acute and Chronic 03sophagi-
tis.—A. The less active forms of the disease
are more frequent  than the acute.  They may
take place primarily, or they may be the conse-
quences of neglected, or partially subdued states
of acute oesophagitis.  Many of the  slighter
cases that have occurred primarily never come
before the physician until organic changes se-
riously interrupting the process of deglutition
have  taken place.—a. The slight or  chronic
states of oesophagitis are characterized chiefly
by the  same symptoms as  characterize the
acute form ($ 20), but in a milder degree; by
soreness and tightness  under the  sternum,  or
between the scapulae ; the discharge of a ropy
fluid,  or acrid  eructations ; sometimes rumi-
nation after a full meal, by a hawking or*short
cough, or frequently  hawking  or  spitting, by
a weak, irritable pulse and emaciation ; and
sometimes by obstinate dyspepsia and costive-
ness.
   30. b. The chronic states of the disease are
generally caused by previous  disorders, partic-
ularly by inflammatory or neglected dyspepsia,
 inflammations of the internal  surface of the
stomach, by eruptive  fevers, and inflammation
of the fauces or pharynx ;  by the acute states
of the  disease, and by the causes producing
these states.
   31. c. The milder or more  chronic  states of
oesophagitis terminate in resolution, or in some
one or more of the organic lesions described in
 another section of this article, or in thickening
 and induration ofthe parietes of the canal, gen-
 erally with some degree of stricture, and in  ul-
 ceration.
   32. B. Thickening and  induration of  the
 parietes of the  cesophagus sometimes take
 place after repeated attacks of inflammation,
 but generally  after chronic inflammation, oc-
curring either in its primary form, or consecu-
tively on the acute state.   Thickening of the
 parietes is usually accompanied with  narrow-
 ing of the  passage, forming permanent stric-
 ture or obstacle to the passage of the ingesta
 into the stomach.   This change may affect the
 whole of the canal in a greater or less degree,
or it  may  be limited to any one part of it.—a.
The  circumstances  which especially favour
this termination are, inefficient  modes  of cure ;
the taking of stimulating  food too soon after
the acute  stage of disease has been subdued ;
the injudicious use  of astringent  and tonic
medicines,  particularly gargles,  which have
been  suggested by the  state ofthe fauces  and
uvula that I have described as frequently  ac-
comoanving the different states of the disease ;
and the strumous diathesis.  But I believe that
fhe most frequent cause of this lesion is  the
use of ardent spirits, as has been proved by the
oKervaUo" olPM,oha.«.i.(Hufelani,uni H[«-
ly, Journ. der Pr. Heilkunde, 1812, p. 52).  1 his
state constitutes the permanent organic stricture
of Doctor Monro, and is ably illustrated in his
work  on the morbid anatomy of the digestive
tube.
  33.  b. The symptoms of thickening of the
parietes, with stricture of the cesophagus, are
the continuance of dysphagia after the decline
ofthe more acute symptoms; dyspnoea, obscure
pain, soreness, and a sense of tightness in the
course of the cesophagus ; sometimes the dis-
charge of a very tenacious mucus; impaired
digestion, despondency, costiveness ;  and feb-
rile exacerbations.  In some  cases, a gurgling
sound  is heard upon attempts at swallowing
fluids,  and  a portion of them is  regurgitated,
exciting a choking cough.  The deglutition of
more  solid  substances is slow,  difficult, and
painful.  The patient often feels the substance
lodged some time in the canal;  and, afterward,
as if forcibly thrust through a narrowed passage.
When the  stricture is  seated low in the canal
the portion above it is often very much  dilated,
forming a sac in which the ingesta lodge, and
whence they are afterward partly regurgitated
and partly pass into the stomach.  In thickening
of the parietes of the oesophagus and permanent
stricture, fluid substances are more readily swal-
lowed than those possessed of some degree of
consistence ; while in spasm of the cesophagus,
fluids  pass  with greater difficulty and distress
to the patient.
  34.  c. Permanent stricture of the cesophagus,
although generally resulting from inflammatory
action ofthe kind now described, may occasion-
ally also proceed from a different cause.   It
may, although rarely, arise from scirrous degen-
eration, or from tumours of a fibro-cartilaginous
nature developed in the  parietes of the tube.
I believe, however, that  a great proportion of
the cases which have  been said to be scirrus
of the cesophagus have  been only the simple
thickening and induration resulting from chron-
ic inflammation.  Permanent stricture of this
passage may also result from the enlargement
of, and pressure upon  the tube, occasioned by
a cluster of enlarged lymphatic glands.  This
is, however, a rare occurrence, and is chiefly
met with in childhood  and early life, in those
of a strumous diathesis, and  in whom the sub-
maxillary, and other superficial glands, are tu-
mefied ;  while scirrous degeneration occurs  at
an advanced age, and is attended by appearances
of the scirrous cachexia.  The dysphagia ari-
sing from the pressure of tumours exterior  to
the tube is  seldom  or  never  so urgent as that
which depends upon narrowing of the  passage
from  change of the parietes themselves.  The
pressure on the cesophagus produced by aneu-
rism ofthe aorta, even shortly before its open-
ing into this canal, seldom occasions very mark-
ed difficulty of deglutition.   This distinction
has been judiciously remarked by Mondiere,
and is based on the  cases  recorded  by MM.
Bertin, Laennec,  Bouillaud, Raikem, Ouv-
rard, and  others.   This canal  may  also  be
partially obliterated from increased thickening
—a hypertrophy ofthe mucous membrane itself!
which is also as if puckered or drawn together.
In the majority, however, of such cases, there
is permanent constriction also of the circular
muscular fibres of the  part affected.
   35.  Permanent stricture  of the cesophagus,
 whether proceeding from inflammatory thick- 
1046
OESOPHAGUS—Ulceration of Tnf.
ening and induration of its coats, from scirrous
or other formations, or tumours developed in
the parietes of, or external to the tube, may be
seated in any  part of the tube, either at  its
commencement in the pharynx, or in any inter-
mediate portion between this and its termina-
tion at the cardia.   Sir E. Home thinks that it
occurs most commonly in the former situation ;
but, although this  may perhaps be,  upon the
whole, the part most frequently affected, the
other  parts are also not unfrequently the seat
of this change.  It is, however, generally re-
marked that, even when the disease is confined
to the  lower portion of the  tube, many of the
more urgent symptoms are often  referred to
the lower part  of the pharynx and top of the
oesophagus.
  36. d. The Diagnosis of permanent stricture of
the  asophagus  is  somewhat  difficult.   This
lesion  may be  confounded with  spasm of the
tube, with inflammation ofthe internal surface
ofthe canal, with disease  ofthe cardiac orifice
of the stomach, or even with affections of the
larynx and trachea ; or these maladies may be
mistaken  for stricture of this  tube.  The per-
manence of the symptoms, generally attributed
to this stricture, would serve  to establish the
existence of it in  doubtful cases, if such per-
manence were always observed ; but Heineken,
Leroux, and others have noticed  marked re-
missions  in the symptoms  of cases  of  this
lesion.  In these cases, the exacerbations have
been owing to more or less of spasm  attending
the permanent stricture.  Indeed, when diffi-
culty of deglutition occurs in any of the diseases
just mentioned as simulating permanent stric-
ture of the gullet, it is generally owing to spasm.
In some diseases of the larynx, or of the stom-,
ach, spasm may occur  in the gullet/  as  in the
case recorded by Mr. Shaw (Lon. Med. and Phys.
Journ., vol. xlviii., p. 185).   When difficult deg-
lutition is observed in affections ofthe stomach,
or of adjoining  parts, and even in consequence
of tumours  in the  vicinity of the tube, it gen-
erally is either owing to, or aggravated by flatus
rising  into this canal  from the stomach, the
flatus occasioning both obstruction to the de-
scent of the matters swallowed  and  spasm in
parts of the tube.  The chief diagnosis, there-
fore, between permanent stricture of the gullet
and other affections is  thus actually between
the former and spasm ofthe parietes ofthe tube.
Permanent stricture is generally  consequent
upon inflammation, and is slowly and  gradually
progressive, until  deglutition  is  impossible.
When  it is far advanced, the difficulty of swal-
lowing is more  or less permanent, although ex-
acerbations are remarked in some cases.  The
difficult deglutition which  is occasioned  by
spasm, and is sometimes caused by disease of
adjoining parts, occurs chiefly in hysterical and
hypochondriacal persons, and  in nervous and
delicate constitutions    When the difficulty  is
caused by the pressure of scrofulous or enlarged
lymphatic glands, this circumstance is generally
rendered apparent by the state ofthe neck and
throat, and by the  appearances and sounds in
percussion, near the top  of the sternum  and
sternal ends ofthe clavicles.
  37.  C. Ulceration of the cesophagus may
occur in consequence of inflammation of its in-
ternal  surface,  in one of two  forms; namely,
ulceration commencing in  the mucous follicles,
and ulceration of the mucou3 and snb-muccnw
cellular tissue unconnected with change of thr
state of those glands—a. It has been consider-
ed doubtful whether or no the ulceration, which
is  seated in, and proceeds from a  particular
change ofthe follicles, is actually a consequence
of inflammation.  It is very probable that ob-
struction of those glands may give origin  to ul-
ceration, and that the inflammatory irritation
either preceding or accompanying the ulcerative
process may be very slight—and possibly of an
unhealthy description.   I believe, from several
instances which have  occurred to me among
children, that such is the case, and that neither
the local appearances nor their causes, nor the
attendant  circumstances and phenomena, are
such as mark sthenic action, or energetic vital
endowment.  This form of ulceration was first
noticed by  Brunner (De  Glandulis Duodeni,
cap. x., p. 136), as occurring in the cesophagus ;
and I believe that it occasionally proceeds to
perforation  of the tube, and  affects most fre-
quently its lower part,  while the next form of
ulceration is more commonly found in its upper
portion.
  38.  b. Ulceration which takes place independ-
ently of the  follicles, I  consider to be more de-
cidedly  a  result of  inflammatory  action than
the foregoing variety.  The procession of phe-
nomena in cases of this description appears to
be the  following:  The  inflammation  of the
mucous surface often implicates more or less of
its subjacent cellular  tissue, and  a serous or
sero-puriform fluid is effused in distinct points,
elevating, in the form of pustules or  minute
blisters, the mucous tissue, the detached por-
tions of which lose  their vitality and separate,
leaving an excoriated or ulcerated spot, which
extends in width and  depth, according to the
habit  and temperament of the patient, to the
cause in which the disease originated, and to
the treatment employed.   Ulcerations of this
description,  as well  as  the preceding, are most
commonly met with among infants and young
subjects, and are frequently connected in  them
with softening of the coats of the tube.  When
ulceration occurs in adult subjects or in persons
advanced in life, it  is generally accompanied
with, if not consequent upon, either thickening
or narrowing of the parietes of the cesophagus,
or both; and it is  usually seated in the part
above the constriction, excepting in scirrus of
the tube, when the narrowed portion itself often
becomes ulcerated, and in  this case carcinoma-
tous.   But it sometimes is met with independ-
ently of either thickening  or  induration of the
parietes of the tube.   Ulceration  from inflam-
mation of the interna] coats of the oesophagus
is very seldom seated in several different  parts
of its surface in the same case, the ulcers of
this description being  never  so numerous as
those commencing in the  follicles, and rarely
exceeding one or two.  This kind of ulcer most
frequently attacks the upper portion ofthe canal,
and extends from three to eight or nine  lines
in  width.  M. Scoutetten met with  a  case in
which the ulcer was twelve lines in  diameter,
and had destroyed all the coats ofthe posterior
part of the tube, and had even laid bare the an-
terior part of one of the vertebrae.  Generally,
when the ulcer is large, one only is found. Sir
Everard Home thinks  that the posterior part,
or that applied to the vertebras, is more usually 
CESOPHAGUS—Ulceration  of  the—Symptoms.                 1047
the seat of ulceration; but this is  not  satis-
factorily shown.  There can be no doubt that
this form of ulceration occurs more frequently
in the upper part of the tube, while the ulcera-
tion which originates in the follicular glands is
more  usually found at  its lower part, and is
more generally consequent upon eruptive fevers
and febrile diseases, particularly those charac-
terized  by  depressed energies of life.   Ulcer-
ation  of the oesophagus may occasion  ulterior
effects of a very important character, previous
to its usual termination  in death.  A case, to
which I shall more particularly allude, occurred
to me where it occasioned a fatal haemorrhage.
And Dr. Monro mentions a case where the ulcer
penetrated the trachea  and occasioned death,
by the escape of matter from the cesophagus
into the trachea.   A similar case I have already
noticed as having  occurred to Zeviani, and
another has been seen by myself.  Rupture, as
well as perforation of this tube, may also be oc-
casioned by ulceration.
   39.  c.  Symptoms.—When the ulceration is
seated in the anterior and  superior portion of
the oesophagus,  posterior  to  the  larynx and
trachea,  many of the symptoms of  laryngitis
and tracheitis are observed.  An interesting
case of this description is recorded by Paletta
(Exercitat.  Patholog., p. 228).  Ulcers in  the
cesophagus  are  generally  accompanied  with
many ofthe symptoms which attend  simple in-
flammation of this tube.  The pains, however,
are usually more acute, particularly upon deglu-
tition ; sometimes  there is  vomiting of a  glairy
matter, generally  streaked or coloured with
blood.   Solid substances are swallowed with
difficulty, but fluids, when  taken in considera-
ble quantity, pass with more ease.   Salivation
often  occurs during the last stage of the dis-
ease.   M. Mondiere mentions a case in which
a large ulcer of the oesophagus was seated near
the cardia, and where the patient, during  the
four months he was under treatment, complain-
ed of a burning sensation at the superior part
of the epigastric region.  This patient frequent-
ly rejected rounded  and  purulent  matter,  a
symptom noticed both by Paletta and Leroux.
In some rare cases, the ulceration  may give
rise to sudden death from haemorrhage.  A case
of this description occurred to me a few years
ago in an aged female who had been under my
care for several years for disorders  of the di-
gestive organs, accompanied with psoriasis. A
few days previous to her death she was affect-
ed with oesophagitis complicated with pharyn-
gitis, and attended  by a constant hacking cough,
and great depression of the powers  of life.  I
was suddenly called to her about the eighth or
ninth  day of the attack for sudden and profuse
discharge of blood, which was described as hav-
ing been ejected upward without evident effort;
but before 1 reached her she had expired. The
quantity of blood thus discharged was very con-
siderable.   Upon  examination,  the stomach
contained about a pint and a half of blood part-
ly coagulated, and its  coats, particularly  the
mucous coat, were considerably softened.   The
pharynx was of a dark colour, in patches, some
of which were of a purplish tint.  In the  upper
third of the cesophagus, towards  its anterior
parietes, upon the left side, was a large irregular
ulcer, which had destroyed, in some points, the
muscular coat, and in all, the mucous and sub-
mucous tissue.  The internal surface of this
part of the tube, particularly around the ulcer,
was of purple hue, tumefied,  soft, and easily
torn.  The bottom of the ulcer was of a deep
red colour, and the subjacent parts red, vascu-
lar, and injected.  The  haemorrhage had most
probably arisen from erosion, by ulceration of
some of the small vessels.
  40. Ulceration, perforation, and rupture, in
consequence of ulceration of the parietes ofthe
cesophagus,  are generally followed  by death
with more or less rapidity; and, until shortly
before death, the patient  may not have come
under treatment, either  from the slightness or
neglect ofthe symptoms.  Instances have even
occurred in which sudden death has taken place,
the patient not having had recourse to medical
advice, and,  upon dissection, a large perforating
ulcer has been found in  some part of the tube.
In a case  of this kind which I saw, the ulcer
was seated a little above the cardia.
  [A case of cancer ofthe cesophagus, opening
into the right lung, has  been recently reported
by Dr. Jackson in the New-Eng. Quarterly Jour.
of Med.  and Surg., Oct.,  1842, p. 253.  The pa-
tient was  a female, 53  years  of age, and for
the last 8 or 10 she laboured under difficult deg-
lutition, with regurgitation  of food, but with-
out pain or nausea.  The skin was sallow, and
the body quite  emaciated.   Latterly, she had
haemorrhage from the bowels, and shortly be-
fore death was seized  with acute pulmonary
symptoms.  The disease was found  to  have
commenced  two inches  and a half above the in-
ferior extremity of the tube, extending upward
in front If of an inch,  and behind 2j- inches.
The cavernous surface was ulcerated, soft, rag-
ged, and of a whitish aspect, not unlike enceph-
aloid.  The cut edge exhibited no  trace of the
original structure.  At  the centre of the dis-
eased mass, on its anterior surface, was a per-
foration through into the substance of the right
lung, which was gangrenous at this part.  The
descending  aorta adhered  to the  altered por-
tion of  the  tube, and had  upon  its outer sur-
face, near this  point, an apparently malignant
deposite.—(Gross.)
  See an  interesting case  of stricture and ul-
ceration of  the oesophagus by Dr. Francis, in
the Transactions of the Literary and Philosophi-
cal Society of New-York, vol. i.]
  41. Scirrous ulceration,  or carcinoma of the
oesophagus,  most frequently occurs  either at
the upper or the lower extremity, more fre-
quently extending from either the pharynx or
the cardiac orifice of the stomach, than affect-
ing the  tube primarily.   It rarely or never ap-
pears without being attended by the lancinating
and burning pains, and  the carcinomatous ca-
chexia characteristic of this disease.
  42. d. The prognosis of inflammation and per-
manent stricture ofthe gullet should necessarily
depend  upon the causes, progress, complica-
tions, and severity of the disease.  Acute and
sub-acute asophagitis, in  which the prognosis is
generally more favourable  than in the chronic
state ofthe malady and  in permanent stricture,
should be  viewed as a most serious disease, as
respects either its more immediate results, or
its  contingent  consequences;  and it  is  still
more so when it occurs  in cachectic habits and
in the course of exanthematous and continued
fevers.  When it is caused by powerful stimu- 
1048               CESOPHAGUS—Inflammation of thb—Treatment.
lants or irritants calculated to produce a local
effect merely, without  directly disorganizing
the parts, or remarkably depressing the vital
power, it is generally removed by appropriate
means ; but when it is caused by agents which
occasion these  injurious  effects,  and  which
even extend from thence to adjoining parts, the
prognosis should be very unfavourable.  When
the symptoms indicate the passage of the acute
or sub-acute into the chronic disease, a cautious,
if not an unfavourable opinion ought to be form-
ed of it; and when they indicate the superven-
tion of stricture  or of ulceration with or without
stricture, the prognosis should be very unfa-
vourable, although the result may be  long de-
layed.   The history of the case, the  previous
health and  present state of the patient, and the
effects of treatment, ought always to be duly
estimated in the opinion which is to be formed
as to the result.
  43. v. Treatment.—A. Of acute (Esopkagitis.
—a. General and local bleeding is indispensable
in this state of the disease.  Bleeding from the
arm should never be neglected ; and afterward
local  depletion  may  be employed, either  by
leeches or  by cupping.  In oesophagitis, the lo-
cal blood-letting recommended by Ccelius Au-
relianus, viz.,  the opening of the sub-lingual
vein, may  be practised.  It  has  received the
sanction of the greatest,  even in  the present
day, of practical authorities, that of Hoffmann,
as well as of Janson and others.  Hildenbrand
recommends the application of leeches in pref-
erence to cupping: in children, either or both
may be employed, according to circumstances.
When the  local depletion  is directed to the
throat, leeches are certainly preferable.  Next
to depletion, as  perfect  inaction of the tube as
possible should be enforced. The patient should
be deprived of all ingesta, excepting cooling
fluids, which may be used merely to moisten
the mouth and throat,  without attempting to
swallow them.   After the acute symptoms are
removed, and the necessity of having recourse
to light nourishment is urgent, the blandest and
most mucilaginous substances, in a  semifluid
form, and of the temperature ofthe blood, may
be taken.  The patient should at the same time
be kept quiet, not be allowed to talk, and have the
bowels freely evacuated by cathartic  enemata,
which,  while they procure the evacuation of
accumulated and hurtful matters, may occasion
a derivation of the circulating fluid to the low-
er  part of  the digestive tube.  In the slighter
forms of oesophagitis, these means, even with-
out any considerable depletion, will be often
sufficient to remove the disease.
   44. b. When it is necessary to exhibit medi-
cines by the mouth, particularly those of a pur-
gative nature, my experience leads me to pre-
fer a full dose of calomel, either alone or com-
bined with James's powder, exhibited in a semi-
consistent  substance.  The advantages result-
ing from the use of  calomel  are, that it dimin-
ishes vascular action in the part to which it is
immediately applied, while it occasions vascu-
lar derivation to the lower part of the intesti-
nal canal.   It may be mixed in some sweet but-
ter, which should be allowed to melt gradually
and pass insensibly along the cesophagus, the
mouth  being guarded by  subsequent ablution.
When it is necessary to act decidedly on the
bowels, and yet prevent the increase of thirst-
one of the most distressing symptoms of the
diseasc-the supertartrate of potash, with a
fourth pan of the sub-borate of  soda, given in
the form of electuary, and combined with con-
fection of senna and the inspissated juice of el-
der-berries, is one of the best means that can
be employed.  If the inflammation be attended
with much spasm of the tube, or if an irritable
state of it still continue after depletions, or if
the morbid action be  apparently still unsub-
dued, the hydrochlorate of ammonia or nitre
should be prescribed in the form of linctus or
mixture with mucilages, sirups, and  anodynes,
in frequent doses, and these, swallowed gradu-
ally and often, will generally afford marked re-
lief.  When the upper part of the tube is affect-
ed, some benefit may be procured from the nse
of emollient fomentations and poultices to the
throat, particularly after the application of leech-
es to the part.
   45. c. Revulsive or derivative means are some-
times of service, especially when  they follow,
as they always should, vascular depletions car-
ried as far as the state of the case may require.
Revulsions ought to be prescribed in a decided
manner ;  for,  in order to be beneficial, the ar-
tificial irritation should surpass in degree that
which it is intended to supersede.  The irrita-
tion  of blisters while  inflammatory action re-
mains unsubdued will  often chiefly tend to in-
crease febrile commotion, and thereby to aug-
ment the local excitement.  As to the means
of derivation and the situation of applying them,
opinions are various.   Bleuland recommends
blisters and moxas to be applied  between the
shoulders.  Many prefer sinapisms  and irrita-
ting pediluvia.  The turpentine embrocation or
epithem applied to the throat and sternum, or
between the  shoulders, or a mustard  poultice
in the same situations, are  the most decided
and the most  rapid in their effects.  Either of
these may be used for children ; but blisters
ought not to be applied to them for a longer pe-
riod than  three or four hours,  when  a warm
bread and water poultice should replace them.
   46. d. Oesophagitis,  in various degrees of ac-
tivity, is not infrequent in children, but it is oft-
en complicated with inflammation  ofthe fauces
and  pharynx, or with  bronchitis, or with in-
flammation of the villous surface  of the stom-
ach, and is generally  seated in  the  mucous
membrane, seldom extending deeper than the
submucous tissue.   In them, also, the mucous
follicles are often chiefly implicated.  The lo-
cal affection is, moreover, often associated with
weak vital power, and sometimes  with general
cachexia—circumstances which require a very
modified practice.  After active inflammatory
action has been subdued by depletion, or  inde-
pendently of  depletion, in this latter class of
cases, I have  derived much advantage, partic-
ularly  in the complications now  alluded to,
from the  hydrochlorate of  ammonia, or the
sub-borate of soda given in honey, or in the
inspissated juice of elder-berries  and sirup of
marsh mallows, or of roses.
   47. e. Oesophagitis, complicated  with the in-
flammations just mentioned, requires very near-
ly the same treatment and regimen as above
recommended ; but when it supervenes in the
course  of eruptive or continued  fevers,  very
different means are necessary, and particularly
when those fevers acquire an asthenic or ma- 
CESOPHAGUS—Hemorrhage from.
1049
lignant character.   I have  seen several  cases
of this description in children and young per-
sons, and have never obtained in them any ad-
vantage from vascular depletion, except from
a cautious recourse, in some cases, to local de-
pletion.   The mineral  acids,  particularly  the
muriatic, camphor, the pyroligneous  acid with
camphor, the boracic  acid, and sub-borate of
soda, small  doses of the sulphate of zinc, or
of the sulphate of quina in confection of roses;
the  solution  of the acetate of ammonia with
camphor mixture and the decoction  of marsh
mallows ;  the hydrochlorate  of  ammonia or
the nitrate of potass in the sirup of roses, <Scc,
are  severally beneficial in  these  associations
of the disease.   When oesophagitis is compli-
cated  with  pharyngitis,  as  observed in  the
more malignant states of scarlatina, or in oth-
er exanthematous and  continued fevers,  the
snlphate  of quinine, the  preparations of cin-
chona with camphor or the  mineral acids, par-
ticularly the hydrochloric ;  or the decoction of
bark with  the chlorate of potash ;  or small do-
ses  of the chloride  of lime in honey  or sirup,
may be prescribed, the derivative means above
noticed ($ 45) being also employed.
  48.  B. The sub-acute'and  chronic  states  of
oesophagitis require similar means to the above,
but in a less active form.  In these,  local  de-
pletions are often required, and  they may be
repeated according to circumstances.   Purga-
tives are generally also necessary.  The fre-
quent use  of refrigerant, demulcent, and sooth-
ing  linctuses and mixtures, as  almond emul-
sion or sirup of marsh mallows with hydrocy-
anic acid, or the  mucilages and sirups with sal
ammoniac or nitre, should  not be neglected.
In some cases of the chronic as well as of the
acute  form of the disease, calomel or the gray
powder may be mixed with  a little fresh butter
and  placed  upon the tongue.  As this melts,
and  is gradually and  slowly swallowed, a heal-
ing  effect is  produced by it upon the  inflamed
surface.  When  there  is reason  to  infer  the
existence of ulceration, this is often of service.
If the bowels require farther aid, enemata should
be administered.   Advantage will often accrue
from the more permanent derivatives, as blisters
frequently repeated, or kept open and freely dis-
charging, and pustulation by means ofthe tartar-
ized antimonial ointment, or of croton oil, rubbed
in the situations about to be  mentioned.  In the
more obstinate cases, moxas may be applied, or
an issue made near the top  of the sternum, or
a seton inserted in the nape ofthe neck.
  49.  For permanent stricture (y 34), as well as
for ulceration (y 37) of the asophagus,  the same
means as have been advised for chronic oesoph-
agitis  may be  employed.   If  these fail, after
having been  fully and appropriately tried, sur-
gical aid should  be  obtained, and dilatation or
cauterization be had recourse to.   But of these
and other surgical measures it is  not my duty
to treat*                            ______
  * [Surgical operations for the relief of organic obstruc-
tions of the cesophagus are rare.  For a very interesting and
instructive case of this  kind, by John Watson, o JVew-
York, see Am. Jour. Med. Sci., vol  viii , N. S , p. 309.  In
thr. case, which was of several months' standing, the ob-
struction existed about the middle of the cesophagus, which
wm contracted so as to scarcely admit an ordinary-sized
bour>*   The patient subsisted entirely on fluids, was free
from rough, hi d no pains of any sort, no soreness or tender-
mm iSiut he throat, either from pressure or from attempt-
      swallow.  He was feeble and much emaciated, had
ing to
III.  HEMORRHAGE  FROM  THE  G3SOPHAOUS. —
   Svnov.  CEsophagorrhagia;  Blutung aus der
   Spcichelrohre, Germ.
     Classif.—See  art. Hemorrhage.
   50.  Haemorrhage  very rarely takes place from
the oesophagus, unless from mechanical injury.
When occurring spontaneously, the source of
the haemorrhage is ascertained with great diffi-
culty during the life of the patient.  Blood ef-
fused from the internal  surface of this tube is
seldom excreted directly upward, but generally
passes  almost  insensibly into  the  stomach,
where it is partially digested, and carried, with
the other ingesta, into the intestines, if it be in
small quantity, or is vomited, if  the effusion  be
very considerable.   In this latter case, haemor-
rhage from the cesophagus  simulates  Hemor-
rhage from the stomach (which see).  The chief
circumstances  which lead us  to suspect,  when
blood is discharged  upward in any way, that it
is effused  from  the  internal surface of the
oesophagus, are the  symptoms of previous dis-
ease of this part, especially  pain  and heat  in
a frequent and copious flow of saliva and mucus from the
mouth ; the thyroid bodies were larger than usual, and one
or two lymphatic glandular swellings existed on either side
of the throat, just below the angles of the jaw.  The fauces
were free from inflammation, the tonsils were not enlarged.
Everything about the fauces appeared perfectly healthy,
and the patient had previously enjoyed good health.  After
trying simple bougies and catheters, an armed bougie was
passed down to the stricture, and a piece of lunar caustic,
as large as a  pin's head, allowed to melt at the seat of ob-
struction.   This afforded  no  relief, although repeated on
the day following.  The patient was then supported by nu-
tritive injections for  ten days, which were  statedly admin-
istered through  a long gum elastic tube passed into the co-
lon.  They consisted of beef-tea, broth  containing boiled
flour, boiled starch and arrow-root, boiled  eggs, and such
other articles as could be administered.  The injections had
a marked effect in recruiting his strength and in assuaging
the  sense  of hunger. They  increased  the volume of the
pulse and the fulness of the capillary vessels; but at times
they excited tormina, and occasionally purged him. espe-
cially when highly seasoned with salt.  All  other resources
failing, the cesophagus was laid open, opposite the thyroid
cartilage: the patient's life was thus  protracted, but  he
sank and died, three  months after the operation.
  On examination after death, the poach  of the pharynx
and upper part of the cesophagus were exteusively ulcera-
ted, the whole surface of  the ulcer being irregular, and of
a greenish colour; its upper  and lower edges were ragged
and irregular.   It was nearly encircled by  a series of tu-
bercular deposites, of a pale,  yellowish  white colour, vary-
ing in size from that of a pea to a small nutmeg, and seated
in the sub-mucous  cellular tissue.  Some of them had bro-
ken down in  the centre,  so  as to admit a probe to pass
through them and under the tissues, among which they
were situated.  The mucous membrane, over a great part
of the ulcer, was wanting, or hung in  shreds, or was bri-
dled and undermined. The septum between the gullet and
trachea was perforated in two places on the  oesopha«ial sur-
face, both  of which were like  irregular, longitudinal slits, a
qnarter of  an inch or more in length, one just under the
lower edge of the cricoid cartilage, the other two inches
lower down.  Below  the ulcer, the cesophagus was healthy
throughout its whole extent.
  Permanent  contractions of the oesophagus are generally
considered  as the result of carcinoma;  but the disease in
the  present instance, according to Dr. Watson,  was of a
scrofulous character.  This was clearly shown by the large
tuhercular  masses imbedded in the surrounding tissues.
There had been no  lancinating pains, nor were there any
appearances of scirrus. Dr. W. mentions another case which
came under his care, which  had a similar origin, and one
which resulted  from an attempt to swallow some very hot
food.  In another case, which occurred in  the New-York
Hospital, stricture  of the  ossophigiis was  produced bv at-
tempting to swallow a solution of corrosive sublimate. This
was cured by gradual dilatation ofthe canal by means of a
stomach tube.   There are but four cases of ujsophatrotnmy
on record  in the living subject, according  to Dr. W, and
this is the only one  in which it has been employed fur the
relief of stricture.  For these cases, and for some very ju-
dicious practical observations on organic obstructions ofthe
cesophagus, see the 8th vol.  Am. Journal  Med. Sciences.
loc. cit.]
II.
132 
thk—Causes—Symptoms.
 1050               CESOPHAGUS—Spasm oi

the course of the canal, with difficulty of, and
increased pain on, deglutition ; and a sense of
heat and  titiilation behind the  trachea, in the
situation ofthe tube.   Haemorrhage seldom  or
never occurs in this part ofthe digestive canal,
unless from pre-existing  disease of a severe
character, as inflammation terminating in  ul-
ceration, a case of which I have had an oppor-
tunity of observing ;  or from the presence of a
foreign body lodged in the canal, circumstances
tending to facilitate the diagnosis ;  but without
which it will be difficult to determine whether
or no the haemorrhage proceeds from the stom-
ach, or even from the respiratory organs.  The
phenomenon already alluded to is calculated  to
confound it with haematemesis, while the cough,
which  frequently accompanies  disease of the
oesophagus, particularly when seated in its up-
per portion, is likely to mislead  us, and to sug-
gest its origin in pulmonary disease.
  51. Treatment.—When the source of the ef-
fusion is tolerably manifest, the treatment dif-
fers but little  from that which is indicated  in
haemorrhages from other parts.  It should have
reference to  the states of vital power and  of
vascular tone.  Oesophageal haemorrhage very
rarely  occurs under  circumstances requiring
general or even local blood-letting.   The ap-
plication of cold externally—as  a stream  of
cold water poured on the throat;  the  use  of
ices, as the lemon ice, or of acids and  other
astringents internally, particularly in the form
of linctus or electuary, or in any semifluid ve-
hicle, are means which should  never be over-
looked.  The  most certain remedy, however,
in these cases, is the spirits of turpentine mix-
ed with honey or the yolk of an egg, and taken
in repeated doses.   In addition to these, hot
pediluvia,  cathartic  enemata, sinapisms, blis-
ters, and other derivatives, may be prescribed.
As haemorrhage from this part is generally con-
sequent upon chronic asophagitis and ulceration,
the same treatment as already recommended
for these diseases (v 48, et seq  ) should gener-
ally be instituted after the effusion has been
arrested.
  IV. Spasm of the CEsophagus.—Syn.  Spas-
  modic stricture of the asophagus.   (Esophago-
  spasmus; der Speiserohrenkrampf,  German.
  QZsophagisme, Fr.
     Classif.—II. Class, I. Order (Author).
  52. Defin.—Difficult and painful deglutition,
occurring either suddenly, and without evidence of
previous disease of the asophagus, or as a symp-
tom of such disease, and of several nervous affec-
tions.
  53. This affection has attracted but little at-
tention, although the justly celebrated Hoff-
mann wrote a treatise on it (De Spasmo Gula
Inferioris, Halae, 1733). It is, I suspect, in  its
slighter forms, more frequently brought before
the physician than recognised by him.  It forms
a most distressing part of the series of morbid
phenomena attending rabies, tetanus, hysteria,
and  hypochondriasis; and it constitutes the
form of dysphagia which is sometimes met with
in delicate and nervous  females,  particularly
those in whom the uterine functions are disor-
dered,  or  the uterus itself in an irritable and
slightly inflamed or congested state.
  64. i. Causes.—The circumstances just  al-
luded to may be viewed as predisposing causes
of this affection.  It may also be considered  as
occasionally appearing hereditarily, particularly
in connexion with  the nervous  temperament
and delicate and hysterical constitution.  The
most  common  exciting causes are swallowing
cold fluids when the body is perspiring ;  fits of
anger or passion in nervous  or  irritable per-
sons ; the irritation occasioned by the ingestion
of acrid, unwholesome, and injurious substan-
ces ; and flatus rising  into the canal and caus-
ing spasm of one part and dilatation of another
part adjoining the former, particularly upon at-
tempts at deglutition.   Owing to this last cause,
temporary spasm of the cesophagus  is not an
infrequent  occurrence  during the course of
dyspeptic, hysterical, asthmatic, and hypochon-
driacal affections.   Indeed, the dysphagia often
attending the slight or imperfectly developed
form of hysteria, consisting chiefly of the glo-
bus, or of  borborygmi, is entirely  owing to
oesophageal  spasm  ;  or, rather, this  spasm is
chiefly the cause of  these phenomena,  espe-
cially  when  a portion of the tube is distended
by flatus.  That spasm  of this  tube is  often
symptomatic  of  inflammations  or  irritations of
the stomach, and of the uterus  and ovaria, is
fully established.  Hoffmann  states  that it is
often attendant upon inflammation ofthe upper
portion of the spinal marrow.  It has also been
caused by inanition, by worms rising into the
canal  from the stomach, by  sea-sickness, by
excessive retchings or vomitings, by menstrual
or uterine irregularities, and even by powerful
mental emotions,  particularly those  of  a de-
pressing kind.   It  forms  a  most  distressing
symptom of rabies, and is a chief cause of the
distress which attempts at deglutition occasion
in that malady ; although spasm of the pha-
rynx is also present in that as well as in some
other diseases  in which it  is a prominent phe-
nomenon.  Oesophageal spasm is occasionally
caused by the influence of the imagination, as
shown by impossible deglutition, or the forcible
regurgitation of a substance through the mouth
or nose, when  disgust is conceived against it,
and by attempts to take disagreeable medicines
by children  or  even grown-up persons.  Gra-
pengeisser  says that  he has seen this spasm
produced  by electricity.  It has  already been
stated (y 19, 20) that it heightens the distress
in cases of acute, sub-acute, and chronic oesoph-
agitis.
  55.  ii.  The  Symptoms of asophageal spasm
are chiefly the sudden occurrence, without pre-
vious disorder  referable to the cesophagus, of
difficult or  even  impossible  deglutition, and
pains  excited by attempts to swallow that are
felt in some portion of the tube.  The symp-
toms vary with the part of it affected.  When
the spasm is seated at the top of the oesopha-
gus and pharynx, then deglutition is  almost or
altogether impossible, and substances are for-
cibly rejected.   When it is seated in the lower
portion, then the morsel swallowed is arrested
at its seat, and is  either immediately regurgi-
tated, or remains there for a  considerable pe-
riod, when it slowly passes into  the stomach,
or is violently ejected  from the canal.  If the
spasm be attended, or is caused, by flatulent
distention of a  portion or portions of  the tube,
attempts to swallow are often  very painful, dif-
ficult, or even choking; but the distress  is re-
lieved, or entirely  removed, by eructations of
flatus, the dysphagia occurring only at  the com- 
CESOPHAGUS—Paralysis of—Diagnosis.
1051
 mencement  of eating,  although  it sometimes
 only occurs  towards the close.   In  some  in-
 stances the  most urgent distress is produced
 by the retention of the substances swallowed
 in the cesophagus, attempts to pass them into
 the stomach or  to reject them  being equally
 unavailing.  I have seen this occurrence con-
 nected with the presence of flatus in the tube.
   56.  The nature,  consistence,  fluidity,  and
 temperature of the substances taken often  in-
 fluence, or aggravate,  or alleviate the  symp-
 toms,  but in no  uniform or  definite manner.
 In some cases,  fluid or warm substances are
 most easily swallowed; in others, consistent or
 pulpy, or semifluid, or cold food.
   57.  The duration of this affection varies with
 its causes, and with the disorders of which it
 is a symptom, or with which it  is associated.
 It may be, hence, of very short continuance,
 and may not again recur; but  where  it  has
 once appeared it  generally returns after irregu-
 lar intervals, or  upon the recurrence  of  its
 causes.   When  symptomatic of,  or associated
 with, any of the  disorders above alluded to, it
 is very prone to  recur as long as they  exist,
 although it may be removed for a time, or pre-
 vented from recurring, by attention to diet and
 by treatment.  Fear of its occurrence often as-
 sists in occasioning an attack, as  well as in ag-
 gravating its severity.
   58. iii.  Treatment.—The cure of this affec-
 tion, which, as above shown, is most frequent-
 ly symptomatic, must necessarily depend upon
 the nature of its pathological cause and rela-
 tions.   When it seems to arise from inflamma-
 tory irritation in the  cesophagus itself,  the
 means advised for acute and chronic oesopha-
 gitis (y 43, 48) should be employed.   If  it  ap-
 pear to proceed from irritation and debility  of
 the stomach, as  frequently is  the case, partic-
 ularly when it is attended by flatus, the  treat-
 ment recommended for the more  inflammatory
 states  of Indigestion (see that article)  is  ap-
 propriate.   When it accompanies other hys-
 terical phenomena, or inflammatory irritation,
 or congestion of  the uterus or ovaria, or irreg-
 ularities of the catamenia, the means prescri-
 bed for those affections (see  Hysteria, Men-
 struation, Ovaria, and Uterus) should be pre-
 scribed.
   59. In  most instances, however,  whether
 idiopathic  or symptomatic, means directed  to
 the affection itself should be employed, linctus-
 es or demulcent mixtures, containing a combi-
 .lation of narcotics or anodynes with antispas-
 modics, as the sirup of poppies, or the com-
 pound tincture of camphor with small doses of
 borax,  or of nitre, or of the hydrochlorate of
 ammonia; the hydrocyanic acid, or the extract
 of belladonna in  mucilage and the sirup  of or-
 ange peel; or the bitter infusions with these,
 or with the preparations of henbane or hem-
 lock.   At the same time, a belladonna or cam-
 phor plaster, or a plaster containing both these
 substances, may be applied to the throat and
 npper part of the sternum.   A portion  of the
 following embrocation, sprinkled on warm flan-
 nel and applied to these parts, is  the most im-
 mediately efficacious  of all other applications
 that I have employed.
  Ni 306   R Linimenti Camphors Co, ;  Linimenti Tere-
binthin*, aa, ?jss. ; Tinct. Opii, 3vj. (vci Ej«r. Belladonna),
3SS.j11 Olei Cajeputi,  31-  M.   Fiat Embrocatio.
   60. Having removed the affection by these
 or similar means, the return of it should be pre-
 vented by a treatment directed to the disorder
 of which it is frequently a symptom.  If it pro-
 ceed chiefly from chronic debility and nervous
 susceptibility, tonics and antispasmodics, with
 generous  diet, pure air, and regular exercise,
 should be enforced.  If it arise from an irritable
 or torpid and weakened state of the digestive
 organs, stomachic aperients, tonics, antispas-
 modic and purgative enemata, &e, ought to be
 given.   If it be caused by functional, or  con-
 gestive, or inflammatory states  of  the female
 organs, or menstrual  irregularities, the reme-
 dies recommended for  the  removal of these
 states,  especially  antispasmodics,  emmena-
 gogues, chalybeate preparations, pure air, reg-
 ular exercise, and chalybeate or alkaline  min-
 eral waters, should  be prescribed.   In cases of
 frequent recurrence of oesophageal spasm, par-,
 ticularly when  it is connected with hysteria,
 much advantage will be procured from chewing
 a piece of camphor, or from holding a piece of
 it  in the mouth, so that the saliva is  imbued
 with it.  In  these  cases, also,  as  well as in
 others, the various kinds of ices, or even  iced
 waters,  will be found most useful palliatives.
 V.  Paralysis of the  OEsophagus.—Palsy oj
   the Gullet, Monro.
    Classif.—See art.  Paralysis.
   61. Dr. Monro remarks that there are various
degrees of palsy of the gullet, and that in many
diseases accompanied by great debility, a tea-
spoonful cannot  be  swallowed, while the  con-
tents of a larger spoon readily pass down.   The
loss of power of deglutition is sudden in some
cases and slow in others.  In many, a difficulty
of swallowing solids only is perceived at first;
and often the effort of deglutition  is attended
by much agitation of the frame,  amounting in
some instances to convulsion.  The throat ex-
hibits nothing uncommon, excepting paleness
and flaccidity ofthe uvula and fauces.  When
difficult  or impossible deglutition depends upon
palsy, it is persistent or continued ; and the
easy passage of a probang  into the stomach
shows that it is not owing to any mechanical
obstruction.   Palsy of the cesophagus is gener-
ally associated  with palsy of some  other  part
or  parts,  palsy of  it  alone being  extremely
rare.  I have seen palsy of this tube associated
with palsy of the pharynx and of the muscles
of articulation, no other part being  paralyzed,
in  three or four cases, all of which terminated
fatally.  It is sometimes symptomatic of hys-
teria, and it often attends  apoplexy, hemiple-
gia, and the last stages of fever and other acute
diseases, in  all which it  is generally  a fatal
symptom.   I have seen it follow, and alternate
with, spasm of the gullet, in the  course of se-
vere and  anomalous  forms of  hysteria, the
most favourable mode or form of its occurrence.
   62. A. The diagnosis of palsy of the gullet is
easy.  The continued difficulty of swallowing
small quantities or volumes  of any substance,
while larger quantities are taken with greater
ease, distinguish this affection from spasm of
the tube, while the passage of a probang shows
that there is no permanent obstacle.   In the
slighter cases, there is much difference in the
phenomena of deglutition, some patients swal-
lowing more easily solid than fluid or semiflu-
id  substances, while others can take the latter 
1052          CESOPHAGUS—Foreion Bodies in—Biblioobaphy and References.
with most ease.   Some swallow with rapidity,
or endeavour with great effort to project the
morsel through the canal; others accomplish it
slowly, and others, again, require the aid of flu-
ids to perfect the act.  When the palsy is com-
plete, then deglutition is impossible.   The ali-
mentary bolus is then arrested in either  the
pharynx or upper part of the gullet; and it may
even pass  into the larynx, and cause cough or
suffocation.  Owing  to the want of power  of
swallowing the  saliva, a discbarge of this se-
cretion from the mouth is usually observed.
  63. B.  The causes of palsy of the  gullet are
rarely such as act directly on this tube.  They
are to be  looked for at the origins, or  in  the
course of the nerves supplying this  part and the
pharynx,  particularly of  the pneumogastric.
Baglivi, Valsalva, Dupuy, and others, have
shown that animals which have died after  di-
vision of these nerves were incapable of swal-
lowing,  and have retained the aliments  in the
cesophagus ; and cases have been recorded  by
Koehlbr, Wilson, Flandin,  Montant, Esqui-
rol, and  others, in which  this form of palsy
was owing to hydatids,  tubercles,  cysts, tu-
mours, or  other organic lesions, at the origin
of these nerves, or at the base ofthe cranium,
or in their vicinity.  Palsy of the gullet is often
a part, and even the most important and prom-
inent part ofthe palsy, so frequently observed in
th^e most severe and chronic cases of insanity.
  64. C. The treatment should depend upon the
cause of which this affection seems, in each
case, to be the effect.  If it proceed from  con-
gestion or pressure at the origins ofthe nerves,
local depletions and permanent derivatives are
required.   If it be viewed as the result of tu-
mours of  any description  pressing upon  the
nerves of the tube, the preparations of iodine,
particularly the iodides of potassium or of mer-
cury, or a solution of the bichloride of mercury,
may be employed.  In a case recorded by Wil-
son, this affection was caused by venereal ex-
ostosis  of one of the  cervical  vertebrae, and
was cured by anti-venereal treatment.  Doctor
Monro  adduces  two cases which  were cured
by electricity,  which agent,  however, is  not
suitable for cases arising from organic disease
at the origin,  or even  in  the course  of the
nerves.  Blisters, mustard poultices, stimula-
ting liniments or embrocations, ointments, con-
taining  strychnine, &c ,  applied to  the neck,
throat, or  upper  part of the sternum; moxas,
issues, setons, and blisters kept freely dischar-
ging for a considerable time  in  the  same  sit-
uations ; stimulating gargles, and sialagogues;
purgative and stimulating enemata, as spirits
of turpentine with castor oil, asafcetida, or cam-
phor, comprise the most efficient  means  that
can be  prescribed for this very unfavourable,
and most frequently fatal affection.   When the
palsy is slight and symptomatic of hysteria, the
means advised for  other  forms of  hysterical
palsy (see Hysteria, v 93) should be employed.
While these or other means, which  the pecu-
liarities  of the  case will suggest, are  being
used, the patient should be sustained by nutri-
tious substances  administered as lavements, or
conveyed  into the stomach  by means of  an
cesophagus tube.
  65. VI. Foreign Bodies in the CEsophagus
—Fragments of bones, or other hard, or solid,
or sharp bodies, are not infrequently swallowed
and arrested in some part ofthe gullet. The usu-
al consequences, when they are allowed to re-
main for any time in this situation, are inflam-
mation, suppuration, ulceration, and ultimately
even perforation of the parietes of the tube.—
A. The symptoms vary with the size  and form
of the foreign body,  and with the position of it
in the part  in which  it is lodged ; but there is
always severe pain, remarkably increased upon
attempts at deglutition, which  is generally  at-
tended by spasm and by more or less difficulty,
or complete inability to accomplish the act.  If
the body be large and arrested in the upper part
ofthe tube, or near the pharynx, there are also
violent  strangulating and  almost  suffocating
paroxysms of cough.   When angular or sharp
bodies continue long in  the oesophagus, they
may not merely perforate the parietes, but even
ulcerate or perforate adjoining parts, as an im-
portant artery  (Kirby), the trachea, etc.,  or
produce caries of a vertebra (Velpeau), and in
still  rarer  instances, dilatation of the  gullet
above the seat of mechanical obstruction.
  66. B. Leeches are  sometimes swallowed,
when drinking water from pools incautiously,
and, fastening themselves to  the parietes  of
the gullet, sometimes occasion severe and pe-
culiar symptoms.  Accidents of this kind have
been noticed by Galen,  Celsus, Pliny, and
Dioscorides, and in  modern times by Larrey,
Double, Duval, and others.  M. Velpeau states
that, besides the pain, they produce  a peculiar
sensation of suction, with difficulty of swallow-
ing,  followed by vomiting of blood ; and some-
times by very severe nervous symptoms.
  67. C. The treatment of these  accidents is
more surgical than medical. When the foreign
body can be extracted, to attempt extraction is
preferable  to pushing it by a probang  into the
stomach.   The nature, size, shape, and chem-
ical  composition of  the body should guide the
physician in his opinion as to the propriety of
attempting extraction or the other alternative.
In some cases  it may  be  advisable  to try the
effect of an emetic, when this can be passed
into the  stomach ; but the propriety of having
recourse to  this treatment should depend upon
our  knowledge of the  obstructing  body.   In
the case of leeches adhering to the sides of the
tube, emetics may  be employed without  risk.
As to the surgical means, I must refer to mod-
ern works in which this subject is treated.
  Bibliog. and Befer.—Avicenna, Canon., 1. iii., fen. 13,
t. ii.,  cap. 7, 12.— Willis, Pharm. Hat., sec. i., c. i., p. 45.—
Brunner, De Gland. Duod., c. 10, p. 136.—H. Boerhaave,
Atrocis nee desenpti prius Morbi Historia, &c.,4to. Leyd.,
1724.—Schneider, in Halleri's Disput. Med., t. vii., p. 594.—
Ziesner, in Ibid., t. vii., p. 629.—Mauchart.— Haller, Disp.
Chirurg., t. ii.,p. 395.—F.Hoffmann, De Morbis (Esophagi
Oper., Sup. ii., p. 251.— Vater, De Deglutitionis difficilis
Causis Abditis.  Vitemb., 1750.— A. Monro, Edin. Essays
and Observat., vol. iii., p. 534.—Dallas, in Ibid., vol. iii., p.
525.—Morgagni, De Sed. et Caus. Morb., Epist. xxviii., 15.
—Malacarne, in Meinnne della Societa Italiaua, t. x., 1.—
Haller, Opuscula Pathol., obs. lxxi.—Gyser, De Fame Leth.
ex Callosa CEsoph.  Angustia, 4to.  Arg., 1770.— Honkoop,
De Morbo (Esophagi lnrlammatorio, Lugd. Bat., 8vo, 1774.
—Helian, Mem. de la Soc. Roy. <le Me.d., Ann. 1777, p. 217.
—Ludlow, Med. Observat. and Inquiries, vol. iii.—Mutray,
in Mem. de l'Acad. des Sc. de Suede, t. xl., 1779.— Wathtn,
in Mem. of Med. Society of Lond., vol  i.—Blair, in Ibid ,
vol. v., art. 33.—Flajani, Collezione di Osservazioui, t.  ill.,
osser. 62-65.—J. Bleuland, Observat. Anatoraico Medica: de
Sana  et Morbosa (Esophagi Structura, 4to, c. fig.  Leyden,
1 Tb5.—Borsieri, Institut. Med. Pract., vol. iv., p. 291.—
Sandifort, Mus. Anat , 1.104, tig. 3.-^4. Portal, Anat. Med.,
t. v., p. 204.—Reil,  Memorab. Clinica, fasc. i., p. 13.—Ze-
viani,  in Memorie  di Fisica di  Verona, t. yii.—Meitr, in
Baldinger's Magazin, b. iii., p. 399.—M.-Baillie, Serieg uf 
OSSEOUS SYSTEM—Inflammation of Bones.
1053
 Engravings,  <fcc, fasc. iii.— E. Home, Pract. Observat. on
 the Treatment of Strictures in the Urethra and (Esophag.,
 Bvo.  Lond., 1803.—Pinel, Nosog. Philosoph., t. iii., p. 153.
 —Sue, in Mem. de la Soc. Med. d'Emulat., t. iv., p. 218.—
 Smith, in Lond. Med. and Phys. Journ., vol. ix., p. 552.__
 Purton, in Ibid., vol. xlvi., p. 540.—/. Shaw, in Ibid., vol.
 xlviii., p. 185.— Bayle et Cayol, Diet, des  Sc. Med., t. iii.,
 p. 615.—Andrews, Observat. on the  Application of Lunar
 Caustic to Strictures of the Urethra and (Esophagus, 8vo.
 Lond., 1807.—Brogna, in Journ. Gen. de Med.,  t. Iii., p.
 31 ; et LechevereL, in Ibid., p. 145.—Chantourelle, Mem. de
 la Societe Med. d'Emulation,  t. ix., p. 295.— Abrahamson,
 in Meckel's Archiv., b. i., st. iii., p. 16.—Kirby, in Dublin
 Hospital Reports, vol.  ii., p. 224.—Noverre, Bullet, de la
 Fac. de Med. de Paris, t. vi.,  1819.—Gaitskell, in London
 Med. Repos., t x., p. 353.—G. De Claubry, Recueil Period.,
 t. xxxiv., p. 13.—J. B. Paletta, Exercit. Patholog., p. 228.
 4to, 1820 — Wilson, Recueil Period., t. xiv., p. 450.— V. N.
 ab Hildenbrand, Institut. Practieo-MedicE, vol. iii., p. 143.
 —Larrey, Mem.  de Chirurg. Milit., t. ii., p. 147.—Dumas,
 Consult, et Observat. dc Med., p. 428, 8vo.  Paris, 1824.—
 Boisseau, Pyretologie Physiol., p. 97, 8vo.  Paris, 1824; et
 Nosographie  Organique, t. i.,p. 131.—Barras, Revue Medi-
 cale, t. i , p.  326, 1826.—Pagenstecher, Journ. des Progres
 des Sciences Medicales, t. viii., p. 268.—C, Bell, Lancet,
 vol. xii.. p. 707.—G. C. Blondeau, Quelques Reflex, sur les
 Corps Etrang. arrets dans le Pharynx ou l'ffisoph. et sur
 les Moyens de les extraire, 4to, c. fig.  Paris, 1830.—A.
 Monro, Morbid Anatomy of the Gullet, Stomach, and In-
 test., <tc, 8vo, 2d edit., 1830, passim.—Andral, Med. Cli-
 nique,  t. ii.,  p. 9 ; et Anat. Patholog., t. i., p. 276.—Lind-
 say, in Med. Chirurg. Review, vol. xxix., p. 407.— Fletcher,
 Medico-Chirurg. Notes and lllustrat., 1st part, p. 26. Lond.,
 1831. — /./. Leroux, Cours sur les  General, de  la Med.
 Prat., t. i., 8vo.  Paris, 1825. — Cummin, in Transact, of
 the Medical and Chirurgical Society of Edinburgh, vol. iii.,
 p. 593.—Nouveau Journ. de Med., t. vi., p. 8.—Mondiere,
 Archives Gener. de Med., t. xxiv., p.  394; t. xxvii., p.
 196; t. xxx., p. 507; et t.  ii., 2d ser., p. 520.—Cassan, in
 Ibid., t. x., p. 79.—Omboni, in Ibid., t. xxi., p. 438 —Begin,
 in Journ. Hebd. de Mf'd., t. ii., p. 94, 1833.—Gcndron, in
 Ibid., t. i., p.  378, 1836. — Carswell, in Ibid., t. vii.. p. 321.
 —Roche, Pathol. Medico-Chirurg., t. i., p. 454.—Raimann,
 Handbuch der Speciellen Therapie, b. i.. s. 322.—Broussais,
 Annal. de la Mfed. Physiol., t. iii., p. 254.—/. M. Arnott,
 in Trans, of Med. and Chirurg. Soc. of Lond., vol. xviii., p
 86.—Blandin, in Diet, de Med. et Chir. Prat.,t. xii., p. 143.
 —Velpeau, in Diet,  de Med., 2d edit., art. Olsophage.—
 Cruveilhier, Anat. Pathologique, livr.  xv., xix., yxvn., «t
 Xxxviii.—H. Mayo, Outlines of Human Pathology, p. 280,
 Svo.   London, 1836— G. F. Most, Encyklopadie  der  Ge-
 sammten Mediciuisch. u. Chirurg. Praxis, b. ii., p. 218.
  [An. Bibliog. and Refer —New-York Medical Repos-
 itory, vol. xxii.. p. 244 ; vols. xii. and xv.—John Watson, in
 Am. Journal  Med. Sciences, N. S., vol. viii. (Practical ob-
 servations on organic obstructions of the (Esophagus, pre-
 ceded by a case which called for resophagotomy and sub-
 sequent opening of the  trachea, with accompanying illus-
 trations).—OsAorne, in Am. Journal Med. Sciences, vol. i.,
 N. 3., p. 495  (Perforations connecting the Oesophagus with
 the air tubes  of the lungs).—M. Wyman, Am. Journ  Med.
 Sciences, vol. xxiv., p. 58 (Case of cancerous ulceration of
 the (Esophagus opening into the trachea);  Am. Jour. Med.
 Sciences, vol. xiv (Case of diverticulum of the ffisophagus).
 —Albers, in Amer. Journal Med. Sciences, vol. xiv., p. 471
 (Spontaneous perforation of the ffisophagus and trachea).—
 John B. Zabriskie, Case of Oesophagitis, in Amer. Journal
 Med. Sciences,"Vol. xiii., p. 567.—M. Begin, in Am. Journ.
 Medical Sciences, vol. xiii., p. 251 (Two cases of ffisopha-
 gotomy).—Thomas Wells,  Case  of temporary Obstruction
 of (Esophagus, in Am. Journ. Med. Sciences, vol. x., p. 31.
 —Samuel D. Gross, Elements of Pathological Anatomy.
 Phil., 2d ed., 1845.—Case of extraction of a Needle from the
 (Esophagus, in Boston Med. and Surg. Journ., vol. xxiv., p.
 17.—R. Davy, in Boston Med. and Surg. Jour., vol. xx., p.
 101 (Retention of a  half penny in the ffisophagus for 39
 days).—if. Green, Case of Stricture of (Esophagus, in New-
 York Journal of Med. and Surgery for 1839.—IV. C. Whit-
 ridge, in Boston Medical and Surg. Journal, vol. xxi., p. 259
 (Singular case of stricture of (Esophagus).—R. Liston, On
 Extraction of Foreign Bodies from the ffisophagus—Sur-
gery.— Death from false Teeth inpacted  in ffisophagus, in
Bost. Med. and Surg. Jour., vol. xxx., p. 181.—C. Bannister,
in Boston Med. and Surg. Jour., vol. xxvi., p. 175 (Directs,
where pins or needles are lodged in ffisophagus, to fasten a
small leaden bullet on a string, and let the patient swallow
it, drawing it  up, and repeating until the body is dislodged).
—Case of Scirrus of the ffisophagus, in Boston Med. and
Surg. Journ., vol. x., p. 172.-R. Dunoon, The  Practice
of Med,c,ne. 2d edit.. 2 vols., 8vo.  Phil., 1844.-Am. Med.
Recorder 1829 p 440 (Case of contraction of the ffisophagus
relieved by the intcrnalndministration of salammontacjrom
Hemiplegia, cured by Electro-magnetism, in Am. Journal
Med. Sci! vol. viii., N. S., p. 481 .J
 OSSEOUS SYSTEM, Diseases of.—The Os-
   seous Structure, or Tissue.
      Classif —Special Pathology, and Patho-
        logical Anatomy.
   1. The bones are liable to the same diseases
 as other parts ofthe frame ;  to similar changes
 of both  a constitutional and a local nature to
 those which affect other structures.   Many of
 these changes are merely results of inflamma-
 tion arising generally from local causes, but
 always modified,  and  sometimes  even  produ-
 ced by constitutional peculiarity or  diathesis,
 or by a vitiation of the fluids and ultimately of
 the  solids of the body, as observed in scrofula,
 gout, fever, scurvy, &c.   Other changes, and
 these the most serious and often the most dan-
 gerous, appear independently of inflammation,
 and are more or less the result of constitution-
 al vice, although frequently  excited  or  devel-
 oped by local  causes, as by contusions or other
 injuries.   I shall consider, first, inflammations
 of bones  and their consequences; and next, the
 organic lesions of bones that appear independ-
 ently  of  inflammation, although often accom-
 panied with it  in their course.
 I.  Inflammation  of Bones.—Synon. Osteitis
   (from  ooreov, a bone).  Ostitis; Inflammatio
   ossium.  Osteite, Inflammation des os, Fr.   Die
   Knockenentziindung, Germ.
     Classif.—III.  Coass, I.  Order (Author).
   2. Defin.—Pain in the situation of a bone, in-
creased upon firm pressure, or when  sustaining a
weight, with more or less swelling, and  often with
symptomatic fever,  the  substance of the bone be-
ing  increased in vascularity, and often otherwise
changed.
   3.  i. Seat  and  Anatomical  Characters. — In-
flammation may attack the substance of a bone
 and  be limited to it; or may affect chiefly the
 periosteum, or the  medullary membrane, and
 extend thence  through the  substance  of the
 bone, or  may extend from  the  latter  to these
 membranes.   In  either case the inflammation
 may affect a portion only, or the whole  bone ;
 or it may be limited to the body, or to the ar-
 ticular extremity.   When commencing  in the
 external  or internal  layers ofthe bone, it often
 is confined for a long  time to them, but it fre-
 quently extends to the whole  structure, espe-
 cially in  the spongy bones, and  in young  sub-
jects.
   4.  Osteitis is generally a chronic disease, or
 it  is rarely so rapid  in its course as  inflamma-
 tions  of  other organs : a circumstance  mani-
 festly owing to the nature ofthe osseous struc-
 ture.   The most  acute or rapid forms  of the
 disease are usually from several weeks to some
 months in duration, while  the  most chronic
 states may endure for several years.
   5. Osteitis may occur in any bone, but  it is
 most  frequently observed in the more  super-
 ficial bones, and in  the more spongy and vas-
 cular  in  their  structure.   The  bones of the
 hands and feet, the bodies ofthe vertebrae, and
 the  articular ends of long bones, are  the parts
 most frequently affected.
   6.  The  anatomical changes consequent upon
 inflammation  of the bones are, increased size
 of all the  vessels  running through the vascular
 orifices and canals ;  vascular injections in parts
 which  usually  do  not contain red blood ;  and a
 somewhat reddened and swollen state  of the
 affected  bone.  In  the more prolonged  cases, 
1054          OSSEOUS SYSTEM—Inflammation  of Bones—Terminations.
the cells and canals increase in size, are irreg-
ular, or partially run into each  other by absorp-
tion of their walls, and are filled with  a  san-
guineous lymph, so that the  fine  membranes
lining  them  are found somewhat  thickened.
The proportion  of lime in the bone is some-
times more or less reduced, according to the
duration and intensity ofthe inflammation ; and
occasionally the periosteum is thickened and
relaxed, particularly when the  disease com-
menced in it, and then the  surface of the bone
usually is rough and porous.
  7. ii. Causes— Osteitis  is more  frequently
met with in  children than in adults.—a. The
predisposing causes are the rheumatic and gouty
constitution, the scrofulous diathesis, and the
scorbutic and syphilitic contamination  of the
frame.  Of these, the  scrofulous, syphilitic, and
scorbutic vices  are the most influential.—b.
These often  also excite osteitis.  Rheumatism
frequently attacks the fibrous  tissue covering
the bones, and the inflammation, thus origina-
ting, often  extends to the bone itself, and ter-
minates in caries.  Articular osteitis occurring
in adults generally originate  in rheumatism.
Gout occasionally excites articular osteitis,
chiefly in persons advanced in age, and  after
repeated attacks.  Scrofula is a most  influen-
tial predisposing and exciting cause of osteitis,
in both children and adults, particularly in the
short bones, and in  the spongy ends  of long
bones.  It  also favours the passage of  the dis-
ease into caries.  Scurvy  seldom  affects the
bones  until it is far advanced, and then it im-
plicates the dense structure ofthe bones, ren-
dering  it softer, and  favouring the rapid su-
pervention of caries, as fully  shown by M. J.
L. Petit.  Syphilis inflames  the bones often
consecutively upon periostitis, and frequently
gives rise  to exostosis.   Exhaustion  of vital
energy, venereal excesses, and masturbation,
fevers, and visceral  disease, also  favour, and
even directly  cause osteitis;  but in these ca-
ses the vertebrae are the parts most frequently
affected.
  8. c.  The more local causes  are usually exci-
ting only, and often concur with the preceding
in developing the malady.  Every kind of ex-
ternal or local injury, as fractures, contusions,
wounds, pressure, &c.; intense heat  or cold
applied to an extremity  or  part ;  inflamma-
tions, particularly those  which are chronic, in
the immediate vicinity of a bone ; and suppu-
ration,  or purulent collections coming in con-
tact with it, are the most  common and active
causes.
  9. iii. Symptoms.—At the commencement of
osteitis the patient feels a dull, sometimes  an
acute  pain within the bone or  deeply  seated.
The pain is increased upon firm pressure, and
upon any exercise that affects the  bone,  as
standing upon it, or  supporting a weight by it.
This is often the only symptom for a consider-
able  period.   After   a  very variable  time, a
slightly hard and smooth swelling may be de-
tected by passing the fingers along the seat of
pain, unattended by  any discoloration of the
surface.  The swelling is fixed, and continuous
with the surface of  the  bone; and, although
the substance of the bone  is generally  more or
less tumefied, still, the chief part of the swell-
ing that is detected  is owing to inflammation
ofthe periosteum covering the affected bone.
  10. The progress of osteitis is always slow,
owing to the low vitality and structure of the
affected part;  but sometimes the pain becomes
extremely acute, and  the  swelling increases
more rapidly,  the disease assuming  a more
acute form.  This  state is most common to
venereal osteitis, and is not readily distinguish-
ed from periostitis, excepting that  the  pain is
referred to the bone itself at the commence-
ment, and  that the swelling is at first  very
slight, and the  progress of the  affection slow.
When the swelling is caused by periostitis, its
progress is more rapid than that of osteitis, it
advances farther, is less hard, and  becomes at
last  somewhat soft and elastic.  The  aching
nature,  the  persistence and the seat of pain,
with the modifications of it by  position, exer-
tion, &c, are the chief guides we possess as to
the existence of inflammation of deeply-seated
bones.
  11. When the inflammation   implicates  the
medullary membrane lining the  canals of long
bones and the cells of the spongy structure,
this membrane is injected, red,  and, according
to Lobstein, more dense;  and the marrow is
augmented in volume,  as well as the fluid con-
tained in the cells of the spongy structure.  In-
flammation of this membrane is not infrequent
after amputations, and is then sometimes prop-
agated from the  amputated surface along the
whole medullary canal.  It is attended by the
same symptoms as those characterizing ostei-
tis ;  but, when following amputations, it is not
so painful, is  more rapid in its progress,  and
more readily passes into suppuration, than in
other circumstances, and other  states of oste-
itis.
   12. iv. The  terminations  or  consequences of
osteitis  are, resolution, exostosis and indura-
tion, suppuration, gangrene or  caries, arid ne-
crosis.—A. After resolution, the structure infla-
med regains its former state, but the swelling
generally continues for some time after pain
has  disappeared.—B. Exostosis  and induration
are sometimes associated results, while either
may occur singly.  The indurated portion of
bone assumes  an ivory or dense appearance,
more especially in some exostoses.   The in-
creased deposition of bony matter—exostosis—
hyperostosis—occurs as internal and external ex-
ostosis.   The former, in a lesser degree, is a
usual consequence of inflammation, the deposi-
tion of bony matter in the diploe  necessarily
increasing the  weight and solidity of the bone.
If the inflammation have been of very long du-
ration, the more the weight and solidity of the
deposite are increased, the part assuming an
ivory state, and the medullary cavity  being en-
croached upon by the deposition.
   13. The external form of increased deposition
of bone is more common than the internal, and
is oftener injurious.   In some cases, the bony
deposite takes place in the loosened periosteum,
which first  becomes  cartilaginous, and after-
ward bony,  in leaf-like patches, forming nodes
or gummata.  In others, the bony deposite oc-
curs in the outer table of the bone, forming a
local and defined prominence—a bony tumour or
external exostosis.  An exostosis may form si-
multaneously  in the internal and external  sur-
face of a  bone.   This takes place chiefly in
the bones of the skull.  These  bones and the
tubular bones  are the most frequent seats of 
OSSEOUS SYSTEM—Inflammation of Bones—Necrosis.
1055
exostosis, and next to them the vertebrae and
pelvis ;  but they may be produced on any bone,
or even on  several  bones at the same time.
They often form  in a considerable number  in
the vicinity of carious bones.  They may as-
sume any form, and attain any size, from that
of a split pea to that of a child's head.  The
structure of exostoses varies remarkably. Some
are firm, dense, and ivory-like ;  in others, innu-
merable bony fibres  spring up  from the bony
surface  into the inflamed, spongy, and loosened
periosteum.   These fibres are harder and closer
at their base than at their termination in the
periosteum,  where they are often soft and car-
tilaginous.  In a third  variety, the exostosis
seems to consist of an expansion of the exter-
nal table or surface  of the bone, from within,
by the effusion or infiltration of matter beneath
it.  Bony tumours of this kind  are common in
the lower jaw and bones of the hand.   Their
interiors are loose,  cellular, or spongy,  very
vascular, and the cavities are  filled with sub-
stances varying in consistence from lymph to
soft cartilage.  This last  variety becomes much.
larger  than the others,  readily inflames, and
suppurates; or increases still farther in bulk, by
dilatation ofthe internal  cells composing them.
   14. C. When suppuration takes  place, in ad-
dition to the anatomical characters of  inflam-
mation, the  periosteum becomes fungous  or
spongy, and less  adherent, when the external
surface of the bone is inflamed.  And this sur-
face is rough, unequal, and eroded, and changed
to  a grayish or dark. hue. If the disease has
commenced by destruction of the articular car-
tilages, the  affected  bone presents similar ap-
pearances.   If osteitis  has originated  in the
substance of the bone,  the bony structure is
 softened, is changed to  a yellowish, greenish,
 or brownish tint, and the centre ofthe softened
 parts is infiltrated with pus, or  with  a dirty
 grayish ichor of an offensive  odour.   As the
 disease proceeds, the softening and discolora-
 tion of the bone  increases, until caries  and  ul-
 ceration are established.
   15. D.  Caries consists in  a  greater  or less
 destruction — ulceration — and  discoloration of
 bone, with a secretion of a puriform or of a foe-
 tid sanious matter.  Young and spongy bones,
 abundantly supplied with vessels, most readily
 become carious.  In many instances, owing to
 destruction of adjoining parts, the periosteum
 and outer surface of the bone are first destroy-
 ed ; but when the  disease commences in the
 substance of the bone, a circumscribed  abscess
 is sometimes formed ; or the softened portions
 of bone, infiltrated with a sanious fluid, are par-
tially absorbed or partially dissolved,   as they
lose their vitality in the effused fluid,  thereby
forming ulcerated or fistulous cavities, contain-
ing puriform or sanious matters.   These cav-
ities, or sinuses, make their way to the surface
of the bone, and  thence  to more external parts.
   16. E. Necrosis, or mortification of  bone, is
a frequent consequence of osteitis, as well as
of destruction ofthe periosteum.   It may occur
in  anv  part  of the skeleton, although  it more
frequently attacks the hard bones, and is always
succeeded by the separation ofthe dead portions
of the bone from the living.   According to  the
state of the bone, and the causes and  circum-
stances ofthe inflammation, of which necrosis
is the consequence,  the  dead bone exhibits  va-
rious  differences.  If the bone die in conse-
quence of gangrene of the surrounding parts,
the necrosed bone is spongy, light,  frangible,
and blackish brown.   If the necrosis be caused
by scurvy or hospital gangrene, it is similarly
discoloured and softened.  In common necrosis,
however, the dead bone is dry, rough, deficient
in gelatin, porous or corroded externally, gen-
erally white, but sometimes coloured blackish
or brown  by the offensive sanies poured out
around it.  When  necrosis follows osteitis, it
may be either trie consequence or the cause of
caries.  Mortification sometimes occurs only in
certain layers of bone : in the external—super-
ficial  or external necrosis; or in  the internal
layer  or table—internal  or central  necrosis; or
the whole  substance or mass—total  necrosis.
The first usually arises from exposure  or de-
nudation of the bone, but it may also proceed
from  inflammation of the surface or external
layer  of bone, and  the consequent detachment
of the periosteum.   Internal necrosis occurs al-
most  only in tubular and  round  bones; total
necrosis in  solid bones also.  Total  necrosis,
especially in tubular bones, is attended by a dis-
charge from the internal  surface of the perios-
teum, and external to the dead bone, of a jelly-
like mass, which gradually hardens and is  os-
sified, surrounding, like a sheath, the necrosed
bone, or sequestrum.   As this bony sheath sep-
arates from the enclosed sequestrum or dead
bone, it becomes lined by a delicate medullary
membrane.   In the midst of the bony sheaths
are one or several  holes—the foramina grandia
of Troja, the cloaca of Wiedmann—which com-
municate with the existing sinuses of the soft
parts, and form an outlet for the  continually-
absorbed and diminished sequestrum, as well
as for the secreted pus  or lymph, and when
these are  discharged, these  holes  gradually
close.  In the internal necrosis  the process is
nearly the same ; but in this case the jelly-like
matter  forming the  new bone is poured  out
from  the internal surface of the remaining  liv-
ing bone—from the surface of the living bone
adjoining the dead bone ;  the living bone often
swelling at the same time, and being somewhat
softened.
   17. a. Causes of Necrosis.—Whatever, either
in the substance of the bone or in the perioste-
um, interrupts the nutrition of the bone, or in-
flames it, may conduce to necrosis.  But if the
mischief in  the periosteum,  medulla, or sub-
stance of the bone, be of trivial extent, limited
suppuration, or abscess, passing into caries and
ulceration, are the more common results.  The
causes of necrosis are the same as those of os-
teitis—are external,  or internal and  constitu-
tional.  But either of these may be so energetic
as almost immediately to destroy the life of the
bone ; but more commonly they excite inflam-
mation ofthe bone, of which the  necrosis is a
termination or consequence.  Mr.  Stanley has
shown that bone may perish from inflammation
of it without our being always able to recognise
inflammatory symptoms, and yet  the existence
of inflammation antecedent to the necrosis is
undoubted.   Owing to the grade, severity,  and
constitutional relations of the inflammation, or
to other causes, the symptoms of osteitis may
 be so slight as to escape notice.   The existence
of necrosis is generally more easily detected.
   18. Osteitis  productive of necrosis may be 
 1056           OSSEOUS SYSTEM—Inflam

 either mild, slight, or severe and active.  The
 symptoms of osteitis are sometimes so mild as
 to  render the  diagnosis difficult. This most
 commonly occurs in debilitated constitutions,
 in which the necrosis affects only the external
 part of a bone, and originates in some chronic
 and constitutional cause, as  scrofula, syphilis,
 scurvy, &c.  But when necrosis supervenes in
 the substance and the interior of a bone, and
 occurs in plethoric, irritable, or robust persons,
 it is both preceded and attended by acute symp-
 toms, by severe pain, much fever, and restless-
 ness ;  the disease proceeding more rapidly to a
 termination.
  19. b. Symptoms.—The swelling accompany-
 ing necrosis forms and increases gradually, par-
 ticularly when caused by osteitis.  In the slow-
 er and  more mild cases, the pain is inconsid-
 erable and dull or aching ;  but when the swell-
 ing increases  rapidly, or when the patient is
 plethoric and irritable, it is  more violent.  The
 swelling, as soon as mortification takes place,
 is much greater than in  osteitis ;  still  it is not
 elevated into an apex, but  is so diffused along
 the bone that its limits cannot be distinguished ;
 and this diffusion of the swelling is  the more
 remarkable the more deeply seated the inflamed
 and necrosed bone.   It may even extend over
 the whole bone or limb.   The swelling com-
 mences with the osteitis,  and  increases until
 the matter which is formed  finds its  way out
 through the soft parts,  when the tumefaction
 partially subsides.  When  necrosis is advan-
 cing, oedema of the soft parts is often present.
 The abscess attending necrosis proceeds more
 rapidly the more intense the inflammation, and
 the nearer the bone is to the surface ; but when
 the necrosed bone is deeply seated, and the in-
 flammation more chronic, the abscess  is great-
 er and advances more  slowly to  the surface;
 but when the necrosed bone is deeply seated,
 and the inflammation more chronic, the abscess
 is greater and advances more slowly to the sur-
 face, often forming  sinuses, particularly if fas-
 ciae intervene.   The matter discharged varies
 in character with the constitutional symptoms
 and origin of the osteitis which has thus  ter-
 minated.  It is sometimes  pure pus, but most
 frequently it is sanious, acrid, and fetid.  As
 the necrosis proceeds the sinuses formed by the
 outlets of the  matter become fistulae,  through
 which  not only the matter,  but  the  remains
 also of the dead bone make their way.
  20. The swelling attending necrosis is always
 diffused and situated  upon a bone, the bone
 seeming included in the swelling.  Even when
 suppuration has commenced  and  advanced,  it
 appears deeply seated and obscure.  The skin
 long retains its colour, and does not exhibit a
red or livid hue until matter is advancing through
the soft parts.
  21. c. The formation of new bone is a most
important part ofthe phenomena attending ne-
crosis, and much discussion and experimenting
have been devoted  to the  subject by modern
surgeons,  the results being nearly as follows :
When the bone dies, consequently either upon
osteitis, or upon destruction of the medullary
membrane or of the periosteum, the phenomena
vary with the part which is  first destroyed.  If
the medullary membrane is destroyed, and the
inner layer, or the whole substance ofthe bone
becomes dead, then the  periosteum acquires a
mation of Bones—Treatment.

 high degree of vascularity, and becomes thick-
 ened, soft, spongy, and loosely adherent to the
 bone.   The cellular tissue also surrounding the
 periosteum becomes  more vascular and infil-
 trated with lymph.  The periosteum thus chan-
 ged, quitting its hold of the dead bone, is now
 the  formative  organ  of the new bone;  and  a
 reddish fluid mass  is secreted by the  internal
 surface  of this membrane,  and is gradually
 changed  into new bone,  and thus  the  same
 periosteum which  had covered the old bone is
 also the  periosteum  to the  new.  If, on the
 other hand, the periosteum is destroyed, togeth-
 er with the  bone, while the medullary  mem-
 brane, which performs the office of an internal
 periosteum, is preserved, this membrane under-
 goes changes similar to those ascribed to the
 external periosteum,- and is the medium of the
 formation of the new bone.   This latter fact,
 insisted upon by Wiedmann and  Boyer, has
 been fully confirmed by the recent experiments
 of Mr. Stanley, who states that, " if one side
 of the walls of a bone be removed without much
 injury  to the medullary texture, the lost bone
 will  be reproduced by the vessels of the me-
 dullary membrane."  Mr. Mayo also remarks,
 that if one aspect of the cortex of a cylindrical
 bone is killed by an injury,  the cancellous struc-
 ture granulates, and reproduces what has been
 lost.
  22. Mr. Stanley has shown that, when ne-
 crosis  is  attended by destruction of the  bone
 and  medullary  structure, the bone may be re-
 generated  from three  sources : 1st. From the
 articular ends of the  original bone, which are
 seldom implicated  ; 2d. From the periosteum
 which  invested the dead bone ;  3d. From the
 soft  parts indifferently, whatever their nature
 may be, which surround the periosteum, suppo-
 sing this to  be destroyed.   Mr. Stanley re-
 moved the periosteum from a dog's tibia, and
 destroyed the medullary texture, yet reproduc-
 tion  ensued, evidently  by the vessels of the
 surrounding cellular tissue, which had become
 exceedingly condensed and adhered to the sur-
 faces ofthe new bone, thus forming its perios-
 teum.   This  result agrees with the evidence
 furnished by the  experiments of Villerme,
 Breschet, and Dupuytren on the formation of
 callus.   I believe that  the surface  of bone it-
 self,  particularly its divided  surface and ex-
 posed cancellous structure, will produce granu-
 lations, or a fluid substance which will be con-
 verted  into bone,  even independently  of the
 surrounding tissue.  I  once  observed  in the
 cranium of" a man who had been  trepanned
 many years before for injury of the head, the
circular portion of  bone removed being unusu-
ally large, that the aperture had been Jully filled
up with new bone, and that the ossific matter had
evidently been produced from the divided mar-
gins  of the old bone, as it proceeded from them
in striae, which converged to the centre of what
had been the  opening, these striae being larger
 near the margin of the old bone, and tapering
as they converged to the centre of the opening
which  they had closed.  The new formation
 was  dense and without diploe.
  23. v. Treatment.—The treatment of oste-
itis  and  of its consequences necessarily de-
pends chiefly upon the predisposing and exci-
ting  causes, and upon the constitution of the
patient.  The pain and swelling should be com- 
OSSEOUS SYSTEM—Organic Lesions of Bones—Sojtening—Fragility.     1057
 bated by local depletions, and the antiphlogis-
 tic regimen ;  by warm  and  emollient cata-
 plasms and fomentations ; by the frequent ap-
 plication of a small number of leeches to the
 seat of pain ; by alterative aperients and diaph-
 oretics.  If suppuration take  place, an early
 vent should be given to the matter that is form-
 ed.   These means should be pursued with an
 activity commensurate with the severity of the
 symptoms  and the strength and youth of the
 patient.  If pus accumulate in the  medullary
 canal, it may be necessary to procure it an out-
 let by perforating the  bone.   Dr. Macfarlane
 trephined the tibia in  two cases with success,
 in order to give vent to the pent-up matter.
 The diagnosis, however,  of such cases is the
 chief difficulty.
   24. If the disease proceed from syphilis  or
 scrofula, the preparations  of iodine, especially
 the iodides of potassium or of mercury, or the
 bichloride  of mercury, with sarsa or the com-
 pound tincture of cinchona, or the iodide of po-
 tassium  with  liquor potassae and sarsaparilla,
 are the most  efficacious  constitutional reme-
 dies.   I  have  lately prescribed Mr. Donovan's
 solution  of the iodides of mercury and arsenic
 with great  benefit in one case of venereal oste-
 itis. If scurvy be connected with the appearance
 of osteitis, the means advised  for that disease
 should be chiefly relied on (see  art. Scurvy).
   25. If necrosis supervene, the indications sug-
 gested by  Wiedmann are  most appropriate,
 namely,  to  remove the original cause  of the
 disease; to alleviate  the symptoms; to sup-
 port the patient's strengh and improve the state
 of the constitution ; and, lastly, to remove the
 dead portions of bone when they become loose.
 These comprise the same means as have just
 now been recommended.   In order to improve
 the constitution of the patient, whether syphi-
 litic or scrofulous cachexia be present, the prep-
 arations of iodine, or of mercury, or a combina-
 tion of both ; those of sarsaparilla and cincho-
 na ; the  chlorides, particularly the chlorate of
 potash, combined, according  to circumstances,
 with other  remedies, should be principally em-
 ployed, and aided by pure air, and suitable diet
 and regimen.
 II. Organic Lesions of Bones, occurring in-
   dependently of Inflammation.
    .Classif.—IV. Class, IV. Order (Author).
   26.  There are various lesions found in bones
 which are independent of inflammation at their
 commencement, although limited or slight os-
 teitis  may be excited  by them in their course,
 particularly around them, or in their immediate
 vicinity.  These lesions are generally of rare
 occurrence compared with those which proceed
 from inflammation.
  27.  A. Softening of Bones—Osteomalacia,
 malacostcon, osteosarcosis,  mollilies, ossium — is
 sometimes  caused to a slight extent by the long
 continued rest of a joint, but commonly by rick-
 ets and scrofula.  Softening is owing  to the
 disproportion of the phosphate of lime to the
 amount of  animal matter or jelly;  the former
being  generally reduced to one half its usual
amount,  and the  latter increased  about one
third.   Softened bones are more or  less flexi-
ble, and are usually bent  or  misshapen, partly
by the action of the muscles, and partly by the
 u eight of the body.  Softening of bones occurs
in two forms, 1st. In connexion with rickets and
    II              133
 general debility in childhood; 2d. In adults and
 aged persons, from constitutional vice or debility.
 —(a) Rickety bones, according to the increase of
 their vessels and the expansion of their cells
 with jelly, become of a red colour and swollen.
 This  softening is sometimes congenital,  but it
 usually occurs in children,  and  is  rarely so
 general and so malignant as that which affects
 persons advanced in age.—(b) The softening
 observed in adults and old persons is often very
 remarkable, and even in the slighter cases is
 very rarely controlled by treatment.   It  is ei-
 ther partial or general.  It is met with chiefly
 in females, and has been observed consequent
 upon  scurvy, syphilis, mercurial disease, tuber-
 cles, scrofula, diabetes, lepra, rheumatism, and
 gout, and the accidents connected with parturi-
 tion, or the more usual consequences  of  child-
 bed, as disordered lochia, &c.
  28.  a. Softening  of  bones,  particularly in
 adults, is generally attended by pains resem-
 bling  those of chronic rheumatism, or by ach-
 ing in the bones affected.   Afterward the bones
 bend or yield to the  action of the muscles, or
 to the weight of the body, and the pains  in-
 crease on muscular action.   The height, size,
 and form of the body are diminished, changed,
 and deformed  respectively; and the affection
 usually continues to advance, with all  the indi-
cations of general debility, until it terminates
fatally.  In some cases, the teeth are the only
bones which altogether escape change.
  29.  b. The softening of bones in adults dif-
fers from the  rickets of children.  The latter
is generally cured by treatment or by the  prog-
ress of age; but the former is progressive, what-
 ever may be the remedies employed.  The soft-
ening accompanying  rickets is not attended by
pain ; that of adults always is accompanied with
pain, although the pain is not constant through-
 out the disease.  The softening in the latter
 also is usually more general and much  more
 remarkable.    These  circumstances  indicate
 that they are distinct maladies.
  30. c. The treatment consists in the employ-
 ment  of tonics, with  lime-water, and small do-
 ses of phosphoric acid, or other prepartions of
 lime and phosphorus.  Sea-air and sea-bathing,
 chalybeate and refreshing mineral waters, ex-
 posure to the  light and to  the sun's rays, nu-
 tritious and  light  diet, a dry and pure air, and
 sleeping in a large airy apartment, are the  most
 appropriate remedies. (See, also, art. Rickets.)
 These are generally  efficacious in softening in
 children ; but  their influence upon the soften-
 ing of bones in adults is very doubtful.
  31.  B. Fragility of Bones.—Britlleness.—
 Spontaneous  Fracture.—This change  is  very
 rarely  congenital, and also rarely observed in
youth.  It usually occurs in advanced age.  In
it  the animal  matter  is  comparatively less
 abundant than the earthy  constituent.  The
 cancerous cachexia is often the cause of this
 alteration, as  shown by  Hamilton,  Strack,
 Lobstein, and others.  Fragility of bones has
 been observed  also consequent upon gout; and,
 in rare instances, upon the same  maladies  as
 have preceded  softening of bones.  Otto states
that fragility is not  infrequently  observed at
 Breslau consecutively  upon  cancer,  syphilis,
 and scrofula.  It  is often preceded by pains in
 the bones.  It  is rarely amenable to treatment.
  32.  C. Erosion of Bones generally arises 
1058          OSSEOUS SYSTEM—Organic Lesions of Bones—Fragility.
from the pressure of aneurisms or tumours of
any kind.  In these cases, the cause is mechan-
ical : the portion of the bone subjected to press-
ure, having its vitality thereby impaired, is re-
moved by absorption ; or the pressure, while it
obstructs the circulation, favours absorption in
the part pressed  upon.   Otto and others, how-
ever, believe  that the pressure excites inflam-
mation  in the parts  subjected to it; that the
inflammation is rapidly  followed by ulcerative
absorption, and  that this  change differs  from
caries only in not being attended by suppura-
tion or discoloration ofthe eroded part.
  33.  D. Sanguineous tumours are sometimes
found in bones, and numerous instances ofthe
occurrence have been recorded by authors.—a.
Some of these tumours  are manifestly aneuris-
mal, or owing to a remarkable dilatation of the
vessels penetrating  the bone.   As the small
aneurismal tumour  enlarges, the surrounding
osseous tissue is absorbed, a cavity is formed,
the two tables ofthe bone are thinned, and ul-
timately perforated.  When the tumour  be-
comes considerable  it presents the same char-
acters as other aneurisms.  The periosteum
around the tumour is generally thickened, and
the nerves  and  surrounding  tissues pressed
upon, stretched, flattened, &c.   In some cases,
related by Dupuytren, Breschet,  Pearson,
Lallemand,  Scarpa,  and  others, the  tumours
acquired very large dimensions.  They gener-
ally occur in adults, consequently upon injuries,
contusions,  &c., and are attended by a pulsa-
ting pain.  When they are large, the superficial
veins are distended, and the limb swollen and
sometimes discoloured.   The  pulsations cease
upon firm pressure on the artery of which the
aneurismal vessel is a  branch.  The treatment
of these cases is principally surgical, by  liga-
ture of the principal vessel or by amputation of
the limb.
   34.  b. Sanguineous tumours of a doubtful na-
ture are sometimes  found  in bones.  These tu-
mours are described by M. Berard as differing
from the aneurismal and  from the fungoid, or
haemato-fungoid, and as  consisting of a reticula-
ted structure, resembling that  of the cavernous
body,  containing altered  blood and  clots of
fibrin.  These tumours resemble those usual-
ly termed aneurism by anastomosis.  M. Bres-
chet considers  them to arise from a peculiar
inflammation of the osseous tissue, in which
the venous canals of the bone are chiefly affect-
ed.  They may be also  viewed as erectile vas-
cular tumours.-  Their  progress  is similar to
that  of aneurismal  tumours,  but more  slow.
They are not amenable to treatment, amputa-
tion being the only certain cure.
   35.  E. Tubercular  formations are  occa-
sionally found in bones, and  have been  very
minutely described by  MM. Delpech, Nichet,
Nelaton, and Berard.  They present them-
selves in two forms, the encysted and the infil-
trated.   The encysted is found in two  states,
the crude and the softened.—a.  In  the former
state, tubercles  occur in the substance of the
bone, the places or cavities they occupy being
a loss of the substance of the bone, owing to
the absorption of it as  they are developed and
increased.    The cavities are smooth  at  first,
but  become, as  they increase, rugous  and an-
fractuous.   They ultimately, by their enlarge-
 ment, open, either into  each other, if the tuber-
cles are clustered, or ultimately in  the perios-
teum, or into a joint.  The bone is generally
slightly injected to the extent of one or two
lines around the tubercles.  As they open into
the periosteum this membrane becomes inject-
ed at that part,  and deposites a layer of ossific
matter, which, for a time, resists their farther
progress.   These tubercles commence in  small
grayish, semitransparent granulations, each of
which  is enclosed in osseous cells  with  solid
partitions ; but  as they increase the partitions
are absorbed, and the matter is contained in a
single  cavity, and  one cyst (Nelaton).   They
thus resemble tubercles  in other organs.  As
the tubercular  mass, thus formed, increases,
it  becomes softened generally from  the centre
to the  circumference, but sometimes at first at
its periphery, and  it ultimately assumes a pul-
taceous state, in which it escapes by an  open-
ing, or a fistula, in the surface ofthe bone, and
gives rise to an abscess  in the soft parts cov-
ering the outlet from the bone.  As it is  evac-
uated,  the cavity in the bone  is  obliterated
gradually by thickening of the membrane of the
cyst,  and  ultimately  a  spontaneous cure is
thereby effected.   The filling up and cicatriza-
tion  of the tubercular cavities is thus fully es-
tablished in respect of bones.
   36. b. Tubercular infiltration of bone has been
only recently described  by M. Nelaton, who
particularizes two forms of it, one semi-trans-
parent  and firm, the other opaque and puriform.
The infiltrated matter softens gradually, and be-
comes liquid and puriform.  At the same  time,
the osseous cells ofthe infiltrated part become
partly  obliterated  by  thickening of  their  parti-
tions,  and the blood-vessels obstructed by this
interstitial hypertrophy, so that the death  of the
portion of bone thus affected often ultimately
follows, the necrosis  not being the result  of in-
flammation, as supposed by M. Delpech,  but of
obliteration of the vessels of the part.
   37. c. Tubercular disease of the bones is much
more common in  childhood  than at any other
age.   It may occur in adults, but is the  more
rarely observed the more advanced the period of
life.    It affects chiefly the spongy parts,  but it
may affect any of the bones.  It is most com-
monly observed in the bodies of the vertebrae,
in the extremities of the long bones, in  the
sternum, &c.
   38. d.  The duration and progress  of the mal-
ady  varies with the parts affected by it.   The
encysted variety generally advances to the  ex-
ternal surface of the bone as it softens,  pene-
trates the periosteum, notwithstanding the de-
fence  offered by this  membrane to its progress
(§ 35), opens into  the soft parts,  suppurates,
and  forms a fistula, and  the matter, advancing
to the surface, is discharged externally.  Ulti-
mately the cavity in  the bone is obliterated in
the manner stated above, if the case proceed
favourably.  When the tubercular mass  forms
in the extremity  of  a long bone, it generally
makes its way to  the articular surface, in pref-
erence to the periosteum.  The infiltrated va-
riety proceeds more  slowly, and generally ter-
minates by caries or  necrosis.
   39.  e. The symptoms of tubercles of the  bones
are very obscure in the early stages.  As long
as the disease  is confined to the substance of
the  bone,  slight  or occasional pains  are only
complained of.  But  when the mass affects the 
OSSEOUS SYSTEM—Organic Lesions of Bones—Osteosarcoma—Hydatids.    1059
 periosteum, and especially if it have penetrated
 into the soft solids, the abscess that is formed,
 and subsequently the tubercular character of
 some of the discharge, will  point out the na-
 ture of the disease.  The changes which after-
 ward  take place vary much; but the  state of
 the bone may be partly ascertained by exami-
 nation, by the local appearances, and  the con-
 stitutional symptoms.
   40; /.  The treatment is  necessarily the same
 as I have suggested for scrofulous osteitis and
 scrofulous necrosis ($ 24, 25).  See, also, the
 article on  Abscess.
   41.  F. Osteosarcoma, or  Malignant  Tu-
 mour of Bones—Bony Cancer—Osteosteatoma—
 Fungus  ossium—Cancer ossium—Exostosis fun-
 gosa — Exostosis carnosa — Ex. carcinomatosa,
 c\c—presents various forms.—a. In some cases
 it approaches the fungo-haematoid or encepha-
 loid character;  in others  it more nearly resem-
 bles the scirrous ; in a few it is fleshy, and in
 many it  presents cavities filled with a substance
 of varied density and colour.   In general, how-
 ever, the tumour at first consists of  a some-
 what homogeneous, grayish, or grayish white,
 unvascular mass, intermixed with bony points
 and fibro-cartilaginous fibres, more or less firm-
 ly consolidated with albumen.  As the tumour
 advances, its tissue becomes rarefied or loosen-
 ed, forming cells of various sizes, filled with a
 light-coloured, semi-transparent jelly.   Inflam-
 matory action or vascular excitement now oft-
 en takes place in the tumour, and the  cellular
 tissue lining the cells becomes thickened, and
 secretes an  albuminous  substance, which is
 sometimes soft  and  bran-like, at other times
 more consistent, or even hard.  In other cases,
 cellular tissue, loaded with albumen, is formed
 in it.  The blood-vessels  gradually enlarge in
 the periosteum,  and in the interior of the tu-
 mour, and cavities are formed in the latter fill-
 ed  with venous blood.   Blood is  sometimes
 also effused in  the brain-like substance, or is
 mixed with it.   Innumerable  bony fibres  or
 plates commonly project  from  the bone  out-
 ward, penetrate  the tumour  in  various direc-
 tions,  and,  becoming softer  and larger,  are
 finally united with the fleshy and membranous
 parts lying upon it.
  42. These tumours assume various changes
 and appearances in different cases.  If they are
 formed  in  the centre of a bone, they  distend
 the layers or plates, and reduce them to a thin
 shell.  In many cases the bone almost disap-
 pears, and  merely a few irregular osseous spic-
 ulae or plates are formed in the tumour.   These
 tumours may reach a very large size — may
 even be two feet or two feet and a half in cir-
 cumference, and  ten or twelve pounds in weight.
 They are generally knobbed or irregular on the
 surface,  and of  various degrees of hardness.
 The bone  adjoining the  tumour is altered  to
 some extent.  The  cells  are  enlarged, red  or
 inflamed, occasionally even carious.   New for-
 mations of bone  are sometimes produced in the
 vicinitv.
  43. b. Osteosarcoma may affect any bone, but
 it is observed most frequently in the bones of
 the face, at the base anJ arch of the cranium,
 in  the  long bones.   It is most frequently ob-
 served in adults and alvanced age, and very
rarely in childhood.  The precise tissue in which
the  malady originates has not been fully deter-
 mined.  Boyer supposed that the disease com-
 mences in the soft parts, and attacks the bones
 only secondarily.  Others believed that it be-
 gins in the bone  itself.   M. Sanson supposed
 that it originates either in the medullary mem-
 brane,  or  in that lining  the  spongy cells, an
 opinion which seems to accord with that enter-
 tained  by  Sandifort,  Siebold Walther, Eb-
 ermayer,  and Ossius.   Lobstein, however,
 considered the medullary membrane not to be
 its original seat, as  the tumour  is sometimes
 found external  to this membrane, which has
 remained sound.  It may probably arise either
 from this tissue, or from  the membrane lining
 the  vascular canals and spongy cells.
   44. c. Symptoms.—This malady is first an-
 nounced by acute, deep-seated pains, which oft-
 en are long felt  before any tumour can  be de-
 tected.   The constitution also frequently be-
 trays disorder before it is observed.  As soon
 as swelling appears, its hard, knobbed, unequal
 surface, the manner of its involving the whole
 bone, and  its complete immobility indicate its
 nature.   At a still farther advanced stage, the
 pains become more acute and lancinating, the
 soft  parts are  involved in  the tumour, and are
 also painful; the skin sometimes is inflamed
 and  ulcerated, particularly when the disease is
 very far advanced, and red, fleshy, or fungous
 excrescences, which bleed on the slightest con-
 tact, spring from the surface.  The patient's
 condition becomes rapidly worse ; fever, sleep-
 lessness, and marasmus characterizing the last
 period of his existence.
  45. d. The prognosis  of this malady is most
 unfavourable ; amputation or  complete  extir-
 pation ofthe disease, where either can be done,
 so as completely to remove the affected part,
 being the only treatment which is of any avail.
  46. G. Hydatids are rarely found in bones ;
 but instances of the occurrence have been re-
 corded by  Van  der  Haar,  Cullerier,  Web-
 ster, Wickham, Fricke, Dupuytren, Cooper,
 Keate, and others.  The  hydatidic cyst, con-
 taining  the small rounded vesicles, &o, pre-
 sents the same appearance and changes  as are
 described in the article Hydatids.  It is usu-
 ally found in the spongy part of the long bones,
 or in the diploe of the flat  bones ;  but it is also
 sometimes seen in the  diaphysis of the former.
 In very rare instances the hydatidic mass, af-
 ter having  perforated the bone, if seated  near a
joint, may  penetrate into the articular cavity.
  47. a. The progress  of  the disease is very
 slow, being seldom of shorter duration than
 several years.   Having perforated the bone, the
 hydatidic cyst invades the adjoining soft  parts.
 Ultimately  these are destroyed, and it reaches
 the surface.  But  in all the cases on record,
 the tumour formed by it has been opened  by the
 surgeon before it has perforated the skin.   The
 hydatidic mass, of various bulk, being evacua-
 ted, suppuration is established  in the cyst, and
 the debris of membranous cysts and dead hy-
 datids, generally mixed with a foetid pus and
 sanies, are discharged.   When the cyst  is in-
 flamed it becomes the seat of an abundant sup-
 puration, which can rarely be arrested without
 its destruction.  When a  considerable portion
of a long bone is destroyed by the cyst, fracture
 of it may take place.   Cases of this kind are
 recorded by some of the writers  referred to;
 and is, upon the whole, a less evil than the next 
1060
OSSEOUS SYSTEM—Bibliography and References.
to be noticed.   If the hydatids are seated near
a joint, they may penetrate into it, causing acute
inflammation of it at first, that generally pass-
es into a chronic state with structural change
ofthe tissues composing it, and ofthe heads of
the bones.
  48. b.  Hydatids of the bones are caused by the
influences which produce them in other tissues.
The majority of cases on record show that con-
tusions or other injuries had been received on
the part in which the hydatids were seated, or
that the  venereal disease had preceded their
appearance.
  49. c. The symptoms of hydatids in bones are
extremely obscure ;  the first indication furnish-
ed by them being a tumour in the part  affected,
and  this  rarely appears until  they have pene-
trated the bone.  The tumour is  attended with
little or no pain or tenderness, and no constitu-
tional  disturbance  besides that  constitutional
weakness or deficiency of vital  power which
favours  the development  of  parasitic forma-
tions.   As the tumour  increases, it  becomes
softer and more elastic, similar to lipoma or
fungo-haematoid tumours.  Ultimately  it may
present more or less fluctuation.   It still occa-
sions little or no pain, although it may altogeth-
er prevent the use  of the limb in which it is
seated.   The  absence  of pain, the slow prog-
ress of the disease, and the slight  affection of
the constitution are the chief means of diagno-
sis afforded by it.   Still, in  most of the cases
on  record, the nature of the  malady   was not
known until the hydatids were evacuated.
  50. d. The prognosis of this malady is always
more or less unfavourable.   As long as the tu-
mour is unopened, it occasions but little con-
stitutional disturbance ; but when  it is opened,
inflammation  takes place, which  seriously af-
fects the general health, commonly already im-
paired, and a prolonged and weakening suppu-
ration is  the usual result, which often destroys
the patient.  The amount of danger, however,
depends upon the seat ofthe hydatids, and the
possibility of removing  not only them, but the
cyst containing them.  When  they are seat-
ed in the bones of  an extremity,  and are not
developed  in any other part,  surgical interfe-
rence, aided by tonic or restorative constitution-
al means, will often prove successful.
  51. e. Treatment.—The indications of cure are,
1st.  To remove or destroy the hydatidic cyst,
or to remove the portion of bone containing it;
2d. To support the  constitutional  powers, and
to enable them to throw off or to resist the dis-
ease ; and, 3d. To subdue accidental  changes
of  an  unfavourable or inflammatory  nature,
whether  local or constitutional,  as they arise.
The fulfilment of these indications is  to be ac-
complished by surgical and medical measures,
of so obvious a kind as not to require particu-
lar notice.
  52.  H. Spina  Ventosa.—I agree  with  M.
Berard in considering this not to  be a distinct
disease  of bones, as generally supposed ; but
the  result of the organic  maladies  described
above, when  they  are attended  by  tumour,
swelling, or protrusion of the external plate of
bone and periosteum,  or by that external con-
figuration which has been described  as consti-
tuting spina ventosa.   These changes and  ap-
pearances are most commonly produced by the
malignant, hydatidic, tubercular,  and  sanguin-
 eous tumours, which have been as fully descri-
 bed as my limits will permit.
   53. J. Foreign  Bodies have been  found  in
 bones ; and these have lodged in them, either
 from external injury, especially by leaden bul-
 lets, small shot, &c., or been conveyed to them
 through the  medium of  the circulation,  as  in
 cases where  mercury,  arsenic, or sulphur has
 been detected in them.   Neither of these, how-
 ever, requires more than a simple notice at this
 place.    It may  be  remarked,  however, that
 leaden  balls may remain  a  long time  in  bone
 without producing much disease ; still caries or
 necrosis may be  occasioned  by them.
  Biblioo. and  Refer.—I. The Pathology of the
 Osseous System generally. — C. Havers, Ostcologia
 Nova, or  New Observations of the Bones and Parts belong-
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 Schaarschmidt,  Kurzer Unterricht. von Krankheiten der
 Knockeu, 8vo.   Berlin, 1740.—J. G. Duverney, Traite de
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 F. Sandifort, Museum Anatom., 4 vols., fol. Leyden, 1763,
 passim.—A. Murray, in Act. Med.  Suec, t. i., p. 395.—A.
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 of Phys., vol. iii., p. 25.—C. F.  Clossins, Ueber die Krank-
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 Lond., 1820.—Ribes, in Bullet, de la Facuhe de Med., vol
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 Anat. Patholog., livr. xx.—.4. W. Otto, Compend. of Hu-
 man and Comparative Patholog. Anatomy, transl. by J. F.
 South, p. 125, 4c, 8vo.  Loudon,  lb31. — G. Gulliver, in
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 p. 1.—E. Stanley, in London Medical  Gazette, vol. xx., p.
 500.—A. Rrard, in Diet,  de Medecine, 2d edit., art.  Os.
   II. Special Diseases of the  Osseous System.—i.
 Inflammations and their Consequences.—Aviccnna, Canon.,
 1. iv., fen. iv., tr. 4, cap. 9.—J. A. Lambert, Comment, sur
 la Curie et Corruption des Os,  8vo, Mars,  1656.—Glass, in
 HallerU Biblioth. Chirurg, vol. ii., p. 198.—P. Hoffmann,
 De Inflam. Ossium.  Halls, 1737.— Wallerian,  Lectiones
 Curiusie de Morbis ex Ossium Inflammatione ortis.  Reg.,
 1764—Morgagni, De Sed. et Caus. Morb. Epist. L., 56.—
 Wiseman, Several Surg. Treat , 1. ii. et iv.—Soemmering,
 De  Morbis Vasorum  Absorben, p. 164.— Sandifort, Mus.
 Anat., vol. iii., p. 275.— Trye, in Med. Communicat., vol. ii.
 Lond., 1790.—J. Thomson, Lectures on Inflammation, p. 39.
 Edin., 1813. — Cullerier, in Diet, des  Sc.  Med., t. xiv., p.
 218.—Cooper and Travers, in their Surgical Essays, vol. i.
 — Gibson, in Philad. Journ. of Med. and Phys. Scien , vol.
 ii., p. 121.—Richerand, Nosographie Chirurgicale, t. iii., p.
 120.—Scarpa, De Aunt, et Pathol. Ossium Couinieutarii,
 4to, fig.   Pavia, 1827.—A. N. Gendrin, Histoire Anatomique
 des  Inflammations, 2 tomes, t.  i. and t. ii., p. 564.  Paris,
 1626 — Meckel,  Pathol. Anat.;  vol. ii., p. 274.-7. F. Mal-
 gnigne,  in  Archives Gener. de Med., t. xxx., p. 59, 177.
 1832.— Masliettrad-Lagemart, in Ibid., 2d series, t. xiii., p.
 273.  lt?37—F. Miesscher, De Inflammatione Ossium, &c,
 4to,  fig.   Berl., 1836.
   ii. Non Inflammatory Lesions.—Tavry, in Mem. de l'Acnd.
 Roy. Paris, 1700.—Morand, Hist,  de la Mai. Singul. et de
 l'Examen du Cadavre d'une Fennne devenue tout-a-fuit con-
 trefaile  par un Ramollissement Gener. des  Os.  Paris,
 1752.—Hasty, in Philos. Trans., vol. xlvin., p. 26.  1753.—/.
 Pringle, in Ibid., p. AU6. — Navier, Observat. sur  la Ramol-
 lissement des Os. Paris, 1755.—Louis, Observat. ct Re-
 marques sur les Effets du Virus Cancereux.  Paris, 1750.
I —C. G. Ludwig, in Advcrsariu  Med. Pract., t. iii., pars jj 
OVARIA—Diseases of the—Inflammation.                      1061
8; et Observat. in Cadarere, cujus Ossa emollita erant.
Lips., 1757.—Else, Med. Observat. and Inquiries, vol. iii.,
p. 169.  London, 1769.—David, Observat. sur une Maladie
connue sous le Nom de Necrosis.  Pari*, 1782.— Wiedmann,
De Necrosi Ossium, fol.  Franc, s. M., c. fig., 1793.—Sail-
lant.  Hist, de la Soc. Roy. de Med., p. 28.  1786.—Pearson,
in Med. Communicat., &c, vol.  ii.—Russel, A Pract. Es-
say on a  certain Disease  of the Bones, termed  Necrosis.
Ed., 1794, plates.—Thomas, in Edin. Med. Comment., vol.
vi., p. 75. — Portal, Cours  d'Anat. Med., t. i., p. 31, 301.—
Dauhenton, Descript. du Cabinet du Roi, t. iii., p. 107.—F.
L. Augustin,  De  Spina Ventosa Ossium, 4to, fig.  Berlin,
1797.—J. P. Frank, Delect. Opusculor., vol. ii., p. 304.—
Webster, in New-England  Journal of Med. and Surg., vol.
viii.  Boston, 1899. — Renard, Ramollissement des  Os du
Tronc d'une Femrae, 8vo, c.  fig., May, 1804. — South, in
Lond. Med. Repository, vol. iv., Sept.—Hutchinson, in Ibid.,
April, 1815.—Boyer, Traite de Maladies Chirurg., 2d edit.,
t. ii., p. 318.  Paris, 1818.—Pelletan, Clinique  Chirurg., t.
ii., p. 14.—/. Howship, in Trans, of Med. and Chirurg. Soc.
of Edin., vol. ii., p.  136.— Whateley, Practical Observat. on
Necrosis of the Tibia.  London,  1815.—Biclard, in Bullet.
de la Faculte de Med. de Paris, 1815, p. 427—Dupuy, De
l'Affectiou Tuberculeuse, &c, p. 50, 265, 8vo.  Paris, 1817.
— Villerme, in Journ. de Midecine de Leroux, t. xxxvii.,
p. 331.—Otto. Selt.  Beobacht., b. i., No. 40, p. 81.—Blaise,
Essai sur la Necrose. Paris, 1825.—Baldy, in Lond. Med.
and Phys. Journ., vol. xl.— Williams, London Medical Re-
p<>».,  vol. xvii., p. 204.—J. F. Bonfils, Descript.  succincte
d'une Maladie grave et rare de l'Humerus, <fec, fig. Nancy,
1817.—R. Keate, in Transact, of Med.  and  Chirurg. Soc.
of Lond.. vol. v.—Flecchia, Sulla Necrosi, <fcc, in Omodei's
Annali Universali de Medic, t. xvii., 1821.—Crampton, in
Dublin Hosp. Reports, vol.  iv., p. 357.—Koschate, Observat.
Nonnullae circa Osteosarcoseos Naturam et Indolem, adnexis
tribus hujus Morbi Histonis, Svo.  Vratisl., 1826.—/. Rus-
sel, in Trans, of Med. and Chirurg. Soc. of Edin., 1824, No.
i.—Lallemand, in Repert. Gener. d'Anat. et de Phys. Path-
ologiques, t. ii., p. 253.—Breschet, in Ibid., t. ii., p. 263.—
Hmdernacht,  Ueber die  Erkentniss u. d.  Behandl. des
Knockenbrandes,  8vo.  Wurzb., 1827.— Wickham, London
Med. and Phys. Journal, Jan., 1827, p. 530.—Henderson, ir
American Journ. of Med. Sciences, vol. v., p. 58.—Flourens,
in Ibid., vol. vi., p.  216.—Lobstein, Anat.  Pathol., t. ii., p.
220.—Scarpa, in Ann. Univers. di Medic, Mai, 1830.—De-
zeimeris, Journ. de  l'Experience, 1838, No. 34.—N. Guillot,
in Ibid., 1830, No.  109.—Nichet, Sur les Tubercles de Ver-
tebres, in Gaz. Med. de Paris, p. 529, 545.  1835.—Nelaton,
Recher. sur PAffect. Tuberc. des Os, 4to, fig.  Paris, 1837.
  III. Regeneration of Bones. —.V. Troja, De Novorum
Ossium in integris, aut maximis, ob Morbos Dependitionibus
Regeneratione Experimenta, <fec, <fec, 8vo.  Paris, 1775 —
G. L. Koeller, Experimenta circa Regenerationem Ossium,
eVo, fig.   Gott., 1786.—E.  Stanley, Observ. on the Condit.
ofthe Bones in Rickets, with Circumstances relating to the
Process of Restoration, &c, in Transact, of  Med. aud Chi-
rurg. Society Loud., vol. vii., p. 404.—Charmeil, De la Re-
generation des Os, 8vo.  Metz, 1821.—Kortum, Experimen.
et Observ. circa Regenerationem Ossium.  Berlin,  1824.—
Rayer, in Archives  G6ner. de Med.,t. i., p. 318,489.— San-
ion, in Journ. Univers. des Sc. Med., t. xx.,  p. 131.  Paris,
1820.—Breschet et  Villerme, in Magendit's Journ. de Phys-
iol. Experimen., t. i., p. 116.—Knox, in Edin. Medical and
Surg. Journ., vol.  xviii., p. 62;  and xix.,  p.  210.—Craigie,
Elein. of Gener. and  Pathol. Anatom., 8vo,  p. 568 (Doubts
whether or not the  apertures after trephining are ever filled
up.  The instance  I  saw, referred  to above (y 22), is con-
clusive of the affirmative).—F. Banneth, Natural Conami-
num  in Ossibus Uesis sanandis Indagatio, 8vo, fig.  Bonn.,
1131.—Heine, in  Graefe u. Walther, Journ., b. xxiv.; and
in Gaz. Med. de Paris, p 386, 1837.—(See, also. Ploucquet's
Literatura Medica  Digesta, art. Os; et Reuss's Repertor.
Comment., vol. xii. et xiv.)
  [Ad. Bibliog. and Refer.—S. D. Gross, The Anatomy,
Physiology, and Diseases  of the Bones and Joints, 1 voi.,
Bvo—Elements of Pathological  Anatomy, 2d ed.  Philad.,
) vol., nJVal Svo.—R. Lislon, Elements of Surgery, with
Notes and Additions, by S. D. Gross, 1816.—/. .1/iHer, The
Principles of Surgery, 1 vol., Svo.  Phil , 1845.— V. Mott,
Am.  ed. of Velpeau's  Surgery.   New-York, 184!i, by Town-
send.— W. H. Ranking, Half-yearly Abstract.  New-York,
1816.—B. Brodie,  Pathological  and Surgical Observations
on the Diseases ofthe Joints. 1 vol., Svo.—Clinical Lectures
on Surgery.  Phil., 1 vol., Svo, 1846.—Hope, Elements of
Morbid Anatomy,  1845. — W. Gibson, The History  and
Treatment of Bony Tumours, in No. 5 of Phil. Jour, ofthe
Medical and Physical Sciences.—Remarks on the same, in
Am.  Med. Recorder, 1822. by ('. B. Gibson— Osteosarcoma
of Jaw, in Am. Journ. Med. Sci., vol. iv., N. S.—J. G. H.
Hodgson  On Lardaceous Tumours of Bone, in Am. Journ.
Med  Sci., vol. v., N. S., p. 472.-.W". Flourens, On Devel-
opment of Bone, in Am. Jour. Med. Sci., vol. v., p. 435.—
B. B. Cooper, in Am. Journ. Med. Sci., vol. xxv.. p. 4,9.-
T B  Curlin", Atrophy of Bone, in Am. Journ. Med. Sci.,
vol xxi p 195— Baker, On Fragility of Bones, in Am. Jour.
tied  Sci   vol. xxi.,  P-  235. — M. Blandin, Osteosarcoma,
in Am. Jour. Med. Sci., vol. xiv., p. 507.—J. P. Jervey, Os-
teosarcoma, in American Journal of Medical Sciences, vol.
viii., N. S., p.  111.]
OVARIA—Diseases of the.—Syn.  Ovarium,
  from Ovum, an egg; Testis Muliebris.   Ovaire,
  Fr.  Eierstock, Germ.   Ovary.
     Classif.—Special  Pathology  ;  Morbid
       Anatomy.
  1.  The diseases of the ovaria are extremely
numerous ;  for these organs are liable not only
to the disorders and structural lesions to which
other organs are  subject,  but they also occa-
sionally  present  lesions  and  displacements
which are peculiar to themselves ; disorders of
formation and of structure connected with the
performance of their functions during the epoch
of sexual maturity and activity.   In the  discus-
sion  of the  pathology of  these organs, I  shall
consider.^Jrsf, their functional disorders;  second-
ly,  inflammation originating in or extending  to
them, with  its consequences ;  and, thirdly, the
lesions of structure presented by  them.
I.  Functional Disorders of the Ovaria.
     Classif.—I. Class, II. Order (Author).
  2.  Defin.—The non-performance of those func-
tions which may be referred more especially to the
vital  energy of the  ovaria, owing to the imperfect
or impaired state  of their energy ; or inactivity of
the ovaria, as evinced by the absence, the defect, or
impairment of the functions imputed to these or-
gans.
  3.  Several ofthe disorders which have  been
treated  of under distinct  heads may be arran-
ged under this  category, as they either origi-
nally proceed from, or  are more  or less inti-
mately  associated with,  imperfect  or  prema-
turely exhausted  vital  activity of the  ovaria;
and to this cause they have been assigned when
discussing  these  subjects.  Delayed [or sup-
pressed] menstruation, chlorosis, some states of
sterility, more especially belong to this patho-
logical condition ; but these, having been fully
considered  under  their respective heads, hardly
require  to  be noticed  in  this place.   I  may,
however, remark, that I have had several op-
portunities  of inspecting the bodies of adult fe-
males long  past  the period of  puberty, who
have been subjects of delayed menstruation and
chlorosis, on which  tubercular  consumption
had supervened, and in  all these the ovaria and
Graaffian vesicles had remained in  the unde-
veloped state of childhood.  In  one case, the
ovaria  were not  only  remarkably  small, but
their coverings were indurated, thickened, and
nearly  cartilaginous.   (See arts.  Chlorosis,
Menstruation,  &c.)
II. Inflammation of the  Ovaria.—Syn. Ooph-
   oritis  (from uov, ovum  ;  <j>epu,  fero), Hilden-
   brand.  Ovaritis,  Ovarite, Fr.   Eierstocksent-
   ziindung, Germ.
      Classif.—III. Class, I. Order (Author).
   4. Defin —Pain in either or in both sides of the
hypogastrium, increased  on touch or pressure, oc-
casionally with  tumour  in  these situations, and
symptomatic fever, generally of an inflammatory
character.
   5. It  has been asserted  by M. Duges and
Madame Boivin, that a case of inflammation of
the ovarium can hardly be adduced,  independ-
ent of the  pregnant and  puerperal states.   It
must be admitted that cases occurring  inde-
pendently of these states are rare ; still they are
met  with, and I have notes before  me  now of
four case*  wh/ch occurred in my practice un- 
1062                OVARIA—Inflammation of the—Causes—Symptoms.
connected with these states.  Primary and un-
complicated ovaritis is comparatively rare ; but
ovaritis is more likely to occur in a primary and
unassociated form in females who are neither
pregnant  nor recently confined, than in those
who are thus situated.  When it occurs after
parturition,  it is  most  frequently  complicated
with metritis, or with inflammation of the uter-
ine veins.
  6. i.  Causes.—A. The predisposing, as well
as  the  exciting causes of ovaritis, have not
been sufficiently ascertained, owing to  the dis-
ease  having been  very generally overlooked
by writers and practitioners, but the following
may be considered as the chief; and the au-
thority  of Hildenbrand and others may be ad-
duced  in  proof  of their influence, especially
when any of the exciting causes come into op-
eration.  Excitement of the  imagination  by
reading voluptuous or  immoral works  or ro-
mances,^ or  by descriptions  of circumstances
which affect the desires and emotions, particu-
larly in females unaccustomed, or unable, from
infirmity of mind, to resist the impulses of feeling
and passion ; frustrated expectations of mar-
riage with a beloved object;  venereal desires
often excited without being fully gratified ; fre-
quent abortions and difficult parturition ;  and
sudden continence on the parts of those addicted
to  sexual  indulgences; hence, says Hilden-
brand,  prostitutes, when they are imprisoned,
and widows, are  more frequently  than others
affected with diseases ofthe ovaria.
  7. b.  The exciting causes are exposure to cold,
particularly  soon  after  delivery ;  injuries  re-
ceived  upon or near the hypogastrium ; the use
of emmenagogues, and of substances to produce
abortion ;  disordered,  and especially  suddenly
suppressed menstruation ; metastasis of rheu-
matism ;  sexual  excitement at the period  of
menstruation;  inordinate venereal excitement
and masturbation ;  premature addiction  to ve-
nereal impulses, or coition too soon after men-
struation, or after parturition, or after inflam-
matory affections  of the  uterus.   Walther
states  that,  in  his numerous post-mortem ex-
aminations,  he very rarely found  the ovaria of
prostitutes free from inflammatory and structu-
ral lesions*

  * I have preserved the notes of four cases of acute uncom-
plicated ovaritis, occurring independently of the puerperal
states.  Besides these, slighter and less clearly defined cases
hme been seen by ine, which have usually been considered
as cases of hysteria depending upon vascular excitement or
irritation of the ovaria.  Of the four cases alluded to, one
was caused by the sudden suppression of the catamenia, and
one from metastasis of rheumatism.  The others might be
referred to a concurrence of several of the causes assigned
above for the disease.  The case, arising from  metastasis
of rheumatism, was remarkable in several respects, espe-
cially for the acuteness of the attack.  The following is
abridged from the original notes :
  Mrs. P----,  of ------ street, Walworth, was attacked,
15th of July, 1821, with most excruciating rheumatic pains
in the loins and limbs, increased on the slightest motion, or
on attempts to turn in bed.  She was in a  profuse perspira-
tion ; and her pulse was  full, strong, und  about 1(10.  Sire
attributed the attack to sleeping in a damp bed when trav-
elling.  She  was about 26 years of aue, strong, plethoric,
and of the sanguine  temperament.  The catamenia were
usually very abundant, and seldom at longer intervals than
14 days.  Their recurrence was, therefore, soon expected.
She had never been pregnant. About three days after the
commencement of the rheumatic attack, and while I was
attending her, she  suddenly experienced an attack of most
acute pain in the hypogastrium, a little above each groin.
Soon afterward two tumours could be distinctly felt in the
regions of the  ovaria. They were extremely painful and
tender u|>on pressure. The pains in the limbs were greatly
abated, but pain was still complained of in the luius.  All
  8. Ovaritis is often observed  after delivery,
but it is then rarely unconnected with metritis
or metro-peritonitis,  or  with  inflammation  of
the uterine and ovarian  veins, or of the Fallo-
pian tubes and connecting cellular tissue • bu»
the associations of  ovaritis, in the puerperal
states,  vary much  with the prevailing epidem-
ic, with the predisposing and exciting causes,
and with the different circumstances in  which
the disease presents itself.   These complica-
ted forms of ovaritis  are often observed in ly-
ing-in  hospitals, in close, ill-ventilated  apart*
ments,  and in low, crowded localities ; and oc-
cur most frequently after difficult parturitions,
after floodings, and upon the sudden disappear-
ance or suppression of the lochia or milk.
  9. ii. Symptoms.—A. The mild and more chron-
ic states  of ovaritis, whether in  the unimpreg-
nated or puerperal states, is generally an insid-
ious, latent, and deceptive disease, unless the
nature of the case be strictly investigated.  In-
deed, in many instances, the complaint  is not
brought before  the physician until it has gone
on  to  structural change, or it is confounded
with hysteria, from the  circumstance of hys-
terical symptoms being its common attendant.
In these cases, a careful examination will gen-
erally  detect tenderness upon firm pressure,
and sometimes even slight fulness or tumour
of either or both sides of the hypogastrium, a
little  above the groins,  with slight febrile ex-
citement ; a  variable, but usually a more fre-
quent pulse than in health, variability and ex-
citement ofthe desires,  emotions, and disposi-
tion, associated with many hysterical and ner-
vous  phenomena ; irregularity or suppression
of the catamenia ;  and costiveness,  with scanty
or varying conditions of the urine.
   10. B. The more acute form of ovaritis is at-
tended by  nearly  the  same  symptoms as the
above,  but  more decidedly or acutely marked.
The pain, tenderness, and swelling in the hy-
pogastrium are  more  fully pronounced, the
mind more evidently affected, and in the san-
guine, the  irritable, and plethoric,  the desires
inordinately excited, so as to amount almost  to
utero-mania.  In some cases, numbness  of one
or both thighs is felt, particularly on  that side
where the  fulness in  the hypogastrium is most
evident.    Symptomatic  fever and hysterical
symptoms  are sometimes also very prominent.
The bowels are constipated, the  urine scanty,
and sometimes retained ;  occasionally it  is
voided in large quantity.
   11.  C. In the puerperal state,  the symptoms
vary remarkably with the prevailing epidemic
and the causes  and  complications  of the mal-
ady ; and is often attended by general  asthe-
the inflammatory symptoms continued.  The bowels wert
costive, the urine scanty aud high-coloured, with frequent
calls to micturition. The countenance was flushed, anima-
ted, and excited ; the temper variable and hysterical.
  The treatment cousisted of one bleeding  from the arm;
of repeated doses of calomel, ipecacuanha, and opium com-
bined, saline aperients being interposed, so  as to keep tha
bowels freely open; of the application of a considerable
number of leeches  below each groin ;  and of the warm hip
bath.  Four or five days  after this attack commenced, the
catamenia came on, and the pain, tenderness, and swelling
gradually disappeared  from the hypogastrium.  This lady,
the wife of an old acquaintance, was, some years afterward,
the subject of abscess between the vagum und  rectum, which
opened into the latter.  She subsequently was attacked by
gout ; und ultimately became consumptive, from an excess-
ive addiction to brandy; but  was carried off by delirium
tremens  before the pulmonary disease had reached its  ut-
most limits. 
OVARIA—Inflammation of the—Terminations—Treatment.
1063
nia, by contamination of the circulating fluids,
and  by depression of the vital powers.  But
the occurrence of the disease in these circum-
stances, and thus associated, is fully considered
in the article on Puerperal Diseases.
   12. iii. Terminations and Consequences.—
A. Resolution is the most frequent issue of in-
flammation ofthe ovaries when the disease oc-
curs independently of the puerperal states ; and
is indicated  by subsidence of  the pain and
swelling; by the accession of the catamenia ;
or by a more abundant flow of the lochia when
this  discharge had been  diminished  or  sup-
pressed in  the  puerperal state of the  disease.
(See Puerperal Diseases.)
   13. B. Softening and friability are generally
present in a greater or less degree when ova-
ritis is very acute and the  swelling considera-
ble.  In this state the organ is generally three
or four times its natural size, or even larger.
In addition to these  changes, it is infiltrated
with a yellowish serum, or with a violet-col-
oured  fluid, and  occasionally it  presents nu-
merous small ecchymoses or bloody points.
   14. C. Suppuration  may  occur in the  puer-
peral and in the non-puerperal states of the
malady, but  most  frequently in the  former.
Hildenbrand met with  a case  in  the latter
state which opened externally and terminated
favourably.   Ovaritis  is  very  commonly fol-
lowed  by suppuration in an advanced stage,
when softening of the organ is very consid-
erable, a puriform matter or serum, infiltrating
the substance of the  ovarium, partially break-
ing down portion* of it, and forming either one
large or more small abscesses.  This result is
often observed  in the  puerperal states, but the
disease is then  usually associated with metri-
tis, or metro-peritonitis, and  the case termi-
nates fatally, from other changes in the pelvic
and  abdominal viscera and circulating fluids,
before any large abscess is formed or breaks
into adjoining  parts.  But in cases occurring
independently of parturition, a considerable ab-
scess is  sometimes formed, which  may open
into the peritoneal cavity,  or into the rectum,
or some other adjoining viscus.
   [Dr. Meigs (Am. ed. of Colombat, p. 412) re-
lates a case  of ovaritis in a female after con-
finement,  attended with  very  painful symp-
toms, and where a hard and extremely painful
tumour formed in the lower part of the left il-
iac region, which fluctuated  and pointed.  It
was opened with a common  lancet, and dis-
charged near a pint of pus, the discharge con-
tinuing for  many days.  At length, the patient
completely recovered.  Dr. M.  also  relates  a
second case of a similar kind in a lady affected
with carcinoma of the cervix uteri; the dis-
charge was very great, but the abscess was
cured.—(Loc. cit.)]
   15. D. Effusions of a puriform lymph or serum,
or of a gelatinous lymph, are sometimes observ-
ed upon the peritoneal surface of the  inflamed
ovaria and Fallopian  tubes, the latter effusion
often gluing  their surfaces to adjoining parts.
It is not improbable  that,  in  the  slighter and
more chronic cases of ovaritis, a similar effu-
sion of coagulable lymph takes place gradually
into the structure of the organ, and occasions
the enlargement, with various grades of indu-
ration observed in a  few instances.   In these
latter cases  the enlargement of the  organ is
somewhat greater than that observed in acute
ovaritis, amounting  commonly to the size of
an orange.  It often remains stationary for a
very considerable time, and affects but little
the general health.
  16. Whether or not the Graafian vesicles are
ever affected by inflammation,  excepting in
common with the substance of the ovarium, it
is difficult to determine.   Purulent matter has
heen met with in cysts after ovaritis of a sub-
acute or chronic character, but it has not been
proved whether this  arises from  inflammation
and suppuration of the vesicles, or is circum-
scribed abscess in the cellular tissue.  Dr. Sey-
mour remarks that it would be still more diffi-
cult to say what is or would be'the effect of in-
flammation ofthe corpora lutea; that is, of vas-
cular excitement greater than what is necessa-
ry for their formation ; for their formation may
be said to be owing  to increased  action of the
vessels  of the part.   Corpora lutea form, in
some cases,  after rupture of the  vesicle, in-
dependently of impregnation, owing to excited
feelings connected with the generative system;
and hence  it  is reasonable to  expect that any
morbid affection of the ovaria dependant upon
such excited feelings would have their origin
in the corpora lutea.*  In the.cases on record,
in which the  ovaria were  altered in structure,
in conjunction with  furor uterinus, no farther
information is generally given than that puri-
form matter was found in  the ovaria.   The
coats of the vesicle, Dr. Seymour remarks, un-
dergo in advanced life remarkable thickening;
" and, instead of containing fluid, are filled with
a thick  matter of a red colour, from the pres-
ence of vessels, sometimes nearly solid, at oth-
ers of a thinner consistence.   This change ex-
hibits on a small scale some of those hard tu-
mours which  are sometimes found in  the pa-
rietes of an ovarian  cyst.  Is it not possible
that these may be some, of/the superficial vesi-
cles, having undergone 'the  change alluded to,
and  magnified by disease I"  The  fluid con-
tained in the Graafian vesicle  is sometimes al-
tered, it being red, or even black from the ad-
mixture of blood.
  [After death from puerperal peritonitis, we
generally find  the peritoneal surface of the ova-
ries red, vascular, and imbedded in lymph with-
out any visible alteration of the parenchyma-
tous structure ;  or their whole volume may be
much enlarged, swollen, red, and pulpy; blood
is seen effused  into the Graafian vesicles, or
around  them, and circumscribed deposites of
pus  will be found ofteu dispersed  throughout
the substance ofthe  enlarged ovaria.  In some
cases we find the structure of the ovaria re-
duced  to a soft vascular, flocculent pulp, no
traces  of their original organization being left.
We often meet with  inflammation of the peri-
toneal coat of the ovaries and false membranes,
by which they are firmly united  to the Fallo-
pian tubes and uterus.]
   17. iv. Treatment.—The treatment of ova-
  * [Recent investigations in medical jurisprudence seem
to have placed this fact of the origin of corpora lutea, inde-
pendent of impregnation, beyond the reach of controversy.
So long ago as in 1821, this doctrine was inculcated by the
then Professor of Midwifery in the University of New-York,
Dr. Fbancis ; and Professor Valentine Mott gives posi-
tive assurance that corpora lutea have repeatedly been ob-
served by him in his dissections of bodies which hud navel
been impregnated.] 
1064
OVARIA—Organic Lesions of Ovarium—Cysts.
 ritis  should depend entirely upon the causes,
 the circumstances  in which the complaint oc-
 curs, and the constitution Of the patient.  The
 means most beneficial when the disease is un-
 connected with parturition are generally either
 inappropriate or unavailing when it occurs at
 this period.  The treatment of puerperal ovari-
 tis is, therefore, comprised in the article on
 Puerperal Diseases.
   18. A. The slighter states  of the complaint
 require chiefly local depletions, as the applica-
 tion of leeches to the thighs a little below the
 groins, cooling aperients,  and  diaphoretics,
 with a mild, unexciting diet and regimen.   In
 the more acute cases, general blood-letting or
cupping in the  loins or  sacrum, antimonial di-
 aphoretics with nitre, small  doses of camphor
 with  nitre, the tepid bath, when much tension
 of the hypogastrium is complained of, and low
 diet, with perfect quietude, and the avoidance
 of mental and sexual excitements.
   19. B. Where the slighter states  of ovaritis
 occur  in persons of the scrofulous diathesis,
 they generally  become chronic, particularly in
 those who present  indications of their having
 experienced scrofulous affections of glandular
 parts,  and are  commonly attended by severe
 pains, and much  swellirg or enlargement re-
 mains after the treatment now recommended.
 In  these  cases, abscess  not  unfrequently is
 formed, and all the symptoms  are aggravated
 until  it makes  its way either into the  rectum
 or vagina, the most favourable  course  it can
 take.   If it burst into the peritoneal cavity, fa-
 tal peritonitis is  usually the result.  In  this
 form  of the  disease, small  doses of the hy-
 driodate of potash, with  liquor  potassa;.  co-
 nium, and sarsaparilla ;  and injections, per va-
 ginam, of emollient  and  anodyne fluids, or opi-
 ate suppositories, are chiefly indicated.  I have
 prescribed suppositories consisting of the ex-
 tracts of hyoscyamus and  conium, and vaginal
injections containing the same medicines, with
very marked  relief.   Dr. Seymour praises the
extract of colchicum, given in the  dose of a
grain, twice or thrice daily.
  20.  C. When abscess  forms in consequence
of either acute  or chronic ovaritis, and makes
its way into the rectum, or vagina, or bladder,
or even externally—this latter being the most
rare course it takes—the strength  of the pa-
tient ought to be supported, particularly in the
scrofulous diathesis, by the preparations of cin-
chona, by suitable diet, pure air, and residence
near the sea-side.   Attention should be paid to
the digestive functions, and moral and physical
quietude should be  recommended.  The  alka-
line and chalybeate mineral waters may be sub-
sequently tried.
III. Organic Lesions of  the Ovarium, appa-
  rently independent of Inflammation.
    Classif.—IV. Class,  I.  Order (Author).
  21.  i. Cysts, of various sizes, having  their
origin  in  some part of the  ovarium, are the
most  frequent lesions to which this organ is
liable.   When one or more of these  cysts con-
tain fluid, the term  encysted or ovarian dropsy
has been given to the disease, although the se-
rous cysts are sometimes  formed in the broad
ligaments and Fallopian tubes.  These cysts
are to be  distinguished from hydatids by their
being nourished by vessels  supplied to  them
from the parts in which  they are found ; while |
 hydatids are parasitic formations, having an in-
 dependent vitality, and are unconnected  with
 the  cyst containing them.  One or both ova-
 ria  may be  changed into  simple  cysts ;  and
 when the cysts are either numerous or large,
 the  cellular substance and  vesicles disappear
 the  fibrous coat of the organ becoming  the
 fibrous covering ofthe cyst.
   22. Dr. Seymour and M. Cruveilhier agree
 in considering this disease  to  originate in al-
 teration  or enlargement of one or more of the
 Graafian  vesicles.   When  the  enlargement
 takes place to a great degree, it is usually on
 the side  nearest  the proper coat, which often
 becomes distended to an enormous  extent, the
 internal  membrane  of the cyst secreting a
 great quantity of fluid.  When the  cyst is sin-
 gle,  the  ovarian  dropsy exists in its simplest
 state, and often in its greatest  degree.   When
 one, two, or more of the Graafian vesicles un-
 dergo the  change, the disease consists of an
 equal number of cysts  filled with fluid.  The
 quantity  of fluid furnished  by this disease  is
 sometimes very remarkable.  In a  case under
 the  care of  my  friend Mr. Worthington, of
 Lowestoft, the quantity of fluid taken away by
 him  amounted nearly to as much as in the case
 detailed  by  Mr.  Martixeau,   in  which  6631
 pints were lost by tapping in 25 years.
   [A case  is related by Mr.  Atkinson (Lancet,
 July 20, 1844), in which a woman aged 53 was
 tapped 78  times  in 7£ years,  six gallons be-
 ing drawn off at each ofthe  first 50  operations,
 hut only  half that quantity on each  subsequent
 occasion.  The  interval  between  the  opera-
 tions, which  used to be five months, came at
 last to be only three weeks,  but the patient re-
 sumed her active habits in a day or two after
 each puncture.]
   23. The symptoms attendant on these tumours
 are not  severe, and  are occasioned chiefly by
 pressure  on adjoining parts.  When  the tumour
 is seated low  in the abdomen, pressure on the
 nerves and veins often occasions swelling and
 numbness ofthe leg and foot on the side where
 it  is largest;  but it may continue  stationary
 for many years, or even for the greater part
of a long life.  In some cases the discharge of
 urine is more or less affected.   The history of
the case  generally assists the diagnosis of this
disease ;  but  I must refer the reader to the ar-
ticle Dropsy of the Ovarium,  for a full account
of its symptoms,  history, diagnosis, and treat-
ment.  (See art. Dropsy, $ 198-213.)
  24. ii.  Cysts containing fatty matter, inter-
mixed with hair and teeth, have  been met with,
either in  the substance of one ofthe ovaria, or
adhering  to it  by a narrow neck, and general'y
before  the period of puberty; consequently
they do not arise from impregnation.   Similar
cysts have been  found in other parts  of the
 body, in  different individuals.   They may  be
 viewed as  a species of monstrosity, termed by
 Ollivier and Breschet, " Diploginisis par pi-
nitration," as the result of an imperfect concep-
 tion in the  mother of the individuals in whom
they are  found.  The hair found in these cysts
varies in  quantity and appearance.  It  may be
 isolated,  or mixed with fatty matter, or short
or long, with  or  without bulbs.  Teeth have
usually been  found implanted in fragments  of
bony or cartilaginous substance, or  even of a
part  or the  whole of a jaw. 
OVARIA—Organic Lesions of—Tumours.
1065
   25. iii. Congestion and extravasation of blood
 in the ovaria  have not been satisfactorily ob-
 served.  The  former may possibly be of not
 infrequent  occurrence,  either  in  connexion
 with inflammation, or independently of it;  and
 the latter has very rarely been seen to  any
 great amount, unless in connexion with ovarian
 fcetation.
   26. iv. Fibrous bodies, resembling those found
 in the uterus, are occasionally found in the ova-
 ria.  They vary in size from a  few ounces to
 30 or 40 lbs.   M. Cruveilhier  met with a tu-
 mour of this kind which weighed 46 lbs.  They
 can  hardly  be distinguished from similar tu-
 mours  connected with  the  uterus.   Indeed,
 they have been formed in  one or both ovaria,
 and in the uterus also, of the same subject.
   27. v. Cartilaginous, osseous, and even  calca-
 reous formations,  are not infrequently found in
 the ovaria.  Meckel considered them to  origi-
 nate in the  Graafian vesicles.  Fibrocartilagi-
 nous transformations,  with or without ossific
 deposites, are often met with in  aged females.
 I have seen this  change in a chlorotic female
 twenty-three years  of age, who died  of con-
 sumption, and had never menstruated, but with-
 out any ossific deposite.  Calcareous deposites
 are more rare ; but have been noticed by  Mor-
 gagni, Saviard, Petermann, Murat,  and oth-
 ers.
   28.  vi. Hydatids are very rarely seen in the
 ovaria.  Instances, however, of the occurrence
 have been adduced by Cruveilhier, Roux, and
 Deneux.
   29. vii. Tubercles are also very rarely formed
 in the ovaria ; but they have been found in
 this situation by Duges, Boivin, Seymour, Ton-
 nele, and Dugast.
   30. viii. Scirrus of the ovarium is  not  often
 observed.  The organ is  increased  in  size,
 sometimes remarkably ; and the tumour is com-
 posed of a very solid substance intersected by
 fibrous  membranes, running in  various direc-
 tions.   Occasionally  portions of  the  tumour
 contain cysts filled with  secretions of various
 consistence.   These  scirrous tumours  very
 rarely ulcerate.   In  a  case referred to by Dr.
 Seymour, the  scirrous  mass  was  breaking
 down into a thick, brown,  foetid fluid.   This
 lesion is occasionally found in females who had
 scirrus or open cancer in the uterus  or  some
 other part, and is attended by weight and pain
 in the seat of tumour, which is hard and move-
 able, and by signs of general cachexia.
   31. ix. Fungoid and other malignant tumours
 are occasionally found  in the ovaria.   Some of
 these consist of a large cyst springing from the
 ovarium, and containing  within it  tumours  va-
 rying from the  size of a  pin's head to that of
 an orange.   Sometimes a great  portion of  the
 parietes of the cyst is formed of tumours grow-
 ing between the  external  and internal or  se-
 creting coat, the interior of the cyst having the
 tumours projecting into it, being filled with fluid
 secreted from the serous lining.  The tumours,
 when divided,  present a semifluid gelatinous
 substance, with white bands running through
 it  between which bands are smaller cysts, con-
 taining the same viscid, glue-like matter  (Sey-
 mour).            ,         ,      .,,
  32  x  Encephaloid or fungo-hamatoid tumours
of a very large size  are formed  in some  cases
in the ovaria.   M. Velpeau supposes them to
       II              134
 be less rare than other malignant diseases of
 the ovarium.   The encephaloid. or fungo-haem-
 atoid formation, may exist in the same ovarium
 or tumour, with  the  scirrous structures de-
 scribed above (§ 30),  or  with cartilaginous,
 fibrous, or fibro-osseous formations, as noticed
 by Meckel, Andral, and Velpeau ; but it may
 compose nearly the whole  mass.   The walls
 ofthe cysts in this disease are thick, and their
 cavities gradually enlarge  until  a tumour  is
 formed which fills not only the hypogastrium,
 but the whole abdominal cavity.   The outer
 surface of the  tumour is unequal;  in some
 points a fluctuation can be felt, while in others
 it  has a hardness equal to bone.
   33.  This fatal  malady  occurs usually in
 younger subjects than those in whom the scir-
 rous and fungoid  tumours already noticed (§
 30, 31) are  usually found.  Dr. R. Lee remarks
 that it sometimes seems to be excited  by im-
 pregnation.   It runs its course with great ra-
 pidity ; and the constitution of the patient is
 sooner affected by it than by other diseases of
the ovarium.   It generally, also, coexists with
cancerous or fungo-haematoid disease in other
 parts, as the pylorus, uterus, mamma, &c.  It
may be recognised by the unevenness, rapid
growth, and hardness of portions of the tumour;
by the occurrence of acute lancinating pains in
 it; by the simultaneous  affection  of other
parts ;  by the general cachexia and rapid ema-
ciation ; by the signs of anaemia ;  and  by the
very rapid, small, and feeble pulse, hectic fever,
remarkable sense of sinking, and aphthous state
ofthe mouth.
  34.  xi.  Melanosis is very rarely observed in
the ovaria.   When it has occurred, it seems to
have commenced, or been seated in the Graafi-
 an vesicles.
  35.  xii. Encysted tumours of the ovarium, as
 well as malignant tumours, have been supposed
 by Dr.  Baron to arise from vesicles formed by
 a change of the lymphatics of the part;  the ex-
 tremity of a lymphatic  being closed,  and thus
 forming, when distended with fluid, a pyriform
 vesicle.  Dr. Baron has shown the important
 fact, that the diseases which are produced from
 these vesicles, as tubercles, encysted tumours,
 cancer, &e, may be artificially excited by bad
 food, impure air, insufficient nourishment, and
 confinement.   Dr. Hodgkin  supposes that, in
 the formation  of these tumours, a large cyst,
 which he calls the superior cyst, is first  devel-
 oped,  from  the inside of which tumours grow,
 of different sizes and shapes, pushing up the
 internal membrane of the superior cyst,  which
 is  reflected over them, as the pericardium and
 pleura are in  the natural cavities of the body.
 These secondary cysts contain smaller.  Some-
 times the  smaller cysts grow so fast as to
 strangulate one another, and the death of some
 of them causes altered appearances in the se-
 cretions of the part.  Occasionally they burst
 through the reflected membrane,  and present
 a fungoid and fringed appearance.
  36.  xiii. Fatuses are occasionally developed
 in  the ovarium, when some obstacle has occur-
 red to the  escape  of the impregnated vesicle.
 Several cases of this occurrence are on record :
 one of the most interesting of these  has been
 observed by Dr. Granville, and published in
 the Philosophical Transactions.
  37. xiv. The Treatment of the foregoing or- 
1066
OVARIA—Displacement and Hernia of the  Ovarium.
ganic diseases of the ovarium, even when their
precise nature is recognised, is  frequently at-
tended by little  permanent advantage  beyond
alleviating urgent symptoms and supporting the
vital energies, and thereby resisting, for a long-
er period than might otherwise elapse, the fa-
tal  progress of  the malady.   Various altera-
tives have been  advised for the removal ofthe
tumours  detected  in this organ, such as the
preparations of iodine, of mercury, liquor potas-
sa?, conium, muriate of  lime, &c, and, when
they are prescribed judiciously and cautiously,
they are sometimes beneficial when  the  tu-
mours are not malignant.  Of these the most
deserving of notice  are the preparations of
iodine and liquor potassa.  Of these prepara-
tions, the iodide of potassium alone, or with the
liquor potassae, conium, or sarsa, or with all of
these and the  iodide of iron, have appeared to
me the most beneficial.  I have employed them
since their first introduction into practice ; but
always in smaller  doses than were or are usu-
ally  exhibited, and generally in combination
with vegetable tonics or alteratives.  In malig-
nant tumours, however, ofthe ovarium,  little or
no benefit will be derived even from them, be-
yond the support they may afford to the consti-
tutional  powers.  The  iodide  of potassium.
however, when  conjoined with  full  doses of
liquor potassae, conium, or other narcotics and
anodynes, not  merely accomplishes this inten-
tion to a certain extent, but also affords consid-
erable alleviation ofthe more painful or urgent
symptoms.
  [Mr. Brown (Lancet, May 4, 1844, and April
5, 1845) combats the generally received  opin-
ion concerning the uselessness of medicine in
ovarian dropsy, and relates five cases in which
the following  plan proved  successful.   Small
doses of mercury were  given internally, and
mercurial frictions made over the abdomen, and
so regulated as to  keep the mouth slightly sore
for some weeks  ; administering also  diuretics,
succeeded by tonics, while  the  food was light
and unstimulating, and daily exercise attended
to.   The local treatment consisted in  careful
and tight bandaging the abdomen with  flannel.
When these means appear to have taken effect,
by the non-increase or positive decrease of the
tumour, he advises that the cyst be then tapped
and emptied.   After the operation, pads should
be applied over the cysts, and tight bandaging
continued for three weeks, and the friction and
medicines for at least six weeks longer.]
  38. Dr. Seymour states that the liquor potassa
given in as large doses as the stomach will bear,
has appeared to  produce in diseases of a malig-
nant nature, more alleviation than any other
remedy, particularly in those tumours that are
not attended by acute pain, or any considerable
symptomatic fever.  Next to the liquor potas-
sae, Dr. Seymour ranks the  muriate of lime in
the treatment ofthe non-malignant tumours of
the ovaria.  It has received from Dr. James
Hamilton much praise in the treatment of en-
cysted dropsy of these organs, but it is of doubt-
ful  efficacy  in  other  organic lesions ;   unless
such as are  of a scrofulous nature, and these
are not frequently  observed in the  ovaria.
  39. Conium  formerly obtained some  reputa-
tion in scrofulous  and malignant tumours, and
has been frequently  employed in cases of or-
ganic disease  of the ovaria ; but I  doubt its
possession of any efficacy beyond that which
may be derived from its narcotic and anodyne
properties. When medicines possessed of these
properties  are required, the  preparations of
opium  or  morphia,  of belladonna, or even of
aconite, may be brought in aid of other means,
or may be conjoined with the preparations of
iodine, of iron, of camphor, &c, according to
the circumstances of individual  cases.  In the
malignant diseases of the organ  they are often
of service as palliatives, and are  advantageous-
ly conjoined with these or with the liquor po-
tassa? or the bromide of potassium.  This last
substance, however, is more likely to be of ser-
vice in the non-malignant tumours of the ova-
rium, in which, however, it has not received
sufficient trial.
  40. Of extirpation of the diseased ovarium some
notice has been taken when discussing the
treatment of dropsy ofthe ovarium (see art. Drop-
sy, § 208,  ct seq.); and I have little to  add to
what I then remarked.  Since that was writ-
ten, however,  this operation has  been perform-
ed successfully by several surgeons;  and in
three cases by Mr. Walne ;  the great majority
of cases being those of dropsy  of this  organ.
While this success places the operation  in a
more favourable light than that in which it was
formerly held, still the great dangers and con-
tingencies connected with it, which I have no-
ticed in the article referred to,  should not be
overlooked; nor should it be attempted with-
out due discrimination  of the nature and mor-
bid relations and connexions ofthe disease.
   [The first of the following tables shows the
rate of mortality from both the  major and mi-
nor operations in all cases where the extirpa-
tion of the ovary has been either attempted or.
actually performed ; and the second, the com-
parative mortality from the two operations in
all cases in which the ovary has been removed.
Four and  six  inches may be taken  as the line
of distinction between the major and minor op-
erations.
                  TABLE I.
Authority.	N... olCnses	Deaths.
Churchill	66	24
Phillips .	81	32
Jeaffreson	74	24
Alice . .	101	38
Rnte of Mortality.
1 in 'lib, or 363 per cent.
1 in 2-50, or 395
1 in 3,   or 32 4
1 in 2-65, or 38    "
TABLE II.
Dfajor Operation.
Minor Operation.
Churchill
Phillips .
Allee  .
Itnte of Mortality
34   38 2 per cent.
40  I 47-7   "
75   41-2   "
Average 423
No. of
  15
  20  I  30
  18  I  27 7
Average 23-3
Rate of Mortality.

13-3 per cent.
III. Displacement and  Hernia of the  Ova-
  rium.
  41.  i.  One ovarium, very rarely both ovaria,
may be displaced, either independently of. or con-
sequently upon, organic lesions of it.  The dis-
placement may also  be  connected with adhe-
sions  of the ovarium to adjoining parts, or it
may be  without  adhesion.   When thus  dis-
placed, the ovarium may he useless in respect
of its generative function, sterility being the
result.
  42.  ii. Displacement of the ovarium is not
infrequently met with to the extent of constitu-
ting a hernia of it.  The ovarium may protrude
through, 1st. The inguinal ring, the most com- 
0ZJ2NA—Treatment—Bibliography and References.
1067
mon form of ovarian hernia ; 2d  The crural ca-
nal ; 3d. The ischiatic foramen; 4th. The umbil-
ical ring; 5th. Any accidental opening  in  the
abdominal parietes;  and, 6th.  Into the vagina.
Hernia of the ovarium is very rarely met with
in any of these situations, excepting the first.
The hernia may be reducible or irreducible, sim-
ple, or complicated with organic lesion of the or-
gan, or with adhesion of it to adjoining  parts,
and it  may be strangulated.  But these displace-
ments, and more particularly the treatment of
them,  concern the surgeon more than the phy-
sician.
  Bibliog. AND REFER.—Fontaine, in Haller, Disser. ad
Med. Pract., vol. iv.,  1751. — J. Sidren, Casus Sphaceli
Ovarii,  4to.  Upsal, 1768. — J. Kruger et G. D. Motz, in
Voering's Tract., vol. i—J. C. G. lorg, Aphorismen ueber
die Krankheiten des Uterus und der Ovarien, 8vo.  Leips.,
1819.—Murat, Diet, des Sciences Med., t. xxxiv., art.  Ovaire.
—Philips, Trans,  of Med. Chirurg. Soc. of Lond., vol. ix.,
p. 427.—Bostock, in Ibid., vol.  x.. p. 77.—Dalmas,  Journ.
llelidom. de Med., t. i., p. 114.— J. Copland, London Med.
and Surg. Journal, vol. v., p. 58.—J. Lizars,  Observat. on
Extraction of Diseased Ovaria, fol. Edin., 1825 —Andral,
Precis d'Anat. Patholog., t. iii., p. 708. — Cruveilhier, Anat.
Patholog., livr. v., xiii., xviii., and xxv.—E.J. Seymour, Il-
lustrations of the Principal Diseases of the Ovaria, Svo,
with Plates. London, 1830 (A very able Work).—Addison,
in Guy's Hospital Reports, vol. i., p. 41.—Archives G6n. de
Med., t. xx., p. 92 (Cases of Extirpation of Ovarium).—
Edin. Medical and Surg. Journal, vol. xxix., p. 305.—Med.
Gazette, vol. xvi., p. 673.—Med. and Chirurg. Review, July,
1836, p. 38— M. Boivin et A. Duges, Traite Prat, des Mal-
adies de l'Uterus et de ses Annexes, 8vo.  Paris, 1833, cum
fig.—T. Ameke, De Ovariorum Degenerationilius eorumque
Signis et Causis, 8vo.  Berlin, 1834.—R. Lee, Cyclop, of
Pract. Med., vol. iii., p. 225.—Cruveilhier, in Diet, de Med.
et Chirurg.  Prat., t. xii., article Ovaires.—Martin Solon, in
Ibid., t.  xii., art. Ovarite.—H. Dugar-t, De l'Exploration des
Ovaires, 4to.  Paris, 1839.—Lowenhardl, in Brit, and For.
Med. Review, Oct., 1836,  p. 529.— R. Bright, in Med. Chi-
rurg. Review, July,  1838, p. 219.—G. A. Spitta, Qua-dam
de Ovariorum Morbis, 8vo. Berl., 1639.—Velpeau, in Diet.
de Med., 2d edit., art. Ovaires.—(See, also, Bibliog. and
Refer, to art. Dropsy of the Ovarium.)
  [Ad.  Bibliog. and Refer.—S. Ashwell, A Practical
Treatise on Diseases Peculiar to Women, with Notes, by
P. B. Goddard.  Philad., 1845 (The diseases ofthe Ovaria
are treated at great length, and in a very satisfactory man-
ner in this work).—Colombat de I'Isere, A Treatise on the
Diseases and Special Hygiene of Females, by Charles D.
Meigs.  Phil., 1845.—VV. P. Dewees, On Females.  Phil.,
tno. — Francis, Denman's Midwifery. — Dunglison, Pract.,
&c—Francis, in New-York Med. and Phys. Jour., vol. ii.—
Guy's Princ. of Forensic Med., by C. A. Lee.—E. H. Dixon,
Cases of Ovarian  Dropsy cured by Injection, in New-York
Jour, of Med. and Coll. Sci., vol. vi.— Camus, On Rupture
of Ovarian Cysts, in Am. Joum. Med. Sci., vol. x., N. S., p.
484.— West, Report on the Progress of Midwifery in 1844-5,
in Brit,  and For. Med. Rev., Oct., 1645.]
OZ.ENA  (from  6fc, I smell).—Synon. Ozene,
  Fr.   Stinkende Nasengeschwiir, Germ.
    Classif.—IV. Class, If. Order  (Author).
  Defin.— A discharge of a foetid, puriform, or
sanious mailer from the nostrils.
  1. a. This disease is generally symptomatic of
ulceration ofthe membrane lining the nostrils,
the palate, maxillary, and frontal sinuses, &e,
or of caries of the  bones  in these  situations,
and always  attends syphilitic  disease of these
parts.   It may accompany also scorbutic, scrof-
ulous,  and cancerous affections,  either in  these
situations, or in the vicinity.   A slighter form
of it sometimes  follows  chronic coryza, particu-
larly in scrofulous constitutions, in the cachec-
 tic, and in those of a lax and leucophlegmatic
 temperament.   In some  cases, the matter  se-
 creted is scanty, but it is often attended by  the
 discharge of foetid crusts.  This state, as well
 as other states, of ozaena may follow or attend
 malignant scarlet fever, and erysipelas ofthe face.
 In a case lately treated by Sir B.  Brodie and
 myself, the ozaena,  with consistent crusts, was
 occasioned  by an injury  of the  nose  received
 when hunting;  and was followed by erysipelas
 ofthe face and head ;  the ozaena, however, con-
 tinuing, in  a slighter form, after the erysipelas
 was cured.
   2. b. The progress ofthe disease is generally
 slow; and  it is rarely attended  by acute pain,
 unless when caused  by cancer.   Hence it is
 often  neglected until  the hones  are  affected,
 when it  proceeds  from  chronic  inflammation
 and ulceration of the membrane.   In some ca-
 ses, however, an aching  is complained of.
   3. c.  The  prognosis  should  depend upon the
 nature of the pathological causes of ozsena,  or
of the  disease of which  it is a symptom.   If
there is reason to infer the existence of caries
of the  bones of the  parts  above named, the
 prognosis  should  be   either  unfavourable  or
guarded.
   4. d. The treatment ought likewise to depend
upon the origin, or cause ofthe discharge ; but
in all circumstances it ought to be both consti-
tutional and local.—(a.) The former should con-
sist of tonics, conjoined with alteratives, as the
 liquor potassa? with the preparations of sarsa,
 and in  some  cases also with  the  iodide of po-
 tassium ;  or the preparations of bark,  either
 with alkalies, or with the hydrochloric or nitric
 acids, or with  both these acids.   A dry, pure
 air, or residence near the  seaside, and light,
 nutritious diet, are generally also  beneficial.  If
 the ozaena proceed from syphilis or scurvy, the
 treatment suitable to  those maladies should  be
 prescribed.
   5.  (b) The local measures consist chiefly  of
 weak injections ofthe chlorides, particularly of
 the chloride of lime, or of the chloride of pot-
 ash, or the passage of a stream of tar-water, or
 of fluid containing  either creasote, or a small
 quantity of the sulphate of zinc, or of nitrate ol
 silver, or of alum, through the fauces  and nos-
 trils.   The  local as well  as the constitutional
 treatment, however, should be guided by a care-
 ful inspection of the parts, and by a correct es-
 timate of the existing extent of mischief,  as
 well as of the exciting and concurring causes.
 In some obstinate cases, the  ozaena have been
 cured by a seton in  the nape  of the neck.
   Bibliog. and Refer.—Paulus .Egineta, L.  iii., ch.  24.
 —Aviccnna, Canon., 1. iii., fen. 5, tr. i., cap. 1, 3.—J. G.
 Gunz, Program. Observat. ad Ozsnam Maxillarum ac Deu-
 tium Ulcus pertinentem, &c, 4to. Lips., 1784.—J. P. Frank,
 De Curand. Horn. Morbis, 1. v., p. 112.— Percy and Laurent,
 in Diet, des Sr. Med., t. xxxix., p. Tl.— Blaud, Revue Mud.,
 1825, t. i., p. 447.—Johnson's Med. and Chirurg  Rev., Oct.,
 1836, p. 514.— Cullerier et Rutier, in Diet, de Med. et Chi-
 rurg.  Prat., art. Ozene.—ft  F. Most, Encyclopadie der Ge-
 sammten Medinisch. und Chirurg. Praxis, b. ii , p. 539.
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