WASHINGTON, D. C
 
 
 
DICTIONAEY
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

             ^jipetiiMx of Qpptomb Sormniac:

   THB WHOLE FORMING A LIBRARY OF PATHOLOGY ANB PRACTICAL MEDICINE,
              AND A DIGEST OF MEDICAL LITERATURE.



         BY  JAMES COPLAND,  M.D.,
Consulting Physician to Queen Charlotte's Lying-in Hpspital; 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.
VOL. IX.
      GEH

W^1
            NEW  YOKE:

HARPER &  BEOTHERS, PUBLISHERS,
            FRANKLIN SQUARE.

                   1859. 
lS5<Jcu
v.  :>


Entered, according to Act of Congress, in the year 1846, by
               Harper & Brothers,
In the Clerk's Ofl&ce of the Southern District of New York.
**-* 
CONTENTS.
TUBERCULAR CONSUMPTION—con-
      tinued.
    Historical Sketch—continued  -
    Prevention of -
    Treatment of First Stage
    Treatment of Second Stage
    Treatment of Third Stage
    Treatment of Latent Form
    Treatment 0/ Acute Forms
    Treatment of Complicated
    Treatment of the Complications
    Remarks on  Remedies used for
    Of Mineral Waters for  -
    Of Inhalation for  -
    External Means of Treatment
    Climate, &c, in
    Diet, &c, in -
    Bibliography and References  -

TYMPANITES—Definition -
    Causes  ------
    Treatment   -
Pago
URINARY BLADDER—Irritability   -
    Spa:^i  ------
    Paralysis     -
    Inflammation,  described -
    Inflammations of the
    Ulceration    -
    Complications of Cystitis -
    Diagnosis of Cystitis
    Prognosis—Causes of Cystitis -
    Treatment of Inflammation
    Malignant and Organic Diseases
    Bibliography and References  -

URINE AND URINARY DEPOSITS.
    Pathological Relations of
    Therapeutical Relations of
    Gravel, and Urinary Concretions
    Urinary Calculi described
    Urinary Calculi, Causes of
    Origin and Growth of Calculi -
    Symptoms of Calculi in Kidneys
    Symptoms of Calculi in Bladder
    Treatment of Urinary Concretions  -
    Suppression of Urine    -
    Bibliography and References  -

URTICARIA—Description  -
    Treatment   -
1241
1250
1252
1258
1260
1261
1262
1263
1265
1267
1274
1275
1276
1277
1284
1285

1289
1290
1291

1293
1296
1297
1300
1303
1304
1305
1306
1307
1308
1312
1313
1314
1325
1339
1340
1345
1348
1349
1351
1352
1353
1355

1359
1360
                                  Page
Inflammation of Fallopian Tubes, &c. 1375
Complications of Uterine Inflamma-
  tions  .....    . 1377
Treatment of Inflammations -    - 1379
Treatment of Chronic Inflammations 1385
                               - 1387
                               - 1389
                               - 1391
                               - 1392
                               - 1393
                               - 1394
                               - 1396
                               - 1398
UTERUS—Morbid Sensibility    -    - 1361
    Treatment of Painful States  -    - 1364
    Inflammation of the Neck    -    - 1365
    Inflammation of its Body — Acute
      Mentntis  ----- 1371
    Inflammation of its Body — Chronic
      Mentritis  ----- 1373
    Prolapse
    Treatment of Prolapse
    Versions and Deviations -
    Symptoms of Deviations -
    Treatment of Deviations -
    Inversion     -
    Fibrous Polypi
    Tumours described -
    Symptoms and Diagnosis of Tumours  1400
    Treatment of Tumours  -           1401
    Cancer—Forms of Cancer    -    -  1403
    Symptoms of Cancer    -           1405
    Prognosis  of Cancer     -           1406
    Treatment of Cancer    -           1407
    Bibliography and References  -    -  1412

VACCINATION—History  -    -    -  l\l5
    Cow-Pox in the Cow    -    -    -  1417
    Irregular or Anomalous -    -    -  1418
    Recurrent Cow-Pox     -    -    -  1419
    Nature of Vaccinia -    -    -    _  1420
    Protective Influence     -           1421
    Small-Pox after   -                1424
    Revaccination -----  1425
    Bibliography and References  -    -  1427

VAGINA  AND  VULVA. — Vaginitis
      described   -----  1429
    Vulvitis described -                 1431
    Treatment of Vulvitis   -            1435

VEINS—Diseases of  -     -     -    -  1436
    Inflammation -----  1437
    Inflammation described  -           1439
    Seats of Phlebitis  -                1441
    Pathology and Treatment of Phlebitis  1442
    Organic Lesions of -     -     -    -  1447
    Bibliography and References  -    -  1453

VENEREAL DISEASES — Gonorrhoea
      described  -                    1455
    Treatment of Gonorrhoea-     -    - 1457
    History of Syphilis -     -     -    - 1459
    Description of Primary Syphilis    - 1465
                                    - 1467
                                   - 1469
                                   - 1471
                                   - 1472
                                   - 1473
                                   - 1474
                                   - 1475
                                   - 1476
                                   - 1478
                                   - 1482
Secondary Syphilis
Tertiary Syphilis
Syphilitic Cachexia
Syphilis in Children
Taws described
Taws, Sibbens, &c. -
Varieties of Syphilis
Diagnosis and Prognosis •
Causes, &c.
History of its Treatment 
CONTENTS.
    Treatment of Primary   ... 14.83
    Treatment of Secondary -           I486
    Treatment of Tertiary   -           1488
    Treated by Inoculation  -           1489
    Bibliography and References -    - 1492

VERTIGO—Description    -    -    . 1496
    Treatment   -                    1497

VOICE AND SPEECH—Affections of
      described  ----- 1499
    Bibliography and References -    - 1504

VOMITING AND  RETCHING—Path-
      ology and Treatment  -    -    -1505
    From Organic Lesions   ... 1507
    From Sympathetic Irritation -    - 1508
    From Sea-Sickness -    -    -    - 1509
    From Exhaustion, Fermentation, &c. 1510
    From Sarcina—Treatment of -    -1511
    Treatment.....1513
    Bibliography and References -    - 1514

WORMS—Introduction to—Origin of  - 1515
    Metamorphoses    -                1517
    Migrations   -     -     -    -    -1518
    Classification ----- 1519
    General View-     -                1520
    Generation  and  Growth of Tape-
      Worms    ----- 1521
    Development of Tape-Worms -    - 1522
    Description  of  the Bothriocephalus
      Latus......1526
    Bothriocephalus Latus—Taeniae    - 1527
 , . Scolex of Taenia Solium  -           1528
    Description of Taenia Mediocanellata 1529
    Description of Taenia Nana   -    - 1530
    Description of Echinococci   -    -1531
    Trematoidea—Monostoma    -    - 1534
    Description of Distomata     -    - 1535
                                      p«g»
    Description of Nematode Worms   - 1537
    Description of Trichina Spiralis    - 1538
    Oxyuris Vermicularis described    - 1539
    Strongylus described    -           1540
    Ancylostomum described     -    - 1541
    Filaria Medinensis -    -     -    - 1542
    Filaria  and Ascaris Lumbricoides
      described  ----- 1544
    Symptoms of Ascaris Lumbricoides 1545
    Symptoms of Worms    ... 1546
    Causes and Prevention  -     -    - 1647
    Treatment.....1548
    Treatment of Tape-Worms   -    - 1549
    Treatment of Distoma, Oxyuris Ver-
      micularis, &c.   -    -     -    - 1556
    Treatment of Strongylus, Ancylosto-
      mum, &c.  -    -    -     -    - 1557
    Treatment of Filaria Medinensis and
      Ascaris Lumbricoides -     -    - 1558
    After-Treatment  -               1560
    Bibliography and References  -    - 1561

ZYMOTEC DISEASES    -     -    - 1563

SUPPLEMENT.....1565
    Supra-Renal Bodies—Structure and
      Functions  -  •  -    -     -    - 1566
    Supra-Renal Bodies — Organic Le-
      sions  ------ 1567
    Table of Cases of  Diseased  Supra-
      Renal Bodies, and of Bronzed Skin 1569
    Supra-Renal Bodies — Bibliography
      and References  -               1572

INDEX (to Complete Work)—TITLES-
      DEDICATIONS — AUTHOR'S
      PREFACE—AMERICAN ED-
      ITOR'S PREFACE — CLASSI-
      FIED  CONTENTS (to Complete
      Work.) 
TUBERCULAR  CONSUMPTION—Historical Sketch of Treatment
1SJ41
few truths which are fully established with re-
gard to it have  been sufficiently demonstrated.
"When, indeed, a fact is once well authenticated,
no accumulation of authorities can be sufficient to
invalidate its credibility; yet we cannot help plac-
ing a greater degree of confidence in opinions
which we are, for other reasons, inclined to adopt,
when we  are informed that they are  sanctioned
by the observations of the most respectable au-
thors of every age."  It is necessary  to premise
that, until the commencement of the  nineteenth
century, the sub-acute and chronic forms of bronch-
itis were very generally described and treated as
forms of consumption, and even as true tubercular
phthisis; and that this want  of precision in the
diagnosis of these diseases led not only to a much
greater diversity of opinion as to their treatment,
but also to a marked difference in the  reputed re-
sults of the means employed.   The general mis-
conception existing among writers respecting the
precise nature and seats of bronchitis, and tuber-
cular formations in the lungs, and their conse-
quences, should be kept in recollection in reading
the following sketch ; for it will then become ap-
parent that much of the benefit produced by many
of the means recommended was actually not man-
ifested  in the cases of tubercular consumption,
but in those of sub-acute, or asthenic, or chronic
bronchitis.  (See art. Bronchitis.)
   242.  Hippocrates frequently mentions tuber-
cular consumption by the  name phthisis,  phthoe,
and empyema,  and states that the age most lia-
ble to it is from 18 to 35.  He notices many of
its most prominent phenomena; as the taste and
appearances  of the  expectoration,  the pain be-
tween the back and sternum, the frequency of
haemoptysis, the quick, wheezing respiration, the
cough,  the condition of the hair and nails ; the
sweats, diarrhoea, emaciation, pleural adhesions,
&c. His treatment is not always consistent with
itself.   He advises caustics externally, emetics,
purgatives in moderation, oxymel, milk diet, es-
pecially  asses',  goats', and mares' milk, warm
from the animal; walking exercise ; avoiding the
extremes of heat and cold.   In addition to these,
several other, and often opposite means, are ad-
vised in different parts of his writings, to which
it is unnecessary to refer.
   243. In the works of Aristotle  is to be found
the earliest notice of the opinion that phthisis is
infectious. He states that this disease makes the
breath corrupt and offensive,  and that those who
approach the diseased person breathe  air vitiated
by him.  Plautus mentions  resin  and honey as
being employed by the Romans for haemoptysis ;
and Dioscorides, the physician of Cleopatra, and
the greatest writer on the materia medica in an-
cient times, recommends  sulphur—a substance
which has been employed in various forms, even
down to the present time.  Aret^us considers
ulceration of the lungs as genuine consumption,
called it phthoe, and gives a good description of
the disease.  Most  of the chapter on the treat-
ment is lost, but in what remains milk diet and
sea-voyaging are strongly advised.
  244.  Celsus states that, in genuine consump-
tion, a  long sea-voyage and  change  of  climate
are most advisable, if the strength will permit, and
the climate of Alexandria is preferred by him.
He remarks that the worst air for any disease is
that in which it has originated.  Among  various
other means he recommends milk diet, with gar-
lic, leeks, &c, with vinegar ; farinaceous articles,
\
occasionally some mil\animal food ;  flour boiled
with mutton suet, and'some light and austere
wines.  He advises the cautery on various parts
of the chest, and the ulcers not to be healed as
long as the cough continues.  He mentions sev-
eral  other remedies,  as horehound with honey;
the juice of plantain ; garlic in wine, raw or soft;
eggs  with  sulphur; hyssop;  turpentine boiled
with butter and honey ; carriage exercise;  sail-
ing on a long sea-voyage.   For haemoptysis  he
advises bleeding, cupping, wool wet with vinegar
to be placed where pain is felt; a cool apartment,
and  rest   The  elder  Pliny enumerates many
substances as specifics for consumption, especial-
ly ammoniacum, a course of milk in the mount-
ains, the juice of plantain, a linctus of betony
with honey ; goats'  fat in  gruel, or with honey
and  water,  and  a little  rue, and  various other
means less rational.
   245. The works of Galen furnish many prolix
and digressive discussions on phthisis.   The ex-
pectoration of cretaceous concretions was first no-
ticed by him.  He believes in the  infectious na-
ture of the disease.  He prescribes vinegar much
diluted with water for the hectic; bleeding,  an
emetic,  purgatives,  frictions, baths, exercise, a
mild opiate at night, and removal to Stabice  for
the advantages of the air and milk of that place.
He remarks that the air of that place is dry, the
pastures healthy,  the  hills of moderate  height,
three miles from the Bay of Naples, sloping gen-
tly to the west, and  near to  Vesuvius, which
makes the  air still drier by its volcanic heat, and
defends  it from  the northwesterly  winds.   At
Stabiae, he says that the milk of cows is used;
but he considers asses' and  goats' milk preferable,
the former being lightest, the latter  of an inter-
mediate nature.  In order to allay the cough and
improve the expectoration,  he prescribes frankin-
cense, myrrh, saffron,  squills, liquorice, mastich,
tragacanth, &c, with sirup of grapes and honey.
When the  discharge  is excessive,  he  employs
opium and castor,  or aloes, mastich, and saffron ;
or the juice of hyoscyamus with  pepper;  or a
lozenge of Scribonius Largus, containing liquor-
ice,  myrrh, turpentine, and tragacanth;  or  sul-
phur, with cardamoms and cinnamon.   Most of
Galen's prescriptions were copied from those of
the physicians who had preceded him.   Various
modes of  preparing the diacodium, consisting
chiefly of sirup of poppies and honey, are given;
and  for dry coughs, iris with  honey is recom-
mended ; and for haemoptysis", roses,  gum, traga-
canth, bole, linseed, and polygonum ; and for the
consumption consequent on it,  iris with hyssop,
bitter almonds, the juice of squills, with honey,
southern-wood, and various other substances.
   246. C*lius Aurelianus gives a tolerably cor-
rect  account of the disease  by the name of phthi-
sis or phthoe.  The  medicines he prescribes are
honeyed water, fenugreek, iris, aristolochia, arum,
and  horehound; also fir-cones, with honey  and
liquorice ; and diacodium, with butter and honey.
Sailing, especially  to a distant climate, and read-
ing aloud, are also advised.   He censures the use
of emetics, and considers the cold bath dangerous.
For haemoptysis he directs astringent electuaries,
and pomegranate with aloe, as  advised by The-
mison.  If the hemorrhage continue in modera-
tion, he prescribes  blood-letting  on  the third day,
as inflammation will  then take place ; but if the
symptoms  are urgent with  dispnoea, bleeding
should be practised at an earlier period.  Oriba- 
1242      TUBERCULAR CONSUMPTION—Historical Sketch of Treatment.
sirs gives merely an abstract of Galen's practice,
and remarks that a milk diet is of more import-
ance than all other remedies.   Aetius makes a
similar remark respecting asses' milk.   He also
recommends venison  fat dissolved in soup, and
caustics  to  the chest.  Alexander Trallian
gives ripe fruit for the hectic of phthisis, especial-
ly grapes.   When concretions are expectorated
he employs  a cooling  diet;  and for the cough the
juice of lettuce with liquorice ; and the diacodi-
um  for  relieving thirst and excessive  perspira-
tion. He also mentions the  hermodactyls and
their combinations. ' In the writings of Paulus
^Egineta and Actuarius,  there  is nothing be-
yond what is contained in the works of Galen.
  247. The  Arabian writers exhibit no views  of
the  nature  and treatment  of phthisis different
from those which have been given by the Greeks.
Rhazes, the most original of these, strongly rec-
ommends a  milk diet, and  fumigations from a
mixture of orpiment, aristolochia, myrrh, styrax,
and  galbanum  in  equal parts, with  a  sufficient
quantity of  butter.  Avicenna prescribes cam-
phor lozenges; in the  early stages, bleeding; and
generally  a  dry air, a milk diet, and sugar  of
roses.   In all else he closely follows Galen.
  248. The  medical writers of the fifteenth, and
of the first half of the sixteenth century, follow
the doctrines and practice of the ancients, with
the exception of Paracelsus.   He recommends
a powder for phthisis, containing crude antimony
and crocus martis.   He considers diet to be of the
greatest consequence,  and  advises a bath to  be
tried containing a  decoction  of herbs with sul-
phur.  Fuchsius was  the first to notice digitalis,
but in a very imperfect way.  Fernelius, whose
reputation was high  in the  sixteenth century,
praises asses' milk, and small  bleedings for hae-
moptysis ; in all things he principally followed
Hippocrates.  Lommius notices  the  infectious
influence of the expectoration and breath in phthi-
sis,  and the  hereditary character of the malady.
The  work of Nicolas  Piso is only a compilation
from Galen and other ancient writers.  Pros-
per  Alpinus merely states, in his work on the
Diseases of Egypt,  that phthisis is one of the en-
demic maladies of  the  country.  Forestus was
among the first to  give cases in detail; but  he
professes merely to follow the doctrines and prac-
tice of Galen.  Among the means which appear
to have been most beneficially used by him  in
consumptions are asses' and goats' milk, and sul-
phur with the white of egg.  Schenck notices the
use  of turtle broth,  and snails  fattened on  sugar
and flour for hectic  ; but his materials are chiefly
compiled from other writers.  Most of the reme-
dies  he mentions have been already noticed ; but
we find  that Avenzoar prescribed olive oil, Ru-
b^eus sulphuric acid, and J. G. Schenck the bal-
sam  of  sulphur, in phthisis.  The  voluminous
writings of Ballonius or Baillou, a physician
in large practice in Paris at  the  end of the fif-
teenth century, contain nothing more deserving
notice respecting phthisis than  a remark as to the
frequent occurrence of the disease in those who
have nursed  others affected with it.
  249. Poterius,  a  physician  to the  French
court, struck out novel modes  of practice in this
disease,  but  kept the preparation  of most of his
chemical medicines secret.  These, as far as they
are known, seem to have been  oxydations of tin,
of mercury,  of silver, of antimony, of gold, &c,
with various other substances.  He employed su-
 gar of lead as a refrigerant;  and a preparation
 which, under the name of the anti-hectic of Po-
 terius, long enjoyed a  great reputation.  Dr.
 Young states that this medicine appears to have
 consisted of two parts of tin and one of antimo-
 ny, oxydated by means of nitre.  He professes
 to have cured phthisis by giving five drachms  of
 balsam of sulphur every morning with sirup, and
 the anti-hectic in the  evening, sulphur lozenges
 and iris being held constantly in the mouth, with
 a diet of wine and.animal food.   The balsam  of
 sulphur he recommends to be made with the  oil
 of almonds, and  given in milk; other oils make
 it too heating.   Spigelius states that consump-
 tions are more common  in England than  else-
 where, owing to the habit of confining the chests
 of females by tight dress;  and that in Venice,
 where this habit does not  exist, females are more
 healthy.
   250. Sennertus, whose works were very gen-
 erally confided in at the  commencement of the
 seventeenth century, closely follows Galen. He
 considers the debility, diarrhoea, &c, to  depend,
 in phthisis,  upon an  acrid  or morbid secretion
 generated in the lungs. He prescribes many med-
I icines,  especially rhubarb, with infusion  of roses
 and goats' whey ;  and he cautions against too
 copious evacuations of any kind.   He advises an
 issue in one or both  arms, if the debility and
 emaciation be not  extreme.  He remarks that
 sulphur was  first recommended in  phthisis by
 Dioscorides ; and he  makes favourable mention
 of honey, roses, horehound,  hyssop, &c.  He
 quotes  other authors in favour of guaiacum and
 ginseng.   Bontius, in his Medicine  of the In-
 dies, gives a  case in which he supposes that frag-
 ments of the bronchi were expectorated, but which
 are mere false membrane formed on the  bronch-
 ial surface.   For true consumption he praises his
 opiate extract of saffron, which, he saj-s,  stops
 bleeding, quiets the  cough, and has alone cured
 many desperate cases.  He  also prescribes  con-
 serve of roses with poppy seeds and sulphur, and
 decoction of ginseng or  of sarsaparilla.  Verily
 there are much worse modes of treatment employ-
 ed in recent times than those adopted by Senner-
 tus and  Bontius.   Tulpius  furnishes nothing
 more deserving notice than the advantage obtain-
 ed in a case of the disease by eating oysters daily.
 Fabricius Hildanus  describes several  dissec-
 tions of phthisical subjects, and notices the com-
 plication of pulmonary with mesenteric  lesions,
 and the presence of calcareous concretions in the
 lungs.  He relates  several instances of success-
 ful recourse to setons.
   251.  Our countryman Bennet, as Van Swie-
 ten and Dr. Young very justly remark, has much
 surpassed his predecessors, and most  of his suc-
 cessors also, as a writer  on consumption, which
 he experienced in  his own  person.   He pays
 marked attention to the breathing and the sputa,
 to the prognosis, and to  the several contingent
 affections in the course of the disease.   For hae-
 moptysis, leading to phthisis, he advises bleed-
 ing, warmth to the extremities, and bleeding from
 the feet in females, if the catamenia be scanty or
 suppressed.  He recommends milk and milk diet,
 but prefers medicated  whey, and reprobates the
 use of saccharine substances, as productive of an
 injurious  fermentation.  He considers the  best
 expectorants to be those which contain resin and
 turpentine.   Bennet also has recourse  to  fric-
 tions and fomentations, and to balsamic fumiga- 
TUBERCULAR  CONSUMPTION—Historical Sketch of  Treatment.      1243
 tions.   These last should consist, in his opinion,
 of frankincense, turpentine, and styrax, with cin-
 namon, colt's-foot, and other articles, made into a
 powder or troche, and burned on coals.  He pre-
 scribes also mixtures of herbs, on which boiling
 water  is poured, and the vapour to be inhaled by
 holding the head over the vessel containing them.
 Issues are much praised, and, according to my
 experience, with very great justice.   He directs
 them in various situations, according to the symp-
 toms,  and he considers that they may be  kept
 sweet  by using  peas of orris root, and when the
 discharge should be promoted equal parts of her-
 modactyls and wax.  He recommends Welsh flan-
 nel to  be worn next to the skin, and not to be too
 frequently changed.  Animal food, neither very
 fat nor lean, is  allowed, and a gentle emetic  is
 given  when the  stomach is loaded, and a decoc-
 tion of sarsaparilla and other woods with ginseng
 is recommended for drink.  If we except the re-
 cent employment of cod-liver oil in phthisis,  in
 what,  it may be asked, has the treatment of this
 disease been advanced  since the appearance of
 the work of Bennet, by the voluminous writings
 of specialists and stethoscopists in recent times 1
   252. The continental writers of the middle of
 the seventeenth century  afford very  little infor-
 mation as to the treatment  of phthisis beyond
 what  was previously known.  Silvaticus  con-
 fided chiefly in bleeding, issues, and sulphurated
 lozenges.  Riverius notices the infection of per-
 sons who had nursed phthisical patients. Among
 the many substances already mentioned he  par-
 t'cularizes guaiacum, Peruvian balsam, and the
 stomachic, and the diaphoretic gold, of Poterius.
 Bartholin furnishes nothing  deserving notice
 farther than that sitting apartments may be made,
 by suitable vapours or medicated effluvia, useful
 substitutes for a voyage to Egypt or other warm
 countries.  Sylvius  attributed phthisis to the ex-
 istence of glandular tubercles, which,  when  in a
 itate of suppuration, constitute the vomicae.   For
 the cure  of the  disease he administers opiates,
 demulcents, and  emulsions, fumigations, decoc-
 tions of the woods, hermodactyls, &c.   He praises
 balsam of sulphur, prepared  slowly with oil of
 anise seed, and says that it facilitates  expectora-
 tion and relieves the breathing.  He considers the
 milk of sulphur to be much inferior  to it.  To
 promote the appetite he prescribes the elixir  pro-
 prietatis, which is made of myrrh, saffron, aloes,
 sulphurous acid, and spirit of wine, digested to-
 gether.  The diet he allows comprises wheaten
 bread,  broths, milk, yolks of eggs, biscuits, with
 a little generous wine.
  253. Gideon  Harvey gives a  tolerably good
 description of phthisis, notices bleeding, and re-
 marks  that great caution is required in practising
 it.  He prefers whey to milk, gives  it liberally
 with conserve of roses, and mentions  the imper-
 atoria as being recommended to him for this  dis-
 ease.   Willis remarks that the atmosphere of
 towns  is not always unfavourable to consumptive
 patients, for he  has  observed  many have better
 health  and less  cough  in London  than  in the
 country.  He prescribes sulphur in all forms, sev-
 eral balsams, and tar-water.  After bleeding, he
 advises narcotics, the muscus pyxidatus, warm
 bathing, frictions, blisters, &c.   Diemerbroeck
 mentions the case of a person who was cured by
taking  goats' milk thrice daily for three months,
without any other medicine.  Bonetus furnish-
es some information as  to the lesions formed in
phthisical cases, but it is of a very loose and im-
perfect kind, chiefly furnished by former writers,
many of them of little reputation.
   254. Of the writings' of Sydenham, which have
been extravagantly praised, but which are now
more justly estimated, Dr. Young justly observes
that, " among the practical writers on consump-
tion he cannot be considered, even by his warm-
est admirers, as holding a distinguished rank."
His pathology of the disease hardly deserves no-
tice.   For a confirmed consumption, medicines
are, he remarks, of little use ;  but bleeding, mild
purgatives, and pectoral remedies  may be tried,
with incrassants or attenuants, according to cir-
cumstances.  For the fever he gives refrigerents,
asses'  milk,  emulsions,  and  opiates.  For  hae-
moptysis he  directs bleeding, cathartics, and the
avoidance of animal food.  Horse-exercise is very
strongly recommended by him;  and he states,
with the truth that many cannot fail to appreci-
ate, that riding cures consumption as certainly as
bark cures  intermittents.  Carriage-exercise  is
also praised by him.   For simple cough he pre-
scribes abstinence from wine and meat for a few
days ;  ten drops of anisated balsam of sulphur,
taken occasionally on a lump of sugar; lozenges
containing liquorice, alecampane, anise seed, an-
gelica, iris, and sulphur; and a linctus of oil of
almonds, with sirup of capillaire and violets.  If
the cough be obstinate or attended by fever, he
orders bleeding  and cathartics ; and if the pa-
tient becomes consumptive, ten drops of Peruvian
balsam three times  a day, a decoction of bitter
plants, riding being the chief remedy.  G. Har-
vey, after ridiculing the treatment of consump-
tion proposed by his predecessors, concludes that
there is a single cheap remedy which does won-
ders ; but this remedy he conceals.  The only re-
mark made by him deserving notice is, that hectic
is generated by the pus which enters the blood;
for the disease is partly an affection of the fluids,
and not, as has sometimes been supposed, of the
solids alone.
   255. The Phthisiologia of Morton was for more
than a century the basis  of practice in consump-
tion, although in all most important matters it
Was anticipated by  the  writings  of Bennet.
There  remain, therefore, but few topics deserv-
ing  notice.   Chalybeate waters are considered
by him as preferable to all other means  for the
prevention of the disease, especially in scrofulous
constitutions ; he directs them to be taken freely,
either cold or warm.   He considers  catarrh to be
the most frequent cause of phthisis ;  and infec-
tion sometimes to occur, for he believes that it
may be communicated to a bed-fellow.  When
proceeding from this latter cause, he considers it
to be most fatal.  He recommends bleeding in
the early stage, but views it as  fatal in the ad-
vanced stages, and  opiates for the cough with
purgatives, as the aloetic tincture.   After bleed-
ing, emetics are viewed by him as of great bene-
fit, in the first stage, but they ought to be follow-
ed by opiates.   He  frequently prescribes his sto-
machic pills, consisting of aloes, myrrh, mastich,
saffron, cloves,  wormwood,  nutmeg,  calamus,
mace, rhubarb, musk, cardamoms, &c.   In scrof-
ulous and scorbutic  consumption he recommends
pills of gum ammoniac, with benzoin, balsam of
Peru, and sulphur.    But in all forms of phthisis,
especially in the more advanced  stages, he con-
siders cinchona the great and general febrifuge.
Several forms and complications of consumption 
•Historical Sketch of  Treatment.
1244      TUBERCULAR CONSUMPTION-

are particularized by him as requiring different or
additional means of cure.  He says that, in asth-
matic phthisis, opium is injurious, by increasing
the dyspnoea ; but that ammonia and the citrate
of potass are most useful remedies.  In the mel-
ancholic and hysterical phthisis, emetics, he avers,
act like magic, and opium is particularly  requi-
site.  For phthisis complicated with haemoptysis,
after venesection and other remedies, he gives
the bark in doses of a drachm every four hours.
He remarks that calculi  may form in the lung,
may lie there  a long, time inactive, or they act
as foreign bodies.   Consumption consequent on
syphilis he considers  to  be of an asthmatic na-
ture.   Chlorosis often passes  into phthisis, he
justly observes, by imperceptible degrees, if not
treated by chalybeates and purgatives.  When he
suspects internal ulceration, he gives from 20 to
30 grains  of calomel every third or fourth  morn-
ing, and  the diaphoretic antimony  at  night.
Brunner  states  that he " entertained  strong
doubts of the propriety of Morton's practice of
giving cinchona  in haemoptysis, till he found by
experience that it succeeded, where every thing
else had failed."—Young, p. 203.
  256.  Ettmuller recommends emetics early in
phthisis, and a diet of milk and raw new eggs.
Bag livi furnishes us with nothing novel, except-
ing that he supposes ipecacuanha to be the best
remedy for this disease, and for all haemorrhages
and discharges.  Wepfer furnishes some of the
earliest information as to tubercles.  In his ob-
servations on diseases of the head, he  gives an
account of an endemic consumption at Waldschut,
on the Rhine, where there is a cavern in  which
mill-stones are dug and  wrought.  The  air is
there always hot—even in winter, and a very fine
dust floats in it.   All the workmen employed in
it become  consumptive, if they remain a year, or
even a shorter time.
  257.  Stahl's  opinions as to the treatment of
phthisis are not worthy  of his reputation.   His
remarks are chiefly directed to the non-efficacy
of most of the means which had been advised up
to his time, and many of his observations are just.
He  reprobates the use of balsams, opiates, expec-
torants, cinchona, myrrh,  balsam  of sulphur, &c,
and confides chiefly in bleeding, and nitre in mod-
erate doses ; and asses' milk, he says, is fit only
for asses.   The too general or inappropriate use
of these and other medicines—the universal  em-
ployment  of a medicine because it has been ad-
vised, or found useful in one or even a few Cases,
is mere empiricism.   It is the appropriate exhi-
bition of a medicine to inferred pathological con-
ditions which constitutes  rational practice.  He
remarks that females are more  frequently con-
sumptive than males ; but they have a greater
chance  of escaping its fatal termination.  lie
considers  exercise on horseback or in a carriage
to be the most  beneficial remedy for  phthisis.
Fuller agrees with Stahl as to riding on horse-
back being most salutary in this disease, when
" without fever or ulcer;" but he adds that " the
patient must be a Tartar, and live on his horse."
  258.  F. Hoffmann, the rival of Stahl in rep-
utation, fully  discusses the treatment of  hectic
fever and  phthisis.  He  remarks that hectic at-
tended by indigestion may often be relieved by
an emetic of ipecacuanha, followed by a dose of
aloes.   If amenorrhcea be a concomitant,  bleed-
ing in the feet and deobstruents are prescribed
by him.  If mesenteric disease complicate phthi-
sis, as often observed in children, warm bathing,
nitre, sulphate  of potass, and sal-ammoniac are
recommended.   In  all hectics he considers milk
a  principal remedy,  especially  woman's milk.
asses' milk, goats' milk, or cows' milk, with man-
na or conserve  of  roses, or with Seltzer-water.
He also ventures to give the tincture or infusion
of roses, cascarilla, cinchona, and nitre.  He gives
the muriate of potass when the appetite is weak.
Bleeding, he says, should be practised with much
caution.   He adverts to  a patient who was kept
alive  thirty years by  losing some blood twice a
year,  and drinking  a decoction  of ginseng  and-
sassafras.  The treatment which he more espe-
cially advises for phthisis is somewhat similar to
the foregoing.   He thinks justly that, where a
predisposition to the disease exists, it may be call-
ed into action by attendance  on a consumptive
patient.  When a milk diet occasions acidity, he
substitutes whey ;  with which, or with milk,
mineral waters, or lime-water, may also be mix-
ed.   He considers the best laxatives in phthisis
to be manna, magnesia, rhubarb, or senna taken
in milk; and milk  or whey with parsley-seeds,
or celery-seeds, to be the best diuretics'.  He is
not favourable  to the use of gum-resins or  bal-
sams, if they occasion, or if given during, febrile
action.   Myrrh, saffron, copaiba, opium, honey,
wax,  spermaceti, and oil are viewed more favour-
ably.   In the young and  plethoric, small and fre-
quent bleedings, air,  exercise, and  warm baths
are, he believes, the best  prophylactics.   He con-
siders half the cases of consumption to originate
in haemoptysis, and  he advises that the bleeding
should not be  stopped too  soon by astringents.
In advanced cases, bleeding to the amount of an
ounce only, often relieves the breathing.  He
says that emetics and strong cathartics are inju-
rious.  He makes favourable mention  of issues,
and of a stomachic elixir, composed of myrrh,
saffron, nutmegs, and buck-bean, which is to be
taken  at meals, consisting  chiefly  of milk diet,
broth, and ptisan.   For the colliquative perspira-
tion he gives  nitre and opium  in  small doses.
He often prescribes also  sulphur and diaphoretic
antimony ;  and the combination of milk with min-
eral waters is much praised by him.   It will be
seen  that  the treatment adopted by  this great
physician is, in most respects, of great excellence,
and when employed appropriately to the  circum-
stances, form, and stage of the  malady, by  no
means inferior to any adopted at the present day.
   259. Musgrave was the first to point out the
connexion  of phthisis in  some instances with ir-
regular gout.   The treatment he advises is not
materially  different from that recommended by
Bennet, Hoffmann,  and others.  Boerhaave
furnishes no information as to the  treatment of
phthisis in any way worthy of his great reputa-
tion ;  his practical judgment appears to have been
overlaid by his  hypothetical doctrines.  The re-
spectable synopsis of Allen furnishes one very
good suggestion, namely, the propriety of the lib-
eral use of buttermilk in  consumption.  He also
believes in the  contagious nature of the disease
in certain circumstances favourable to its opera-
tion.   Wherlhof comes to the defence of cin-
chona and Morton against the attacks of Stahl.
Dover, in  his ancient Physician's Legacy, ap-
pears  in his heroic character of buccaneer in the
treatment of phthisis.  He  advises a frequent
repetition of bleeding in  small quantities, horse-
exercise, crude  quicksilver in large quantities, a 
TUBERCULAR  CONSUMPTION—Historical Sketch of Treatment.       1245
substance much in fashion at the commencement
of the eighteenth century;  and anise seed and cro-
cus martis made into  pills  with the balsam  of
Locatelli, in the morning, and elixir of vitriol in
the afternoon.  He gives also his powder, which
originally contained nitre instead of the sulphate
of potash of the modern powder.  He  advises
the antiphlogistic regimen.
  260.  P. Desault deserves notice for his hav-
ing been the first to contend that tubercles in the
lungs  constitute  the  essence of consumption;
that they are generally antecedent to haemopty-
sis ; and that ulceration of  the lungs is  merely
an effect, and not a cause.   He adds nothing to
what has already been stated  as  to  the treat-
ment.   Juncker, the methodizer of the doctrines
of Stahl, furnishes but little information respect-
ing phthisis, and  almost none deserving notice,
excepting his approval of riding, and his disap-
proval  of warm  balsams and  aloes.   Waine-
wright considers Cheyne correct in concluding
that the quantity of blood is much diminished in
hectic, and thinks that pectorals and balsamics
are injurious, unless  they serve as stomachics
and diuretics.   He prescribes  gentle emetics,
mild stomachics, riding, pure air, frequent blis-
ters, and a light, digestible diet.   Dr. Thomson is
in favour of small doses of antimonial  wine in
consumptions.
  261.  Dr. Huxham's  reputation induces a de-
sire to  know his practice in phthisis.   He re-
marks,  that  catarrh occasions this disease  only
when tubercles  had previously been  formed in
the lungs, and that the malady may be fatal be-
fore an ulcer is formed.  Instead of sweet, oily,
emollient, and other substances, which often dis-
agree with the stomach, and  occasion acidity and
diarrhcca, he employs gentle  diaphoretics, blisters
between the shoulders, mild  cathartics with ano-
dynes interposed, the decoction of cinchona, with
guaiacum and styax, and inhalations of drying
fumigations.  He advises those of a consumptive
tendency to remove into the country in the spring,
and to lose a little blood as a precaution.  Rus-
sel's work on glandular decline is of some im-
portance as  recommending a remedy within the
reach of most persons, and one of great efficacy
when judiciously  employed, namely, sea-water,
especially when taken internally, warm  or  cold,
according to the circumstances of the case.   He
employs it also externally, at different tempera-
tures.
  262.  Dr. Mead insists on the intimate connex-
ion of phthisis with scrofula, and considers that
the use of bark  in the disease is indicated by the
periodicity of the attendant fever; but he believes
it to be injurious when the  lungs  have become
ulcerated.  Goats' milk  and whey are  recom-
mended ; and when milk disagrees with the bow-
els, it may be boiled with roses, pomegranates,
and cinnamon, with the addition of water.  The
fumigations  advised by Bennet, change of cli-
mate, a voyage to Naples or Lisbon, are severally
noticed with approbation.  Dr. Bryan Robinson
praises  emetics, especially those with ipecacuan-
ha, in haemoptysis, and adduces evidence of their
effects.   Dr. Horsburgh gives some cases show-
ing the  benefits produced by the  aluminous  cha-
lybeate  spring,  the  Hartfell Spa  near  Moffat, at
an advanced stage of consumption.
  263.  Dr. Gilchrist  adduces  numerous cases
showing the (jreat advantage accruing from sea-
voyages.  He considers haemoptysis a  conse-
quence of tubercles previously existing, and re-
marks that there are still tubercles to be resolved,
even  after ulceration has taken place, and hence
the difficulty to give appropriate remedies for
every  stage in which tubercles may be found.
But sailing and sea-air appear the best calculated
to fulfil all the indications.   On a rocky coast,
where the inhabitants live much on shell-fish, he
observed consumption decidedly more rare than
in the country inland.   He considers that the
practice in this disease should consist in a prop-
er administration of bleeding, issues, mercurials,
balsams, diet, sea-voyaging, and sea-air.   The
practice of Dr. Marryat has been very generally
adopted, at least in many  of its parts, until mod-
ern times.  He strongly  objects to bleeding in
consumption, and recommends a nourishing diet,
especially of pork broth, and exercise on horse-
back, but, above all, the "dry vomit," consisting
of a grain of tartar emetic, with three of ipecacu-
anha, to be taken fasting twice or thrice a week,
without drinking after it.   If there be diarrhoea,
he directs a grain of sulphate of copper with four
of  ipecacuanha.   If ulceration exist, he gives
twenty drops of copaiba in sugar night and morn-
ing    For haemoptysis he gives his emetics in  in-
creased doses.  Bark,  nitre,  sulphur, chermes
mineral, and alum are also severally employed,
according  to  circumstances.   For  scrofula  he
prescribes corrosive sublimate, with the addition
of a few drops of the hydrochloric acid, &c.
  264. There are few topics connected with the
treatment of phthisis more  important than that
respecting the employment of opium, and to this
Tralles has devoted much attention, in a prolix
and discursive work, in  which the general treat-
ment  of the disease also is fully discussed.  He
considers  opium to be useful  in the first  stage,
but to be injurious afterward.   He thinks that
it is not even a palliative.   He, however, gives it
in enemata with decoction of bark and milk, for
the palliation  of the colliquative diarrhoea, and
admits that it is useful in small doses when the
cough is violent, for which also he gives the sirup
of poppies.  He recommends  Plummer's pill,
ammoniacum, soap, squills, and honey, milk diet,
milk with lime-water, emulsions, and farinaceous
substances.   The works of Morgagni furnish no
precise information as to either the morbid anat-
omy or the treatment of pulmonary consumption,
beyond what was previously known.  Of the oth-
er contemporary writers  on medicine there is
none  who gives any information respecting the
treatment of consumption  deserving notice, until
we  arrive at the woiks of Sir John Pringle,
Donald Monro, and others.
  265. The observations  of Sir John Pringle
deserve the high estimation in  which they have
always been held.   In recent  coughs he  gives,
after  bleeding, mucilages,  oils, and  ammonia, in
the form of an emulsion ; and at night laudanum
with oxymel of squills, or gum ammoniac.  When
the symptoms assume the form of hectic, he re-
peats  the bleeding, recommends low diet, and the
employment of setons or issues, which he justly
considers still more beneficial than bleeding.   If
thirst  or heat be great, acidulated drink, or but-
termilk, without animal food, are advised.  To
check the  sweats he uses sulphuric acid, or lime-
water, conserve of roses, air, exercise, a milk and
vegetable  diet, and where  there are debility and
lowness  of spirits, the  bark is  recommended.
Donald Monro  appears  to have  adopted the 
1246      TUBERCULAR CONSUMPTION—Historical  Sketch  of Treatment.
practice  of  Pringle  in  phthisis.   He  has re-
course to bleeding when there is pain, and to cin-
chona when neither pain nor difficulty of breath-
ing is experienced.   Setons and issues, he says,
are always of use.  A gentle  emetic is advised
for difficulty of breathing.  For diarrhoea  rhu-
barb and afterward opiates are given.
  266. Lieutaud, in  his  Synopsis of Medical
Practice, considers  bleeding injurious, and ad-
vises chiefly a milk diet, with pectoral decoctions,
balsams  in  small  doses, sulphur, tar-water,  or
Morton's balsamic pills, the fumes of balsamic
herbs, the waters of Bonnes or Seltzer, or lime-
water mixed with milk,  riding, issues  between
the shoulders.   For the  consumption produced
by hard study, he prescribes camphor with Hoff-
mann's anodyne, baths, frictions, change  of air,
horse-exercise,  and  generous  wine.   Linn^ius
suggests the use of the  lichen pulmonarius  in
phthisis.   The  Lichen Islandicus was known to
earlier writers, according to Dr. Young, although
it  is  not mentioned  by Linnaeus.  Mr. Read
lauds a residence in a cow-house in cases of con-
sumption, and says that  it is  preferable to any
fumigations.  The recommendation of a medi-
cine called the  decoction of a  thousand flowers,
which was much used from two to three centu-
ries ago for  the different forms of consumption,
is  more  rational than this singular residence.
This  decoction, or infusion, as sometimes  pre-
pared, was made from the recent dung of cows
while feeding in open pastures, warm or  cold
water being mixed with it,  and allowed to stand
a considerable  time, and the  clear fluid being
poured off for internal use.   The bile existing in
the dung was thus partially extracted, and em-
ployed as a stomachic.
  267. The works of Heberden, Sauvages, and
Fothergill furnish no additions to the method
or means of treating  phthisis already  known.
Stoerck is extravagant in his praises of hemlock
in this disease.   Van Swieten, in his commenta-
ries on the aphorisms of Boerhaave, observes that
persons exerting their voice in their professions
are more liable  to haemoptysis  than  others; and
that Moliere died of an attack  of this disease im-
mediately after performing his " Malade  Imagi-
naire" for the fourth time.   He believes in the
communication  of phthisis by infection, and con-
siders that an hereditary disposition to the disease
does not necessarily imply its actual existence.
He approves of camphor as prescribed by  Avi-
cenna (§ 247),  and of the treatment adopted  by
Pringle.  He praises the use  of milk, small but
frequent  bleeding,  horse-exercise, the  cautious
employment of cinchona, and of opiates.  For
relief of the  diarrhoea,  he directs an enema of a
drachm of turpentine, rubbed down with yolk  of
egg, adding half an ounce  of theriac  and  four
ounces of new milk.  The treatment recommend-
ed by Macbride is, in most  respects, the same as
that already  so  frequently noticed, namely,  gum
ammoniac, soap, and  ammoniacal iron, early in
the disease ;  gentle  emetics to promote expecto-
ration and relieve dyspnoea; bark, in some cases,
goats' whey, asses' milk, buttermilk, Seltzer, Bris-
tol, or Malvern waters ; riding, and especially sea-
voyaging, setons, or issues, &c.   For haemopty-
sis, he directs bleeding, opiates, and demulcents.
Winteringham disapproves of fumigations,  as
prescribed by Bennet and Mead, but thinks that
the steam of hot water  containing vinegar  of
squills may be inhaled with advantage.
  268. Dr. James Sims, the founder of the Med-
ical Society of London, is favourable to emetics,
to sulphur, and to cinchona, suitably  employed.
Tar-water is also useful, but he considers tar pills
to be preferable.   The following remarks are cor-
rect :  Females not  uncommonly  have a respite
from  consumption when  they marry, but sink
under the disease after having had two or three
children.  The catamenia may remain natural till
the last stage, but this, I may add, occurs only
occasionally, and chiefly in the more chronic and
protracted cases.   Schoenheyder  employs the
decoction of Iceland moss, especially in phthisis
consequent on measles, or after the removal of
inflammatory symptoms.   Tode very judiciously
gives the bichloride of mercury in the infusion of
cinchona, with Iceland moss, and a milk diet, in
syphilitic consumption.   Dr. Moses Griffith is
deserving  of notice, chiefly for his recommenda-
tion of chalybeates in  consumptions, and more
particularly  for  his  Mixtura  Ferri Composita.
This mixture is, however, varied by him according
to the circumstances of the case ;  adding nitre in
young subjects and recent cases, myrrh at a more
advanged stage, and when there is more debility.
He farther advises a diet of asses' milk,  or skim-
med  milk, puddings, rice, potatoes, and a little
light  animal  food, once  a day, and,  above all,
snail-broth, or snails boiled in milk.  Linne re-
ports favourably of the Hypericum perforatum in
haemorrhagic and ulcerous phthisis, a handful of
the tops of the plant being made into a decoction
with Spanish wine, boiled down to one third, and
an eighth taken morning and evening.
  269. The treatment adopted  by Cullen for
phthisis was  generally followed  in this country
until early in the present  century.  When ex-
pectoration of purulent matter, with hectic fever,
is present, he believes that ulceration exists.  He
views catarrh as rarely a cause of phthisis in per-
sons not predisposed to this disease, but it ought
not to be neglected.  Spasmodufasthma not unfre-
quently terminates in phthisis.  In two  cases of
the expectoration of chalky concretions, the pa-
tients recovered by the aid of milk diet, &c.   Con-
sumption from haemoptysis is less universally fa-
tal than other forms.  " Haemoptysis is not  al-
ways  followed by ulceration, nor is ulceration al-
ways  attended with hectic.  Pregnancy retards
the symptoms, but they generally recur and be-
come fatal soon after child-birth."   In the haemor-
rhagic form of the disease he thinks the acetate
of lead dangerous, and chalybeates and chinchona
improper,  as  tending to increase the  phlogistic
diathesis, and as having been found injurious in
his practice.  He prefers evacuations of all kinds,
a low regimen, and blisters to the breast or back,
followed by issues.  Sea-water  and other min-
eral waters are wholly useless, and mercury is
prejudicial.  Milk is a chief remedy ; and violent
exercise, and the  extremes of cold and heat, are
to be avoided.  He  thinks that sea-air is desira-
ble only for its moderate temperature ;  that the
balsams, myrrh, &c, have sometimes done harm;
that bark increases the phlogistic diathesis, and
even when it relieves for a time, the  symptoms
speedily return ;  that acids are useful, especially
vegetable  acids;  that opiates  are necessary for
allaying the cough, but  they often  increase the
sweats; that demulcents frequently disagree with
the stomach ; that the diarrhoea requires astring-
ents  and mucilages,  and that all purgatives are
dangerous, but ripe fruits are often both agreea- 
TUBERCULAR  CO^NSUMrTlUJN— Historical Sketch of Treatment.       1247
ble and beneficial.  M. Brillonet records cases
illustrating the connexion of tubercular phthisis
with scrofula, and the successful treatment of the
former by small doses of corrosive sublimate, and
by a diet of soup, eggs,  and vegetables.
  270.  Stoll offers some judicious observations,
although others are more open to objections.  For
tubercular haemoptysis he advises  small and re-
peated bleedings ; gentle emetics ; acid and ni-
trous drinks, and afterward lichen, poly gala sen-
ega, or  cinchona.   For hectic diarrhoea he gives
the powder of the root of arnica.  He disapproves
of balsams, bark,  and astringents, where there  is
any inflammatory complication.   Bergius strong-
ly recommends  the Iceland  moss  in phthisis.
When its tonic qualities are not required, he di-
rects the  bitterness to be extracted by previous
maceration.   Dr. Mudge employs the inhalation
of medicated vapours for consumption.  He be-
lieves haemoptysis to  result from the obstruction
caused by tubercles ; and for this state of the dis-
ease he advises  nitre in solution, a  moderate
bleeding, and emetics ; for cough, the inhalation
of emollient vapours, the ammoniacum with laud-
anum, or  half a drachm of the  anisated balsam
of sulphur, a very large scapulary  issue, if these
fail, and a milk diet and vegetables.   He repro-
bates the  use of small issues, and advises them  to
be large and  efficient—a recommendation agreea-
ble to my experience.
   271. Dr. Simmons notices the form of consump-
tion produced by  dry-grinding,  or by  breathing
the minute particles of sandstone and iron.  He
considers  the practice of bleeding to have been
carried  too far by Dover.   He  prescribes  nitre
and camphor, myrrh with spermaceti; and or-
anges and ripe fruit in preference to sulphuric acid.
Setons  and issues, he says,  are useful, opiates
mischievous,  and ripe fruit and antiseptics are the
best remedies for diarrhoea.   A little animal food,
plainly dressed, may be  allowed  if much desired.
Change of air is advised ; but he justly adds that
migration to  a warm climate, late in the disease,
merely hastens death.  Emetics of sulphate of
copper, twice or thrice a week, in the early stage,
preceded and followed by a draught of water, are
also given with the vain hope of dispersing the
tubercles.  The  observations of Home, Duncan,
and Reid furnish  little or no information.   The
last-named physician advised chiefly the exhibi-
tion of ipecacuanha emetics, morning and evening,
and considered sea-voyaging beneficial, mainly by
producing nausea and vomiting.   Verily his treat-
ment seems to have been as bad as the disease.
Borsieri again thinks emetics injurious, and bal-
samic remedies hazardous;  but  he approves of
bark in incipient  cases,  of camphor,  and of bal-
sam of tolu  and turpentine in advanced stages.
Pouteau advises, when pain is experienced, bleed-
ing, and cupping, and blisters.
  272. Dr. Stark's posthumous observations con-
tain the earliest correct  account  of the anatomy
of tubercles.  He is favourable to bleeding in the
early stages,  to oleaginous  and demulcent medi-
cines, and to  vinegar of squills, &c, when cough
and dyspnoea are  urgent.  Raulin's views as to
the treatment of phthisis are in some respects
heterodox.   He is more correct in recommending
ipecacuanha in the catarrhal complications of the
disease.  He considers gums to  be preferable to
emulsions; and the preparations ofcascarilla to be
appropriate for the sweats and for diarrhoea.  Sir-
up of tolu with ptisans ; and myrrh, camphor, and
a little opium every night, are very generally pre-
scribed.  He praises opium in large doses for hae-
moptysis ;  and the mineral waters  of Cauterets
and Bonnes for convalescents.  Dr. Withering,
in 1785, in his account of the foxglove, notices
the recommendation  of this medicine by Mr.
Saunders  in  consumption, and  states that  he
found it of advantage in  several cases when it
was  given  in  a  decided manner.  Dr. Darwin,
however, is doubtful of its good effects ; and Sir
G. Baker is of opinion that its influence in phthi-
sis is owing to the sickness it occasions.
  273.  Sir G. Blane considers the best climate
for the  consumptive to be between  30° and 40°
north latitude.   Vogel prescribes the vegetable
acids with gum arabic ; and, for phthisis after  fe-
vers, the  taraxacum, bitter extracts, and  hore-
hound, or the cold infusion of cinchona with rhu-
barb, if inflammatory symptoms be absent.  The
cold infusion  of  bark he  gives most frequently
with acids  or nitre, or made with whey, and pref-
erably  during  the remissions of the hectic.  He
agrees with Sims as to the use of oysters as  an
article of diet.   Quarin considers emetics unsafe
in phthisis ; he gives bark with sulphuric acid  for
the sweats ; Spa water with milk in preference to
Seltzer water; and the senega when the expecto-
ration  is difficult.   Dr. Moseley believe* that
England furnishes  change sufficient for an  inva-
lid ;  but that a voyage to Madeira early in the dis-
ease may  be  of advantage.   For haemorrhagic
phthisis and pulmonary oppression he prescribes
a vitriolic solution with the sulphates of zinc and
alumina as an emetic, instead of bleeding, fol-
lowed by a sea-voyage.
  274.  Dr. May states that, in  a  well-marked
case of phthisis in a young person of a scrofulous
constitution, the patient took laudanum night and
morning, an ipecacuanha emetic when the stom-
ach was loaded,  and cinchona ;  and that the diet
consisted of soup, meat, wine, porter, brandy and
water, eggs, oysters, &c, with proper condiments.
Swinging was employed twice  daily, and horse-
exercise completed the cure.  A similar case was
published by Dr. Kentish.  I recollect meeting
Dr. May in 1820.   He argued strongly in favour
of his  tonic and  nourishing method of treating
phthisis, which   then  appeared  heterodox, but
which is now more  or less adopted.   Dr. Grieve
notices his employment of koumiss, a fermented
liquor made from mare's milk, in  the early  stage
of phthisis.  The fermented whey of cow's milk
is used  as  a popular beverage in this disease in
Norway and the  Shetland  Isles.  Dr. Crichton
gives a favourable report of the Iceland moss in
cases of phthisis uncomplicated with inflamma-
tion.  Bang, of Copenhagen, recommends the oil
of asphaltum,  in doses of eight  drops morning
and evening in rye broth.   The pneumatic treat-
ment, first tried by Fourcroy, and more fully dis-
cussed and employed by Beddoes, furnishes  no
satisfactory results.  Dr. Senter, of the United
States, prescribes emetics of ipecacuanha and sul-
phate of copper, every second or  third morning,
without eating or drinking, and as much of Grif-
fiths's chalybeate mixture ($ 268) as the stom-
ach will bear in the intermediate time.  For chil-
dren especially, the sulphate of zinc is a prefera-
ble emetic.   A milk diet is also  directed.
  275.  The first volume of the  " Medical Inqui-
ries" of Dr. Rush, of Philadelphia, contains some
of the most important observations on consump-
tion which  appeared towards the close of the last 
1248      TUBERCULAR CONSUMPTION—Historical oketch ok ubA-»tm.
 century.   He was himself subject to consumptive
 symptoms during a considerable portion of his
 life — a circumstance  which imparts -additional
 weight to his advice.   He recommends, upon the
 first indication of the disease, or as soon as heat
 in the hands, weakness of the eyes on wakening,
 dryness of the feet, inactivity, and other slight
 febrile  symptoms appear, the patient to  have re-
 course  to a more active  life, with bathing, bark,
 and steel.  When the pulse is hard, with pain or
 bloody  expectoration, he  directs frequent bleed-
 ings, and  where bleeding cannot  be  employed,
 emetics and milk diet.   In the last, or typhus
 stage, as he terms it, he  considers that a tempo-
 rary benefit is derived  from balsams, horehound,
 vegetable tonics, bitters,  cinchona, &c,  the  diet
 being now stimulating and nutritious.   He  be-
 lieves damp situations  injurious in all states of
 the disease, and a high, dry, and temperate resi-
 dence in the country most beneficial.  He advises
 also flannel always to be worn  next to the skin,
 the dilute vapour of tar, or the smoke of resin to
 be inhaled, opiates to be given in small doses dur-
 ing the day,  and more largely  at night,  and  re-
 peated blisters and small issues to be employed.
 He admits of a moderate  exercise of the lungs in
 speaking, reading, and singing; and a gradually
 increased exercise of the  body, especially of the
 limbs.
   276.  Dr. Gregory, of Edinburgh, in  his  lec-
 tures considers mercury injurious ;  cinchona of
 little  use, and myrrh of less.  The mineral acids
 he views as palliatives only, and as inferior to the
 citric acid.  Emetics are  sometimes useful, even
 without operating powerfully;  sulphur is liable
 to be too laxative, but beneficial nevertheless;
 and purgatives hazardous as either inducing or
 aggravating the diarrhoea.  Dr. Ferriar finds
 digitalis with change of air of service in the mu-
 cous  consumption (chronic bronchitis),  and  in
 checking incipient phthisis, when the patient is
 too weak to bear evacuations.  The pneumatic
 means, so much and so sillily vaunted at that time,
 and like other means puffed, with their authors,
 into undeserved notice much more recently, he
 justly considers quite undeserving adoption.  Dr.
 Garnet introduced several chemical  medicines
 into practice about the end of the last century.
 He prescribes  the sulphuret of potass, and pow-
dered charcoal, in the florid states of consump-
tion, and gives a drachm of each of these,  four or
five times a day, in warm water, with the effect
of promoting expectoration and improving  the
other symptoms.  I question, however, the ulti-
mate good  arising  from medicines  which "pro-
mote  expectoration," as  I have too frequently
seen them promote other more unfavourable symp-
toms.
  277. In the writings of Darwin, in which there
is  a  mingling  of hypothesis, fancy, and poetical
imaginings, with ill-assorted experience, I find
nothing on the treatment of phthisis  deserving
notice, or at least nothing worth attention which
had not been previously advised by many of his
predecessors.   J. Frank professes himself an ad-
vocate for the  tonic and nutritious treatment  in
phthisis proposed by Salvadori, May, and oth-
ers, though with much more moderation in the
degree; palliating the urgent symptoms  by opi-
um, and endeavouring to  relieve the debility by
cinchona, lichen, milk, wine, exercise, and nutri-
tious food — a treatment,  however, by no  means
 admitting of general adoption. Dr. Barton men-
 tions  the Arum  triphyllum boiled in  milk as a
 remedy in phthisis, states that he has known only
 of one case of the disease cured by digitalis ; and
 that he finds more benefit from emetics of sulphate
 of zinc than from other means.
   278. Dr. Fowler and Dr. Ferriar relate cases
 of consumption cured by digitalis given as decoc-
 tion or infusion; but it is not improbable that
 more benefit was imputed to the medicine than it
 really deserved, as most of the cases were charac-
 terized chiefly by haemoptysis, and as those are
 often  attended by prolonged  periods  of  amend-
 ment.  That it is, however, followed by some de-
 cree of benefit, especially early in  the haemoptys-
 fcal form of the  malady, appears  from the testi-
 mony of Beddoes, Mossman, Maclean, Sher-
 wen, and others, although this position is denied
 by Dr. Bree.   Dr. Magennis's success with dig-
 italis may be  attributed chiefly to  the  very large
 doses, and to  the early period of the  disease in
 which he prescribed it.  Busch in his  researches
 employs chiefly aconite, hemlock, henbane, and
 dulcamara,  combined with  either ipecacuanha,
 chermes mineral, or honey of squills.   He prefers
 the leaves of aconite to the extract, and gives two
 grains every two hours, increasing the dose to a
 drachm daily.   Dr. Beddoes insists upon the pro-
 priety of confining the phthisical patient to a tem-
 perature varying only from 60° to 65°, and be-
 lieves that the muriate of lime is sometimes  of
 service.
   279. Dr.  Heberden considers  asses' milk  to
 be of use  in allaying the fever; decoction of bark
 and sulphuric acid in relieving the sweats ; opium
 in quieting the cough and favouring sleep ; bleed-
 ing to the amount of five ounces only, when pain
 is urgent; and the application of  a blister when
 the pain is obtuse.   He advises a  vegetable diet
 chiefly, and the purest water for drink.  Dr. Thom-
 as recommends an emetic every second or third
 day, especially in  the early stage, Griffith's iron
 and myrrh mixture, and digitalis.   Dr. Trotter
 is favourable to cinchona and sulphur;  and  to
 digitalis with opium.  Dr. Wilson considers sul-
 phuric acid to  be most efficacious in checking the
 sweats; and a demulcent mixture with sperma-
 ceti and a little  laudanum most useful for the
 cough.  He allows animal food in moderation;
 and the vapour of warm water, in which  onions
 have been boiled, to be inhaled in order to facili-
 tate  expectoration.  Dr. Bourne  furnishes ex-
 periments on the  use of the uva ursi in  consump-
 tion, from which he infers it to be  of service ear-
 ly in the disease, in doses often or twelve grains,
 twice or thrice daily, sometimes  taken with  a
 small dose of opium.  The end of the last centu-
 ry and the commencement of the present abound
 with writings on the treatment of phthisis, many
 of them most inconclusive, some of them trifling
 or puerile, and nearly all of them deficient in pre-
 cision  of  description, and in  logical inference.
 Most of these are filled with discussions  and cases
 proving and disproving the efficacy of digitalis,
 and commenting upon the operation of this medi-
 cine.
  280. Dr. Badham, in 1808, was the first to dis-
tinguish between asthenic and chronic bronchitis
 and tubercular phthisis, the former having been
generally viewed as varieties  of pulmonary con-
sumption,  and thus confounded with the tubercu-
lar disease.  A large proportion of the recoveries
of cases which had been considered tubercular,
was evidently cases of bronchitis.   Several writ- 
TUBERCULAR CONSUMPTION—Historical Sketch of Treatment.       1249
 ers at this period added nothing to our knowledge, I
 or placed before us the " cram be bis coctum," or !
 rather deciescoctum, of their predecessors.  Rus-
 sell expresses a favourable opinion of bark, ca-
 lumba, chamomile,  sulphuric acid, and iron, with
 hemlock.  But these require discrimination as to j
 the cases in which  they may be individually pre-
 scribed.   He considers the virtues of hemlock to
 be much overrated.  Both he and Thomson state
 the muriate of lime to be without any efficacy.  In
 the more purely scrofulous phthisis, he considers
 issues to be decidedly beneficial, and sulphuric
 acid and salines as preferable to cinchona in the
 early stage.  Barton and others in America em-
 ploy the super-acetate of lead with ipecacuanha
 and opium in the hscmoptysic form of phthisis.
    281.  The remarks of Dr. Parr are upon the
 whole judicious.   He advises the pain in phthisis
 to be pursued by blisters as it changes its place ;
 emetics  to be given chiefly in  haemoptysis, and
 without informing the patient, ipecacuanha being
 preferred ; and mild diaphoretics in an early pe-
 riod. He considers balsams of use only when ex-
 pectoration is checked by debility;  myrrh occa-
 sionally of service as a slight tonic and sedative ;
 hemlock to be preferable to opium in palliating
 the cough without occasioning sweats; cicuta and
 the seeds of hyoscyamus to be often useful; and
 digitalis to do more harm than good.  Asafoetida
 is recommended for flatulency and as an expec-
 torant.  In the last stage, emetics and other means
 are quite inefficacious, or palliatives merely. The
 work of Portal, although interesting at the time
 when it  appeared, contains  very little of import-
 ance in respect of  treatment.   He considers the
 mildest food the best, and particularly new-laid
 eggs ; and issues, setons, and moxas, of service.
 Dr. Buxton furnishes  additional evidence to that
 adduced by Beddoes in favour of a regulated tem-
 perature  in phthisis, of from 60° to  65°.   Dr.
 Shearman notices  the connexion of consumption
 with amenorrhcea,  and 6bserves that Griffith's
 chalybeate mixture has been more successful in
 females than in males, owing to this connexion.
 There is much truth in this : early in the disease
 this mixture is advantageously conjoined with the
" compound decoction of aloes  and conium, and
 even in more advanced stages, if it do not increase
 the severity of the cough.
    282.  M. Bayle very justly referred many  of
 the  cases of imputed  recovery  from phthisis to
 the circumstance of chronic bronchitis, or chron-
 ic pulmonary catarrh having  been mistaken for
 phthisis ; and he described, with greater precision
 than heretofore, the structure of the tubercular
 deposits, and the pulmonary and  the associated
 lesions.   The granulated form of this writer is
 merely the earlier stages  of the disease, excava-
 tions not having taken place.   In this state  he
 advises,  according  to the features of individual
 cases, composing and emollient medicines, occa-
 sionally  bleeding, blisters, and  issues; aconite,
 hemlock, henbane,  nightshade, and  opium, and,
 where the expectoration is very copious, balsamic
 and resinous medicines.   In the state of ulcera-
 tion, he employs medicated vapours and external
 drains and revulsants of various kinds.   In cases
 complicated with chronic bronchitis or catarrh,
 the lichen, with diaphoretics and balsams, is pre-
 scribed ;  or with bark, when there are well-mark-
 ed rigours.   Streaks of blood in the expectora-
 tion require lemonade or orangeade, and bleeding
 if the pulse be hard;  blisters, if soft.  As pro-
      Ill.               79
phylactics, he recommends travelling, voyaging,
change of air and climate, nutritious diet, anti-
scorbutics, tonics, alkalies, muriate of ammonia,
&c.;  for incipient cases, repeated emetics, bitter
and stomachic purgatives, a sea-voyage, exercise.
the sulphuretted waters  of  Bonnes, Cauterets,
Bagneres, or Mont d'Or;  and later in the disease,
mild tonics, as the lichen, sirup of cinchona, &c.
  283. Dr. Wells contends that phthisis is much
less prevalent in marshy  countries and districts
where agues are endemic, and advises that con-
sumptive patients should be removed, at least for
some time, to these places.   He quotes several
authorities and statistics, by both which the sub-
ject is placed in exaggerated points of view.   It
is not yet satisfactorily proved that malarial situ-
ations are beneficial in either the early or the ad-
vanced stages of phthisis ;  at  least the  matter
should be farther investigated, as well as the as-
sertion that places wherein ague is endemic  are
free, or nearly free, from  phthisis; inasmuch  as
the position  is controverted by several more re-
cent  writers, although contended  for by Mar-
shall, Weekes, Harrison, and  others, towards
the close of the last century and at the commence-
ment of the present.
  284. Dr. Roberts has endeavoured to discover
a more effectual remedy for consumption among
the active mineral salts and other substances, than
those hitherto employed.   He has, however, only
to record the failures of his experiments, with  the
nitrate of silver, superacetate of lead and opium,
sulphate of zinc, oxyde  of zinc, alone or with
myrrh ; white oxyde of manganese (10 grains);
arsenite of potass ;  black  oxyde of cobalt (one to
four grains) ; ammoniated copper, muriate of ba-
ryta,  nitric acid, phosphoric  acid, aconite, hen-
bane, stramonium, belladonna, and toxicodendron.
  285. Dr. A. Duncan gives the results of his
long experience in the treatment of phthisis.   He
considers haemoptysis as  often  a salutary occur-
rence early in the disease ; bleeding with low liv-
ing to have hastened death in many cases ; emet-
ics to be of use in  promoting expectoration,  but
to be useless as  respects the cure of the disease;
and blisters to be of service in most forms of the
malady.   He believes that  vegetable acids  are
more beneficial than the mineral or acetous ;  that
digitalis is of little use, and sea-voyages are coun-
teracted by the inconveniences  and risks attend-
ing them ;  that bark, myrrh, lichen, or these with
hemlock, are sometimes of service in scrofulous
cases, but that the pneumatic practice is altogeth-
er unsuccessful; that the diarrhoea may be mod-
erated by mucilaginous fluids and broths, melted
jellies, rice,  catechu, opium, &c. ; that  the  in-
spissated juice of the common lettuce is one of
the best  substitutes  for opium,  and that  the  pa-
tient should take asses' milk, wear flannel next to
the skin, and have walking and riding exercise.
Dr. Southey has remarked upon the frequency
and infrequency of phthisis in different countries.
He is in favour  of the use of issues, of digitalis
for haemoptysis, of a regulated  temperature, by
means of a stove, from 60° to 65°, of riding, sail-
ing,  and swinging, and of change of air, at an
early stage, to Valencia, Hieres, &c.
  286. Dr. Thomas Young, in his able and learn-
ed work  on Consumptive  diseases, has given an
interesting account of the  treatment of these dis-
eases,  and  a  full digest of the means employed
for this purpose  in this country during the first
quarter of the present century ;  and until the di- 
1250                TUBERCULAR CONSUMPTION—Prevention of.
agnostic method of Laennec and the pathologic-
al and numerical disquisitions  of French writers
allured the minds of practitioners to the neglect
of rational therapeutical doctrines.   Dr. Young
considers  bleeding an  important remedy  at  an
early period of the malady, for  the removal of in-
flammatory and congestive symptoms, and for ob-
viating the suppuration and debility consequent
on them.   From  six to twelve ounces of  blood,
he remarks, may be  taken  away with safety in
every incipient  case,  and the operation may gen-
erally be repeated with advantage three or four
times, at proper intervals;  but to do more than
this might justly be called an experiment which,
however laudable in proper circumstances, is not
to be recommended  in  the  ordinary routine  of
practice.  Dr. Young was himself bled twice, by
the direction  of his uncle Dr. Brocklesby, and
was-in favour of small bleedings, to the extent of
three  or four ounces—locally, when there is pain
in any part of the chest.  He  advises purgatives
at an  early stage, and considers that fears of pro-
moting the diarrhoea by them at this period should
not be entertained.   He justly views sulphur as
an excellent  aperient in the disease, and espe-
cially when complicated with haemorrhoids.  Dr.
Young also recommends emetics, and prefers ipe-
cacuanha, especially in cases of haemoptysis, com-
bining it  with  acetate  of lead or  other means,
according to  circumstances.  On sorbefacients,
especially digitalis, mercurials, and  alkalies,  he
places very slight reliance, although they may be
prescribed in some circumstances of the disease
with advantage.  Epispastics and issues are view-
ed by him much more favourably.  He considers
that the tendency to night  sweats is not  a just
reason against  the  use of sudorifics, especially
Dover's powder and  antimonials.   In expecto-
rants  he has  little faith, although ammoniacum,
squills, senega, myrrh,  and ipecacuanha may be
employed  with benefit in some  cases, in conjunc-
tion with hemlock and other palliatives.  Demul-
cents  and  narcotics are prescribed by him in cir-
cumstances indicating their  use, sometimes with
balsams, the  benzoic acid, &c.  Of astringents,
when required to moderate the secretions  of the
skin and of the intestines, the sulphuric acid is
considered the  best, especially when conjoined
with aromatics and opiates ;  but he  is also in  fa-
vour  of catechu, kino, the  extract  of logwood,
with chalk mixture, or  the compound powder of
chalk.
  287. Dr. Young believes  cinchona to be the
most important tonic, and both its advantages and
inconveniences to have been  exaggerated.  He
has known it decidedly beneficial  at the  com-
mencement of the disease, and he has never ob-
served that it increased the  hectic symptoms at
any period.   Besides the powder, and the decoc-
tion, he has  employed the  cold infusion with
Seltzer water, in his  own case, as well as in oth-
ers.   He has had little experience of chalybeates;
but he justly remarks that, when  they can  be
taken alone, or with myrrh, as in Griffith's mix-
ture, without increasing cough  or pain—effects
which may also proceed from cinchona—they are
sometimes beneficial.  The diet  most favourably
mentioned by Dr. Young consists chiefly of milk
and the  farinacea, especially  asses' milk  twice
daily, cow's milk boiled with soda-water or lime-
water, butter-milk, new eggs, vegetable and fari-
naceous articles.  He has found milk boiled with
mutton suet  of great service.   Exercise in the
open air, riding, walking, &c, are  also severally
advised.   Change  of climate is  recommended,
and he considers that the remark of Celsus, that
the worst air for the patient is the air which has
given rise to the  disease, is founded on good
sense.
  288. I have now brought down  the Historical
Sketch of the treatment of phthisis to a sufficient-
ly recent period.  Notices of some more modern
writers will appear in the  sequel  only in so far
as they may furnish any thing deserving notice.
Their works will, however, be mentioned in the
Bibliography and References;  so that the  reader
may be aided in satisfying himself as to the views
of those  who have written on this difficult  sub-
ject, or on topics appertaining to it.  I shall next
endeavour to state those means of prevention which
seem most efficacious against this malady, and aft-
erward proceed to give  the results of my experi-
ence as to the means which  appear  to me the  most
appropriate, or which have been advised for the sev-
eral stages and states of this disease, conformably
with the division above adopted ($ 17, 76, et seq.).
  289. ii. Of the Prevention of Phthisis.—
The full exposition of the causes of phthisis which
I have given above, and which many readers may
consider  tedious  and unnecessary, will not be
viewed in this light, when it  is admitted that a
knowledge of these causes, and of their modes of
operation, is the  most  certain basis  of rational
means of prevention. By ascertaining the causes,
and the ways in which they act, as far as  they
may be ascertained, we are enabled either to avoid
or to  counteract them.   When we can neither
avoid nor arrest the causes, we should endeavour
to arrest  or to palliate their effects, by means ra-
tionally selected and, employed—guided by the
lights of science, and by careful observation and
induction.   The great objects, therefore, of treat-
ment are, in the first place, to avoid and to coun-
teract the causes of the malady;  and, secondly,
when this end cannot be attained, to arfest or pal-
liate their effects.  The former constitutes the pre-
vention, the latter the cure, of the  disease.   But
in the procession of morbid conditions from the
first impression of the  causes, there is an inter-
mediate state between the operation of the causes
and the development of their effects in a mani-
fest form, that requires the prompt  recognition of
the physician, and rational decision as to treat-
ment.  This state of incubation—of threatened
or incipient phthisis—requires great acumen for
its detection, and equal promptness for its  arrest.
For this  state measures of prevention should be
conjoined with means of cure, either predomina-
ting according to the circumstances of individual
cases.
  290. The prevention of phthisis  is either radi-
cal  and  efficient, or conditional and uncertain.
The avoidance  or  removal of the causes is re-
quired for the former;   the counteraction or the
arrest of their more immediate or early effects is
all that can be expected from the latter ; the one
is positive, for the causes have not existed or act-
ed ; the other is contingent, for the causes have
been present, have probably acted and produced
their more immediate effects, the means of coun-
teraction or of arresting these effects either suc-
ceeding  or  failing, as  numerous  circumstances
may determine.  Prevention thus may be divided
into, first, that which consists of the avoidance
of all the  causes of the malady ; and, second, that
which attempts the counteraction, or the removal 
TUBERCULAR CONSUM
of their more direct and immediate effects, before
the malady is fully developed.
  291. .1. The efficient prevention of phthisis con-
sists in the  avoidance and removal of the  causes
which predispose to, and directly occasion, the
malady.   Those  which affect  one or  both par-
ents, or which  operate during the earliest epochs
of childhood, have generally produced their ef-
fects  upon  the constitution before professional
advice is obtained.   The transgressions  of the
parent  have already injured the offspring, and
the scrofulous taint  has either been  communi-
cated to, or generated in, the child, before efficient
measures of prevention could be instituted.  The
remarks which I have offered  on the prevention
of Scrofula (see <J 148, ct scq.) apply with equal,
if not greater, force to the prevention of phthisis.
Consumptive persons who  marry are even more
culpable in  this than those who are imbued with
the scrofulous diathesis, or who have been affect-
ed with external tuberculosis.   The offspring of
the former  may be  scrofulous, but  the taint is
more likely to be manifested  in the form  of tu-
bercular consumption, while the offspring  of the
latter arc more liable to external tuberculosis, al-
though they may be attacked  with phthisis, es-
pecially when the external malady has not occur-
red.  When the predisposition, whether it be he-
reditary or  occasioned by the habits or the dis-
eases of the parents, or  by the management of
infancy  and childhood, has been produced, the
radical  and complete prevention of the malady
can then rarely bo  effected, the best  efforts to
this end being merely conditional or  uncertain.
It is  only by the  avoidance of those causes which
I have arranged under the head of Causes apper-
taining to one or both parents, aided by the re-
moval of those which usually act during the  early
epochs of life, that the efficient or certain preven-
tion of this  disease can be expected.
   292.  B.  The conditional prevention of phthisis,
although uncertain, should  not  be  neglected.
Where the  predisposition, arising from either the
constitution or the health of the parents, already
exists, prevention  may be hoped for, but it can-
not be insured.—a. During infancy and ehildhood
the hygienic precautions which were offered when
treating of Scrofula (6 148,  et seq.) are even
more urgently required when tubercular consump-
tion has appeared in the family of either parent,
or  when the causes mentioned under the first
class of the arrangement have injured the consti-
tution of one or both parents.   For children thus
circumstanced, a dry, pure, and mild  air, consid-
erably elevated above the surface of the sea ; fre-
quent change  of air; clothing  suited to the tem-
perature and  season ; exercise in the open air ;
light, digestible food, with strict attention to the
digestive functions ;  a milk, farinaceous, and veg-
etable diet,  with  a moderate proportion of whole-
some animal food, as childhood advances ;  but the
milk of a healthy nurse,  asses' milk, &c, during
infancy, and the  other means advised in the place
just  referred to,  strictly avoiding the causes inci-
dental to this period of life (§ 49, et seq.), are sev-
erally of great importance, especially when aided
by  such other means as the circumstances of in-
dividual cases  will suggest.
   293.  b.  During puberty and adult age, the
causes  of phthisis which have been  noticed as
most frequently operating in these epochs of life
(Y 184, ct scq.) should be carefully  avoided, es-
pecially those  which relate to schools, sleeping
PTION—Prevention  of.                 1251

apartments, &c.   A strict surveillance ought to
be instituted over youths of both sexes in order
to prevent masturbation, and as soon as this vice
is detected, its enormity should be represented to
the delinquent,  and measures taken to prevent
the mental contamination from extending to oth-
ers.   The sleeping rooms should be well venti-
lated ; but their temperature ought not to be much
lower in winter than that of the sitting apart-
ments, especially for the delicate and predisposed.
For these a physical and mental regimen should
be  enforced, aided by proper food and clothing;
by change  of air, preferably to a warm, dry, and
pure air; by chalybeates in forms suited to the
peculiarities of the case; and, where the predispo-
sition is manifest, by travelling to and in healthy,
warm, or mild and dry countries, as Egypt, Syria,
Upper Egypt, South of Spain, or north coast of
Africa,  &c.
   294.  These  preventive measures are  chiefly
suited to the rich only;  and to  these  especially
hunting, riding,  farming in a dry, elevated dis-
trict,  and field sports are remarkably beneficial.
The selection of professions and trades for those
who are hereditarily or otherwise predisposed to
phthisis is attended by great difficulty.   Agricul-
ture and the out-door exercises which it involves
are salutary to those who can  adopt them.   Gar-
dening offers some advantages, but these are in-
ferior to those furnished by other agricultural oc-
cupations.  Poorer persons should become sail-
ors and butchers; but  the life of a soldier, even
in the best circumstances, is very unfavourable to
those in any way predisposed to phthisis.   To
such  persons especially, and even to the most ro-
bust, several trades are most injurious.   Sculp-
tors, stone-masons, miners, millers, flax, wool, and
cotton  dressers  and  workers, weavers, tailors,
bakers, milliners, dress-makers, and other needle-
women are severally more or less liable to phthi-
sis in consequence of their occupations;  and so
liable are " dry-grinders," knife, fork, razor, scis-
sor, and needle grinders to tubercular consump-
tion and other  pulmonary diseases, that it has
been said  by Dr. C. Holland that about  one
fourth of those engaged in these  occupations died
every five years.*  (Sec Arts and Employments
in relation to disease.)
  * All nuisances, all dangerous and insalubrious estab-
lishments, especially in large towns, besides being pro-
ductive of several other maladies, are liable to develop
phthisis, especially in the predisposed.  The government
of this country has as  yet paid little or no attention to
the due regulation of these as regards the public health;
hut in France, as Dr. Waller Lewis has recently shown,
these establishments arc divided into three classes, and
before they are permitted to be carried on, certain au-
thorizations and formalities are indispensable. In the
first class are placed those establishments that must be
isolated from private  habitations, but not necessarily
from the outskirts of a  town; in the second are included
those factories which do not rigorously require their iso-
lation from habitations, but which it is important not
to allow until assurance has been obtained that the op-
erations proposed to be carried on in them are  executed
so as not to be a nuisance to the neighbourhood, and not
to cause damage.  In the third class are such factories
as may remain without inconvenience near dwellings,
but which should be subject to the surveillance of the
police.
  As regards the  effects on health of various professions
and occupations, it is  shown by M. Lomi-.aed that,  in
1000 deaths, consumption had furnished the following
proportions, viz.: Occupations with vegetable and min-
eral emanations, 17G; with various dusts, 146; with sed-
entary life, 140; with work-shop life, 138; with hot and
dry  air, 127; with stooping posture, 122; with sudden
movements of arms, 116; with muscular exercise and act-
ive life, 89; with exercise of the voice, 76; living in the 
1252
TUBERCULAR CONSUMPTION—Treatment of First  Stage.
  295. iii. Treatment when Phthisis is threat-
ened.—When phthisis  is imminent, the  meas-
ures  of prevention  already  noticed, conjoined
with  others  of a more  strictly medicinal kind,
should be adopted, according to the predisposi-
tion, ao-e, diathesis, and circumstances of the pa-
tient.  The digestive and assimilating functions
ought to be promoted by the usual means, and es-
pecially by change of air,  by voyaging, by trav-
elling in warm and dry  countries, more particu-
larly in those already mentioned (§ 293), by suit-
able clothing, and by attention to the temperature
and ventilation of sleeping-places.  The prevent-
ive and curative influences of districts where ma-
laria  and the diseases which proceed  from  this
source  abound  have been insisted  on by  Dr.
Wells and  several of his contemporaries.  He
states that it was common for the consumptive in
Flanders to  remove to the marshy parts of the
country.  In Minorca, where agues are endemic,
consumption, according to Dr. Cleghorn, is very
rare.   Dr.SEQUEiRA  states, that in the marshy
country of Alentejo phthisis is rarely seen.  Vol-
ney says that consumptive patients are frequent-
ly sent  from Aleppo  to the sea-coast, where in-
termittents prevail. .Other instances are adduced
by Dr. Wells in favour  of his opinion ; and, al-
though it has been controverted by several writ-
ers, yet I believe,  from several facts with which I
am acquainted, that it is not quite devoid of truth.
  296. In this, as well as in other periods of the
disease, the clothing, especially that worn near-
est the skin,  should be warm, and  the best suited
to the preservation of the functions of this part of
the frame.   With this object flannel ought to be
worn during the  night and day;  and  the dress
in females  should be sufficiently high to protect
the upper  regions of the  chest and the  neck.
Close cinctures of the chest  and steel supports
in corsets are injurious.  Due attention ought al-
ways to be  paid  to the  digestive  and  excreting
open air, To; with animal emanations, 60;  and with wa-
tery vapojir, 53. In manufactures the majority of work-
men are affected with scrofula; this scourge marks'the
children  and  the youths with its scars, swellings, and
deformities, and attacks more especially the weavers.
  The women furnish more  maladies and diseases than
the  men, partly owing to the comparative paucity of
thi'ir earnings, from which it arises that the poor work-
woman is ill-fed,  ill-clothed, and ill-lodged.  In one
sense, indeed, not money, but the want  of it, may be de-
nounced as the root of all evil.  So, in  this case, "want
is a bad adviser, and quickly triumphs over the weak
resistance of a conscience without religious light to guide
it." Debauchery, followed by excesses of all kinds, comes
in to consummate the work of destruction commenced by
distress.   The  worst occupations  are those  of needle-
women, or couturieres,  dress-makers, embroideresses,
and modistes, from whose ranks the public women are
largely recruited.
  The separation of the sexes in work-shops is a measure
imperiously demanded for the moralization of the work-
ing classes.
  As to the healthfulness of employments much depends
upon whether they are carried on  in the open air or in
confined  air.   Consumption is twice as frequent in the
first as in the second case; the latter group comprising
occupations carried on in vast spaces well aerated, and
in others which confine the workmen in close localities.
In the latter phthisis is far more prevalent.  The action
of dusts on the lungs is in the direct ratio of the vo'ume,
weight, and consistence of their molecules.  The inha-
lation of coarse particles is less dangerous than that of
dusts finely divided, which penetrate  more easily into
the last ramifications of the  air-cells.  Dusts from hard
substances cause a  far greater number of consumptive
cases than dust from soft bodies, or of ordinary hard-
ness.  The specific  gravity of the dusts does not affect
in any marked manner the production of phthisis.  The
order of the respective fatality of dusts is as follows:
viz., 1, mineral; '2,  animal; and, 3, vegetable___Report,
&c., by Dr. W. Lewis.
functions,  and to the  state of the uterine dis-
charges, which are often more or less disordered
in the states of the disease now being considered.
In many instances cod-liver oil may be of serv-
ice; in others, as well as in these, sulphuretted
or chalybeate  springs, or a course of the one tol-
lowing  that of the other.   For females, the mix-
tura ferri composita, and the decoctum aloes com-
positum, in varying  proportions, according to the
state of the bowels, are often of service, especially
when the pulse is languid, the catamenia scanty
or difficult, and when the cough is not increased
or rendered hard or  dry by these medicines.   In
these cases flannel  drawers,  in  addition  to  the
other articles of flannel  clothing,  and woollen
stockings should be worn.  In other circumstan-
ces, or  when  the natural secretions  and excre-
tions are not suppressed, the infusion, or a weak
decoction,  of cinchona, with a mineral acid;  or
other tonic infusions, with aromatics, &c.; or the
tinctura muriatis ferri, either with or without the
preparations of calumba and an increased quan-
tity of the  acid, may be prescribed, and may even
be made the vehicle on the surface of which the
cod-liver oil may be taken.   Confined positions
of the body, the labours of the desk, and close ap-
plication to either study or business, ought to be
avoided, and a due restraint should be placed on
the instinctive desires and passions.  Mental and
physical occupations ought  to  be  pursued  as
much as possible in open and airy  places and
apartments, and  in  a temperature  never lower
than 60° nor  higher than 70° ;  and  should  not
be such as to  fatigue, but such as moderately or
pleasantly  engage the mind and body.
   297.  In  this state, as well as in the preceding,
and more  particularly  when  the predisposition
is marked, or the tubercular  cachexia manifest,
warm or tepid salt-water bathing,  or sponging
the surface of the body daily with a warm, tepid.
or  cold solution of salt—the temperature and
strength of the solution varying with the state of
the patient and the effects produced—is often
beneficial;  but this practice should always be fol-
lowed by  rubbing  the  surface  smartly with a
rough towel, and by the constant use of flannel
nearest the skin.  Various medicated fluids or lo-
tions have been advised as washes for the chest
and neck,  in the circumstances  now being con-
sidered, as well as in the first stage  of the dis-
ease.  Of these, however, the  most deserving no-
tice  are, a weak solution of  the nitro-muriatic
acid, a  weak solution of the  pyroligneous acid,
and  tar-water, varying  in strength with the cir-
cumstances of the case.  This last lotion has been
employed only by myself, the  temperature of it,
as well  as of the others, being varied according to
the feelings of the patient and the  state of the air.
Friction of the surface also should always follow
a recourse  to either  of these.
   298.  iv.  Treatment of the usual form  of
Phthisis.—Treatment of the First Stage  of this
form.—The imminence of tubercular  consump-
tion may be viewed almost in  the same light as
the commencement  of this stage ; and the treat-
ment advised  for the former is altogether appli-
cable to the latter, with various additional  means
adapted or modified  to the circumstances of indi-
vidual cases.  When this stage has commenced,
as indicated by the symptoms  ($ 187, et seq.), the
question is no longer, Are tubercles already form-
ed 1   This  must be  answered in the affirmative.
But their development may be delayed or  pre- 
               TUBERCULAR CONSUMPTIO

vented by judicious treatment;  or  their absorp-
tion may even be  procured, although  this is  a
doubtful or rare occurrence.  The great principle
of treatment in this stage, as well as when the
disease is merely threatened (§ 295, et seq.), is to
develop the powers of life, and increase the vital
resistance to the farther advance of the malady,
without  producing or augmenting  febrile symp-
toms:  1st.  By diet and regimen — by hygienic
means;  2d. By medical treatment.  A selection
of means belonging to each  of these heads, ap-
propriately  to the peculiarities of the case, will
frequently promote the assimilation of the chyle
globules and of the  colourless  globules  of the
blood, by supporting or developing the powers
of life.
   299.  A. The food and  regimen of the patient
are  of the utmost importance in this  stage.—a.
The food has always been discussed, questioned,
dogmatically prescribed, and often  pertinaciously
persisted in, according to the doctrines of the day
and the  views of prevailing authorities ; and in-
stead of accommodating it to the peculiarities of
the case and to the effects produced by it, an in-
discriminating mode of administering it has been
too  generally adopted.  At different periods of
medical history, and by different physicians, very
opposite kinds of food have been  recommended.
Some  have praised a milk diet;  others  farina-
ceous and vegetable food only ; many a combina-
tion of both;  some have allowed a large propor-
tion of animal food ; and even not a few have per-
mitted the usa of fat meats, and a rich, full, and
nutritious diet.   The praises of certain kinds of
diet have often been accompanied by denuncia-
tions of all others.  Thus the inexperienced, and
those who treat a disease according to its name
and not  according to the successive pathological
conditions it presents, are bewildered, and an im-
portant part of the treatment is adopted and ap-
plied not more rationally than if it were drawn by
lot, or were the turn-up of the die.  Now  each
of those kinds of diet, modified and added to, ac-
cording to circumstances, is appropriate and ben-
eficial when appropriately employed, and  when
aided by a regimen judiciously prescribed.  The
diet in this stage should always have strict refer-
ence to the regimen which the situation and cir-
cumstances of the patient permit,  and especially
to the locality, temperature, and air in which he
resides; and both diet and regimen ought to be
directed  according to his temperament and diath-
esis, to the states of vital power and vascular ac-
tion, as indicated by the pulse and by the febrile
symptoms, and to the indications of existing local
lesions.
  300. When the disease is not ushered  in by
haemoptysis, or by indications of active conges-
tion, and especially when it is traced to depress-
ing or exhausting causes, then a nutritious  diet,
animal food in moderate  proportion, the white
kinds of fish, boiled,  with  a  squeeze of lemon,
with little or no  other kind of sauce, and shell-
fish, especially oysters, may generally be adopted.
The  fresh livers of the cod, torsk, ling, haddock,
and coal-fish, and the fresh oil of their livers, may
be very beneficially used as sauce for these kinds
of fish ;  or the oil may be taken in  a more strict-1
ly medicinal form soon after a meal.   In these
and in  similar states  of the disease even  richer
and more nutritious kinds of food than those  may I
be tried, and the effects carefully  observed.  I
have often  advised a frequent use of fat venison I
^—Treatment of  First Stage.          1253

in some cases, and  the fat of lambs or of mutton
boiled in milk in others, with much benefit.   In
cases where this stage is characterized by little
or no acceleration of the pulse, by despondency,
by a poor  state  of  the blood, and by absence  of
sub-inflammatory or congestive symptoms, a dry
and  nutritious diet, or a more full and restorative
diet; animal  food,  consisting of mutton, game,
&c, and even wine or malt liquors in moderation,
may be allowed, if exercise in the open air, espe-
cially horse-exercise, short of fatigue, be regular-
ly taken.
  301.  For persons of a fuller habit of body, or
more sanguineous  temperament than those just
referred to, and especially when oppression, or
constriction, or  pain at the chest, or a dry, hard
cough  is complained of, the diet should consist
chiefly  of milk and of farinaceous and vegetable
substances, ripe fruits, &c, and the antiphlogis-
tic regimen should be  adopted in every respect;
but  it  should not be carried too far,  especially in
the  scrofulous diathesis.  In these cases,  local
depletions, issues,  and  other derivatives, as will
be hereafter mentioned, should be employed ac-
cording to the state of the pulse and other pecul-
iarities of the case.  For these, buttermilk, whey,
and skimmed milk are excellent beverages and
aids to diet.  After the more inflammatory and
congestive symptoms are removed, and when is-
 sues or setons have  commenced to  discharge,
then a more liberal and nutritious  diet  may be
allowed, and the cooling, antiphlogistic, and feb-
rifuge  medicines  hitherto prescribed may  be
changed for those  which  are more restorative,
and more  calculated to support vital power and
to promote a healthy assimilation.   In these cir-
cumstances the fish diet, as advised above (§ 300),
may be first employed, and the more nutritious
articles of food be afterward given with caution.
   302.  b.  In this stage, change of air, voyaging,
more particularly in latitudes from 30° to 50°, or
from 10° to 15° or 30° in winter, in vessels pos-
sessing comfortable accommodations ; travelling
in temperate and warm climates, with due regard
to the  temperature and climate, and to season ;
residence  in  a warm  and dry air, the elevation
above the  surface of the sea, and the degree  of
atmospheric dryness being such as the patient
finds to be most beneficial;  regular exercise in
the  open air, preferably on horseback, and short
of much fatigue;  are  severally of manifest ad-
vantage.   Exercise on  horseback  is, however,
rarely of benefit to  females, and is generally too
exciting, and consequently exhausting to them ;
walking or driving in an open carriage being more
beneficial.   In all cases, extremes of temperature,
and  sudden changes or vicissitudes  of tempera-
ture, must  be avoided, even by those who are able
to take active exercise, as well as by those  who
are much less able.
  303.  Travelling,  at proper seasons  and hours
of the day, is generally beneficial, especially when
the patient is able to travel on horseback.  Trav-
elling on land by other conveyances  is les^ serv-
iceable ; although an open carriage,  when the
weather will admit,  is little inferior to riding, es-
pecially in  the cases of females.  But when a
close carriage is  used, the patient should sit with
his back to the horses; and when he  travels by
railway, this  seat should always be taken, a suf-
ficient  ventilation of the carriage  being  always
preserved.
  304. Tepid and cold-sponging, and washing the 
1254          TUBERCULAR CONSUMPTION—Treatment of  First Stage.
 surface of the body, or the surface of the chest
 merely,  with variously medicated lotions, have
 been advised in this stage;  but, excepting with
 those already mentioned, or with the lotions, lin-
 iments, and embrocations about to be noticed, this
 practice  is seldom of much service when this pe-
 riod is far advanced, unless exercise can be reg-
 ularly taken in the open air, and flannel be con-
 stantly  worn nearest the skin.  It is, however,
 beneficial when employed as a preventive meas-
 ure for the predisposed, and for those of a tuber-
 cular cachexia (§ 170,  171); and when adopted
 at the commencement of this stage, and followed
 by very active frictions  of the surface.
   305. c. A winter residence is of the greatest im-
 portance in this stage to patients in cold or tem-
 perate climates, for that residence should  be se-
 lected which will  admit of regular  and daily ex-
 ercise in the open air.   But this is not the only
 consideration by which we ought to be guided.
 Elevation above the surface of the sea, a situation
 near the level of or close to the  ocean, or removed
 at a distance  from it, and frequent or prolonged
 voyaging on it, are severally topics which require
 to be duly considered.  As to the last of these—
 voyaging—very well-founded expectations of suc-
 cess from it may be formed,  if it be commenced
 in this stage, or before the second be far advanced,
 more especially in cases which  have been attend-
 ed by haemoptysis  at their commencement or ear-
 ly course, and if it be continued for a sufficiently
 long period.   Voyaging in the Mediterranean or
 in the Atlantic between the degrees of latitude
 named above  (§ 302), and preferably in the Pa-
 cific Ocean, especially when prolonged, either in
 naval cruisers or by repeated voyages, so as to
 avoid the winter  and spring  of this and other
 countries  unfavourable  to  consumptive patients,
 deserves to be more frequently recommended than
 it has hitherto been.  Now that the passage across
 the isthmus of Panama is easy, voyages thence,
in various directions in the Pacific Ocean, may be
made, and a return to  this country  effected in
May or June.
  306. Elevation above the surface of the sea, es-
pecially in warm climates, and  when  dryness of
air is attained by elevation, is generally beneficial.
 Even in  temperate climates, where elevation is
conjoined with dryness, the diminished tempera-
ture which results is not so injurious  as general-
ly, believed.   The cold of Canada is by no means
 injurious to the consumptive, owing  to the dry-
 ness of the  air being great in  proportion to the
 lowness of temperature.   If such a residence ad-
 mits of regular exercise in the open air,  it may
 be salutary, although a  warmer air,  and  an ex-
 emption from sudden atmospherical vicissitudes,
 may be preferred.
  307. The only question connected with resi-
 dence that remains to be considered  is, whether
 preference should be given to a sea-coast or to an
 inland locality.  This is  a difficult question to
 answer;  and judging from the indisputable ad-
 vantages  derivable from sea-voyaging, and the
 very frequent recommendations of places on the
 sea-coast  by modern physicians as winter-resi-
 dences for the consumptive, it may  be inferred
 that these places are actually the most healthy.
 But this inference is neither  logical, nor prac-
 tically correct as respects phthisical cases.  The
 benefit derived from voyaging depends  chiefly
 upon uniformity of temperature and the motions
 of the vessel, aided by  the influence of a pure
 sea-air on the digestive  and assimilating  func-
I tions   Residences on the sea-coast furnish only
I two of these elements of benefit, in an imperfect
! manner,  but they are altogether deprived of the
 third and that which appears to be the most im-
 portant.   We must therefore refer to the results
1 of observation for a decision; and, as far as my
I experience enables me, I may state, where two
| localities, one inland the other on the sea-coast,
 possess equal advantages as to dryness of the air;
 as to annual, monthly, and daily ranges of tem-
 perature ; and as to vicissitudes of weather, and
 facilities for out-door exercise, that the inland sit-
 uation should be preferred.
   308. Whatever be the locality adopted for the
 consumptive, or however the patient may be lim-
 ited in his choice, exercise should not be neglect-
 ed, in air and sunshine, while he is able to enjoy
 it; and the  temperature  of his sleeping apart-
 ment should not fall below 60° or rise above 70°.
 The advantages derived from stoves, when prop-
 erly regulated, are  shown by their preservation
 of the warmth of apartments at  all hours of the
 night;  but a due ventilation ought always  to be
 preserved where they are the only means of keep-
 ing the temperature at a proper elevation.   Hav-
 ing insisted upon regulation of diet and regimen
 appropriately to the pathological states of the case
 in this stage, and upon the advantages of change
 of air, of travelling,  voyaging, and of suitable resi-
 dence during the winter and spring months, the
 means which are more stricty medicinal  are next
 to be considered.
   309.  B. The strictly medical  treatment of the
 first stage of phthisis must depend entirely  upon
 the diathesis, temperament, and habit of body of
 the patient,  and upon the states of vascular ac-
 tion, of local lesion, and of vital power.  The pre-
 disposing and determining causes should also be
 kept in view; for these should influence or  even
 almost change our indications and means of cure.
 —a. In cases where vascular action is excited, or
 the pulmonary circulation is oppressed or  con-
 gested, or where pain is  felt in the thorax, or
 where haemoptysis occurs  without being very co-
 pious, neither anaemia nor vital exhaustion being
 remarkable, bleeding ought not to be either neg-
 lected or  delayed.   The only consideration is, in
 what manner may it be most advantageously re-
 sorted to.  Venesection, unless the patient be ro-
 bust or plethoric, is rarely required.  Scarification
 and cupping are most frequently to be preferred,
 as the circumstances are few in which this oper-
 ation may not be efficiently performed, and a due
 quantity of blood withdrawn  in a very short pe-
 riod, the operation itself generally proving a  salu-
 tary derivative.  When the quantity of blood  to be
 taken is small, and  in certain complications, the
 application of leeches may be preferred.*
   310.  The  quantity of blood abstracted at one
   [We are obliged to dissent from the opinion here ex-
pressed, that  bleeding is  occasionally proper in this
stage of the disease.  When we bear in mind that weak-
ness and defective nutrition are its essential character-
istics, and that cases of uncomplicated pneumonia, where
hepatization is well marked, will frequently recover soon-
er and better without blood-letting, we cannot but call in
question the expediency of resorting to this heroic reme-
dy in tuberculosis. Hence, as Bennett well remarks the
great effort of the practitioner, so far from diminishing
the strength, ought to be to support it, and favour cell-
growth and disintegration; then, when the blood is load
ed with the effete matter thus introduced into it, to assist
its excretion  by means of diaphoretics, diuretics and
purgatives, according to circumstances.— Ed.]    ' 
TUBERCULAR CONSUMPTION—Treatment  of First Stage.          1255
time should be small, or at most not great.   In
the majority of cases it may vary from four to
twelve  ounces; this  last amount  being allowed
only where the  habit of body and circumstances
of the case appear the most to require depletion.
Time should be allowed to observe the effects of
the first bleeding; and after a due interval, if the
symptoms still  continue, or upon the return of
the indications for having recourse to it, the op-
eration may be  repeated.  The amount and the
repetition of the depletions should be determined
only by the peculiarities of the case and the judg-
ment of the physician.   It will often be observed
that even when bleeding appears to be required,
it is but ill endured, although the quantity with-
drawn  has been small.  When this stage is de-
veloped by the suppression of an acustomed dis-
charge, as of the  catamenia, or of haemorrhoids,
then the necessity of having recourse to vascular
depletion is obvious, and that method of perform-
ing it which is most  likely to re-establish the in-
terrupted discharge should be adopted.  Leeches
may be applied around the anus when the haemor-
rhoidal discharge  has been suppressed; and be-
neath the  groins  when the catamenia  are inter-
rupted, difficult, or scanty ; and, for both causes
of aggravation, calomel, the preparations of aloes,
and warm fomentations or the hip-bath, may be
prescribed.   The  older writers advised bleeding
from the feet when  immersed in hot  water, in
cases of catamenial  obstruction, and  this mode
may be adopted by those who  prefer it.  I have
sometimes prescribed it, and  seen it employed,
with benefit.
   311.  Vascular depletion has been advised in the
first stage of phthisis  by some authors, and repro-
bated by others.   I have now stated many of the
circumstances which require it; but there are oth-
ers, more especially certain complications here-
after to be noticed, which also are benefited by it.
But cases are common for which, even at an ear-
ly period, bleeding cannot be ventured on  with
safety;  or, if employed at all, it can be prescribed
only to a small amount, and in the immediate vi-
cinity of parts which appear to require it.  The
numerous class of cases caused by the depressing
and exhausting  causes mentioned above (§ 192),
by want,  by misery,  by debilitating discharges,
by confinement  and  etiolation in factories, close
apartments, &c, and by sedentary and ill-reward-
ed occupations—those cases which present anae-
mied, cachectic, discoloured,  and debilitated ap-
pearances, or in which the pulse is either  slow
and beneath the healthy condition, or very quick,
small, or soft, or when the blood is inferred to be
thin and poor in red  globules—are severally in-
jured even by the smallest local depletions, un-
less  they be prescribed for the removal  of the
pains occasioned by  pleuritic complications, for
which the additional  and often more successful
means hereafter to be noticed should be employed.
  312.  The indications for and against vascular
depletion in an early  stage of phthisis arc, how-
ever, not  always to be  depended upon.  While
many are manifest, others may be doubtful.  Much,
therefore, should be left to the close observation,
the enlightened experience, and the acumen of
the physician, in the interpretation of these indi-
cations  and the discovery of others.  The season,
climate, peculiarities of race, modes of living, and
prevailing constitution and character of disease,
the prevalence of a sthenic or an asthenic condi-
tion of morbid action, are severally weighed in his
 mind before bleeding in any way, its amount and
 its repetitions are decided upon, and before other
 important means are prescribed.   The prevailing
 constitution of disease, so much insisted upon by
 Sydenham, differs most remarkably in  different
 periods  of time.   The sthenic constitution, so
 general in the first quarter of the present century,
 was changed to the asthenic in the second quar-
 ter, and  this latter still appears to  continue.   The
 vital  energies of the residents in large cities and
 manufacturing towns, especially in low situations,
 are weaker than those possessed  by the inhabit-
 ants  of rural districts and elevated localities; and
 these differences, with others manifested by in-
 dividual cases,  require due consideration when
 devising our indications and means of cure.
   313.  The necessity of having recourse to vas-
 cular depletions,  especially to local depletions,
 when congestion, sub-inflammatory  action,  pain,
 the state of respiration or of cough, or other symp-
 toms, require them, does not  necessarily prevent
 the exhibition of nutrient and even of restorative
 means, more  particularly when vital power ap-
 pears depressed and vascular action is not much
 increased.   Indeed, in large cities and  manufac-
 turing towns, these latter medicines, or even more
 tonic remedies, are often required, although local
 depletions are  equally necessary for the local le-
 sions.  For these milder tonics, conjoined with
 sedatives and narcotics, as the infusions of chey-
 reita  or calumba, with hydrocyanic acid, or coni-
 um, or hyoscyamus, or the tinctura camphorae
 comp., may be first prescribed, and  be  followed,
 according to the effects observed, by infusions or
 decoctions of a more tonic kind.   When,  with
 debility, a cachectic or an anaemied appearance is
 present,  the preparations of iron  may be given,
 commencing with the mildest.  I  have  generally
 preferred the  mistura ferri composita,  with the
 extract  or  tincture of conium, or  the powder or
 extract  of liquorice; and, if the bowels  be slug-
 gish,  and the catamenia be deficient, with a suffi-
 cient quantity of the decoctum aloes compositum,
 or tinctura aloes.
   314. The effects of chalybeates of every  kind
 require to be closely observed in this as in every
 other stage and state of the disease. This class of
 medicines are contra-indicated where any inflam-
 matory complication exists, or where a tendency
 to  haemoptysis is observed, unless haemorrhage
 has occurred to a large amount, when the tinctura
 ferri hydrochlorici, with additional acid and ap-
 propriate medicines, may be given in a suitable
 vehicle ;  but on all occasions the effects of chalyb-
 eates  on the respiration and the cough should be
 strictly watched, and, if rendered more oppressed,
 difficult,  or hard by them, they ought to be relin-
 quished.   I have  often prescribed the iodide  of
 iron,  in sirup  of sarzae, or in  other sirups, with
 conium,  or some other anodyne; but I  have not
 considered it  more  beneficial than  Griffith's
 myrrh mixture, even in cases where the cata-
 menia are deficient; and I have found it in some
 cases  to aggravate the cough and tightness of the
 chest  more than that mixture.
  315. When the  above medicines are either not
 indicated or prove inefficacious, the infusions of
 cinchona, prepared either with cold or with warm
 distilled water, may  be prescribed  with hydrocy-
 anic acid, or with  any of the preparations of Co-
nium  or hyoscyamus;  and it may be taken  in
milk in  which a little of the bicarbonate of pot-
ash or of soda has  been  dissolved.   When fe- 
1256          TUBERCULAR CONSUMPTION—Treatment of First  Stage.
 brile symptoms harass the patient, the liquor am-
 monia; acetatis may be given with the infusion of
 cinchona, and the spirit of nitric ether and hydro-
 cyanic acid added to them.   In some instances
 the  liquor ammoniae  acetatis may be prescribed
 with an  excess of acetic acid, especially where
 haemoptysis occurs;  and in  others,  particularly
 where sinking or exhaustion is present, with an
 excess of the carbonate of ammonia, other sub-
 stances which the symptoms will suggest being
 also added.
   316. In this early period of phthisis the func-
 tions of digestion—of both stomach and liver, are
 often more or less impaired; and it is often ben-
 eficial to them, as well as to the state of circula-
 tion in the lungs, to commence the treatment
 with an  emetic.   The older writers recommend-
 ed this practice, and experience has shown  that,
 when  the emetic  has been judiciously selected,
 and  the treatment otherwise appropriate, benefit
 has been produced by  it.   The Italian physicians,
 and  after them  Laennec  and his  pupils, pre-
 scribed tartarized  antimony as an emetic in this
 disease, having,  as they believed, derived great
 advantage from it in the more strictly inflamma-
 tory diseases of the lungs ; and not only did they
 employ it as an emetic, but as a contra-stimulant,
 and  in doses which were seldom efficacious  in
reducing the febrile symptoms, but which rarely
failed in reducing the vital powers of the patient.
 I frequently  saw  the effects  of this  substance
while it was in vogue, and sometimes prescribed
it; but I considered it  of inferior utility to ipe-
cacuanha and to sulphate  of zinc as an emetic in
phthisis, their operation being facilitated and in-
creased by a draught  of a weak infusion, tepid,
of chamomile flowers.    Afterward  demulcents
or emollients, or stomachics, with the addition of
a little hydrocyanic acid, if the retching or vom-
iting be more than we desire, may be prescribed,
and  subsequently the other  internal remedies
which the features of the case will suggest.
   317. The  effect of the emetic  early  in  this
stage, and the repetition of it when the functions
of digestion  are disordered, will generally be  ben-
eficial, as shown by the appetite and the state of
the evacuations,  especially when followed by the
medicines just mentioned, or by  small doses of
the nitro-muriatic  acids taken in the  tonic infu-
sions already noticed,  or in others which the state
of the case appears to require.  If the bowels be-
come irritable, the tinctura camphorae  comp.,  or
the pilula saponis composita, will correct the dis-
 order ; the former being given in the mistura cre-
tae, or  any other suitable vehicle or form of com-
 bination,  the latter with small doses  of ipecacu-
 anha, and of an  aromatic powder.  If the biliary
 secretion be deficient, as not infrequently observed
 in this period, although the bowels are relaxed,
 Plummer's  pill  or blue  pill may be  cautiously
 given, with  soap and extract of taraxacum, in-
 stead of the nitro-muriatic acids; or these latter
 may be prescribed instead  of the mercurial, an
 occasional dose  of which should only be taken.
 In this stage of the disease the bowels are more
 frequently confined than  much relaxed, and the
 intestinal secretions and excretions are very often
 more or less disordered.   It thus becomes an im-
 portant object to  improve these secretions, and
 to regulate the function of defaecation.   The med-
 icines just named  will often aid in attaining this
 end  ; but they require to be either conjoined  with
 others, or followed by suitable laxatives or aperi-
 ents, conjoined with vegetable tonics, stomachics,
 &c.  I have also observed great benefit result
 from the  following, when appropriately adminis-
 tered or modified:
  No. 350.  R  Pulv. Ipecacuanhse, gr. viij.; Extract! Fel-
 lis Bovini, 3ij.; I'ilulse Khei comp. (vol Pil. Aloes cum
 Myrrhii), 3ijss.; Extr. Conii (vel Extr. Hyoscyami), 3ss.;
 Saponis Castil.. gr. xij.; Olei Anisi, q. s. Contunde bene
 et divide massam in pilulas xxxvj. quarum  capiat duas
 hora somni.
  No. 351.  ft  Extr.  Glycyrrh., jss.; Tinct. Aloes comp.
 fss.; Tinct. Conii, 3j. (vel Tinct. Hyoscyami, 31J.); De-
 cocti Aloes comp. fvss.   Aquro Carui ad fviij.  Misce.
 Fiat mist, cujus capiat cochl. ij. vel iij. ampla hora som-
 ni vel primo mane.
  No. 352.  R  Pilulae Ehei comp., 3ijss.;  Pilulic Scilhc
 comp. et Pilulso Conii comp., aa., 3j.; Saponis Castil. gr.
 x.  Contunde  bene  et massam divide in  pilulas xxiv.
 Sumantur binse horu somni.

  318.  These  medicines  are most  suitable in
 cases devoid of any imflammatory complication,
 which, as occurring either  in  this or  in  subse-
 quent stages, will  be more particularly considered
 in the sequel.   The objection of not being appli-
 cable to these  and other complications cannot,
 however,  be  urged against  equal  proportions of
 magnesia and  sulphur  as an  aperient  in  this
 stage, especially when rendered more  agreeable
 by the addition of liquorice powder  and a little
 ginger.   Where this aperient proves too depress-
 ing, or where vital power and vascular action and
 assimilation are much impaired, a little powdered
 cascarilla  may be added to the former, the whole
 being taken in some water.
  319. b. External medication is  a very import-
 ant part  of  the treatment of phthisis ; and, as
 will  be  seen from the  historical sketch  given
 above ($ 242, et  seq.), it has been considered such
 from  a very early period of  medical history.
 Probably external  derivation by means  of moxas
 was as early resorted to in  eastern countries for
 this and other diseases, as by issues  and setons
 among the Greeks and Romans; but there  can
 be no doubt of the  benefit to he derived from
 these and similar means in aid of judicious  in-
 ternal treatment and regimen.   As it was in re-
 spect of internal, so it has been as regards extern-
 al means, different kinds and various modes of
 prescribing them having been advised in success-
 ive  ages,  and those which had fallen into disuse
 having been  revived from time to time, again to
 be neglected  or  forgotten.   The moxas  employed
 in far eastern countries from time immemorial
came into vogue in Europe after the former were
visited by voyagers and travellers from the latter;
but failed in superseding issues and setons, which
 have always  held  their place, and  deservedly, in
the treatment of this disease, especially with  the
 judiciou sand experienced.  Early in  the pres-
ent  century moxas came again into use in some
places on the continent of Europe, and pustula-
tion by means of tartarized  antimonial  ointment,
or of croton oil in  this country ; the latter means
having so entirely superseded issues  and setons
 as to have caused the complete disuse of them.
 I have seen much  of these modes  of derivation,
 and have had considerable experience of their ef-
 fects, both in phthisis and in  other  diseases.
 Moxas are of more or less use according to the
amount  of discharge which may be procured sub-
 sequently  to their  incandescence;  but  their op-
eration is uncertain.   Both the tartarized  anti-
 monial ointment and the croton-oil liniment pro-
duce external irritation, but little discharge, their
 influence on the disease  being seldom beneficial. 
TUBERCULAR CONSUMPTION—Treatment of  First Stage.          1257
while they distress the patient and even augment
the constitutional disturbance in some cases.
  320. Issues, made sufficiently large, have proved
most  beneficial in my practice.   I have  always
prescribed them when I have seen the patient in
the first, or even  in the second stage, and sev-
eral persons are now alive who had recourse to
them  from twenty to  thirty years ago, as I ad-
vised them.   I have generally recommended them
to be made near the margins of the ribs, when the
patient is not  much emaciated; or in any other
situation  which may  be  preferred.  The chief
objection to them is the preliminary measure  of
destroying the integuments for the lodgment of
the peas.   Where setons appear preferable, as re-
spects the state of the patient, or the situation in
which they may be inserted, so as least to incom-
mode  him, care should be taken, in respect  of
them  as well as of issues, that they should be suf-
ficiently large to be effective, and that a free pu-
rulent discharge  be  uniformly  procured from
them.  When both issues and setons are object-
ed to, especially the formation of an issue in the
usual way, then the inner bark of the mezereon,
previously moistened, may be placed on a part of
the surface of the extent of a crown-piece, and
confined there by means of a larger piece of ad-
hesive plaster spread on paper  or leather, the
bark being renewed from time to time.  This lat-
ter plan, however, is not preferable to a blistered
place of this extent kept open and discharging by
the usual means; but neither the  one nor the
other is so effective as an  issue or a seton, the
benefit being derived chiefly from a uniformly co-
pious  discharge.  When this is  procured, the
internal treatment  and regimen  of the  patient
should be more restorative and generous than in
other circumstances of the disease ; tonics, cha-
lybeates, animal food, restorative  beverages, &c,
being  allowed, according to the  peculiarities of
the case, especially as respects the vital and vas-
cular conditions.
   321. I  have,  since 1819, never  neglected to
prescribe  an embrocation to the chest, in phthisis
and in some other diseases, which acts less as an
external irritant and derivative than as a  source
from which a salutary agent is inhaled into the
lungs in so mild a form as neither to irritate nor
to stimulate, while it is slightly absorbed.  This
embrocation I have  employed in many internal
diseases, in various  forms or modifications, as a
liniment, or as an embrocation or epithem—sprin-
kled on folds  of flannel, or on spongio-piline, and
covered over by a napkin, or otherwise—and va-
ried as respects the constituents, the principal
one being always present.
  No. 353.  R Linimenti Terebinthinse, Linimenti Cam-
phorffi compositi, iia, 5jss.; Olei Olivse, fss. ad 3vj.; Olei
(Jnjuputi, 3j. ad 3jss.   Misce et sit embrocatio.
  No. S54.  R Linimenti Terebinthinae, Linim. Saponis
cum Opio, afi^ij.; Linim. Camphora; comp., ?jss. ; Olei
Cajuputi, 3JssT  Misce.
   322. When it is desired that external irritation
should follow the first of these, the olive oil may
be  omitted.   Either of these should be renewed
every  night, the vessel being previously shaken,
and applied, by the means already mentioned, to
a sufficiently  large surface, either of the front, or
of the back of the chest, or of the side, where pain
or uneasiness is most felt.   It should be kept ap-
plied  all night, or the following day, and even be
renewed again in the morning, the quantity sprin-
kled over the surface of the  flannel or spongio-pi-
line being sufficient to moisten, or more complete-
ly to wet these substances, according to the ef-
fect we wish it to produce, whether by inhalation
of the fumes proceeding from it, or by the extern-
al derivation it may occasion, in addition to the
former mode of action.
   323. Blisters, mustard poultices, the cauteries,
urtication, and dry-cupping have  severally been
resorted to as derivatives in this stage.   Blisters
are often of much service, especially when ap-
plied after local depletions ; and when a discharge
has been.procured from them for some time.   The
others, excepting the  cauteries, are seldom pro-
ductive of much or permanent benefit.   The tar-
tarized antimonial  ointment and liniments with
croton oil have deservedly fallen into disuse.  The
actual and potential cauteries were not infrequent-
ly employed in  former times for this disease, a
discharge from either having always been promo-
ted.   They are now never resorted to in phthisis.
   324. c. In  this,  as well as in more advanced
stages of the disease, the  inhalation of medicated
vapours, and of certain fumes, effluvia, and odours,
has been recommended and been adopted.  I have,
however,  very rarely observed much benefit de-
rived from it, especially as commonly employed by
means of an inhaling apparatus.  The substances,
also, generally prescribed for inhalation have been
used in so concentrated a form, or are so acrid or
stimulating, as often to increase the existing irri-
tation in the bronchi, or the morbid action in the
substance of the lungs, and in the seats of vom-
icae or of cavities.   It is also very questionable
whether or no the inhalation of vapours—whether
watery, emollient, or anodyne, or narcotic, or pos-
sessed of all these properties—is actually benefi-
cial in  phthisis, more especially at an early period
of the  malady.  The inhalation of these may be
useful as palliatives at an advanced stage, especial-
ly when an irritable cough, a sense of constric-
tion in the chest, difficult expectoration, &c, are
much complained of; but, in other circumstances
and stages of the  disease, they only  tend to ob-
struct or impair the functions of the lungs, by in-
terrupting the progressive metamorphosis and ox-
ygenation of the globules of the blood, and by fa-
vouring congestion or a partial collapse of the or-
gan.   The modes of inhalation, or of having re-
course to the respiration of the effluvia of sub-
stances which are  calculated to prove beneficial
in this disease, will be considered in the sequel.*
   325. C. Treatment of the second stage of the
common form of Phthisis.—At the commencement
of this period, or when the symptoms, especially
the appearances of the  expectoration, and the
character of the febrile action, indicate the recent
supervention of this stage on  the first, then it

  * [We unhesitatingly concur in the truth of these re-
marks, as will doubtless every practical physician who
has had much experience in regard to inhalation in this
disease.  That it may palliate the cough, when harass-
ing and of an irritative character, when  Droper sub-
stances are used, is  a matter of common observation;
but we cannot admit that it exerts any decided curative
power.  Forcible inspiration, which expands the air-
vesicles, is far more efficient than the local contact of
aerial or vapoury medical agents; for a more perfect ox-
ygenation  of the blood aids materially the nutritive
function,  primary and  secondary assimilation.   It is
possible that certain  substances, such  as chlorine and
iodine, which act as stimulating and tonic alteratives,
when introduced into the circulation, may exert the same
curative influence as when taken into the stomach. But
these are few in number, and it is very possible that the
local irritant effects  exerted  on the lungs may overbal-
ance any good  effects which  they otherwise might pro-
duce.   We reserve farther remarks on this  and other
allied topics to the Appendix.—Ed.] 
1258       TUBERCULAR CONSUMPTION—Treatment of the Second Stage.
 will become a question how far the means which
 have been  or still are  in use may be continued,
 and in what they may be modified or changed, or
 what additions may be made to them.  In this
 the physician will be guided by  the peculiarities
 of each case,- but in the circumstances  of most
 the same principles and means as have been dis-
 cussed should be  continued,  modified so as  to
 meet prominent symptoms, and commencing  or
 fully developed complications, or intercurrent af-
 fections.  The  softening of the tubercles in this
 stage is generally attended  by an increase of
 cough and expectoration, of the hectic symptoms,
 and of the morning perspirations, with occasional
 attacks  of  diarrhoea or disorder of the  bowels.
 One or more of these usually become more prom-
 inent as the disease advances ; or other phenom-
 ena are superadded, requiring the treatment to be
 directed more especially to  them.
   326. a. The cough generally  suggests pallia-
 tives, in connexion with the other means which
 the state of the patient demands.  Thus hydro-
 cyanic acid, or henbane,* or hemlock, or the com-
 pound tincture of camphor,  may be added  to mix-
 tures  containing  the liquor ammoniae acetatis,
 and any demulcent which may appear most ap-
 propriate to the nervous and vascular conditions
 of the case ; or they may be conjoined with bitter
 or tonic infusions or decoctions, when the states
 of the pulse, of the fever, and of the vital  powers
 require them:  these latter are  often rendered
 more beneficial by the addition of the solution of
 the  acetate  of ammonia, and of the sweet spirits
 of nitre.  Where there is much pallor of the sur-
 face, the pulse being either  weak or but little ac-
 celerated, any of the anodynes above mentioned
 may be added  to the mistura ferri composita, and
 the effects upon the cough  and upon the hectic
 and other symptoms carefully observed.
   327. b. The perspirations during the night or
 early part of the morning are always productive
 of great exhaustion, and are the most difficult to
 restrain or prevent.  They have been very differ-
 ently treated by both ancient and  modern phy-
 sicians, but most frequently  by mineral acids, and
 by various refrigerants, astringents, and tonics, as
 shown in the historical sketch given above (y 241,
 et  seq.).   Either  of these may be  prescribed in
 combinations suited to the case, with emollients,
 stomachics, or tonics, and may be made  the vehi-
 cle, on the surface  of which the  recent cod-lwcr
 oil may be taken shortly after a  meal,  twice or
thrice daily, and in sufficient quantity; this be-
ing the substance most deserving of reliance for
moderating this distressing symptom.   Some of
the medicines advised with this object have often
disordered the bowels, or induced  an  attack of
diarrhoea, and  even augmented the suffering of
the patient, without effectively diminishing the
perspirations and their  consequent exhaustion ;
but these results rarely follow from the  use of
  * [Great caution is necessary in regard to the use of
hydrocyanic acid, henbane, or any other powerful seda-
tive in tubercular disease, inasmuch as the vital powers,
already prostrated, may be still farther reduced by the
influence of the remedies.  When there is " great pallor
of the surface with weak pulse," we have found the night
sweats augmented by the use of the above-named drugs,
as well as the veratrum viride, and the  general prostra-
tion aggravated, under which circumstances the disease
invariably makes more rapid progress.   We have, how-
ever, used of late, with apparent advantage, Tildkn's
'■'Fluid Extract of Hyoscyamus," with paregoric, which
serves to allay the pulmonic irritation without causing
any increase of debility.]
  this oil.  The mistura ferri composita is s°me"
  times  of service in allaying the severity of the
  hectic and the excessive perspirations, especially
  when there is no inflammatory complication pres-
  ent, and when it neither  produces  headache  nor
  renders the cough harder or more severe.   Dr.
  Watson  has found  the  tinctura  ferri  munati3
  successful in allaying the perspirations after other
  means had failed.*  The dose he prescribes of this
  medicine is twenty minims thrice daily.   I have
  likewise given this preparation with advantage
  in the infusion of calumba, with  an additional
  quantity of the acid, and have  sometimes made
  this combination the vehicle on the  surface of
  which the cod-liver oil was taken.
   328. c. When diarrhcea occurs it is often in-
  duced  by some purgative medicine, or by errors
  in diet, or by means employed to  moderate the
  perspirations.  The cause of it should be ascer-
  tained, and the medicines to restrain it be suggest-
  ed or selected accordingly.  It is,  however, fre-
  quently independent of either of these causes, and
  the result of indigestion—of the acidity and the
  accumulation  of sordes in the prima via conse-
 quent  upon the  imperfect performance of the
 functions of primary assimilation.   In either of
 these circumstances antacids and absorbents, con-
  joined with mucilages, anodynes, or narcotics, or
 with mild tonics, will prove of service ; as the cre-
 taceous mixture with the compound tincture of
 camphor, or the tincture  of hop, &c, and with
 the  tincture of catechu, or with other vegetable
 astringents, if they be required.  But the bowels
 should  not be confined by these or other  medi-
 cines ;  and when there is any risk of such an oc-
 currence magnesia may be given with sulphur or
 rhubarb, or with cascarilla; or the compound de-
 coction of aloes may be prescribed with the tinc-
 ture or with other suitable medicines—[Opium
 is well suited to such cases, and  may be used
 freely with the best effects]
   329.  d. In this stage of the disease emetics and
 bleeding are seldom beneficial, unless the states
 of the digestive and respiratory functions require
 a recourse to the former, and the occurrence of
 pain or the appearance of an inflammatory or con-
 gestive complication demand the latter.   Ipecac-
 uanha is in most instances the best emetic, and
 local bleeding the most beneficial, especially when
 the embrocation prescribed above (y  321) is after-
 ward applied and duly persisted in.   Although
 it may  be necessary to  have recourse to  these
 means,  others of a restorative or even tonic kind
 —both medicinal and regimenal—maybe equally
 required ; often, however,  in different cases, but
 not infrequently in the same case, and sometimes
 even soon after the more antiphlogistic measures
 have been employed.  Generally, when local de-
 pletions are required, febrifuge medicines, chiefly
 such as the solution of the acetate ^»f ammonia,
  * [The oxide of zinc will be found one of the most effi-
 cacious remedies for the night sweats of phthisis.  It
 may be made into a pill with extract of hyoscyamus, two
 fwo IvSW P '!: f-Which one> *nd  in ^e cases
 !J^ *»*»at bed-time.  Dr. Barlow recommends
 ?ipfir?$hZT ^dl°-UT grs- ext- of hyoscyamus to be
 rPK,f»i  Ac?hP " % b:dt,m«' and generally finds it suc-
 cessful.  As the oxide ofzmc is insoluble, Professor Woon
 advises the use of the sulphate; but though the former
 S?,i£,°mCl and Tny*°ther mineral substances b™^
soluble in water, they find their appropriate solvent in
the stomach or intestinal canal; so that, in fact, the oxUe
ui jurt as efficient as the sulphate, and less irritatinfto
the mucous membrane.  We have found a combination
of sulphate of quinine and morphia very  useful for the
night sweats of phthisis.]                       me 
TUBERCULAR CONSUMPTION-
    camphor mixture, &c, are the most appropriate ;
    but they may be afterward conjoined with others
    of a more tonic nature, such as the  infusion of
    hop or the infusion or decoction of cinchona, and
    to these anodynes may be added, the  selection of
    which should depend upon the features  of the
    case.   Hydrocyanic acid, monkshood, hemlock,
    henbane, meadow-saffron, and digitalis, have been
    individually employed in combination with these
    or other medicines; but they require caution in
    their use, and careful observation of their effects.
    Monkshood, or aconite, is most appropriate in the
    more inflammatory tendencies of this and the pre-
    ceding  stage, but it especially demands a most
    cautious observation of its effects ; a remark not
    less applicable to colchicum and digitalis, which
    are suited to  the same states of the disease as
    those for which aconite may be  given ; these be-
    ing useful chiefly as antiphlogistic means, either
    in aid of vascular depletion, or when the condition
    of the blood and of vital power contra-indicate  a
    recourse to depletion ; although the  local morbid
    action requires to be  restrained or even lowered.
       330.  e. The remarks offered above respecting
    issues, setons, and other derivatives (y 319-323),
    apply to this  as well as to the  first stage.  In-
    stances are rare in which either the one  or the
    other should not be resorted to.  The great diffi-
    culty often is, owing to the emaciation of the pa-
    tient, in which situation they may be placed, so as
    to produce the least amount of discomfort.  When
    emaciation is not very remarkable, then  the mar-
    gins of the ribs  may be selected ; but in different
    circumstances an issue of good size may be form-
    ed over the pectoral muscle, or between the shoul-
    der-blades.  When this stage in females is char-
    acterized by suppression  or marked diminution
    of the catamenia, the issue may be made near the
    groin, in the anterior aspect of the thigh.   When
    setons are preferred, the arm, near the axilla, may
    be  selected.   If neither of these nor moxas be
    adopted, blisters, kept open as long as  possible,
    and renewed from  time to time, are generally
    necessary.  The embrocations advised above (y
    321)  ought not to be overlooked, inasmuch as, in
    the  more  urgent cases, they may be  applied
    while the foregoing means are also in operation,
    and as they are  sources both of derivation and of
    inhalation.  When the above produce a sufficient
    discharge,  then Griffith's myrrh  mixture, or
    other chalybeates or tonics, may be prescribed,
    with  anodynes,  narcotics, &c; and their  effects
    upon the cough, the pulse, and the hectic  should
    be carefully observed.  If these symptoms become
    aggravated by them, they ought  to be relinquish-
    ed, and the salines, especially the solution of ace-
    tate of ammonia, or of" citrate of potash,  with hy-
    drocyanic acid,  conium, &c, as noticed  above
    (y 329), may be  substituted.   If these effects do
    not result, then  the more generous regimen rec-
    ommended for the  first stage (y 314, et seq.) is
    equally, if not even more, required for this.
      331. /. Inhalation of dilute medicated vapours
    and fumes may  be tried in this stage, as well as
    in the first.  The opinion I have formed  of them,
V   and stated with reference to that period (y 324),
    is not materially different as regards this.  Cases
    may occur in which they will be more serviceable
    in the second than in the first stage,  and still
    more  so in the third than in either of the forego-
    ing ;  but the amount of benefit, or the want of it,
    will entirely depend upon the substances selected
    for this mode of administration, and upon the way
■Treatment of the Second Stage.       1259

 of effecting this intention (see I) 412).  But mild
 or weak jumigations of the patient's apartment
 are generally much more beneficial than inhala-
 tions, which often irritate and increase the local
 lesions (y 413).
   332. g. In females the  state of the catamenia,
 as respects both the intervals  and the  duration
 and quantity of the discharge, is of the greatest
 importance, especially  in  the  first and second
 stages of  the  malady.   Excessive  discharge,
 whether as to frequency of recurrence, the dura-
 tion of its continuance, or the quantity, not infre-
 quently predisposes to, or more directly occasions,
 phthisis ; and the same disorders of this function,
 if allowed to proceed, will also aggravate or hasten
 the progress of this malady, if they occur in either
 the first or second stages.   The rapid or sudden
 disappearance of this  discharge, on the  other
 hand,  is even more certainly and rapidly injuri-
 ous, in whatever stage this may take place.   A
 difficult or scanty catamenial  discharge requires
 attention, although it is not so dangerous as either
 of the former states, especially the latter.  Ex-
 cessive states of the catamenia should be moder-
 ated with caution, and by such means as are  not
 likely to be followed by suppression.   The decoc-
 tion or infusion of cinchona with either of the
 mineral acids, or the sulphate of quinine in the
 compound  infusion  of roses, and  tincture  of
 orange-peel may be prescribed, or the sulphate of
 quinine may be mixed in some water and taken
 without any addition.   If anaemia have been pro-
 duced by this discharge, the tincture  of the ses-
 quichloride of iron  may be given, either alone or
 with the preparations of calumba or quassia.   It
 should not be overlooked that the disorders of the
 catamenia in the early stages of phthisis are often
 caused by masturbation;  and when this is sus-
 pected, and when advice can be prudently given
 and  precautions taken against this vice, it  be-
 comes the duty of the physician to act  accord-
 ingly.   In  these, as well as  in other circum-
 stances of profuse catamenia, ipecacuanha, con-
 joined with extracts of gentian, catechu, and a
 narcotic, may be given in  such quantity as to oc-
 casion some degree of nausea to even retchings.
   333. Scanty or difficult menstruation requires
 means appropriate to the peculiarities of the case;
 for either of these states may be attended in one
 patient with an anaemied or chlorotic appearance,
 and  in another with little or no apparent defi-
 ciency or poorness of blood.  In the former case,
 the compound mixture of iron, with as much of
 the compound decoction or the tincture of aloes
 as will act moderately on the bowels, or prevent
 constipation, with a little  of the extract or tinc-
 ture of conium,  will generally be of service.   In
 other cases, where there is no deficiency of blood,
 a  few  leeches may be  applied  below  the  groins
 shortly before the expected period of the catame-
 nia ; and the  hip-bath  and pediluvia, at a suffi-
 ciently warm  temperature  and  with the addition
 of salt or mustard, resorted to.
   334. In  cases attended  by suppression of this
 discharge, strenuous efforts should be made to re-
 store  them.   The hip-bath, pediluvia, &c, ren-
 dered stimulating by bay salt and mustard, leeches
 applied around the anus  or beneath the groins,
 the preparations mentioned above (y 333), walking
 exercise, or riding on horseback or in  a carriage,
 and the several  emmenagogues advised for sup-
 pression  of the  catamenia (see Menstruation.
 y 64-95, et seq.), should be prescribed in combi- 
1260
TUBERCULAR  CONSUMPTION—Treatment of the Third  Stage.
nations or forms suited to the 6tate and stage of
the pulmonary disease.
   335.  In this stage various complications ap-
pear, either as temporary or intercurrent affec-
tions, or as morbid associations, which  continue
to the termination of the malady.  These will be
noticed in the sequel;  but there is one which is
rarely absent, and which renders  the treatment
difficult, namely, the bronchitic affection.  This,
in many cases, becomes  the prominent  disorder,
and  requires the treatment to be more especially
directed to it;  the most generally serviceable
means being, according to the accompanying fe-
ver and the state of the patient, the solution of the
acetate of ammonia with the spirit of nitrous ether,
dilute hydrocyanic acid  and camphor mixture;
or in somewhat different states, with carbonate
of ammonia, compound tincture of camphor, or
henbane or conium.  If there be a haemorrhagic
tendency, the acetic acid may be added ; and in
most cases the terebinthinate embrocation should
be applied to the chest.
  336. h. The diet  and regimen in this stage may
in a  very large proportion, if not in the  majority
of cases, be altogether the same as I have advised
for the  prevention and for the treatment of the
first  stage of the disease  (y 292-308).  In many
cases a fish diet will agree  well in  this stage;
the white kinds of fish, always boiled, but never
fried, a squeeze of lemon, with little butter, but
preferably with the liver  of fish, being the chief
or only  sauce.  The fish  and their livers, which
are most beneficially used as articles of diet, are
the Gadus brosmius, or torsk ; the Gad. morrhua,
or cod ;  the Gad. molua, or ling; the Gad. agle-
finus, or haddock;  the Gad. merlangus; the Gad.
callarius; the Gad. carbonarius, or coal-fish;  the
skate, turbot, soles,  &c.   The recent livers of all
these species of the genus Gadus, boiled in such
a manner as to preserve their oil, may  be used
either as sauce to the fish, or may be  eat with it,
or the oil may be  taken after the meal, in  the
usual medicinal way.  They  are beneficial both
as articles of diet and as medicine.   When quite
recent they  have no fishy or unpleasant flavour,
and  are  easily digested — the  more easily  the
more oil they contain.
  337. As to other articles of diet, regimen, change
of air, exercise, travelling, voyaging, and choice of
residence, the remarks which I have made  above
(y 292-308), and in the sequel (y 420, 421), and
in the article Climate (y 42, et seq.), are applica-
ble to this stage, according as the strength of the
patient and  the prominent symptoms will  admit
of their adoption, and as the presence or absence
of any of the more important complications will
suggest.
  338. D. The treatment  of the third stage of the
common form of phthisis (y 38, et seq.) is frequent-
ly but little different from that  already  advised.
The  state of the patient may not, in some in-
stances, be materially different from that charac-
terizing the second stage, although cavities—one
or more—have already formed in one  or even
both lungs.   The patient may not  be materially
worse in respect either of strength or degree of
emaciation,  or  of  cough and respiration, espe-
cially if the more aggravated symptoms and com-
plications have  not as  yet  been  experienced.
More commonly, however, he is much worse as
regards  all these ; and colliquative perspirations,
attacks  of diarrhoea, severe paroxysms  of cough
and of oppressed breathing, and pains in various
 parts of the chest or its vicinity from inflamma-
 tory congestion of portions of the lungs or train
 the extension of the morbid action to the pleura,
 are more or less experienced, and are generally
 relieved with  greater difficulty than  in the pre-
 ceding stages.  The treatment depends chiefly
 upon the complication, or rather complications,
 which characterize this stage.
   339. a. In all cases there is more or less bron-
 chitis, chiefly, however, of the bronchi communi-
 cating with"the softened  tubercles and cavities;
 but there may be in addition inflammatory or sub-
 inflammatory action  in the surrounding portions
 of lungs, or even  also in parts  of the pleura in
 the vicinity.   These may require, or at least sug-
 gest, a treatment which neither the strength nor
 vascular condition of the patient may well bear,
 especially when carried so far as to  subdue the
 superinduced local mischief.  But to  leave these
 complications to their natural courses,  when clear-
 ly manifested by symptoms, may be more injuri-
 ous than the effects of judicious means prescribed
 for their removal; and, as far as my experience
 enables me to decide, the employment  of such
 means is the safest alternative.  For these states
 of this stage, therefore, local depletions, by leech-
 es or by cupping, are required, according to the
 condition  of the patient  and symptoms of the
 case, the quantity of blood taken at  first being
 small.  When the  indications for having recourse
 to this measure are doubtful, dry-cupping, after-
 ward blisters, the terebinthinate embrocations al-
 ready advised (y 321), and the febrifuge medicines
 recommended  above, are most appropriate.   Of
 this class of medicines, the solution of acetate of
 ammonia, in forms and combinations already no-
 ticed (y 315), is the most generally of service.
   340. b. In this stage, especially in its advanced
 course, the  colliquative perspirations and diar-
 rhoea exhaust the patient,  and  more or less waste
 the red globules of the blood.  While these symp-
 toms should be restrained, the powers of life and
 the supply  of duly  assimilated blood-globules
 must be supported and promoted.   The means
 which fulfil the one indication often also aid the
 other.   This is more particularly demonstrated
 by the effects  of cod-liver oil, and by medicines
 which improve the digestive and assimilating pro-
 cesses,  and  correct, counteract, or remove  the
 contaminating matters which are carried into the
circulation from the lesions seated in the lungs,
 whether softened tubercles or ulcerating cavities,
 and which thereby affect the cutaneous and mu-
 cous surfaces and  follicles, so as to give rise to
 these exhausting and distressing symptoms of
 the malady.   Numerous means, beside those al-
 ready mentioned, have been proposed for these
morbid conditions, especially the  acetate of lead
 with pyroligneous acid and laudanum, the sul-
 phate of zinc  with sulphuric  acid, the sulphate
of copper with opium, the substances  containing
tannin,  gallic acid, &c, and catechu, kino,  kra-
meria, haemotoxylum, nux vomica, &c. ;  but very
few of these, even while they restrain the  diar-
rhoea, dimmish the perspirations, or in any other
respect alleviate the malady.   Indeed, in some   •
cases they aggravate the disease, and  only accel-
erate  its progress to a fatal issue by  preventing
the elimination by those emunctories of the effete,
morbid, and  contaminating materials  conveyed
into and circulating in the blood.
  341. c. Much more rational and efficient indica-
tions for the abatement of the colliquative diar- 
TUBERCULAR CONSUMPTION—Treatment of Latent  Form.          1261
rhoea and perspirations in phthisis would be the
improvement  of the  digestive and  assimilating
functions by  such means, or combinations  of
means, as would at the same time, by their partial
absorption into the circulation, correct, change,
or counteract the contaminating matters which
are imbibed from the seat of the disease ; whether
these  matters  be purulent  or tubercular, or the
sanious fluid formed in or on the surface of ul-
cerating  parts, and whether  they are  actually
present in the blood, or are more or less changed
in the course of the circulation of the blood.
That they actually contaminate more or less this
fluid, however small may be the quantity which
passes into it,  and thereby give rise to the  most
distressing and dangerous symptoms of phthisis,
cannot be doubted, the skin and the bowels being
two of the  chief channels through which they,
and other injurious matters they may form, are
eliminated from the circulation;  but the selection
of the means  of fulfilling  these indications is
much  more difficult than devising them, and de-
pends entirely upon the peculiarities of individual
cases, as  respects especially the progress of the
disease and the states of respiration and circula-
tion.  The bicarbonate and the nitrate of potass,
prescribed in  tonic infusions  or decoctions, with
aromatic  or astringent or narcotic tinctures, ac-
cording to the state of the  case ;  magnesia and
sulphur, with the powder of cascarilla or of cin-
namon or ginger and liquorice powder, or with
other substances, as the  state of the bowels will
suggest;  the compound iron mixture, or the aro-
matic mixture of iron (D  P.); the bitter or tonic
infusions, with carbonate or citrate of potass or
of soda and anodynes ; balsams, the purified or
inspissated ox-gall, with conium or with the com-
pound soap pill and ipecacuanha, or with the pu-
rified extractof aloes, according to circumstances ;
and camphor, the terebinthinates, tar or tar water,
conjoined with such  of the foregoing medicines
as the features of the  case require, may severally
be employed.   In some instances where the col-
liquative state of the bowels and other symptoms
indicated  a contaminated  state of the blood, and
consecutive alteration of the mucous surface and
follicles of the  bowels, I have prescribed the fol-
lowing pills at night, or night and morning, or
with the meals;  the bitter vegetable tooics, with
alkalies, &c, having been taken in the intervals
between meals :
  No. 355.  R Pilulap Ferri comp.; Pilulse Rhei comp.;
Extracti Fellis bovini; Picis liquid*, aa. 3ss.  Mi.-ce et
contunde bene, dein divide massam in pilulas xxx.; qua-
rum capiat unam ad tres pro dose.
  No. 35G.  R Extr. Fellis Bovini; Sulphuris prsecipit.;
Picisgyquidte; Confect. aromat. in pulv., aa. 38s. ;  Olei
anisi, q. g.  Contunde bene et divide in pilulas xxxvj.
Sumat j. ad iij. pro dose.
  No. S57.  R Magnesia1 carbon.; Sulphuris prsecipit., aa.
3ij. ; Confect. aromat. in pulv. 3SS.; Creasoti Ttlviij. ad
xij.; Olei anisi, ct mucilag.  q. s.  Misce et fiant secun-
dum  artem pilulw xxxvj.  Capiat j. ad iij. bis terve in
die.
  342. It may be noticed that the above, both
mixtures  and  pills, may  be modified, or receive
additions, so as to meet  the peculiarities of the
case   If irritation or pain in the bowels be ex-
perienced, small doses of the extract of opium or
the  soap pill with opium, may be added to either
of the  foregoing ;  and if diarrhoea, or tenesmus,
or dysenteric symptoms be present, ipecacuanha
in full  doses may also be conjoined with these.
  343  With the other distressing symptoms, to
which I have directed notice, there are others for
which relief is required, and although we may be
unable to impart it, we should at least attempt it
The dyspnoea, difficulty of breathing, the feelings
of suffocation, &c, in this stage, are sometimes
distressing.  In many  instances the terebinthi-
nate embrocations already mentioned (y 321), ap-
plied over  the chest or between the shoulders,
will afford  some relief; and an  opiate conjoined
with either of the  pills just prescribed, or  with
expectorants  and  antispasmodics, or the com-
pound galbanum pill, or with stimulants and oth-
er means indicated by the state of the case, as
already mentioned, will often be of service.  When
the dyspnoea is urgent or distressing, an  emetic
will be found to afford most relief.  The aphthae
which, towards the close  of this stage,  often ap-
pear in  the mouth, tongue, and  throat,  farther
increase the distress of the patient, and require
the  treatment advised for this  condition  of the
mouth and  throat in the  articles Throat (y 40,
et seq.) and Thrush (y 11, et seq.).
  344. d. Delirium rarely occurs in this form  of
phthisis until shortly before dissolution, unless in
females, when this stage  of the  malady is accel-
erated by, or occurs in the puerperal  state, or in
cases where the nature of the medicines or the
idiosyncrasy of the patient has given  rise to this
symptom.   Most of the narcotics and anodynes,
especially henbane, conium, aconite, opium,  mor-
phia, digitalis, &c, will have  the effect of indu-
cing delirium in  the advanced  progress of this
stage, especially in  nervous and  exhausted states
of the patient, and when either  of  these  sub-
stances are  given in too large doses, or continued
too long; or when  substances which are calcu-
lated to prevent or to correct their injurious ef-
fects have not been conjoined with them.  The
delirium, in most  instances, is  slight;  but  it is
sometimes  more  severe or acute, and is attend-
ed with restlessness and sleeplessness, or it ap-
proaches the character of delirium tremens.  For
these modifications of mental disorder,  lowering
means only hasten  a fatal issue.   If they have
been occasioned by either of the medicines just
mentioned, they will frequently disappear after
the cause has been removed, especially if judi-
cious means be prescribed ; but  under every cir-
cumstance  the state of vascular  action, especial-
ly as respects the brain and membranes, should
be observed.  If  it  be increased in these, cold-
sponging the  head, mustard  pediluvia, &c, are
required; and even when such  increase is pres-
ent, it  will be more readily relieved by restora-
tives, prescribed in small and moderate doses, and
their effects watched, than by  opposite means.
The medicines from which most  relief may  be
expected in the delirium  occurring in this peri-
od,  are  camphor, ammonia, the  solution  of the
acetate of ammonia, the carbonate of ammonia,
the compound spirit of ether, the spirit of nitric
ether, the  hydrochloric ether, the  preparations
of serpentaria, of arnica, and of sumbul.  These
may be prescribed  individually, or in combina-
tions of two or more, or with the alkaline,  saline,
and restorative medicines I have mentioned as be-
ing useful when the blood is contaminated, the
delirium often  arising from that condition, as well
as from exhausted  organic, nervous, or vital in-
fluence.
  345. v. Treatment of  the Latent Form  of
Phthisis.—This variety of the  disease (y 77, et
seq.) generally eludes  the notice of the friends
and the fears of the patient until it has advanced 
1262         TUBERCULAR CONSUMPTION—Treatment of Acute Forms.
 to a state hardly admitting of hope.  If, howev-
 er, the symptoms characterizing it should alarm
 either friends or patient, if depression of spirits,
 impaired digestion and assimilation, or other in-
 ilication of disorder lead to the procuring of med-
 ical advice, and the detection of the malady in its
 silent and stealthy course, although no promi-
 nent or unmistakable sign be present, the treat-
 ment which will be found most beneficial is that
 which has been already  advised for the  preven-
 tion and for the threatened appearance of the mal-
 ady (v 292-298).  It  is  obvious, however, that
 the best-devised means will have no  beneficial ef-
 fect if the causes which injured the constitution
 still continue to act.  The physician  should en-
 deavour to ascertain what these are; and if they
 be such as may be removed, the necessity of mak-
 ing the attempt should be insisted upon, and the
 patient be made acquainted with the consequences
 of the neglect of this advice, especially when the
 removal of these causes depends upon himself.
 In most of the cases of this variety the causes
 are usually depressing and exhausting; and in
 many, as soon as the nature of the malady is sus-
 pected, the digestive and  assimilating functions
 require restoratives, mild  tonics, change of air,
 moderate exercise in the open air, travelling, and
pleasurable occupation of the mind; the regime-
 nal and medical treatment I have advised above
 (y 299-324) for the first stage of the usual form
 of the disease being also necessary.   In this la-
 tent or silent course of phthisis vascular deple-
 tions are not well sustained; and if they be at
 all attempted, they should be small,  and their ef-
 fects watched.  In the great majority of cases of
 this form, and especially when depressing or ex-
hausting causes have occasioned the malady, med-
icines of a decidedly restorative or tonic kind, at-
 tention to the digestive functions, cod-liver oil,
and the other means recommended  at the place
 referred to, should be adopted.  These may arrest
the disease ;  but if it should advance neverthe-
 less, and become unmistakingly  developed, the
treatment must necessarily be the same as I have
 advised for the more common form  of the mala-
 dy, modified as above, according to the manifes-
tations of the advanced stages.
  346. vi. Primary  Acute or Rapid Phthisis.
 —A. The symptoms of the first  variety of this
 form (y 82-84) have been described by me as in-
 termediate between those  of congestive bronchi-
 tis on the one hand, and of congestive  or nervous
 pneumonia on the other (y 83), both lungs being
 more or less  affected.  The cases which I have
 observed  have been consecutive of measles in a
 scrofulous diathesis, or of delayed, suppressed, or
 excessive catamenia.  In these bleeding seemed
 injurious, or was of no avail.  Emetics, the solu-
 tion of the acetate of ammonia, with  ether or am-
 monia, small doses of camphor, the terebinthinate
 embrocation  applied  over the chest or between
 the shoulders, and blisters, were the means which
 appeared to  be  of most service.  Cod-liver oil
 was  either not retained, or was nauseated  and
 not taken, or failed of producing  any benefit.
 The infusion or decoction of cinchona, with ni-
 trate of potash and bicarbonates of the alkalies,
 or with  the solution of acetate of ammonia and
 various ethereal preparations, and small doses of
 camphor with aconite, &c, were also prescribed
 in different cases, or in the same cases at differ-
 ent periods of the disease, but with no marked
 advantage.
   347 B The second variety, or more strictly fe-
brile form of acute phthisis described above ($85,
86), is often mistaken for low nervous or typhoid
fever, which it  closely resembles, especially in
its advanced progress.  In the few cases which
have fallen under my observation I prescribed the
remedies I have just mentioned (y 346); and of
these, the last-mentioned, or those consisting of
the preparations of cinchona with the substances
stated to have  been conjoined with  them, the
chlorate  of potass, camphor,  the  terebinthinate
embrocations, &c, appeared to be of service only
in prolonging the life of the patient  for  a few
days.  The nature of these cases  precludes any
hope  of farther advantage than this  from any
treatment whatever.
   348. vii.  Consecutively acute  phthisis  (y
87) is merely the supervention of either of the
acute varieties of the disease  described above (y
81-86) upon the latent form (y 77-80), of the de-
velopment of this latter form owing to an attack
of haemoptysis in its course, or to some determ-
ining or aggravating cause or occurrence.   Al-
though  an attack of haemoptysis  often relieves
the pulmonary symptoms when they have  been
unequivocally manifested previously, at least for
a time ; yet it is sometimes followed by an acute
state of the disease, most frequently by the more
common form, when it occurs in the course of
the latent variety.  In the consecutive manifesta-
tion of acute symptoms the treatment should de-
pend upon the character of these symptoms and
upon  the associations they present.   If haemop-
tysis take place, the treatment I have advised for
it (y 353-5) may be adopted as far as it may be
appropriate to the peculiarities of the  case.  If
the local symptoms and signs indicate congestion
or inflammatory action in one or both lungs, local
vascular depletions, or even a repetition of them,
emetic, antiphlogistic, and  saline  medicines, es-
pecially the solution of the acetate of ammonia,
terebinthinate embrocations, blisters, and  other
means already noticed, will be  of service ;  and if
the disease assume the acute or febrile states, the
medicines noticed above (y  346, 347) may be pre-
scribed, although with little or no hope of benefit
from them.   In some instances the malady as-
sumes a less acute or febrile form, the  treatment
having temporarily mitigated the severity of the
symptoms.  This is  probably  owing to the con-
gestive and inflammatory states of tjje bronchi
and substance of the lungs,  which had super-
vened upon an extensive but latent formation of
tubercles in both lungs, having been partially sub-
dued by the means employed.  In these cases the
development of the tubercles by the morbi<$ ac-
tion in the bronchi and substance of the lungs
afterward prevents this action in  these parts to
subside; and thus both these  morbid conditions
act and react on each other, so as to occasion an
acute  state  of disease.  The extension of these
lesions in a more or less marked degree through
both lungs generally terminate  fatally before large
cavities,  or even  any  cavities, are formed °*
      the
pulmonary
  t* Of 750 cases of acute pneumonitis treated  in
great hospital of Vienna from 1847 to 1850, pulmow,
abscess was observed in but a single instance, and with
regard to the physical signs of excavations thus formed,
Skoda remarks as follows:  " I have frequently examined
patients suffering from pneumonia, in whose lungs new-
ly-formed abscesses were found after death; but I have
nf T„wla,nyMillg!S instance, recognised the presence
of abscess by the aid of auscultation or percussion   In
every case, the abscess, though communicating with the
bronchial tubes, was filled with pus  or sanieK.''_SKOi>A 
TUBERCULAR  CONSUMPTION—Treatment of Complicated.
1263
whereas, in the common form of the disease, the
greatest  part of the lungs  remains free from
change, although other  portions are ulcerated,
excavated, or otherwise disorganized.  In these
circumstances the principles of treatment already
developed should be adapted to the peculiarities
of individual cases.
   349. viii.  Protracted phthisis (y 89-91), es-
pecially when  early recognised  or  manifested,
and judiciously treated, furnishes many chances
either of recovery or of prolonged existence.  For
this variety, particularly when the pulse and res-
piration are not much disturbed, the several Hy-
gienic means advised for the prevention of the
disease and for the treatment of the first stage
(y 292-323) are generally of great service, more
especially change of climate, voyaging, exercise
and agreeable occupations in the open air, and
in a dry and temperate situation, attention to the
digestive and assimilating functions, aided by di-
gestible and nutritious food; by sulphur, balsams,
a farinaceous and milk diet, &c.;  by tonics, sto-
machics, and chalybeates when the disease ap-
pears to have proceeded from depressing  or ex-
hausting causes; and by emetics and other an-
tiphlogistic  means, or by small bleedings, issues,
setons, terebinthinate embrocations, blisters, &c,
according as vascular excitement or congestive or
inflammatory complications may occur.  In the
simpler states of this form, when the pulse is
weak or slow, and no congestive or inflammatory
complication is present, and especially if the blood
be deficient or thin, the mistura ferri composita,
or the tinctura ferri muriatis, will be given with
benefit; and with either of these other medicines
may be conjoined,  especially cod-liver oil, ano-
dynes, &c.
   350. ix.  Phthisis in infants and children
(y 92-95)  requires more  particularly the Hygie-
nic measures I have  recommended  under the
head  Scrofula and Tubercles  (y  148-153)  ;
and in the sections  above on the prevention and
early  treatment of the  usual  form of phthisis (y
292-308).   Asses' milk, a milk and farinaceous
diet, moderate exercise in the open air, change
of climate, strict attention to the  promotion of
the digestive and assimilating functions by means
of diet, regimen, and suitable medicine, the cod-
liver oil in as large  quantity as the stomach will
bear,  and taken in the modes hereafter to be no-
ticed, are  the chief means in which confidence
can be placed, although others should be  added
which the circumstances of particular cases will
suggest.   When the disease advances to the sec-
ond or third stage in children, then the treatment
advised above for these stages, in the usual form
of the disease, will, with due reference  to the
ages and states of the patients, be equally appro-
priate for them.
  351  x.  Phthisis  in the Dark Races  (y 96,
and note)—The forms and states of the disease
may reasonably be  considered  as varying with
race and climate (y  200-222), and also with the
habitual food and clothing, or amount of clothing,
of these races (v 219-222, 420, 1. and Climate,
y 42, el seq.)  From what I have seen or gath-
ered from  writers respecting the disease in these
races, I conclude that for them a tonic and re-
storative treatment, with attention to the digestive
organs and to the functions of the skin, is espe-

On Auscultation, Am. cd., p. 311.  Professor Flint re-
marks that his "own  observations do not supply facts
bearing on this question" (toe. tit, p. 425).]
cially and generally required.  In other respects
the means of cure advised above for the several
forms of the disease in the white races are also
suited to  these forms when they appear in the
dark races.   In these latter the causes are com-
monly depressing and exhausting.  Confinement
to close situations, where the air is rendered im-
pure by frequent respiration  or  by numbers, re-
moval to  colder and more humid climates than
those from which they have been taken, venereal
excesses,  and insufficient  food, are the most fre-
quent causes of phthisis in these races, and hae-
moptysis  is a common occurrence at the acces-
sion or early stage of the disease.  For these the
more astringent tonics, the preparations of cin-
chona or  of cascarilla, conjoined with laxatives
or aperients, or with diaphoretics, according to
the states of the bowels and skin ;  ipecacuanha
combined with the balsams and restoratives, cha-
lybeates with stomachics, and terebinthinate em-
brocations externally, are most  frequently  indi-
cated. If febrile action be present, the warm and
restorative febrifuges  and diaphoretics are re-
quired ; especially the solution of acetate of am-
monia, the carbonate of ammonia, camphor, and
the infusion or decoction of  cinchona.  If the
bowels become disordered, ipecacuanha in large
doses, with opiates, the bitter extracts, and  such
of the medicines already  mentioned as the cir-
cumstances of the case will suggest, will be found
most appropriate.   Dr. Archibald Smith states
that the several dark races, and the  crosses be-
tween these races, on the coast of Peru especial-
ly, when  attacked by the  haemoptysic  form  of
phthisis, were most  benefited by a residence for
several months in the mountains at  an elevation
of 5000 to 10,000 feet above the  level of the sea.
  352. xi. Treatment of complicated Phthisis.
—The complications which severally appear from
the accession to the close  of this disease require
a few remarks.  These complications are not con-
fined to any one form or stage  of the  malady, but
occur in  all; although more frequently perhaps
in some cases than in others, owing to the con-
stitution and predisposition of the patient, to the
exciting and determining  causes, and to the ex-
posures and other influences in operation during
the progress  of the malady.  Some of these com-
plications may appear in the character rather of
prominent or more urgent  symptoms than of act-
ual superinduced or  intercurrent affections ;  but
as phthisis may, and actually often does, run its
whole course without the appearance of any of
them, or  of one only in some cases, and of an-
other in others, while two or more  may occur
even in the same case, although  not at the same
time, they may be more correctly considered as
contingent symptomatic affections, complicating,
and  often rendering the tubercular  or original
malady  more severe and more rapidly fatal.
With a few exceptions, these affections have al-
ready been  considered with reference to treat-
ment when discussing the successive stages.
  353. A. Hczmoptysis is  a frequent occurrence
in phthisis.   The treatment of it should depend
upon the state of the pulse, the age and habit of
body of the patient, the stage of  the disease, and
the amount of  blood lost.  I have, however, so
fully treated of haemoptysis under the head Hae-
morrhage from  the Respiratory  Organs (y
123-141),  that it is quite unnecessary to enter-
tain this subject farther than to remark that hae-
moptysis is generally the result, at the accession 
1264          TUBERCULAR CONSUMPTION—Treatment of Complicated.
 or at an early stage of phthisis, of capillary con-
 gestion arising from the obstruction or irritation
 caused by tubercular deposits, and at an advanced
 stage  either of the same cause or of exudation
 from an ulcerated cavity, or of discharge from an
 eroded vessel or vessels.  The  older writers, ob-
 serving the relief following a free  discharge of
 blood  at an early stage of the  disease,  advised
 that the haemorrhage should be allowed to pro-
 ceed for some time.  But to do this would often
 greatly alarm the patient, and be running the risk
 of the blood passing into and obstructing or irri-
 tating many of the bronchi which  had remained
 free from disorder.   It is, therefore, safer to ar-
 rest the haemorrhage by suitable means, such as
 those  which I have  detailed under the article
 Hemorrhage (y 123-141), or by general or local
 bleeding, or by the internal exhibition of the spir-
 its of turpentine in doses of twenty or thirty  drops
 every  half hour or hour, and by the  turpentine
 embrocation  or epithem  applied over the chest.
 There  are numerous other means which may be
 employed, and which are mentioned in the arti-
 cle just referred to; but these are most generally
 of service.  The bleeding should be rather repeat-
 ed than large, and  be regulated by the circum-
 stances already stated.  Large doses of ipecacu-
 anha, or one or two grains  given every quarter
 or half hour, are also of great service ;  but  if the
 bowels be confined, half an ounce each of spirits
 of turpentine  and castor-oil may be taken in a
 suitable  vehicle, and  the same substances  in
 larger  doses administered in gruel as an enema.
 Dr.  Cheyne advises, especially  in  cases  of hae-
 moptysis with inflammatory symptoms, a quarter,
 or even an eighth of a  grain of tartarized  anti-
mony with five to ten grains of nitre every  hour.
 The chief advantage from ipecacuanha and  from
 antimony is produced by the nausea they  occa-
 sion.   Much, also, of the benefit experienced from
 sea  voyages, especially in this form or complica-
tion of phthisis, is produced by the nausea there-
by occasioned.*
  354. When called to these and other forms of
haemorrhage I have often found the practitioner
assiduously applying cold or ice to the chest. The
instantaneous shock or impression of cold some-
times does good ; but if this effect does not im-
mediately follow, to  persist in these  applications,
especially in haemoptysis, always does mischief,
by increasing or perpetuating conjestion of, and
vascular determination to, the lungs.
  355. When haemoptysis has not sufficiently re-
 lieved the congestion or the inflammatory symp-
toms attending it, then bleeding, general or  local,
 should be repeated, according to the effect  or to
 the  circumstances at  the time or subsequently
 When, on the other hand, the quantity of the dis-
charge, the existing symptoms,  the stage of the
disease, and state of the patient, require  an im-
mediate arrest of haemoptysis, without having re-
 course to vascular depletion, then the other means
 advised are the most efficient, the spirit of turpen-
  [* We have rarely known the Gallic acid fail in check-
ing haemoptysis.  Dr. James Fountain strongly recom-
mends an infusion of the common Witch Hazel (Hama-
melis Virginica).  As the flowers of this singular shrub
appear after it has shed its leaves, in autumn, and the
fruit is not perfected till the following season, all manner
of magical properties have been ascribed to it.  It pos-
sesses astringent properties, and perhaps slightly ano-
dyne.  An empirical preparation  is  kept in  the shops,
prepared from this shrub, which goes under the name of
" Coryle Extract," the proprietor mistaking it for the
" Corylus Americanus" or Hazel-nut]
tine or ipecacuanha acting more promptly than
the  acetate of lead or other astringents.   ine
secale cornutum I have also found  to act very
promptly in  haemoptysis, five grains of it being
given  every five, ten, fifteen, or twenty minutes,
until it produces the effect, or causes vomiting or
much nausea.  The repetition of small bleedings,
or of other means subsequently, should  depend
upon the state of the pulse, the existence of pain
in any part, or  of dyspnoea and the state and
stage of the disease ; but in most cases the tere-
binthinate embrocations already advised should be
continued  to  those regions of the chest  where
most uneasiness  is felt.
  356   B  Inflammation of portions of the lungs
or of the bronchi, or of the trachea or larynx, fol-
lowed  by more  or less of the consequences  of
these,  as stated above (y 109-112), often compli-
cates phthisis, and requires means of an antiphlo-
gistic  kind in some respects the same as those
just advised.  It should, however, be recollected
that the inflammatory action affecting one or more
of these parts, owing to its asthenic or congestive
character, to  impaired  constitutional power, to
previous disease, and  to the associated  morbid
conditions, admits not  of the same treatment as
that which is  found most beneficial in idiopathic
or some other states of this action.  Vascular de-
pletions, generally  local, as in haemoptysis and
pleuritic attacks, are  required, and  sometimes
should be repeated.  When the state of the case
admits of venaesection, to however small an ex-
tent, this  should  be preferred to the  application
of leeches, to which also  cupping ought to  be
preferred.
  357. a. Pain in the chest, independently of hae-
moptysis, is often relieved by small bleedings, by
cupping or leeches, by blisters, and by the con-
tinued  application of the terebinthinate embroca-
tion.   The usual cause of this pain—its connex-
ion with partial pleuritis (y 112)—should not bo
overlooked ; and the advantage generally follow-
ing a recourse to mercurial  and antimonial prep-
arations in combination, and  sometimes  also to
anodynes, demulcents, &c , in the  intervals be-
tween  the  exhibition of the former, ought to  be
kept in view.
  358. b.  Cough is often a most distressing symp-
tom, especially in the advanced stages of phthisis,
and more particularly when it is associated with
dyspnoea.   In the less urgent states of cough,
compound  tincture of camphor, or hydrocyanic
acid, will often give relief   The preparations  of
anise seed have long been highly esteemed for their
effects  in ameliorating the  cough and even the
dyspnoea   To the preparations in  common use
Dr. Watson states that Dr Prout preferred an
infusion of three drachms or half an ounce of the
bruised seeds of anise seed in half a pint of distilled
water,  at a temperature not exceeding 120°, al-
lowing it to stand until it is cold.   This  may  be
made an excellent vehicle for the compound tinc-
ture of camphor, hydrocyanic acid, or conium, &c.
But the severer attacks of cough, in the advanced
stages, require more energetic means, especially
the  preparations of opium or of morphia   These,
however, often are followed by unpleasant symp-
toms, particularly morphia, if they be not conjoin-
ed with aromatics and  gentle  stimulants—with
small doses of camphor, of spirits, or oil of cara-
way, or of lavender, or of anise seed, &c.  Opium
may be given in the form of the confectio opii  or
conjoined with a little of the confectio aromatica ■ 
TUBERCULAR CONSUMPTION—Treatment  of the Complications.       1265
or the pilula galbani composita, or the pilula sa-
ponis composita, or the pilula styracis composita
may be prescribed with either  of the foregoing.
I have frequently preferred the following solution
of the acetate of morphia, conjoined with aromat-
ics, in order to counteract the depressing effects
often produced by it.
  No. 358.  R Morphia? acetatis, gr. vj.; Liq. Ammonias
acetatis, Jj.;  Acidi acetici diluti, 3ij.; Spirit. Anisi, %ss.;
Spirit. Carui et Spirit.  Lavand. Comp., aa 3iij.; Mist.
Camphors? (vel Syrupi  Tolutani) ad 5"j- misce.  Fiat
mist, cujus capiat jj. pro dose, vel 3IJ. hora decubitus, et
3j. primo mane, in aquae hordei cyatho vinario.

   359.  C. Laryngeal and  tracheal affections are
often the most  distressing of those which occur
in the  course of phthisis (y 109, 110), and  in
some of the usual or  more protracted forms of the
disease present more or  less of the characters
noticed above (y 109, 110), or of the sub-acute or
chronic states described in the article on Diseases
of the  Larynx and Trachea (y 105, et seq.).
Since this  article was  written, the  diseases of
these parts  have been  ably investigated  by Dr.
Horace  Green.  He contends that  inflamma-
tory affections of the larynx, trachea, and throat
are seated in the mucous follicles.  It is, howev-
er, chiefly in the sub-acute and chronic affections
of these parts that the follicles are either prima-
rily or conseoutively implicated, and  especially
when  these affections are  complications of
phthisis,  and are produced either by the protract-
ed irritation of the trachea, larynx, epiglottis, and
even of the pharynx  and fauces, by cough, and by
morbid secretions passing through  them, or by
the existence of tuberculous matter in their folli-
cles or muciparous glands.  At first these sources
of irritation and contamination enlarge these fol-
licles, increase their discharge, thicken and some-
what soften the mucous and sub-mucous tissues,
and ultimately occasion an ulceration of the mu-
cous follicles, and  an  atrophy, with increased
softening, of the mucous  and sub-mucous mem-
branes.   That  the  affection of the muciparous
glands, in the advanced course of phthisis, is oc-
casioned  not only by the morbid secretions pass-
ing  over  them,  but also by the deposit of tuber-
 culous matter  in them, is  extremely  probable.
 Dr H. Green insists upon this latter change, al-
 though it is denied  by  several eminent patholo-
 gists.  In either case, the treatment cannot ma-
 terially differ.   Dr. H. G. found this complication
 of phthisis  most frequent between the ages of 25
 and 38 years.   He also often observed this affec-
tion  of the throat  and larynx after influenza,
eruptive fevers, and more  particularly in persons
habitually using tobacco.  Dr. Gellerstedt con-
siders the ulcerations so commonly found in the
 larynx, in phthisis, to be of tubercular origin ;
 while those of the trachea he regards, with Louis,
 as of an  aphthous nature, arising from the con-
 stant irritation of the cough and expectoration.
   360. The treatment  of this  complication of
 phthisis  has been by inhalation, insufflation, lo-
 tions, and the application  of the solid nitrate of
 silver to the tonsils, uvula, and pharynx.   Dr.
 Laycock remarks, in an able article in the British
and Foreign Medical Review (vol. xxiv., p. 497),
that the application  of the nitrate of silver to the
cavity of the larynx is not, however, to be classed
among these ordinary methods ; and the practice
of it by Dr. Green seems to have been received
with so much incredulity in the United  States,
that he has thought  it necessary to multiply evi-
     III              80
dence  as to the fact that he  has introduced a
strong solution of nitrate of silver within that
cavity.   " Trousseau and Belloc are supposed,
by Dr. Green, to have been the first to prescribe
and employ topical medication •in chronic laryn-
geal disease.   They found a solution of the ni-
trate of silver, in the proportion of two drachms,
or sometimes four drachms, to an ounce  of dis-
tilled water, to  be the most efficacious and harm-
less application.  Two  methods were adopted by
them : the one was to  saturate a small sponge
attached to a bent  rod  of whalebone, and to ma-
nipulate so that the solution be expressed into the
larynx :  the other was  to  use a small silver syr-
inge, with a tube suitably adapted for  effecting
the same  object.   Dr. Green, however, several
years before the appearance of Messrs. Trousseau
and  Belloc's  book, had instituted experiments,
and come to a similar conclusion."  Dr.  Laycock
farther remarks that, without wishing to dispar-
age the labours of our Gallic or American breth-
ren. Sir Charles Bell successfully adopted the
method  of treatment so fully  illustrated by Dr
Green; and Dr. L. refers to cases published by
Sir C. Bell (Surgical Observations, &c, Lond.,
1816, p. 34), for which this practice was employ-
ed.  Dr. Watson states that Sir C. Bell had re-
course to this local application of the strong caus-
tic solution  in a case under  his  care; and re-
marks in his Lectures as follows on the  practice:
" It is said that a little  practice will enable a per-
son to pass his finger into a patient's throat, and
to familiarize his sense of touch with the ordina-
ry condition of the upper part of the respiratory
apparatus, so as to be able to detect swelling, or
irregularity, or thickening about the chink of the
glottis.  And  great advantage is said to  have
been obtained from applying remedies directly to
the diseased or irritable part.  This practice was
much  followed by  the  late Mr. Vance,  who had
been for many  years a naval  surgeon  ; and he
called  it, in naval phrase, swabbing the affected
organ."*
  [* As the question of priority in regard to local appli-
cations to the larynx  has given rise to some discussion,
and is alluded to by Dr. Laycock and our author, it is
proper to state the principal facts relating to the subject.
There can he  no doubt that Sir Charles Bell and Mr.
Vance were in the habit of making local applications to
the inner surface of the larynx with the sponge and pro-
bang, much after the manner of Dr. Green.   The state-
ment that " Dr. Green, several years before the appear-
ance of Messrs. Tboubseau and Belloc's book, had in-
stituted experiments, and come to a similar conclusion,"
is quite erroneous.  The work above mentioned was pub-
lished in Paris in the summer of 1837, and was reviewed
by Dr. Johnson in the October number of his Review for
1837, and the January number of 1838.  In the summer
of 1833, Dr. Green had a conversation in London with
Dr. Johnson on the subject of the treatment of laryngi-
tis, "and the suggestion was made," says Dr. G., "that
if proper applications could be applied below the glottis,
no difficulty would occur in successfully treating the dis-
ease.  Acting upon this suggestion, after my return horn'1,
I made the attempt, and was successful in entering the
larynx, and thereby succeeded in curing a well-marked
and severe case of laryngeal disease.  With the like suc-
cess other cases were treated  in the same year, and the
appearance of the Tboufbeau and Belloc soon after,
confirmed my confidence in a method of treatment which
I have since pursued," &c.  (Preface to Treatise on Dis-
eases of the Air-Passages, &c, New York, 1846.)  Dr. G.
probably refers to the American Translationof Trousseau
and Belloc, which appeared in 1841; the original work.
however, we have seen, was published four years, and re-
viewed more than three years before this period.  It is
to be remembered, moreover, that  these authors do not
claim to have entered the  larynx with the probang and
sponge, and Trousseau has expressly disclaimed it in a
published letter to Dr. Green.  The similarity of their
modes of procedure will appear, however, from  the fol- 
1266       TUBERCULAR  CONSUMPTION—Treatment  of the  Complication!
   361. Where the laryngeal complication occurs
 in the advanced course of phthisis, this practice
 can prove only of temporary benefit.   I have been
 consulted in many cases of this description where
 it had been said to have been resorted to, but ap-
 parently either with no advantage, or with very
 temporary relief.  However, in idiopathic or pri-
 mary cases, or when the  complication occurs in
 an early stage of phthisis, for which a rational and
 an appropriate treatment  is prescribed, this local
 medication  of the laryngeal complication may be
 employe J, by one capable  of performing it, safely
 and  satisfactorily.  I  do not, however, believe
 that the appliances here advised enter the larynx
 and trachea once in twenty times ; whatever ben-
 efit results  arises from the applications to the
 under surface of the epiglottis and adjoining parts.
 I have, since the commencement of my practice,
 trusted much in those  cases to the inhalation of
 the weak vapour of turpentine arising from the
 application of«the embrocation so often mention-
 ed, either around  the throat and  neck, or to the
 chest, or between the scapulae.
  [In  this  connexion, we should bear in mind
 that  diseases  entirely located  in  the larynx or
 pharynx are often mistaken for pulmonary tuber-
 culosis ; that even when tubercles exist, the more
 prominent symptoms may be owing to the  pha-
 ryngeal and laryngeal complications ; and  that
 these complications may be greatly alleviated, or
 even  removed, by local treatment, and in this
 way,  as suggested by Professor Bennet,  thus
 tend to arrest the pulmonary disease.  Dr. Hor-
 \ce Green  has extended topical medication  in
 pulmonary diseases to  the injection of a solution
 of nitrate of silver into the bronchial divisions by
 means of a  gum-elastic tube or catheter passed
 down the  trachea.   In the  volume of Transac-
 tions  of the American Medical Association for
 1856, he has reported over one  hundred cases of
 pulmonary and bronchial disease treated in this
 manner.  Of these, 71  were stated to be cases of
tuberculosis, and 32  cases of advanced  phthisis,
 in which  cavities were  recognised  in  one  or
 !)oth  lungs ; 39 were reported  cases of incipient
phthisis.   Of the first division, advanced phthisis,
 14 died, 25 were said to be more  or less benefit-
ed, and 7 not benefited by  the injection.    Of
the 39 cases incipient  tuberculosis, 12 apparent-
 ly recovered, and 5 convalescent at the time of
making the  report (May, 1856).  Of the remain-
lowing quotation from  Messrs. T. and B.'s work (Am.
Trans., p. 125):
  " When we wish to cauterize the pharynx, the base of
:he tongue, and the top of the larynx at the same time,
v.c take a whalebone at least a line and a half thick, that
it may not bend readily; this is heated an inch or more
frjm one end, and, when sufficiently softened, we curve
it at an angle of 45°.   To this end we fasten a spherical
, ioce of sponge six lines in diameter; the sponge is to be
moistened with a solution of nitrate of silver, the mouth
opened, and the tongue depressed.  When the isthmus
of the gullet is passed, there occurs an effort of deglutition
■vhich elevates the larynx, and we seize this opportunity
to  draw forward the sponge, which  had been at the en-
trance of the oesophagus. By this manoeuvre we get at
(lie glottis, and then it is easy to express the solution in'o
ihe Urynx; the cough which now occurs favours the in-
troduction of the caustic," &c.  Dr. Green, instead of a
■|)'.on, uses a broad spatula, bent at rightangles,and in-
stead of " expressing the solution into the larynx," passes
the sponge directly into the cavity.  To him, therefore,
undoubtedly belongs the credit of establishing the possi-
bility and utility of the direct introduction of nitrate of
silver into  the laryngeal cavity; just as Dr. Morton
jiroved the safety and  advantage of the inhalation  of
ether as  an ana;sthetic, although  it had been suggested
and used occasionally by others for similar purposes.]
 ing 22 cases,  17  " have been greatly improved,
 3 moderately benefited," and 3 only failed to find
 relief  Of the 28 cases of bronchitis, 16 were re-
 ported as cured ;  all  the others had been greatly
 benefited, though  some were still under treat-
 ment.]
   362.  D.   The  Abdominal  Complications of
 phthisis have  been  already partly  considered,
 when remarking upon  the treatment of the diar-
 rhoea (y 328), and  of the impaired digestion and
 assimilation  (y 234)  so generally  observed pre-
 viously to, and in  the course of the malady. But
 the functions ofthe liver are also not sufficiently
 discharged in the  course of the disease ; and due
 attention has not hitherto been directed to them.
 That this organ has been long disordered in cases
 of phthisis is shown by the nature  ofthe organic
 lesions  it generally presents after  death (y 118).
 It has been  insisted upon by an able and close
 observer of the causes and nature of disease (Dr.
 McCormac, of Belfast), that phthisis is not only
 caused, but is  also perpetuated,  by an imperfect
 supply, and an insufficient digestion and assimi-
 lation of pure  air  in and by the lungs ;  conse-
 quently, the  red globules of the  blood are not
 oxygenated and assimilated to such an extent or
 amount as to supply the requisite materials by
 their waste for the elaboration of healthy bile :
 owing also to this cause, the carbonaceous and
 hydrogenous elements  are not sufficiently com-
 bined with the oxygen of the respired air, so as
 to contribute to healthy assimilation  and nutri-
 tion ; and they  consequently, under the influence
 of life, form morbid or adventitious  products, and
 give rise to the fatty enlargement ofthe liver so
 generally found after death (y 118).
  363.  The  great importance  of promoting the
 digestive and assimilating processes from the very
 commencement of phthisis, whatever other means
 of treatment  be adopted, will appear from what
 has been advanced above; and I know of no surer
 means of attaining this end, than  by improving
 the secretions  and excretions by suitable medi-
 cines and food, and by removing the patient to a
 high, dry, and temperate air, where he may en-
 joy the  advantages of sunshine and exercise, and
 avoid those causes which reduce  organic nervous
 or vital power   In general physicians have been,
 during the last  half century, in which such won-
 derful advances have been made in the practical
 sciences, so much  occupied in listening to sounds
 which they often could neither interpret nor re-
 fer to their proper  sources—in splitting the diag-
 nostic hairs floating before their troubled, if not
always dazzled vision, and in hearing what they
believed even when not believing  what they heard
— as  to be  carried along by  the  pathology in
 fashion, neglecting those great views of physio-
logical pathology  which alone furnish the true
basis  of rational and successful practice.   While
a murmur, a bruit, a  rale, a ronchus, and  every
sound for which a term could be coined, and then-
various  grades, cadences, &c , were observed, or
were  feigned to be observed, and  were noted, and
paraded and admired, on all occasions, the  condi-
tions  of the vital  powers and  functions, upon
which both disease and recovery  from disease
mainly depend,  were entirely neglected. But at-
tention to these latter, to the states ofthe  secre-
tions  and excretions, to the manifestations of im-
paired vital power, to the causes of this impair-
ment, to the removal of those causes, and to the
true means of restoring  lost energy, as regarded 
TUBERCULAR CONSUMPTION—Remarks on Remedies used for.       1267
a malady the most fatal, the most prevalent, and
the most constant in its  prevalence, was practi-
cally discarded ; and fussy manipulations, strik-
ing examinations—where such examinations and
manipulations were often unnecessary—were pa-
raded in the place of these, and of other more pro-
found, more physiological, and more practical in-
vestigations.
  364. E. Several other complications, of less fre-
quent occurrence than the above, have been men-
tioned (y 119-123), but the  means appropriate to
each will readily suggest themselves to the phy-
sician.  QZdema ofthe lower extremities (y 120)
not unfrequently occurs  in the advanced stages
of phthisis, and is sometimes diminished by pre-
scribing small doses of biborate of soda, or of pot-
ash, with the tonic infusions or the diuretics, or
with the means employed for the disease.  Press-
ure on the course of the veins of the lower ex-
tremities, by  the sitting or other posture of the
body, sometimes favours the oedema, and even oc-
casions a permanent obstruction of these vessels.
  365. xii.  Brief Remarks on some  of  the
Means  advised for Tubercular  Phthisis.—
Having considered the treatment which appears
the most suited to the several forms and stages
of phthisis, I am next desirous to notice the med-
icines which  have been recommended by writers
for this disease, and to mention the circumstances
or states of the malady  in which they may be
prescribed, and in which  they are contra-indica-
ted.   Most of these medicines have been  pre-
scribed empirically in phthisis ;  for,  although the
treatment of  the disease  had assumed a rational
aspect in the works of our countrymen Bennet
and Morton, there were few besides, even among
the most eminent of medical writers, who  pre-
sented us with a plan of cure which was even
tolerably appropriate to the stages and states of
the disease;   and, even  among  those who had
cultivated the most the diagnosis and pathology
of this malady, there were  very few who recom-
mended their favourite remedies with due refer-
ence to the states and complications of the dis-
ease, and to  the pathological conditions  which
they had themselves described or admitted.  1
shall, therefore, attempt to inquire, in my brief
notices ofthe substances recommended, into the
circumstances in which either experience or the
operation of these substances warrants their use.
  366. Acids.—Most of the mineral and vegeta-
ble acids have been employed in phthisis, but sel-
dom with any definite object, or to fulfil a rational
indication.  The chief intention with which they
have been prescribed in recent times is to repress
or prevent haemoptysis, or to act as a refrigerant
when the febrile action is  considerable, and the
night-sweats  exhausting    They are merely pal-
liatives—and  in this they  often fail, and  some-
times they even render the cough harder and more
severe; and, with the exceptions ofthe hydrocy-
anic and boracic, they are  injurious to the sub-
inflammatory  states, and in the inflammatory com-
plications of  the  disease    The acetic acid  has
long been employed in phthisis,  and when the
contraindications just mentioned do  not prevent
recourse to it, either simply or in the form of rasp-
berry-vinegar, or oxymel  more or less diluted, it
is a grateful and cooling medicine, especially after
haemoptysis has been considerable or excessive.
In  states  of  great exhaustion or  colliquation,
when it is desirable  to produce an antiseptic as
well as  an astringent effect, the pyroligneous
acetic acid may be given, or even a drop of the
aromatic.
  367. Sulphuric acid, much  diluted, has been
commonly prescribed  in phthisis, and generally
with the same object as the acetic.   Bang gave
it with mucilages;  Joerdens with the  Phelan-
drium aquaticum, a medicine much employed in
Germany for this disease, and Portal in states
of weak dilution, as a cooling drink ;  Rollo and
Hufeland considered it useless; butCoLLBATCH,
Grant, De Haen, Home, Fothergill, Simmons,
Sims, and  Marx, entertained a more favourable
opinion of it, especially in the form of acidum
sulphuricum aromaticum, or vitriolic elixir.  Qua-
rin very justly cautions against  its use in  the
more inflammatory states and complications  of
the disease.  Weak dilutions of  the nitric and
the hydrochloric  acids may be prescribed, in  the
same states as those which admit ofthe use  of
the foregoing; and the combination of the two—
one part of the former to two of the latter—when
the contra-indications mentioned  above  are not
present;  and when exhaustion, colliquation, and
other symptoms of vital  depression are urgent,
these two may be added to the infusion of cin-
chona, or other restoratives, especially when  the
functions of the liver are much impaired.  I have
prescribed them with benefit in such cases, and
sometimes given the cod-liver oil  on the surface
of a mixture of these or of similar substances.
  368. Hydrocyanic acid is one of the most use-
ful medicines in this disease.  It was introduced
into practice by Magendie, Granville, and El-
liotson, who took  a just view of its effects both
in phthisis and in dyspepsia—complaints so inti-
mately allied in their origins and in their pathol-
ogy, as already shown.   Its influence in the lat-
ter benefits the former, while it exerts a soothing
effect on  the cough, without aggravating,  but
rather ameliorating, any complication which may
appear in the course of the malady.   It may,
moreover.be advantageously conjoined with other
acids, with the neutral salines, most of which it
is incapable of decomposing, and with the great
majority of other  medicines usually prescribed
for phthisis.  Ofthe other acids, the most import-
ant are the citric, the benzoic, and the  boracic.
The  citric is serviceable in  the states of the dis-
ease for which the acetic is given; but, either in
the pure form or as it exists in lemon-juice, it is
most useful  as an adjunct to beverages,  or in
combination  with  the alkalies.  In these  latter
states it aids, with other means,  in preventing,
counteracting, or removing the morbid conditions
ofthe circulating fluids in the advanced stages of
phthisis.   Benzoic acid  has been  frequently ad-
vised in various combinations for this disease, but
has rarely been confided  in alone.   It is chiefly
in the more asthenic and colliquative conditions
that it is at all of service.   I have seen more ben-
efit from  the boracic than  from  benzoic acid.
Either of these acids may be given conjoined
with  mucilaginous, balsamic, and  expectorant
medicines, when these are indicated.  The boracic
acid  and its alkaline salts—the biborate of soda
and B. of potash—are  not contra-indicated by the
inflammatory diathesis, and may be given in those
states in which the mineral acids are inappropri-
ate.   I have found the dilute phosphoric acid  of
much service in the few cases in which I have
tried it   It  may be prescribed in  doses  of 20 to
40 minims in cases of phthisis characterized  by
vital depression  or exhaustion, especially when 
1268        TUBERCULAR  CONSUMPTION—Remarks on Remedies used
the disease  appeared to result from depressing
causes, or from masturbation.  For  such it may
be given in the infusion of absinthium, or of gin-
sen o- root, with or without the addition ofthe tinc-
ture of sumbul.
  369. Aconite was first prescribed  for  phthisis
by Portal, who afterward relinquished the use of
it.  Busch gave the powder ofthe dried leaves in
doses of two grains every two or three hours, and
increased the dose until a drachm was taken in the
twenty-four hours.  I have prescribed the powder
in smaller doses in a few cases, and the extract
in doses of a  quarter of a grain in others, cau-
tiously increasing the dose ;  but I have ventured
upon it only in the more  inflammatory states as
a substitute for bleeding.   I cannot say that it
was so beneficial as Busch and Harel du Tane-
rel have stated it to  have been.  It  had, howev-
er, the effect  of lowering the pulse, of  causing
perspiration, of diminishing  pain, and of afford-
ing ease ; and although I cannot view  it, with
the writers just mentioned, as a cure for phthisis,
yet I  consider it as an excellent medicine in the
more inflammatory states and complications ofthe
disease, when prudently  exhibited,  or when its
doses are increased, or its use interrupted and re-
sumed from time to  time, as circumstances re-
quire.
  370. Alkalies and alkaline  salts are serviceable
in several states of phthisis.  The  former, and
their  sub-carbonates, were much praised  by Bar-
ker and Spalding.   I have often prescribed the
liquor potassae and Brandish's alkaline  solution
in the scrofulous forms of the disease, with sar-
saparilla, demulcents, and narcotics, and, in the
protracted form, with tonics  or bitters and ano-
dynes, with temporary, and sometimes with per-
manent benefit.  In certain states, and more par-
ticularly when the blood is probably  more or less
contaminated  by the passage into it of morbid
matters from the lungs, the alkalies are often ad-
vantageously combined with  the solutions  of the
neutral salts, as the bicarbonate of potass  with the
nitrate, or the  solution ofthe acetate with the car-
bonate of ammonia, and with the other substan-
ces now mentioned.
  371. Ammoniacum was frequently prescribed
in phthisis, and often injudiciously, especially in
combination with squills  or other heating gum-
resins.   It  should be given only  in the more
chronic states of the disease, and even  in these
with caution, and rarely with the medicines now
mentioned.    I have  prescribed it  with benefit
when an expectorant was required, and when no
inflammatory  complication  existed; but  if the
cough became severe or  hard during its use, it
was always relinquished.  I  generally gave it as
follows :
  No. 359. R  Ammoniaci, 3jss.  tere cum Aq. Destill.
fivss.; dein adde Vini Antimonialis, 3ij.; Liq. Ammonia;
acetatis, fij.; Tinct. Conii (vel Tinct. Hyoscyami), 31J.;
Syrupi Altha?sB officinalis ad Jviij., misce. Sit mistura,
cujus capiat cochl. j. vel ij. larga, 4tis vel 6tis horis.
  No. 360.  R Ammoniaci, 3jss.; Tinct Benzoini Comp.,
f-iij.;  Tinct. Cam phorae Comp., fss. ; Aquae Flor. Auran-
tii, Aq. Sambuci, aa, ^iij. Tere bene, et adde Tinct. Conii,
3jss.; Acidi Hydrocyanici diluti,- 353.; Syrupi  Tolutani,
fij.; Syrupi Althaeas officinalis ad ?viij. Misce.  Capiat
cochl. j. amplum, 3tis vel 4tis horis.
  No. 361. R Ammoniaci, Balsami Sulphuris Anisati
(vide § 400), aa,  3J.; Extr. Hyoscyami (vel Conii), 3ij.;
Saponis Castil., 3ss.; Extr. Glycyrr., 3ss.   Misce.  Fiant,
secundum  artem, Pilulas L.  quarum  capiat unam vel
duas,  omni 4ta vel 6ta hord.
  No. S62. R Ammoniaci, Galbani, Extr. Conii, Sapo-
nis Castil., aa, 3SS.; Fol. Belladonna?, gr. xv.; Antimonii
Potassio-tart.,gr. v.  Contunde  bene, et fiant secundum
artem Pilule xxxvj.  Sumantur birnr vel trcs ter in die.
(The HUs prescribed by K.cutee (op. tit.) for tubercular
phthisis.)
  372. Balsams have been long in use in chronic
pectoral diseases, and especially in phthisis ; and
although they are  sometimes of servioc, they are
as often injurious, unless they be given with great
discrimination.  Under this denomination the Co-
paiba, the Peruvian, and the tolu balsam fall more
strictly ;  the  others more correctly belong to the
terebinthinates and to the gum-resins, and to these
likewise  the older writers often  extended the
term.  The circumstances and the combinations
in which  the balsams, and even the  other sub-
stances often ranked in the same category, may
be prescribed in phthisis, arc the same as  those
which I have stated in respect of the exhibition
of ammoniacum (y 371).  When it is considered
that these medicines, and those  closely allied to
them, are appropriate only in certain states ofthe
malady, that  an empirical use of them may be as
often injurious as beneficial, we  should not be
surprised at  finding them recommended by De
Haen, Godbold,  Simmons, Rush, &c.; and de-
nounced by Fothergill, Frize, and others.  The
Copaiba balsam was preferred by Fuller, Hoff-
mann, Monro, and Gessner ; but it  is now sel-
dom prescribed for  phthisis.  A substance be-
comes a remedy only by its appropriate use.—
Barytes, the hydrochlorate, has been recommend-
ed in phthisis by Hufeland, Herz, and Craw-
ford ; but although it has  been prescribed by
many, yet no satisfactory result has been adduced
respecting it.
  373. Bitters and tonic infusions, as those of ab-
sinthium, Gentian, Calumba, Chereita, &c, have
been advised  for phthisis by CjElius Aurelianus,
Chalmers, Salvatori, Rush, May, and Pears,
generally also with a nourishing and digestible
diet.  Although  too  generally and  empirically
prescribed by these and other writers, yet  these
medicines are often required in the usual and more
chronic states of the disease, especially with the
view of removing the symptoms of indigestion so
frequently attending phthisis from its commence-
ment, and of supporting the vital powers.   These
infusions, moreover,  may be made the vehicles
in which other medicines, whether  saline, ano-
dyne, or  alterative, or narcotic, may be prescribed.
  374.  Camphor was given in phthisis by Bur-
serius ;  by Marx, with nitre and hydro-chlorate
of ammonia; and by Kortum with this  latter
salt.  It is useful chiefly as an adjunct to other
more appropriate  medicines, or when it is  given
with the object of abating urgent symptoms.  In
small doses it is beneficial, especially when con-
joined with nitre, the spirits of nitric ether, and
a solution of the acetate of ammonia, in allaying
febrile action and inflammatory complications.
In larger doses, and combined with the sesqui-
carbonate of ammonia,  it  is of service in the
advanced stage of phthisis, in rallying the vital
power and in counteracting morbid conditions of
the  blood, while it promotes expectoration; and
with the extract of conium or of henbane, or with
a preparation of opium,  it allays  irritation, both
locally and generally.
  375.  Carbon or charcoal was  formerly  much
employed in  the colliquative states of phthisis, in
dysentery, and in putro-adynamic fevers.  I have
given it  at  an  early period of  my  practice  in
several cases, but  generally with camphor, chalk,
cascarilla, and aromatics,  in doses varying from a 
TUBERCULAR  CONSUMPTION—Remarks  on Remedies used  foe.        1269
scruple to a drachm, and chiefly with the inten-
tion  of correcting the  fetor of the  excretions.
Sobernheim  states that Schonlein gave it in
phthisis with digitalis ; and  Garrett prescribed
it with sulphur and the extract of the smaller
centaury.   I  suspect,  however, that whatever
benefit resulted from these combinations cannot
be imputed to  the carbon.  M.  Jourdan justly
remarks,' " Lorsque les theories chimiques reg-
naient en Medecine, on  attribuait au  Charbon
vegetal puissantes vertus dans la phthisie pulmo-
naire, la  dysscnteric, et surtout les maladies pu-
trides.  Le temps n'a justifie aucune des espe-
rances qu'on  avait concues a cet egard."
  376. Cascarilla was often prescribed with the
same intention as cinchona and the medicines last
noticed.  I have given it  only  in the  form of
infusion in the more colliquative states and non-
febrile forms of phthisis, and have generally made
this  preparation the vehicle  for such  other medi-
cines as the peculiarities of the case suggested.
Cascarilla has received the approbation of Thi-
lenius, Wendt,  Krugelstein, and  Hecker, in
the usual and more chronic forms of the disease,
indeed, in the states for which I have prescribed
it.   The  historical  sketch I have given  above
will sufficiently show the diversity of opinions as
to the propriety of employing the  tonic and as-
tringent barks in phthisis, and more  parVjcularly
as to the use of cinchona, &c.
  377. Chalybeates have been already mentioned
in connexion with the states of the disease in
which they may be prescribed.   They have been
recommended by Griffith,  Gunther, Stanger,
Schuller,  Velsen,  and  many others.    The
compound  mixture of iron, the ammonio-citrate
of iron, the ammonio-chloride of iron,  the solution
of the pernitrate  of iron, the potassio-tartrate of
iron, the tinctures of the acetate and of the muri-
ate of iron, and the compound  pills of iron, are
severally of use in certain states of phthisis ; but
there are few  medicines which require greater
discrimination  and caution  in their  use in  this
disease than they.  Cases  which  proceed from
depressing and exhausting causes, in which the
blood is poor in  red globules, or which are  free
from inflammatory or haemoptysic complications,
are often benefited by chalybeates, as well as by
other tonics, especially if dyspeptic symptoms are
prominent; but their effects upon the cough, ex-
pectoration, breathing, pulse, and the accompany-
ing hectic, should be carefully watched ;  and any
aggravation of these should cause the discontinu-
ance of the medicines and  the adoption of other
means.   The good effects of chalybeates may be
aided by other  medicines, with which they may
be conjoined  according to the stage and compli-
cations and other peculiarities of the  case.
  378. Cinchona.—While Desault, De Meza,
and  Romans considered it injurious, and Foth-
ergill said that it was rarely  of  use,  Quarin,
Vogel, Raulin, Marx, Jaeger, Horn, Schmidt-
ma nn, and others, recommended  it.  Haller,
Home, and Chapman prescribed cinchona with a
milk and vegetable diet.  Callisen gave it with a
powerful stimulant, the oil of asphaltum, of which
notice will be  taken hereafter; Thomann with
opiates;  and Ryan and May with animal food.
Stoll advised  cinchona,  when  inflammatory
symptoms were absent, and Simmons when  the
expectoration was abundant and puriform.  Met-
ternich  preferred  the  extract,  and  gave it in
large doses.  In more  recent times, the  sulphate
of quina has been substituted for the preparations
of cinchona, in phthisis as well as in other dis-
eases ; but I doubt the advantage of the substitu-
tion  as respects this malady, for the infusion, the
decoction, the extract, and the compound tincture
of cinchona,  furnished  the  physician with  the
means of selection according to the features ofthe
case for which he was prescribing.   However,
the  sulphate of quina is an  excellent medicine,
when it is desirable to have recourse at the same
time to an acid and to an astringent; and then it
may be given in the compound infusion of roses,
and at the same time also, as advised by Guen-
ther, Amelung, Droste, and some other Ger-
man writers,  with the  tincture of digitalis, or
with the powder of digitalis in  the form of pill.
I have prescribed it with small doses of camphor
and conium, with benefit in some states of the
disease.
  379. Conium has,  from the days of Stoerck
down to  the  present time, been more generally
employed in  phthisis and scrofula than perhaps
any  other  medicine.  It has been  praised by
Quarin, Zeviani, Fothergill, Adair, Butter,
Busch,  Hufeland,  and  many  others ;  and  yet
there are few medicines whose effects in phthisis
are  more  equivocal, and, as usually  employed,
are  more uncertain.   At the present  day it is
seldom confided in alone ; and when given as an
adjunct to other means it is often in insufficient
doses, or in imperfect states of preparation,  and
not persisted  in for the time required to evince its
effects.
  380. Crcasote  has  been  recommended  for
phthisis by  Schroen,  Reichenbach, Cartoni,
Rampold, and others.  I have employed it, since
its introduction to medical practice, chiefly as an
adjuvant of other means in the last stage of the
disease, and for the mitigation of the disorders of
the  stomach  and bowels—of nausea, vomiting,
diarrhoea, &c.  It is also of great benefit when
used to slightly impregnate the air of the apart-
ment in which the patient chiefly resides (y 413).
Creasote, however,  should not  be prescribed in
the circumstances contra-indicating chalybeates
and tonics—when the cough is dry, hard, or con-
strictive—when a state of erythism or of active
congestion is inferred, and when an inflammatory
complication or active haemoptysis is present.  It
is chiefly in the colliquative or asthenic conditions
of phthisis that it is a valuable adjunct  of other
means,  and especially when the excretions arc
more or less fetid, and the circulation is contam-
inated  by the passage  of morbid matters into it
from the primary seat of disease.
  381. Digitalis has been recommended by some,
and praised by others, for phthisis.  Indeed there
is, perhaps, no other medicine  which has been
more generally  employed u» this disease,  and
whose  operation has been less understood, than
digitalis—has, in short,  been  more  empirically
prescribed.   It has been sanctioned by Beddoes,
Withering,  Darwin,  Ferriar, Spence, Fow-
ler, Kinglake, Magennis, Meyer, and Thomas.
Dr. Drake says that citric  acid counteracts its
unpleasant or cumulative effects, when given in
too  frequent   or  too  large  doses.   While  the
above, and many continental writers, are favour-
able to the use of digitalis in phthisis, Bree  and
Bailey contend that it is injurious  in some cases
and  useless  in others.   I have, however, seen
some benefit derived from the infusion, prescribed
at first in very large,  and  afterward  in  rapidly 
1270
TUBERCULAR CONSUMPTION—Remarks  on Remedies used for.
diminished doses; especially in the haemoptysic
and febrile states, and in the congestive and in-
flammatory complications of the disease.—Dul-
camara  was advised for phthisis by Burserius,
and afterward by  Stark, Richter, and Hufe-
land, who generally gave it in conjunction with
the Iceland moss.
  382  Emetics  have  been  recommended  for
phthisis since the days of Hippocrates to  the
present time.  Morton, Brvan-Robinson, Mar-
ryat, Simmons,  Sims,  Kentish, Maret,  Reid,
Metternich,  Swediaur,  Parr, Richter, Du-
mas, &c, advise emetics at an early stage of
the disease; some, as Reid, Bayle, and others,
with a frequency which appears to be excessive
or even  injurious;  others, as  Young, Clark,
Witt. &c, in a more moderate and rational man-
ner.   Many physicians in Italy, early in the pres-
ent century, pretended to have cured  phthisis
by the exhibition of a solution  of tartar emetic,
in the  infusion of the  flowers of the  sambucus
nigra, or in  other emollient infusions—generally
three  grains of the former in six ounces of the
latter.   A quantity sufficient to produce vomiting
was directed night and morning, and milk and
water were drunk freely.   If  diarrhoea super-
vened, digitalis and ipecacuanha were  prescribed
in small and frequent  doses, with other means
calculated to moderate  or  arrest the diarrhoea,
and the emetic tartar was relinquished.
  383. Emetics  are  often of service,  especially
in the early stage  of the malady, and when ad-
vised as above (y 306, 317); but they  should be
prescribed with caution, and with strict reference
to the functions of the stomach  and liver, and to
the assimilative and vital powers.  I have already
mentioned those which may  be preferred;  but
even they ought  not to be given so as to impair
digestion and assimilation ; and if these functions
be weakened by them, or in cases where this risk
appears great, mild tonics and a restorative and
digestible diet, aided by external derivation, should
be prescribed.  In the advanced stages of phthisis,
emetics are of more doubtful advantage, but even
in these they may be of service.   Blumenbach
recommended them even in the third stage; but
either in this or  in an earlier period, they  some-
times constitute an important  part of rational
practice, especially if appropriately selected, when
the digestive mucous surface appears to be loaded
by sordes, when the expectoration is  difficult or
scanty,  the  breathing  suffocative or  oppressed,
and the biliary secretion interrupted, or deficient
in the evacuations.  But even  in these circum-
stances, vital power  should not be exhausted by
a too frequent recourse to them, and the digestive
functions ought to be restored soon afterward by
suitable tonics and anodynes, as the infusion and
tincture of calumba, or of chereita, or  of other
bitter tonics, with hydrocyanic acid, conium, &c.;
or with one ofthe vegetable extracts, the purified
ox-gall, &c, in the form of pill.  Ipecacuanha  is
useful in phthisis not merely as  an emetic, but as
a nauseant, expectorant, and promoter of diges-
tion, and  as a corrector of morbid actions  in the
bowels, according to its dose  and mode  of ad-
ministration.  As  a nauseant it was  praised by
Piderit, Barbari, and others ; and it certainly is
a valuable  medicine in  the more inflammatory
and haemoptysic states of the disease ; and in the
form  of pill with bitter tonics and anodynes,  or
astringents when the bowels are much relaxed.
   384.  The iodides, especially the iodide of potass,
have been employed in phthisis, but are appro-
priate only in the more chronic states ot the dis-
ease.   Since the discovery of iodine, the use of
its  preparations in  scrofula  had  extended to
tubercular consumption.   The earlier preservers
of this substance, and of iodides generally,  erred
in giving them in too large doses,  in  scrofulous
and other diseases, and in neglecting to conjoin
them with a  sufficient quantity of alkalies, where-
by the irritating effects of the iodine, or the de-
composition  of the iodide, by  the acids of the
stomach, might be prevented.   Thus, even  when
a very small dose of the iodide of potass is pre-
scribed in a  vehicle suited to the features of the
case,  the solution of potass or the  bicarbonate
should be given in sufficient quantity to prevent
the decomposition of the iodide.  Whatever form
or combination of iodine is given in phthisis, the
effect upon the digestive functions, the pulse and
the cough should be watched, and if it induce
dyspeptic symptoms, or aggravate those  already
present, it should either be relinquished, or the
dose of it much reduced.   The Karagecn Moss,
or Fucus crispus, has  been long employed as a
popular remedy in consumption, and it has been
favourably noticed  by M. Beral, myself, and
others.  It,  as well  as others among the fuci,
may be used as a demulcent in this disease, with
some benefit, probably arising  in part from the
minute quantity of iodine this class of sea-weed
contains.
   385. The  Lichen  Islandicus has been  very
commonly used in consumptive cases by Quarin,
Bergius,  Thilenius,  Marx,  Regnault, Rich- '
ter, Schmidtmann, Chrichton, and others.   It is
one of the  most generally useful medicines in
this disease ; its bitter, demulcent, and tonic  prop-
erties, divested of exciting action, rarely proving
injurious, even in the most febrile cases.  Wendt,
myself, and  others, prescribed it with milk, add-
ing to these  such other medicines as the circum-
stances of the case required.   Sachtleben rec-
ommended a decoction of three ounces each of
the lichen,  and of the polygala amara, of six
drachms of  liquorice-root, and of three drachms
of dulcamara, to be made  with milk, as a prefer-
able mode of prescribing the lichen in  consump-
tion.   The decoction of these substances is best
made with water to  which a  small quantity of
the carbonate or solution of  potash  is added,
boiled milk being added to the strained decoction,
and such anodynes or  other remedies as the pe-
culiarities ofthe case suggest
   386. Lactucarium was  much  employed by
Duncan, Rothammel,  and Francois to allay the
cough in phthisis and bronchitis,  and was con-
sidered appropriate in  the inflammatory state of
the disease.   It may be given  under almost any
circumstances with  this intention, and  may be
conjoined with the ipecacuanha, digitalis, demul-
cents, mild  tonics or bitters, or other medicines
suited to the case
   387. Lead,  the acetate of, has been often pre-
scribed in phthisis, but chiefly with the view of
arresting haemoptysis, and it has then been given
either with  opium and ipecacuanha, in the form
of pill, or in solution, with the addition of  acetic
acid.   These combinations of acetate have been
advised by Kopp, Stark, Ettmlller. Amelung,
Hildenbrand, Horn,  and others.   Weber pre-
scribed the  acetate with digitalis, myrrh, balsam
of Peru, extract of hellenium, and mucilage, in
the  form of  pills.   Hoffmann  preferred  the 
TUBERCULAR  CONSUMPTION—Remarks  on Remedies used  for.        1271
phosphate of lead, in the dose of a grain, to the
acetate, and conjoined it with the extract of hen-
bane.
  388. Lime water and the muriate of lime were
advised by Quarin, Marx, Beddoes, and Hufe-
land.   Effervescing lime water (Carara water)
is very advantageously given with milk, espe-
cially when the bowels are much  relaxed.   For
this  state of the malady not only may  catechu,
kino, and other means already recommended for
it, be employed, but the nitrate of silver, the ex-
tract of nux  vomica,  tar made  into pills with
liquorice powder, &c, also be individually tried.
  389. Mercurials are occasionally of service in
phthisis, especially in  certain states of the  dis-
ease, and when judiciously combined with other
medicines.  Mercury with chalk, the blue pill, or
Plummcr's pill, will be of service, when the bil-
iary  functions  are  torpid, either alone  or with
soap and taraxacum, or with  the compound rhu-
barb pill, or with the aloes and myrrh pill, when
the digestive functions require to be assisted.  In
the more inflammatory states or complications of
the disease calomel may be prescribed, as advised
by Beddoes ; although it should not be pushed
so far  as  to produce salivation, as recommended
by Rush, unless the disease be consequent upon
syphilis;  when the  very  unfavourable  state of
the  malady may require this decided treatment.
When partial pneumonitis, or pleuritis.  or pneu-
mo-pleuritis  complicate phthisis, then  calomel
may be employed, and be beneficially conjoined
with antimonials, or with ipecacuanha, or with
opium, or with other narcotics.   The beneficial
effects ofthe bichloride of mercury, prescribed in
the decoction, or in either ofthe tinctures of cin-
chona, in scrofulous cases, have induced me, as
well as  other  physicians, to employ the same
combination in the  more manifestly scrofulous
states  of phthisis, and  in  some instances with
much  benefit;  but in  my own cases,  as other
means were also employed, especially the exter-
nal treatment about to be noticed, the amount of
benefit derived from the former could hardly be
determined.    Schaeffer  and  Valentin have
also  given the  bichloride with tonics and opium
in phthisis, and, as they conceived, with advant-
age.
  390.  Myrrh  and various gum-resins, especially
asafaztida, galbanum, 6(C, are most appropriate
in the more   chronic  or  protracted forms of
phthisis, when they are attended by dispncea or
difficult expectoration, and in females when the
catamenia are  difficult  or scanty, or when  the
disease has been  caused by depressing or ex-
hausting causes.   They are contra-indicated dur-
ing  inflammatory states and complications,  and
in the  febrile forms of the malady; and  are best
suited  to the circumstances of the disease which
admit of chalybeates, tonics, balsams, cinchona,
&c   In the form of Griffith's mixture (y 314,
377), or when conjoined, as in  the compound
galbanum, or compound iron pill, or when  far-
ther  combined as with soap, extract of conium, or
extract of henbane, they are sometimes  of serv-
ice.
  391. The oils, especially fish oils, have only
recently been employed in consumptive diseases,
although they have been long previously used in
other disorders.  Hankel appears to  have been
the first to prescribe the cod-liver oil in  phthisis
in Germany, and  Professor  Bennett in Edin-
burgh, to whom the credit of having first recom-
mended  it is clearly due.  Contemporary with
the earliest employment  of it in this country, it
was prescribed for a lady, whom I frequently saw
in consultation with my friend Dr. Baird; and
at that time it was not to be had in London, Mr
Morson  having procured it, at our request, from
the continent.  Since then I have employed it in
this and  several other diseases, and have always
seen more or less benefit derived  from it,  espe-
cially in the more usual, and in the protracted
states of phthisis.   It may be given in various
ways; but generally with  greatest benefit, from
an  hour  to two  hours after a meal, in the dost
of half an ounce  or even more for an adult, on
the surface of any agreeable vehicle, as of an in-
fusion of orange peel, or of any bitter tonic  or
aromatic infusion, with either a little acid or car-
bonate or citrate  of an alkali, and any anodyne,
&.c.;  or  on the surface of milk, or of ginger or
orange wine, &c.  This oil may be taken  twice
or thrice daily, and  in all stages of the disease
After continuing it for some  days or weeks, it
may be intermitted for a few days, and medical
treatment may then be directed more  especially
to the digestive  functions, and to  the promotion
of the biliary and intestinal secretions and excre-
tions ; and after such intermission, its use should
be  resumed and continued for a time which the
state ofthe case and its effects will indicate.
   392. All the fish  oils, especially the oils from
the livers of the Torsk, Cod, and other fish which
I have enumerated above (y 336), are beneficial
in phthisis,  especially when they are recent  or
fresh,  and then  they may be  taken in larger
quantity. The common use of fish oils in  the
most northerly countries of Europe probably is
partly the cause  of the  infrequency of phthisis
in those countries.  The use of vegetable  oils,
especially olive oil, in countries near the Mediter-
ranean, and in the north of Africa, may have the
effect of diminishing  the  number of phthisicaj
cases in  those countries ; and the adoption of the
palm-oil nut, as  an article of food, in Western
Africa, and  of the oil for daily inunction of the
surface of the body,  may have a similar effect on
the natives of that part of the world.   It is not
unlikely  that other mild vegetable oils, as linseed,
almond,  &c, may  also prove of  service when
taken in sufficient quantity, and when judiciously
conjoined with other medicines.   Formerly  the
oil  of asphaltum  or of bitumen was often pre-
scribed   for   phthisis,  especially  by  Callisen,
Bang, Thilenius, Healde, and others.  Quarin
said that it  was  only slightly palliative, while
Frize  considered it injurious.  It was probably
employed then, as  other things have been used
recently, or are praised now, merely with the ob-
ject of being, with their abettors, talked of.
  393. Opium and Opiates, in various forms, have
been advised in  phthisis by many writers, and
condemned by others.  There are, however, states
of the  disease which indicate the  propriety of
having  recourse  to  them, and  circumstances
which contra-indicate their use.  They are  more
frequently injurious than  beneficial in the  first
stage of the disease, although Tralles has given
a different opinion.  Sometimes in the second
stage, but most  frequently in  the third stage,
opiates, or even the preparations of morphia, are
of great  service ; but much of the benefit pro-
duced by them will  depend upon  the combina-
tions  in  which  they are  prescribed.   Marcus
gave them with  myrrh  and Peruvian balsam, 
1272       TUBERCULAR CONSUMPTION—Remarks on Remedies used for.
and, in the advanced and more chronic states of I
phthisis, this combination, or that with the com-
pound galbanum pill  and the compound soap j
pill, will be appropriate.  Peart advised opiates
to  be  given  with the  carbonate  of ammonia,
ether, and  aloes; and J. Frank laudanum, with
the aromatic  sulphuric acid.  In the third stage
of the disease, preparations containing more or
less opium, especially the compound tincture of
camphor, the compound styrax pill, pills of ipe-
cacuanha and opium, &c.; and,  when diarrhoea
is present, the opiated cretaceous  powder,  the
compound  cretaceous powder with  opium,  the
compound  ipecacuanha powder, the compound
kino powder, or the  combination of opium with
the extract of nux vomica, or with the nitrate of
silver, or with the sulphate of copper, or with
the sulphate  of zinc, will be found individually
of service,  when judiciously prescribed.  When
there is  much debility, opiates  should not be
given in full doses, unless  they  be combined
with aromatics, tonics, or stimulants, or with
balsams or gum resins; and when  the prepara-
tions of morphia are preferred to other opiates,
then this recommendation  should  be especially
kept in  recollection,  because I have seen much
distress  result from its neglect.
  394. The Phillandrium   aquaticum,  or water
hemlock, especially the seeds and herb, has been
much recommended  for phthisis by Stern,  Os-
wald,  Fischer, J.  Frank,  Ricamier, Rosen-
muller, Henning, Michaelis, &c, who have
employed  chiefly the powder of the seeds,  in
doses of ten to twenty grains, the decoction and
tincture.  Its action  is stimulant, narcotic, and
diuretic.  Some of the authorities now adduced
have given this medicine with sulphur.  Lange
prescribed it after bleeding,  in robust or plethoric
cases, in goats' milk twice or thrice daily ;  Herz,
with nitrate of potass, sugar of milk, and gum
Arabic,  thrice daily;  and   Hufeland,  Muller,
Chiappa, Remer, Berkun, and Heine, in vari-
ous forms and combinations—in powder,  decoc-
tion, and tincture.
  395. The Polygala  amara has  been  much
praised in phthisis by Thilenius, Plenciz, Col-
lin, Baume, Frize,  &c, and is  certainly to be
preferred to the Polygala senega in  this disease,
as it is more  tonic and pectoral than this latter.
It was formerly much employed in consumptive
diseases, but  has now fallen into  undeserved
neglect.  The root is chiefly used ; and either in
powder  (from fifteen to thirty grains), or  in  ex-
tract or  infusion, or decoction, in which forms it
is directed in several of the Continental pharma-
copoeias.  The Polygala Senega is much more
stimulating than the  P. amara, and is not  ap-
propriate in the more inflammatory and compli-
cated states of phthisis, unless it be given with
ipecacuanha,  or with antimonials, so as to occa-
sion nausea or vomiting.  The decoction is, how-
ever, sometimes of use, not  only when prescribed
with this intention, but also in the less febrile  and
more chronic forms, or in  the advanced stages, j
when it is desirable  to promote expectoration or
to relieve dispnoea;  and in these circumstances
it may  be  conjoined  with  orange-flower  water,
or with  hydrocyanic acid, or conium, or the com-
pound tincture of camphor, or with other ano-
dynes, as the peculiarities  of the case will sug-
gest.
  396.  Sahx, Sec.—Besides  the  barks already
mentioned  (§ 376,  378), others,  especially  the
willow, the cedar, the larch, and fir-barks, have
also been employed in phthisis, but they are use-
ful chiefly  as  tonics and astringents, and  have
few other virtues to recommend  them.  ^°ur-
raud and Schneider prescribed an extract of the
middle bark of the willow in this disease ; and the
cedar and pomegranate barks were prescribed not
merely as tonic in phthisis, but also with the object
of destroying  intestinal worms, with which this
disease was sometimes complicated, especially in
low, cold, and  damp localities.
  397. Sage  is  an old and popular remedy for
coughs and colds; it was also  much used in pul-
monary consumption.  It is by no means a bad
adjunct to  other medicines, and may be advan-
tageously combined with the decoction of marsh
mallows, in which  form it  was  prescribed by
Qoarin and others.
  398.  Salts  and  saline  solutions of various
kinds have been prescribed for phthisis,  with the
intention of moderating the  hectic  and  other
symptoms rather than with hopes of curing the
disease, although  several  of  them  may be as
rationally  considered capable of  effecting  this
latter object as many other medicines which have
been employed with this expectation.   Of this
class of substances none are more generally use-
ful than the solution of the acetate of ammonia,
and of the citrates of the fixed  alkalies, of ammo-
nia, and of magnesia.   The solution of acetate of
ammonia is of service chiefly  in the early stage
of phthisis, and may be prescribed, according to
the state of the case, with the nitrate of potash,
sweet spirits of nitre, and camphor mixture, with
hydrocyanic acid,  or with  compound camphor
mixture, or with conium, henbane, &c.   In more
advanced or chronic states the ammonia of the
acetate may be given in excess, and other medi-
cines  substituted for some of those now  men-
tioned.  The  citrates  of potass, of soda, and of
magnesia are  of service, either individually or
with the nitrate of potass and the other sub-
stances enumerated, chiefly in advanced stages
of the disease, when the blood becomes contami-
nated by the absorption of morbid materials.  In
similar states of phthisis the carbonates of the al-
kalies are also of service, especially when given
with the nitrate of potash or with the chlorate of
potash, in solution  or in vehicles—bitter, tonic,
or demulcent—suitable to  the requirements  of
particular cases.  The hydrochlorate of ammonia
was much employed by Thilenius and Marx in
phthisis, as well as in all forms of hectic and in
some other fevers,  periodic and  continued; and
was a favourite remedy in these diseases among
German physicians early  in  the present cen-
tury.
  399. The secale cornutum has been found very
efficacious  in  arresting  the haemorrhage, in the
haemoptysic states of phthisis   Dr. T----, who
had been for many years subject  to attacks of
haemoptysis, had recourse, and generally with
success, to  the secale, in doses of five grains, at
intervals of a few minutes, until  the discharge
began to cease  It was not until at an advanced
period  of life, and when travelling on the railway,
that he was disappointed in the effects of this
remedy, for he always carried it on his person.
I saw him on his arrival in  town, and prescribed
oil of  turpentine.  The haemorrhage   returned
some time  afterward, and produced  suffocation.
I had  an  opportunity of examining the lungs
The  appearances are  noticed in another  place 
TUBERCULAR CONSUMPTION—Remarks on Remedies used for.       1273
(y 91).  The haemorrhage proceeded from ulcer-
ated vessels.
  400. Sulphur was formerly much employed in
phthisis,  and was prescribed either in  combina-
tion with myrrh and various balsams, gum resins,
or powders, or in the form of a balsam or electu-
ary, prepared with an essential oil, as the oil of
anise seed, or with honey or sirup, and given with
such other medicines—demulcent, emollient, ano-
dyne,  absorbent, or narcotic—as the state of the
case suggested.  The anisated balsam of sulphur
especially, and other combinations of  this sub-
stance, were strongly recommended by Ettmul-
ler, Busch, Sims, Agricola, Rollo, and others.
Hunold  prescribed it with  charcoal in the ad-
vanced stage of the disease.  The anisated bal-
sam of sulphur, the preparation  most frequently
used, consisted of one part of the flower of sulphur
and four parts ofthe oil of anise seed, which were
digested in a sand-bath.   If diarrhoea was pres-
ent, the sulphur was given with preparations of
chalk, or with astringents and tonics.   Sulphur
has long  since fallen into disuse in phthisis ; but
I have seen much benefit from it in several states
of the disease, when judiciously combined and
prescribed.
  401. Tartar  emetic was prescribed by Schle-
gel in small and frequent doses, and was prob-
ably employed by him and others on account of
the apparent benefit derived from  it and other anti-
monials in the inflammatory complications of the
disease.   The contra-stimulant doctrine in vogue
in Italy at the end of the last  century, and in
France at the commencement of this, carried the
use of tartar emetic in diseases of excited action
to  an  extravagant  height; and very   probably
more injury than advantage  was derived from it,
owing to its  improper  use.  However,  in the
more inflammatory, and in the more active haem-
orrhagic states of the malady, it  is often of serv-
ice when given  either as an emetic, or in frequent
small  doses, as a contra-stimulant.
  402. Tussilago farfara has been for ages a
popular remedy for chronic coughs and consump-
tions ; and the several parts of the plant have been
used in the form of infusion, decoction, electu-
aries, sirups, &c., for these complaints.   It was
recommended for phthisis by Percival, Reusner,
Kramer,  and others ; and the  mucilaginous, bit-
ter, and mildly tonic virtues of the plant appear
to warrant their recommendation.
  [The Black  Snake-root (Cimicifuga racemosa)
has long  been a very popular remedy in consump-
tion in this country, and  has been highly recom-
mended by several able practitioners, as Dr. Gar-
den,  of  Virginia  (Am.  Medical  Record, Oct..
1823), and Dr. Hildreth,  of Ohio (Am. Jour
Med. Sci., N S , iv., 281).  It is  believed to allay
pulmonic irritation like the wild  cherry bark, and
to exert a sedative influence over the circulation.
Dr. Hildreth  recommends employing  it in the
early  stages of the disease, in  connexion with
iodine]
  403. Turpentine, in the various  modes of its
existence, from the essential oil through the tere-
binthinate balsams to the pine-tops, tar, and tar-
water, have been for ages found of benefit in vari-
ous states of phthisis, some in certain states, and
others in  other  states.   These  substances,  in
their several modes of employment, are often of
service, not only when exhibited internally, but
also when employed externally, and when the
much diluted vapour, or even  the  odour from
them, is inhaled into the lungs.  In the hremop-
tysic states of phthisis, when it is proper to ar-
rest the haemorrhage, there is no remedy that is
more certainly efficacious than turpentine, when
exhibited in small and frequently repeated doses,
epithems of the same substance being  applied
over the chest.  It may be taken in doses vary-
ing from twenty minims to a drachm every hour,
or two or three hours, according to the urgency
of the case;  or even  oftener,  either  mixed  in
honey  and liquorice  powder, as  prescribed by
Gasser and myself, and as advised in a memoir
on the use of this medicine, published in 1820, in
the London Medical and Physical Journal; or as
directed in  a  case  lately attended by Mr. W.
Barnwell and myself.
  No. 363.  R Olei Terebinthinte, 3iss.; Spirit. Athens
Sulphurici Comp., 51J. Pulv. Tragacanth. Comp., 3ijss.;
Mist. Camphors;, fij.; Syrupi Rosae  et Syrupi Tolutani,
aa, 3J8S.; Aqua; destillataj ad fvj.  Misce. Fiat mistura,
cujus sumatur pars quarta, quarta quaquc hora.

   404. The quantity of the oil may be diminished
or increased, or the frequency  of the dose in-
creased or otherwise,  according to the circum-
stances of the case.   There are almost no com-
plications of phthisis which contra-indicate the
use of this remedy, when  judiciously prescribed,
as respects the dose and mode of exhibition ; and
especially when  employed  externally  also,  as
hereafter recommended.  The terebinthinate sub-
stances, in which the  essential  oil exists in dif-
ferent  forms and combinations, are also beneficial
when suitably prescribed.   The  infusion of pine
tops  was  praised  by  Celius  Aurelianus for
phthisis ; tar-water was recommended by Bishop
Berkeley for this and other diseases ; and tar
was  given by  Sims for this malady.  I have had
recourse to these, especially to tar and tar-water.
Tar, in the form of pill, with liquorice powder,  is
often of great service in  the colliquative states
of diarrhoea, and when there is reason to fear in-
cipient ulceration of the mucous follicles of the
bowels.  Tar-water,  when sufficiently  weak not
to be unpleasant to the patient, is also of service
in this state of the disease, and in its  haemor-
rhagic and  congestive complications.   Indeed
there are several states of this  malady, and sev-
ral other diseases,  in which both tar and  tar-
water  may be  very  usefully employed.   The in-
judicious or rather extravagant praises of some
writers at the commencement of the last century
have caused the complete disuse of an excellent
remedy.
   405.  Uva ursi, in powder, decoction, and ex-
tract,  was recommended  for  phthisis  by  Dr.
Bourne, and  subsequently by  Drs.  Hamilton
and  Davy.  The tannic and gallic acids it con-
tains,  and its astringent and  tonic  qualities,
would justify its use in several states of this dis-
ease, especially in the haemoptysic, and in the col-
liquative sweats and diarrhoea which occur in the
advanced stages   It may, moreover, be combined
with other remedies—demulcent, tonic, and ano-
dyne—with opiates, bitters, &c, according to the
peculiarities of the case.
   [Alcohol has recently come into extensive use,
not only as a prophylactic, but also as a curative
agent in the treatment of tuberculosis.   Dr. Mar-
shall Hall  a  few years  since  extolled very
highly the efficacy of alcoholic inhalation, as cal-
culated to check both the deposition and soften-
ing of tubercular deposits;  one part  alcohol to
three water is applied, at first  tepid,  afterward 
1274           TUBERCULAR CONSUMPTION—Of  Mineral Waters  for.
of the temperature of the air, by means of a few i
folds of soft linen across the upper part of the
chest, the compress to be fastened to the shoul-
der-straps or other part  of the dress, and moist-
ened every  few minutes by  means of  a small
sponge.  Dr. H. recommends that it be applied
every five minutes during the day, so as to secure
a constant effect, and he states that it possesses
a power in  checking the progress of the depo-
sition and softening of tubercle in the lungs be-
yond  any other which  he  has ever tried.  He
speaks also  of " numbers of patients  who have
recovered under its use.  When taken in this
way, as well as through  the medium of the stom-
ach, alcohol  promotes digestion, retards the meta-
morphosis of  tissue,  and sustains the  animal
heat."   As the process of tuberculization, as we
have seen, is due  to defective haematosis  and im-
perfect nutrition, we might, a priori, expect that
alcohol would  prove beneficial.  Its prophylactic
power,  however,  we believe to be  overrated.
The alleged facts on this point  need revision
The whole treatment of this disease may be sum-
med up  in the aphorism of  Dr. Rush :  " The
remedies for consumption must be sought for in
those exercises and employments  which  give the
greatest vigour to the constitution."]
  406. Venisection and other modes of vascular
depletion, as by cupping or leeches, or  by the ap-
plication of these  last to the anus, as insisted on
by  Plenciz  and Lakeren,  with antiphlogistics,
emollients, and demulcents, have been  advised by
many in  the early stage  of the malady.  At this
stage venaesection, hardly amounting to more than
eight or  ten ounces at a time, and repeated ac-
cording to circumstances and to  its effects, has
been recommended by Morton, Mead, Pringle,
Monro,  Fothergill, Salvadori, Stoll, Hos-
ack, Farr,  Cheyne, and others.   I have stated
above (y 309-313)  the  circumstances in which
the practice  may be adopted ; and that it should
not always be  accompanied with other antiphlo-
gistic remedies, either in an early stage,  or when
prescribed for inflammatory or hemorrhagic com-
plications ; for depletion, although manifestly indi-
cated, may be  followed,  in many  cases,  by suit-
able tonics and nutrients, provided that  exercise
be taken with  due care in the open air, and that
the external derivation  about to  be noticed  (y
415, 416), such as issues or setons, be kept dis-
charging.  Rush  advised, for cases requiring ve-
naesection, recourse to it in  preference, in spring
and autumn.  But this recommendation is in con-
formity rather  with an old custom than with cor-
rect pathological  inference.  Rhodius,  Tracy,
and Rush considered an attack of haemorrhage
from  the nares,  rectum,  or  even  from  the
lungs,  beneficial,  and the larger the better, and
that it should not be too  soon arrested, unless
manifestly injurious.  The opinion is certainly
often correct, but the numerous exceptions should
not be overlooked.
  407.  Various other substances have been pre-
scribed for  phthisis by eminent writers;  and,
although they may be of little use, farther than
as  adjuncts to other more  beneficial remedies,
they may be very briefly  enumerated at this place.
The arum triphyllum was recommended  by Bur-
ton, in  the form of decoction  with milk, the
carduus bencdictus, either in decoction, infusion,
or extract with senega, by Thilenius  ; the cryn-
gium campestre,  by Hoffmann ;  the gcum ur-
banum, by Buckhave, in doses of a scruple and
upward ofthe powder ofthe root, as a tonic and
astringent; the tops and flowers of Hypericum, for
its balsamic,  bitter, and tonic qualities, by L,ik-
njeus;  the  nasturtium aquaticum,  by Pouteau
and Brillonet; myrrh, conjoined with sulphur,
or various other substances, by numerous writers ;
the rhus radicans, by Gibson ; the  raphanus, or
horse-radish,  by  Schenck and Osiander ;  the
marubiumvulgare, by Alibert, a popular remedy,
in various forms of preparation, for pectoral com-
plaints in most European countries ; the conserve
and other preparations of roses, by Moseley and
very many other writers; the phosphoric acid, by
Goedin ; the sulphate of iron, by Stranger ; and
taraxacum, by Schmidtmann.  These  hardly re-
quire any remark.  They may be employed under
circumstances which prevent the  use of other
more beneficial remedies; or in conjunction with
such  means  as have  already  been advised, as
with the Iceland moss, digitalis, conium, &c., or
with  bitters,  as absinthium,  calumba,  cascarilla,
arnica,  &c,  when a restorative diet is required,
or when  indigestion, flatulence,  or sinking  are
experienced.  In certain states or complications,
as in those just named,  the preparations  of am-
monia,  as the carbonate, &c, or the ethers, may
be conjoined with  other means with benefit.   Of
the etherial preparations, the compound spirit of
sulphuric ether, the spirits  of nitric ether, and
the hydrochloric ether are the most useful.  In
cases where  I have prescribed the hydrochloric
or nitro hydrochloric acids, with or without  the
hydrocyanic  acid,  I have often  added the  hydro-
chloric  or other  ethers when the state  of the
case required such an  addition
  [In this connexion the wild-cherry bark deserves
favourable mention, for its admirable combination
of sedative  and tonic  properties.  The cold in-
fusion of the inner bark of Ccrasus Serotina  has
long had a high reputation in this country, in
cases of general debility, with feeble digestion,
and frequent pulse, and especially in pulmonary
tuberculosis.  It rarely  fails to  lessen the  fre-
quency and increase the force ofthe pulse, while
it invigorates all the functions.  " Few remedies,"
says  Prof. Wood, " are  better adapted to hectic
fever,  from  whatever  source it  may proceed."
The best preparation is  the cold infusion, made
with half an  ounce of the bark to a  pint of water,
prepared  by percolation, and given in doses of
two ounces  three or four times a day.  It may
be used to great  advantage in connexion with
cod-liver oil.]
  408.  xiii.  Mineral  waters have been  recom-
mended by  several authors ;  but they require
much  caution and consideration before entering
upon the use of any of them, when the disease
has  fully declared itself.   In the scrofulous di-
athesis, and  when the disease is threatened, or
when  its prevention should  be attempted, these
mineral waters are often of great  benefit, when
taken in proper quantity, and in suitable dilution,
in certain cases.  The quantity  of these  waters
usually recommended is often not duly regulated,
or suited to the nature  of the case and  to  the
effects produced ;  and hence they  are either in-
efficacious or injurious.   There are three kinds
of mineral waters, which, when used in prop-
er quantity  and combination,  and their effects
watched,  are sometimes  beneficial both  in  the
prevention and in the treatment  of the early
stages of phthisis; these are the chalybeate, the
sulphureous,  and  the  alkaline;  each,  however 
TUBERCULAR CONSUMPTION—Of Inhalation for.              1275
being suited only to certain states or forms of the
disease.  It should not, however, be overlooked
that all these waters contain various proportions
of different saline ingredients—the oxides or salts
of  iron,  or sulphureted hydrogen, or  alkaline
carbonates,  being present in  certain  of these
waters also in various proportions.
  409. a. The chalybeate mineral waters are chief-
ly indicated  in  those  states  of the disease for
which the compound iron mixture has been  rec-
ommended above (y 378), more especially in lym-
phatic and phlegmatic temperaments, and when
the pulse is weak, small, or slow, and the blood
poor  in  red  globules.   Generally  the  weaker
chalybeates, or the stronger more or less diluted,
are most beneficial, and should be preferred for
cases where their use is of  doubtful propriety.
The mineral waters of Aix-la-Chapelle, especial-
ly the sulphureted chalybeate, have been recom-
mended for this class of cases ; but the mineral
waters of this country, of a similar composition,
are equally appropriate with those, especially the
chalybeate and saline spring at Harrowgate, which
may be  taken alternately with the sulphureous
waters  of that  place.  The  mineral  waters of
Kissmgen are also of service early in the disease,
or  when phthisis  is threatened, especially when
the several springs are employed under judicious
medical direction.
   410. b. Sulphureous mineral waters are often
beneficial in phthisis, especially if the composi-
tion of the several springs containing sulphuret-
ed  hydrogen gas be such as may be appropriate-
ly  employed for individual cases.   The several
springs at Harrowgate supply a sufficient variety
of composition to suit the various states  of differ-
ent cases.  The  waters of Moffat and Strathpeffer
are stronger in  sulphur than those of  Harrow-
gate, but they present a less variety of composi-
tion.   The waters of Enghien and Bareges may
also be tried, but they offer even fewer advantages
than those already mentioned.
   [There are several mineral springs in the United
States whose waters  are reputed beneficial in
phthisis  pulmonalis, especially the chalybeate
waters  of Saratoga, and the  sulphur and saline
springs of Virginia, particularly the Red  Sulphur.
The  latter, containing carb. acid, nitrogen,  oxy-
gen,  hydro-sulphuric acid, sulphate soda, carb.
lime, carb.  magnesia, sulphur compound, &c,
have  the property of reducing the frequency of
pulse and tranquillizing pulmonic irritation  in a
very remarkable degree.  It is not uncommon for
a hectic pulse of 120 to be reduced to the natural
standard in the course of a few days under the use
ofthe waters, while at the same time the appetite
is increased, the night-sweats  checked, and the
general system invigorated.  The medicinal vir-
tues of these waters, together with the delicious
climate in summer and autumn,  the  romantic
scenery, and the accommodations and comforts
afforded to the guests, render the Virginia Springs
a pleasant and  profitable resort to the  invalid.
The sulphur  springs of Richfield,  Sharon-, and
Avon also deserve favourable mention in this con-
nexion]
  411. c. The mineral springs  abounding in the
carbonates  ofthe alkalies, as well as holding va-
rious other substances in solution, have  likewise
been  recommended for threatened  and incipient
phthisis   The chief of these  are the waters of
Ems, Seltzer, and  Vichi.  These are usually most
beneficial when  taken  with milk or with whey.
The Ems waters are much praised by Bruchman
and others, and the Seltzer by Bang  and Kra-
mer, in this disease, especially when diluted with
milk or whey.  The  waters of Cauterets  have
also been recommended by many ;  and those of
Bonnes  and St. Sauveur of the Pyrenees  have
proved most beneficial in several instances which
have come before me.   Whatever mineral water
be adopted, other means, medicinal, regimenal,
and dietetic, are generally also required.  Some
advantage, moreover, is derived by consumptive
invalids from change  of scene  and of modes of
living, and from dryness of the air  and elevation
above the level of the  sea, when they visit some
of the inland or continental watering-places.  In-
creased  exercise in the open air, and in open day
and sunshine, is also not devoid of some benefit
  412. xiv. Inhalation of various fumes and va-
pours, chiefly medicated in various  ways, and by
diverse means, has been advised by many.—a. I
have seen several modes of inhalation  employed,
and have prescribed certain of them, but without
any very manifest benefit.   The great  disadvant-
age of most of these means is  occasioned either
by the  amount of aqueous vapour thus  passed
into  the lungs, or by  the irritating or other ef-
fects produced in the  air-passages  by the ingre-
dients employed.  I have already noticed the sub-
ject of inhalation above (y 324), and when treat-
ing of bronchitis (see art. Bronchi, y 98, et seq.);
and the opinion I have stated  under  this latter
head a farther experience has fully confirmed.
I may mention, however, that the inhalation of
sulphuric ether, with the vapour from preparations
of conium, was advised by Dr  Pearson ; of va-
pour containing the fumes of Burgundy pitch, by
Home ;  of aqueous exhalations from  henbane,
myrrh, and " naphtha vitrioli" (sulphuric ether),
by Joerdens ; of the  fumes from pine-tops, and
various  balsams, by a number of writers; and of
tar-vapour, by Crichton and Pagenstecker.  But
the usual modes of inhalation, especially those in
which inhalers are employed, are most objection-
able, and much more injurious than beneficial.
  [After much experience in the use of inhala-
tion  in  phthisis, we fully agree with our author
that, in general, it is, as practised, more injurious
than beneficial.   We  have tried a great variety
of substances,  as iodine, chlorine,  creasote,  tar,
bals. Tolu and Peru, styrax, benzoin, copaiba, tur-
pentine, &c,  and we  cannot say that we  have
ever seen any essential, permanent benefit  from
their use in tubercular  phthisis.  In bronchial dis-
ease they often prove  useful by their local altera-
tive action, and doubtless in many such instances
exert a curative influence.  As consumption is
generally connected with bronchial irritation and
inflammation, medicated inhalation often proves
a useful palliative, allaying irritation, and afford-
ing some relief to the cough.   Hence the popu-
lar belief in its efficacy in such cases.   But  in a
constitutional affection  like tuberculosis, the lo-
cal application of medicines to the bronchial tubes,
whether by inhalation  or any other method, can
only be  expected to palliate, never to  cure, the
disease.  Patients are  often flattered into a belief
that they are  rapidly improving under this proc-
ess, while all that is effected is a slight diminu-
tion  of  the  most harassing  symptom, viz., the
cough.  This mode of practice is now chiefly re-
signed to the hands of noted quacks and empir-
ics, where it properly belongs.
  The  late Dr. Morton, of Philadelphia,  em- 
1276       TUBERCULAR  CONSUMPTION—External Means of' Treatm
ployed inhalations to a considerable'extent in ev-
ery stage  of phthisis, and, as  he believed, with
beneficial  effects.  In some cases he combined
conium  with iodine, after the manner  of  Sir
Charles Scudamore, as follows :
  R Iodini  puri, Iodidi Potassii, aa, gr. vj.; Aqua; dis-
tillates, fv.-fvj.; Alcoholis, 3J. Fiat mistura.
  From 3SS. to 3J. of the saturated tincture of
conium  is added, with the same quantity of the
iodine mixture, to the water in the inhaler of
120°, at each inhalation of 8 to 10 minutes' du-
ration, increasing the quantity of each according
to circumstances.  We  have tried this combina-
tion in  several  cases of phthisis with apparent
temporary benefit.  Instead of the  above,  Dr.
Morton came at last to prefer the following prep-
aration :
  R Iodini puri,  gr. iv.;  Foliorum Conii, gr. viij.;
Etheris Sulphuiici, Jj.
Digest  for 48  hours;  add a  teaspoonful to  a
wine-glass of warm or tepid water ;  hold in the
hand, and inhale the vapour as it rises.   In 10
to 15 minutes the evaporation is complete.  If  it
causes cough or dizziness, use a smaller  quanti-
ty, or hold it farther from the nostrils.  Dr. Mor-
ton preferred this  method to the inhaler.  The
most that inhalation, however, can do, in any case,
is to palliate some  ofthe symptoms.]
  413. b.  Weak fumigations diffused through the
apartment occupied by the patient are much more
beneficial than  any mode of inhalation ;  and the
vapour,  or the weak fumes, or rather the odours,
exhaled from the  substances  employed  for the
purpose of impregnating the air ofthe apartment,
are sufficiently strong to  be respired by the pa-
tient in  most cases.   The greatly-diluted fumes
or vapours proceeding from creasote, from  tar,
from  turpentine or the several terebinthinates,
from  pine-tops, from various balsams, from the
ethers, especially pyroligneous  ether or pyroxalic
spirit, from cedar, and  from resins,  gums, &c,
independently of any combination with aqueous
or narcotic vapours, are  generally much more
beneficial and pleasant to the patient than the in-
halations  commonly employed.   The embroca-
tions so frequently recommended for this (y 321,
322, 403)  and  several other diseases act benefi-
cially, chiefly in consequence of the inhalation by
the patient of the ingredients as they are evapo-
rated, or as their  dilute fumes are exhaled  and
diffused in the air surrounding him.  A young
man, who had repeatedly come under my observa-
tion in an advanced stage of phthisis, completely
recovered his health after he had been for a con-
siderable period employed in the manufacture of
creasote.  When  the cough is distressing, the
fumes of ether, arising from the sprinkling of one
or other of these, especially ofthe spiritus aetheris
sulph. comp., the pyroligneous ether or pyroxalic
spirit, or the hydrochloric ether, or of chloroform,
on the bed-clothes  ofthe patient or on any article
more or less removed from him, will often have a
very palliative effect.
   414. xv. The  external means of treating phthi-
sis have been already partly noticed (y 319, 323).
—A. Among these, medicated  and mineral baths
have been advised  by several writers, more espe-
cially the warm mineral  springs of the continent.
Sulphureted chalybeate  baths were recommend-
ed by Lentin ;  the baths  of Baden were  praised
by Schenck, and those of Weisbaden by Ritter,
especially for the  early stages of phthisis;  but
they are more likely to be of service  for the pre-
vention of the disease, aided by more beneficial
means ; for very little dependence can be placed
upon thermal springs or baths, either in the pre-
vention or cure of this malady.   Whatever ben-
efit is derived in some cases is to be imputed as
much to change of air, exercise, and regimen as
to the effects of the baths.                •
  415  B  External derivatives and exuiones have
been advised for phthisis from the earliest periods
of medical history.   I have stated above (y 319-
323) the modes in which these may be employed,
and the general results of my experience of them.
I shall only notice the opinions of a few writers
respecting them :  the views of many eminent au-
thorities on this important department of medical
practice may  be  gathered  from the  historical
sketch I have given above (y 242-287).  During
the course of my medical experience I have not
observed this practice employed in the manner in
which it is most efficacious.   Tartar-emetic oint-
ments, croton-oil liniments, &c, have  been  fre-
quently resorted to in recent times;  but  issues
and setons have been rarely employed, although
the experience of numerous writers, as well as
my own experience in several cases, has demon-
strated their great utility.  The  selection of a sit-
uation in which an issue may be made or a seton
inserted is often  the chief difficulty in the way
of either.  Bartholin directed an  issue to be
made in the back, below  the scapulae; Duplan
and Riverius  between  the scapulae ; Gebel,
Dreysig, and Billard, in the upper arm  ; Sim-
mons recommended a seton to be inserted in the
pape of the neck;  Monro, Portal, and Hilden-
brand, in the  arm;  Zacutus Lusitanus,  at the
edge  of the pectoral muscle, near the axilla;
Whytt and Rush preferred the same situation
for a seton, or near the  sternum for an  issue,
Lentin also selecting these places in preference
to others.  While these and many other authors
have  thus resorted to these means in  phthisis,
they  have not considered them suitable to all
states or stages of the malady.  Quarin, Win-
tringham, and Souville, who have been  less in
favour of these means than the writers just re-
ferred to, consider them worse than useless in the
far-advanced course ofthe disease, and when there
is much exhaustion.  Having  often  employed
them with advantage—in some instances in the
families of medical men of my acquaintance—I
am enabled to state that I have generally  prefer-
red issues, kept discharging by means of a num-
ber of peas, to setons ; that, when the patient is
not much emaciated, some part of the breast, or
over the margins of the false ribs, has been pre-
ferred ; that this practice is of service chiefly in
early stages, before cavities are formed, and in the
more usual and chronic  forms  of the disease;
that it is more especially beneficial in the haemop-
tysic  and congestive complications;  and  that it
should not be resorted to in the more febrile, de-
bilitated, and emaciated cases, and when the signs
of cavities are  manifest.  It ought to be  farther
recollected that time is a necessary element in
the development ofthe effects of this treatment;
that the other  means of  cure,  the diet and the
regimen adopted, should be restorative and nutri-
tive, without being heating or stimulating, espe-
cially as the discharge from the issue or seton be-
comes copious ;  and that air and exercise in the
open day, avoiding injurious exposure, should not
be neglected.
   416.  C.  Blisters, rubefacients, and embrocations 
TUBERCULAR CONSUMPTION—Climate, etc, in.               1277
(y 319-323) have been sufficiently noticed.  The
first  of these, when  kept discharging for some
time or frequently renewed, is often of service,
and may be substituted for issues or setons when
these latter will not be adopted by the patient.
The  embrocations which I have so often mention-
ed are of service, both as irritants or rubefacients,
and  as furnishing the best means  of inhalation.
Cauteries, actual or potential, formerly employed
and  recommended by Hippocrates, Galen, and
others of the ancients, and by Portal, Aulag-
nier, Gardouin, &c, among  the  moderns, are
rarely prescribed; and even moxas, although much
praised by Larrey and  other recent writers, are
seldom resorted to.   Urticalion, which was  rec-
ommended by Lange, is also superseded by oth-
er means.  That pustular eruptions and purulent
discharges artificially produced have more or less
influence in delaying or arresting the progress of
phthisis, when the disease is not far advanced,
is among the most  important facts in medical
practice ;  but much more is required than an em-
pirical recourse to such means.   A knowledge
ofthe  cases, states, and stages ofthe malady in
which they are likely to be of service, or at least
not  to be detrimental, and of the other means,
constitutional,  local, external, and regimenal,
which may be brought to their aid, is essential to
success in the employment of them.  That the
production of a purulent discharge or the forma-
tion of a purulent eruption has sometimes cured
phthisis, appears to  have been known from the
earliest periods of medical history.  After the ap-
pearance of small-pox, it was observed that a co-
pious eruption in that  malady often cured pul-
monary consumption in an early  stage, and as
often accelerated the progress of this latter dis-
ease in an advanced stage.  This was  remarked
by Muynik, Brachet, and others; and it has been
stated by writers that phthisis is rarely observed
in persons much marked with small-pox (y 231)
—a  statement which has appeared to be confirm-
ed by my own observation.
   417.  xvi.  States of the air were much dis-
cussed by writers from the middle ofthe last cen-
tury until early in this, in respect of consump-
tion, and all sorts of air were considered with ref-
erence to the cure of this disease.  The air of
cow-houses was advocated by some, of marshes
by others (y 295).   Even the mephitic air pro-
duced by bilge-water (arising chiefly from the ac-
tion of salt-water upon the ship's timbers) was
considered by  Beddoes and  Harrison as the
cause ofthe  benefit derived from voyaging.   The
use  of fixed  air, soon after its discovery, in the
treatment of phthisis, was most unprofitably dis-
cussed by writers from 1780 to the commence-
ment of this century; and although the influence
of the  carbureted and  sulphureted  hydrogen,
and  other gases given off from bilge-water, may
be considered by  some as disposed  of, yet it is
still  viewed as not without some favourable influ-
ence by those who believe in the good effects of
marshy exhalations in threatened phthisis.
   [Dr. S. G. Morton, in his " Illustrations of Pul-
monary Consumption," first published in 1833,
suggested (p. 261) that, as the only equable cli-
mate ofthe United States is that of the Mammoth
Cave of Kentucky (its temperature differing but
little the year round  from 56°, and perfectly dry),
it might at some future period become a place of
hybernation  for  invalids, " where they  will be
shielded alike  from  the cold, the wet, and the
noise of the world above them."  This hint was
taken advantage of by its proprietor soon after,
and several huts were erected a mile or more from
the entrance of the cavern, which were inhabited
throughout the winter months by consumptives
from  different parts of the United States.  The
first effect ofthe under-ground residence in a few
cases appeared decidedly favourable;  the cough
was arrested in a great degree, and a quiet, plac-
id feeling pervaded the system.  The absence,
however, of light, the want of exercise, the mo-
notony  of life, the smoke from fires and lights,
&c, rendered existence under such circumstances
intolerable, and, on emerging again to the light
of day,  the disease progressed with astonishing
rapidity to a fatal termination. Altogether, twelve
different patients  tried the experiment of living
within the cave from one to six months each, but
in no instance with any permanent benefit.—See
31st vol. Boston Medical  and  Surgical Journal,
June, 1844.]
   418.  That fixed air contained in fluids is a use-
ful palliative  in  this  disease, and  for the dys-
peptic symptoms which accompany,  cannot  be
doubted; and that the sulphureted hydrogen con-
tained in some mineral waters is often beneficial,
as most preparations of sulphur are also more or
less so,  in tubercular states of the lungs, must be
admitted, as far as medical observation and expe-
rience warrant the belief.  But  this refers only
to the gases  impregnating fluids taken into the
stomach.*
   419.  Of much  greater  importance is the de-
termination of the questions, whether or no the
air in very elevated situations, or in low places,
and whether that near the sea, or at  a distance
from  it, is the most beneficial to phthisical cases 1
Or, in other words—1st. What is  the state or
states ofthe air which the phthisical patient may
breathe with greatest benefit 1   2d. Should the
states of the air,  found beneficial in certain sea-
sons, be continued in  other seasons'? and, 3d. If
change  of such an air be found requisite, how
should it  be  most appropriately and beneficially
changed with the procession of the seasons 1
   420  1st. Sea voyages were praised by Celsus,
Aret^eus, and others  among the ancients ;  and
by Grant, Savary (Lcttres sur VEgypte, t. hi.,
p. 8), and many among the moderns.  But it is
very doubtful what share  of the benefit observed
proceeds from the sea air itself, or from the mo-
tions and other circumstances connected with the
voyage.   It is not improbable that the sea air may
contain certain elements beneficial  to  morbid
states of the lungs, and sufficient  to  counteract
any  injurious  influence which  humidity alone
might produce.   But persons living on the sea-
coast are  not much more exempt from phthisis
than  those living inland, where equally humid
states of air, within the same ranges of tempera-
ture,  usually exist.  A greater exemption may be
experienced, but the amount has not yet been as-
certained, or even an approximation to it.  The
ancients inferred benefit from sea air, because the
  [* If we bear in mind that the principal indication in
phthisis is to improve the faulty nutrition,  which is the
cause  of the tubercular exudation, and  invigorate the
general system, we shall avoid the use of such drugs as
tend to impair the tone of the digestive organs, and we
shall find, moreover, that as the digestive powers and the
general health  are strengthened by suitable hygienic
means, the local as well as general  symptoms will
yield, and there will be little  occasion for those special
remedies for sweats, cough, diarrhoea, &c, which have
hitherto  been in such general use.] 
1278
TUBERCULAR  CONSUMPTION—Climate, etc., in.
voyages for the cure of pulmonary diseases were
generally made to Egypt, and very probably the
relief manifested soon after the arrival of patients
in that country was partly at least attributed to
the voyage.  Although Dr. Smyth is not in favour
of sea air for consumptive cases, yet I know that
voyagino- in  the Mediterranean and in the Atlan-
tic has been most beneficial in  several cases in
which I have advised it.  But I agree with Cm-
lius Aurelianus, Gilchrist, Blane, Reid, and
many others, in saying that, in order to be of serv-
ice, it should be adopted early in the disease ; if
it be resorted to at a far-advanced period, and if
a very  warm latitude be entered into, the disease
will most probably be accelerated to a fatal issue.
The doubt expressed by me above (y 307) of the
superiority of the sea-coast to inland situations,
other circumstances being equal, appears to be
confirmed by the observations of Dr. Richardson
respecting the  climate of Nubia, of Dr. Barclay
on the climate of Egypt, and of Dr. Archibald
Smith  on the influence  of high elevation in warm
climates on consumption.  In Nubia, Egypt, the
South  of Spain, and at a considerable  elevation
on the  Andes, cases of this disease, whether at-
tended  by haemoptysis  or not, were remarkably
benefited soon  after their arrival;  and a removal
from the last-named place to the  sea-coast was
often followed by a return ofthe malady.  From
the testimony  and experience of these eminent
writers, and  from what  other sources of informa-
tion have furnished, I infer that dry states ofthe
atmosphere,  in  moderate grades and ranges  of
temperature, and at considerable or even moderate
elevations above the sea-level, are most favourable
to consumptive  patients; that the places just
named, and  Malaga, and various other  places in
Syria and the East, are most to be preferred ; and
that, before the commencement of the hot season,
Nubia, Egypt,  and other places, where  the  tem-
perature rises very high, should be relinquished
for others  which are more temperate.
   [ Climate in Tubercular Phthisis.—With regard
to the influence ofthe climate of different regions
ofthe United States in  the causation of tubercu-
lar phthisis, the positive facts bearing on the sub-
ject are not yet sufficiently numerous to enable
us to draw any very positive conclusions.  The
late Dr. Samuel Forry, in his able work on " The
Climate ofthe United States and its Endemic In-
fluences"  (based chiefly on the records  of the
Medical Department and Adjutant-general's Of-
fice, United  States Army), having first establish-
ed the  isothcral  and isochcimal lines, represent-
ing the mean temperature of summer and winter
(from which it appears that the  same parallels of
latitude present  systems of climate very diverse
in character, as, 1st. The regions bordering on the
ocean ; 2d.  Those under the influence  of inland
seas; and, 3d. Those remote from such control-
ling powers), demonstrates very clearly that these
laws of climate maintain an intimate relation with
the etiology of pulmonic diseases, and that the
prevalence of catarrh and influenza in each system
of climate increases and decreases in proportion
as the  seasons are contrasted, thus  maintaining
an unvarying  relation  with the extreme range
of the  thermometer as connected with the sea-
sons.
   The  following table from his work, exhibiting
the ratio of cases per 1000 of mean strength, will
show  the comparative  prevalence of pulmonary
diseases in each system of climate :
Northern Region of the
    United States.
Atlantic Posts..........
Posts on the Lakes.....
Posts remote from the
  ocean and the Lakes.
      Total............
    Southern Region.
Coast from Delaware to)
  Savannah...........j
Southwestern Stations ..
Posts on the Lower Mis-
  sissippi..............
East Florida............
 3,130
 5,970
12,004
21,707

 3,190
11,140
 3,381
 4,C07
22.32V
230
  If these statistics are reliable, the annual ratio
of pulmonary diseases, with the exception of ca-
tarrh and influenza, is lower in the northern than
in the southern regions of the United  States;
pneumonia, pleuritis, and phthisis pulmonalis are
most prevalent, however, in the middle  regions
of the United States, and Florida has a lower av-
erage than any other.  The ratio of deaths  per
1000 of mean strength is, in the northern region,
2.1, southern 4.4, from phthisis ; and in  the for-
mer 0.5, the latter 1.8, from pneumonia, pleuritis,
and catarrh.  This  corresponds with the  conclu-
sions deduced from the " Statistical Reports on
the Sickness, Mortality, and Invaliding" among
the British troops stationed in  every part of the
globe.   The reporter shows by  numerical results
that  phthisis pulmonalis is more prevalent in
southern than northern latitudes, and infers " that
it is by no means likely that any beneficial influ-
ence can be exerted by climate itself in  pulmo-
nary affections."
  These facts also correspond with what has been
observed in Europe.  Phthisis  is far more prev-
alent in the middle  and southern regions of Eu-
rope than it is farther to the north;  while in Swe-
den the ratio of deaths from this disease  is only
63 in 1000, in London it is 236.   The northern
parts of Russia are comparatively exempt from
the disease, while from the 35th to the 45th par-
allel of latitude it is very common.
  The popular notion that a changeable  climate
favours  the production of phthisis is undoubtedly
erroneous.   Those who are most exposed to the
vicissitudes of climate are  least exposed to  pul-
monary disease of  every kind.   Statistics have
fully proved  that  the maximum  of liability to
phthisis is found among those who suffer the least
exposure to climatic variations ; and it will even
be found true that the most variable climates are
best calculated to develop the physical and men-
tal powers.  Doubtless, it is owing to this cause
that  the Indians, our frontier inhabitants, and the
hardy backwoodsmen of the West, are so  little li-
able  to attacks of phthisis.   The above  holds true
also, according to Dr. Forry, in regard to pleu-
ritis, pneumonia, and  catarrhal  affections, which,
he says, are far less prevalent  in the moist and
changeable climate  peculiar to the Atlantic coast
and the borders of our great lakes than in  the dry
atmosphere ofthe interior parts ofthe continent.
The  above  facts are also corroborated by the re-
cent "Statistical Report  on the  Sickness  and
Mortality in the Army of the United States, com-
piled from the Records in the Surgeon-General's
Office," for sixteen years   (Washington, 1856,
4to).  For  example, Surgeon Wotherspoon, in
giving an account  ofthe "Medical Topooraphy
and Diseases of Fort Kent" (lat. 47° 15' N& long 
TUBERCULAR CONSUMPTION—Climate, etc, in.
1279
68° 38' W.), remarks that "the climate of Fort
Kent does not seem favourable for the production
of pulmonary phthisis.   During my sojourn at
the post, I have neither seen nor heard of a case
of this disease among the French or American
settlers.  Assistant-Surgeon Isaacs, who, during
the two years he was resident at the fort, had a
much better opportunity than myself of becoming
acquainted with the diseases of the country, in-
forms me, not only that he never saw a case of
consumption in the country, but that  some ofthe
inmates of the garrison, who were affected with
suspicious  symptoms, recovered from them en-
tirely" (p. 27).
   From this recent" Report" we copy the follow-
ing " Consolidated Table," exhibiting the amount
and ratio of sickness and mortality in the several
regions from phthisis pulmonalis :*
				R^tio of |
Regions.	Mean strength.	Number treated.	Deaths.	Cases 1 per 1000 of mean strength.
Coast of New England ..	3,903	19	5	4.8
Harbour of New York ..	9,387	56	35	5.9
West Point............	6.901 3.553	6 17	8 10	0.8 4.7
North Interior, east___				
	10,340	47	33	4.5
North Interior, west___	7,'.30	30	15	4.1
Middle Atlantic........	6.249	16	19	2.5
Middle Interior, east ...	2,450	6	3	2.4
Newport Barracks, )	1,454	5	4	3.4
Jefferson Barracks and j St. Louis Arsenal... j	5,580	23	21	4.1
Middle Interior, west...	5 319	28	13	5.2
	2,800 5,919	26 43	5 28	9.2 7.2
South Interior, east....				
South Interior, west___	10,013	20	25	2.
Atlantic Coast of Florida	835	2	1	2.3
Gulf Coast of Florida ..	2,299	16	3	6.9
Texas, southern frontier	4,450	18	11	4.
Texas, western frontier.	6.324	25	12	3.9
	5.873 l,7i tT	8 9	3 5	1.3 5.2
California, Southern....				
California, Northern....	1,599	9	4	5.6
Oregon and Washington	1,831	6	2	3.2
  From this table we gather that the lowest ratio
of cases of consumption occurs in New Mexico,
being only 1.3 per 1000, and the highest in the
South Atlantic region, where it is 9.2 per 1000.
Assistant-Surgeon Hammond  observes  that  he
had never seen but two cases of the disease in
the country (New Mexico), and those came from
the United States.   The south interior, east, and
Gulf coast of Florida give the next highest pro-
portions, being respectively 7.2 and 6.9 per 1000
of mean strength.  The ratio for these three re-
gions, and also for California, are higher than for
any of the regions  in the  United States.  The
compiler of this work, Dr. Coolidge, arrives at
the following conclusions in regard to  climatic
influences in the production of this disease :
  " 1st. That temperature,  considered  by itself,
does not exert that marked controlling influence
upon  the development  or  progress of phthisis
which has been attributed to it.
  " 2d.  That the most important atmospherical
condition for a consumptive is dryness.
  " 3d.  That next to dryness in importance is an
equable temperature—a temperature uniform for
long periods, and not disturbed by sudden or fre-
quent changes.   A uniformly low temperature is

  [• The northern division includes that portion ofthe
United States north of the 40th degree of latitude and
east of Rocky Mountains; middle division lying between
35th and 40th parallels of latitude;  southern division
between 30th and 35th degrees of latitude. Besides these
are the divisions of Florida, Texas, New Mexico, Cali-
fornia, Oregon, and Washington Territories.]
much to be preferred to a uniformly high tem-
perature.   The former exerts a tonic and stimu-
lating effect upon the general system, while the
latter produces general  debility and nervous ex-
haustion.   The worst possible climate for a con-
sumptive is one with long-continued high tem-
perature, and a high dew-point."   The British
Army Statistical Reports confirm the truth  of
these statements, the ratio of cases of phthisis
among the troops in Canada being 5.7 per 1000
of mean strength, while in Bermuda it is as high
as 8.9.
  Such being the facts  in regard to climatic  in-
fluences in the production of tuberculosis, the im-
portant question recurs, are consumptive patients
to be sent  away from home;  and if so, whither
shall  they  be sent 1  English physicians  have
from time immemorial been in the habit of send-
ing their pulmonic cases to Rome, Naples, Nice,
Florence, and other parts of Southern Italy, Mont-
pellier, Lisbon, &c, places particularly subject to
bronchial and tubercular affections, and where a
greater proportion of the native inhabitants per-
ish from  this class of diseases than in any part of
Great Britain.  Even in Madeira, so vaunted as
salubrious in tuberculous cases, consumption and
scrofula are very common diseases, and the  av-
erage duration of life is inferior to that of our own
country.   Indeed, all known facts seem to prove
that the notions which have hitherto prevailed in
regard to the beneficial effects of change  of  cli-
mate in this disease are utterly unsound and  fal-
lacious.  As Dr.  Burgess* has well remarked,
" We may seek in vain along the entire range of
organized existence  for an example of diseased
animals being benefited by removal from a warm
to a cold,  or from  a cold to a warm country.
There appears nothing in the Book of Nature so
violently inconsistent.   The fishes which inhabit
the waters of the British islands will not  thrive
in the Arctic seas, nor those of the latter  in  the
ocean  of the tropics ;  our birds  generally  die
when carried to Europe, and the wild animals of
Africa and Asia perish when translated to our
own continent.   Man, it is true, is a cosmopolite,
and can bear sudden changes and unnatural tran-
sitions better than  any other animal; still,  his
constitution and health are endangered by such
opposite conditions, as we see among the blacks
removed  from the South to Canada, and among
the inhabitants of northern latitudes who remove
to the tropics, and vice versa.   Well may it be
asked, if such extreme changes of climate prove
obnoxious  to the health  of individuals having
naturally a sound constitution, how arc we to  ex-
pect persons in a state  of organic disease  to be
thereby benefited 1   Nature has, in  fact, adapted
the constitution of man to the climate of his  an-
cestors, and that is the natural climate of man in
which not only he himself was born, but also  his
blood relations  for several generations.  This is
his natural climate, as well in health as when  his
constitution is broken down by positive disease,
or unhinged by  long-continued neglect  of  the
common  rules of hygiene."   We believe,  there-
fore, with Burgess, that change of air in his own
climate, or  removal to one nearly approaching to
it, is the  natural indication, and will effect what-
ever good climate can effect in consumption.
  When tubercular disease, then, is fully  estab-
lished, a residence at home, if in a favourable sit-
  [* "Climate of Italy, in Relation to Pulmonary Con-
sumption."  London, 1652.] 
1280
TUBERCULAR CONSUMPTION—Climate, etc, in.
uation, with all the comforts and consolations of
home, is far preferable to any of the remote re-
sorts recommended in such cases.   We have seen
that more cases of phthisis originate in warm than
in cold climates, and are also more speedily fatal;
and it would be easy to show that while cold re-
tards the progress of the disease, heat accelerates
it.   Tubercular softening, as we have had many
opportunities of observing, is much hastened by
warmth and moisture, as in removing from New
England to Cuba, or any of the West India isl-
ands.  We admit, however, that  there are ex-
ceptional cases, where consumptive persons seem
relieved  as soon  as  they reach  a warmer and
more uniform  climate.   But  these  are  cither
cases of pure bronchial disease, or broncho-tuber-
cular, where  a warm, moist air allays the irrita-
bility of the bronchial mucous membrane, and af-
fords great relief to the  cough and the general
sensations of the patient.  It is a  mistake, how-
ever, to suppose that rapid variations and  an ex-
tensive range of temperature are unknown  to
warm  climates.   Such variations are very great
and frequent in Southern Italy, and along the At-
lantic coast of Florida and our Southern States.
  If, however, it is thought desirable, for the pa-
tient or physician, that a change of climate should
be made, there is no necessity that he should be
sent abroad while we have every possible variety
of climate in our own country.   Change  of air
in the same climate is what should be sought, and
not a climate greatly foreign to that of his own.
An equable temperature is what is required, and
every consumptive patient who has tried a change
of climate will testify that a low degree of tem-
perature, with a limited range, gives more per-
manent ease  than a high  degree subject  to fre-
quent  alternations.  Such a winter  climate  is
found in  many parts of the United States.  We
have little doubt the time is not remote when, in-
stead of sending tuberculous cases to spend the
winter at the South, southern  invalids will seek
the bracing atmosphere of the North,  and  return
home in  the  spring greatly invigorated.   The
above remarks, I am aware, are in opposition  to
the maxim of Celsus, that " the air in which a
man grows sick is  the very worst air for him ;"
and  also  in opposition to  the opinions  of many
enlightened physicians, like Professor Dickson,
who thinks a change of climate in such cases " is
always desirable ;"* and that " a northern  winter
should be avoided by migrating to a southern lat-
itude ; and that a  southern  summer  is  almost
equally dangerous  in its ultimate effects," &c.
Dr. Rush advised American patients to pass the
winter and a part of the spring in South Carolina
and Georgia; in summer to go northwardly into
Canada as far as Quebec, and to return in autumn
to Pennsylvania and New Jersey.t  He incul-
cates strongly the necessity of keeping far from
the sea-coast, believing a mixture of sea and land
air highly prejudicial.  Dr. Dickson remarks that
" the atmosphere of islands, of many points on
the  coast, Madeira, the West Indies,  St. Augus-
  [* Essays on Pathology and Therapeutics, p. 317, vol.
ii. (1845).]
  [t It is a common belief that there has been a gradual
change in the temperature of our summer and winter
months during the last 60 years, our summers growing
hotter and our winters colder during that period.  An
examination ofthe following tables, for which we are in-
debted to the kindness of Professor Parker Cle weland,
LL.D., will show that there has been no essential change
in these respects during that period:
tine, and Savannah, is found to be generally sa-
lubrious to pulmonary patients."—Loc. cit.  Of
the numerous patients we have sent to these dif-
ferent  places  with confirmed  phthisis,  we  can
scarcely call to  mind a single case which was es-
sentially benefited, while in numerous instances
the patients became suddenly worse.  Great re-
laxation and debility ensued, with an increase of
the night sweats, hffimoptysis, and  diarrhoea, if
present; the high temperature rendered exercise
in the  open air next to impossible, while there
was a general absence of those comforts and ap-
pliances procurable at home.  The appetite usu-
ally fails on transference to a tropical clime, and
tubercular softening makes rapid progress.
  Admitting that the  ratio of pulmonary diseases
is as high, or higher, in southern than in north-
ern latitudes, we grant it does not necessarily fol-
low that benefit may not be derived  from change
of climate in the way of a winter residence.   This
must be decided  by actual experience only, and
experience we hold to be generally adverse to the
doctrine.  The late Dr. Forry, who was person-
ally acquainted with the climate of Cuba, Florida,
and our Southern States, was in the habit of rec-
ommending a residence in those localities during
the winter months, in cases of bronchial disease
and incipient or  threatened phthisis, or "when
mostly limited  and merely nascent," but  never
after the latter disease was unequivocally estab-
lished.  Sir James Clark also remarks that " the
climate ofthe West Indies is an improper one for
patients with tuberculous disease of the  lungs."
—" On Climate."
  The  idea is a prevalent one in the profession,
that residence  in a malarious district acts as  a
prophylactic against tubercular phthisis ;  but the
evidence on this point is very conflicting.   It is
The Mean Temperature  at Brunswick, Maine, for the
  Winter Months, December, January, and February,
  from the Year 1S07-8 to 1856-7 inclusive.
	Mean		Mean		Mei.n
Year.	Tempera-	Year.	Tempera-	Year.	Tempera-
	ture.		ture.		ture.
1807-S	25.29	1824-25	23.60	1841-12	2S.52
1808-9	19.88	1825-26	24.33	1842-43	24.86
1S09-10	24.75	1S26-27	22.25	1843-44	24.S7
1810-11	23.54	1827-28	27.69	1844-45	22.37
1811-12	21.57	182S-29	22.08	1845-46	27.81
1812-13	21.79	1829-30	22.18	1816-47	21.37
1S13-14	24. S9	1830-31	27.66	1847-48	28.13
1814-15	20.97	1S31-32	23.14	1S48-49	22.76
1815-16	22.09	1832-33	22.05	1849-50	22.06
1810-17	21.29	1833-34	26.54	1850-51	23.07
1817-18	21.52	1834-35	22.95	1851-52	20.39
1818-19	26 99	1835-36	29.31	1852-53	24.52
1819-20	23.74	1S36-37	25.64	1853-64	21.52
1820-21	23.23	1837-38	31.06	1854-55	17.95
1821-22	19.73	1838-39	28.85	1855-56	20.07
18!2-23	17.47	1839-40	32.39	1856-57	20.14
1823-24	22.73	1N40-41	27.25		
The Mean Temperature at Brunswick, Maine, North Lat-
  itude, 43° 53', for the Summer Months, June, July,
  and August, from the Year 1808 to 1856 inclusive.
Year.	Mean Temper-ature.	Year.	Mean Temper-ature.	Year.	Mean Temper-ature.	Year.	Mean Temper-ature.
1S08	61.80	1821	68.57	1833	62.16	1845	61.72
1809	65.70	18-^2	65.70	1S34	64.20	1846	62.37
1810	65.24	1S23	67.69	18R5	63.18	1847	61.22
1811	66.59	1824	65.97	1836	61.99	1S48	61.03
1812	63.58	1825	69. S7	1837	65.08	1S49	62.72
1813	66.08	ls'6	71.70	1838	69.76	1850	61.79
1S14	64.90	1827	67.56	1839	67.24	1851	00.23
1815	67.13	1828	66.87	1840	69.76	1852	61.70
1816	63.39	1829	64 54	1R41	64.90	1853	61.84
1817	64.88	1830	61.64	1842	63.67	1854	62 87
1818	70.03	1831	66.17	1843	62.29	1855	60 66
1819 1820	69.31 67.40	1832	55.77	1844	61.21	1856	61.71
 
TUBERCULAR CONSUMPTION—Climate, etc, in.               1281
doubted whether malaria exerts any antidotal or
curative power in regard to tuberculous affections.
On the contrary, it  is stated on good authority
that malaria powerfully predisposes to  such at-
tacks, and that a malarial  fever frequently lays
the foundation for tubercular disease.  Nothing,
indeed, is more  common than to witness the su-
pervention of rapid  pulmonary consumption in
constitutions deteriorated by malarial  diseases.
" An attack of ague," says Sir James Clark, " is
much more likely to favour the occurrence of con-
sumption than to prevent it."'—" On Climate."
" Whenever any cause," says  Dr. Forry, " de-
presses the vital energy, and lowers the power
of assimilation beyond a certain point, the tuber-
cular diathesis will be produced.  Moreover, the
connexion of pulmonary phthisis with congestion
and derangement  of the abdominal viscera has
been long since noticed ; and as abdominal pleth-
ora is  the predominant character  of the prevail-
ing diseases of tropical latitudes, we have a ready
explanation of the high ratio of tubercular con-
sumption in the West Indies.  Hence malaria
has a tendency to develop this disease, for it tends
to destroy the balance of the functions and dimin-
ish the tone of the system, thus robbing the blood
of  that  rich, fibrinous, and vital condition, by
which proper nutrition and the  organic functions
are sustained.   Malaria holds a prominent place
among the causes productive ofthe cachectic con-
dition  of the system which precedes the forma-
tion of tubercle."—Loc. at., p. 266.
   The opinion generally prevails  that a mixture
of  sea and land air, such as  exists on all  our
maritime situations, is unfavourable to delicate
lungs, especially where there  is  phthisis, or a
strong predisposition to it.   Such was  the opin-
ion ofthe late Dr. S. G Morton, Sir James Clark,
and perhaps a  majority of writers  on  this  dis-
ease.  Such also is the result of our own obser-
vation.  But it  conflicts with the statements of
Dr. Forry, and  other statistical writers, that pul-
monary diseases are scarcely half as prevalent on
the moist and variable coast of New England, as
well as the Lakes, as in the dry and  less change-
able regions of the same  latitude.   We regard
this question, however, as far from being settled.
The laws and conditions regarding the causation
of tubercular disease are probably far from being
the same as those connected with inflammatory
affections ofthe lungs.  Laennec has remarked
that few consumptive cases occur near the sea;
the comparative ratio, however, may vary in dif-
ferent  countries in the same latitude, and also at
different latitudes.   In Georgia and Florida the
opinion prevails that the dry air of the interior,
in  conjunction with the aroma of pine forests, is
more congenial  to delicate lungs than the moist
air on the coast.  The ancients sent their con-
sumptives to  the pine-forests  of  Egypt.   Clot
Bey, in  his recent work, states that Egypt en-
 joys an  exemption from lung diseases, especially
from phthisis, and he therefore  recommends it as
a residence for persons predisposed to or labour-
ing under this disease.   Such pulmonary invalids
as  seek  a milder winter climate  may  be  safely
recommended to the pine regions  of the interior
of  South Carolina, Georgia, or  Florida, where all
the advantages  of a change of climate may be
found  which are to be expected in such cases.
   Mr.  A. Keith Johnston (" The  Physical Atlas
of  Natural  Phenomena," ed. 1856)  observes, as
regards consumption, as follows :  " It originates
     III.              81
in all latitudes—from the equator, where the mean
temperature is 80°, with slight variations, to the
higher portion of the temperate zone, where the
mean temperature is 40°, with sudden and vio-
lent changes.  The opinion long entertained that
it is peculiar to cold and humid climates is found-
ed in error.  Far  from this being the case, the
tables of mortality of the army and navy of this
and other countries, as well as those of the civil
population, warrant the conclusion that consump-
tion is more prevalent in tropical than in temper-
ate countries. Consumption is rare in the Arctic
regions, in Siberia, Iceland, the Faroe Islands, the
Orkneys, Shetlands, and Hebrides.  And, in con-
firmation of the opinion that it decreases with the
decrease of temperature, Fuchs shows,  from ex-
tensive data, that in Northern Europe it is most
prevalent at the level of the sea, and that it de-
creases with increase of elevation to a certain
point.   At Marseilles, on the sea-board, the mor-
tality from this cause is 25 per cent.;  at Olden-
burg, 80 feet above the sea, it is 30 per cent. ;
at Hamburg, 48 feet  above the  sea, it is 23 per
cent.; while at Eschwege, 496 feet above the sea,
it is only 12 per cent.; and at Brotterode, 1800
feet above the sea, it  is 0.9 per cent."]
  421. The second and third questions are partly
answered by what I have now stated; for although
a continued residence in these climates may not
be injurious to many consumptive patients, yet it
may give rise to diseases of a  different nature, or
may occasion complications  of  phthisis which
otherwise might not have occurred; or it  may
prove too exhausting, or  otherwise injurious  to
the patient:  in many  cases, if not in the majority,
a change to a more temperate climate is there-
fore beneficial before the hot season commences ;
and if the change can be made to a climate both
dry and temperate, it will generally prove of the
greatest advantage.   Patients who are subject to
haemoptysis, or other states of the more usual  or
the chronic forms of phthisis, will derive very great
benefit from a voyage to Alexandria, and a jour-
ney thence to Cairo and Upper Egypt, and, hav-
ing resided there or in Nubia some time, proceed-
ing thence to Syria, they may return by  Malaga,
Granada, or other places in Andalusia, in April or
May, to England ; or, if it be preferred, a voyage
may be made across  the Atlantic early  in Sep-
tember with great benefit;  and  having crossed
the isthmus of Panama, the Pacific may  be trav-
ersed ; and having visited Lima, a residence  in
the mountains of Peru may be tried at the eleva-
tion  and in the  season found  most beneficial for
phthisical patients.  A fter a satisfactory residence
in this locality, the patient may return to Europe
by the same route as  that by which he went out,
or by one more direct, taking care, however,  to
return to England about May  or  June.*   If this

  * There are many places in the south of Spain that
may be chosen for winter residences by persons either
threatened by or in the first stage of tubercular consump-
tion, especially in Andalusia; and if the vicinity of Mal-
aga, or of Granada, or of Seville be not selected, other
places in the above extensive province may  be tried.
During the warmer months the more elevated situations
on the southern side, or the southern ridges of the Sierra
Morena, furnish many situations which cannot fail  of
possessing most of the advantages required by phthisical
invalids.
  Dr.  Mitchell (Brit and For. Medico-Phirurg. Rev.,
No. xxxiii., p. 226) states that "the climate of Algiers,
during winter and spring, vies with that of Madeira, be-
ing as warm  and steady in temperature, but drier and
more bracing."
  It has been a generally received opinion among medi- 
1282
TUBERCULAR  CONSUMPTION—Climate, etc, in.
plan  be followed out for  two, or three, or four
seasons, at an early stage, with due precautions
aeainst injurious exposure, the disease will cither
be  arrested for some  years, or altogether over-
cal and scientific men that very high elevations above
the level ofthe sea are injurious to tubercular consump-
tion, especially when it is either ushered in, or attended
by, or even threatened with hsemoptysis.  Dr. Archibald
Smith's very interesting account of the very remarkable
benefit he saw, in numerous cases (see above, § 420), de-
rived from residing at an elevation above the sea-level
of 6000 to 10,000 feet, completely upsets this opinion.
This very able and experienced  physician  has  farther
remarked upon this subject, in a communication he has
kindly favoured me with since the earlier pages of this
article were published; and he has stated, respecting a
diminished or increased frequency of phthisis in  the ab-
origines of a country by change to a colder or to a warm-
er climate, or to a higher or lower elevation, " that, as
regards Lima and the coast of Peru generally, the  change
to the maritime climates of Chili and Ecuador—the first
colder, the second warmer—has a decidedly bad effect on
the Peruvian phthisical invalid; but the higher elevation
on his own mountains of 5000  to 10,000 feet has a decid-
edly curative influence.   In these regions  the climate
is moderately dry and temperate,  favourable to exercise
in the open air, and the patient is also removed from a
luxurious and sensuous society, as well as from a warm,
humid, and relaxing atmosphere.   Very possibly the de-
cided benefit received by the  natives of Peru from the
change from coast to mountain may not be equally shared
in by strangers.  I hope, however, that this may be a fair
trial, and, as you recommend  navigating by Panama to
the  Pacific, that you will  find room  to recommend, on
fair trial, to Europeans, the migration to elevated spots
on the Andes, from time  immemorial known of para-
mount importance to the native races affected with pul-
monary consumption."   Dr.  Archibald Smith's very
long and extensive experience  of the  diseases  in this
part  of the New World renders his opinion of the great-
est value on this subject.  He farther remarks:  " I ob-
serve at § 218 what you say with respect to the effect of
migration on  the  Chinese;  and I can say  that,  among
the  thousands of this race lately introduced into Lima,
I never met with an instance of phthisis.  It is likely,
however, that this disease will show  itself in their off-
spring born in Peru of Indian or dark women.  When
the  Chinese crop  their hair and  take on the Peruvian
dress, it is not easy to distinguish them from native Pe-
ruvian Indians."   Is not this last remark in favour of
the opinion that the Indian races are offshoots from the
Mongolian, or Chinese?
  Dr. Richardson, in his account of his travels in Egypt
and  Nubia, published more than  thirty years ago, has
strongly recommended these countries, and especially the
latter, as winter and spring residences for phthisical in-
valids.  The more recent evidence of my eminent friend,
the  Rev. Dr. Barclay, fully confirms this recommenda-
tion.  The very interesting account given by Dr. Bar-
clay of the climate of Middle and Upper Egypt, Malaga,
&c, is so very important to our profession and to  phthis-
ical patients,  coming as it does  from one  whose great
talents and acquirements  I have long known and ad-
mired, that I quote it at this place without abridgment,
of which, indeed, it does not admit:
  "The object of this communication is to draw atten-
tion  to those characteristics of the Egyptian climate by
which an opinion may be formed of its curative influence
in cases for which a removal to a milder and warmer at-
mosphere is usually recommended,   The result of my
own  observation  and experience, during five  months
spent in that country, is a thorough conviction that there
is no accessible part of the world so well adapted for the
relief of most of that formidable class of diseases to which
the  respiratory organs are subject.  In venturing to ex-
press this opinion, however, I am far from affirming that
all Egypt, or any part of Egypt at all  seasons, fulfils the
conditions required in a climate suitable for such cases.
On the contrary, it will be readily perceived that  no part
of the Delta is at any season adapted to patients who are
subject to these affections, nor, it may be added, to those
who are either dyspeptic or rheumatic; and from the be-
ginning of May to the end of September the heat in ev-
ery part of Egypt is too great for a European constitution
weakened by disease.  But in Middle and Upper Egypt.
from the beginning of October to the end of April, the
invalid may breathe, under a bright and cloudless sky,
an atmosphere at once of a warm and  equable tempera-
ture, of perfect purity, and free  from "all excess of hu-
midity.   The climate of other regions may be equally
distinguished by one or more of these properties (though
even that is doubtful), but assuredly there is no  other
habitable part of the globe in which they are all com-
bined in so great perfection.
  "The malady for which I sought relief in a southern
climate  was chronic bronchitis in its most aggravated
form   All the usual remedies, both external and intern-
al had b. en resorted to and steadily persevered in, un-
der the ablest medical advice, but with little temporary
and no permanent benefit   I had tried with the same
unfavourable result those places on  the south coast of
En "and which are usually recommended to invalids.
The symptoms obstinately resisted every medical roeas-
ure. The chronic character of the disease was frequent-
ly exchanged for attacks of a sub-acute form.  These
always commenced  with inflammation of the pharynx,
creeping insidiously down the glottis and trachea to the
bronchial tubes, which became gorged with mucus through-
out their whole extent, and on every spot on which the
stethoscope could be planted over the lungs the mucous
rale was to be heard.  Dyspnoea, accompanied with loud
wheezing, was at all times d.stressing; but its nocturnal
exacerbations, which invariably occurred after a short
sleep, like fits of spasmodic asthma, were often so fear-
fully violent as to threaten suffocation.  The digestive
organs were deranged, I had no appetite  for food, my
frame was emaciated, and my strength prostrated.
  "I was so enfeebled as to be unable to encounter the
voyage till the month of November, and thus I  lest two
months of the season suitable for the residence of an in-
valid in that country.   Yet the benefit which, by the
blessing of Providence,  I reaped from that delicious cli-
mate was most  signal, and  far exceeded all  that my
most sanguine hopes had ventured to anticipate.
  " On the passage outward I stopped five days at Malta,
but found the heat so oppressive in the daytime, and the
chills in the evening so  severe, that I was glad to make
my escape.   The extreme humidity of the atmosphere in
that island, notwithstanding its high temperature, must
always render it, I apprehend, an unfit resort for a bron-
chitic patient; and the greatness of the diurnal range
of the thermometer, at  least in winter, makes  it ques-
tionable how far it is an eligible residence for consump-
tive patients.   It is believed that an inquiry into results
will not tend to give a favourable idea of its sanative in-
fluence on that class of complaints.   Of the climate of
Alexandria also  I have  reason, as  I shall show after-
ward, to speak unfavourably.   In Cairo, however, a very
different climate was found;  and I had not been many
days there when I began to experience its effects in al-
laying  the irritability of the respiratory mucous mem-
brane.   The coldest season there is the latter part of De-
cember  and the early part  of January; and though the
temperature even then is equal to that of our best sum-
mer weather, yet the evenings are somewhat chill. The
following observations, made with the register thermom-
eter and Dollond'a hygrometer, show the temperature and
the dryness of the atmosphere at Cairo during the cold-
est  fortnight of the year:
			ID	K	6.	
	c — £ .			■o	B	
	— u ** flC					
Date.	s= Jl		~	£	s	State of weather.
	t&i-a-		£	u>	fn	
	►J iS		5		a	
	o	°	o	o	o	
Dec. -.'5.	50	64	5	7		Bright sunshine.
" 26.	58	63	5	7		Do.
" 27.	58	6.'	4	5		Do.
" 28.	M	60	3		5	Rain and blowing.
" 29.	57	60	3	1		Showery.
" 30.	58	60	2		4	Wind and rain.
" 31.	5'	64	5	5		Bright sunshine.
Jan. 1.	60 ! 6t		4	8		Do.
" 2.	57 j 62		5	4		Cloudy.
" 3.	r>3 ' 63		5	0	0*	Do. and blowing.
" 4.	.'■8 1 64		6	5		Bright sunshine.
" 5.	57	64	V	4		Cloudy.
" 6.	58	61	3		4	Drizzling.
" 7.	bV	60	3		1	Cloudy and windy.
  " From these observations it will appear that, warm
and equable as the winter temperature is at Cairo, the
weather at that season is not free from frequent and sud-
den changes.  It is in Upper Egypt that the invalid
must seek entire  exemption from these, and  there he
«'ill not be disappointed.
  " While I was there my register was kept on the Nile,
and consequently it shows a lower temperature, at least
in the night time, than would be denoted  at a little dis-
tance from  the river, while the dryness indicated by the
hygrometer in the latter case was  many degrees greater
than that registered on the river.
 * The zero of the hygrometer correspond* to eummeTdrouirhtTn
Rintniri                                         ° 
TUBERCULAR  CONSUMPTION—Climate, etc, in.                  1283
come, in a great many cases—indeed in most, if
it be not delayed to a too far advanced stage.
  [The following table shows the mean tempera-
ture for each season, each month, and the whole
year, at  St. Augustine,  Fort  Brooke (Florida),
Nice, Rome, Naples, and Madeira, for the years
1825,  1828, 1830, rejecting decimals :
Place.	Lat.	Mean Ann'l Tem-pera-ture.	Mean Temperature of the Seasons.				Mean Temperature for each Month.											
			£	.S CO	1 s 5	a B •3	Jan.	Feb.	Mar.	April.	May.	June.	July.	Aug.	Sept.	Oct.	Not.	Dec.
St.Augns-1 tine .. ,J Ft. Brooke. Nice...... Naples___ Madeira...	O / 29 48 27 57 43 41 4154 40 50 32 37	0 72„4 73.19 59.48 60.79 61.40 64.56	62.8.1 65.02 47.82 48.90 48.50 59.50	70.55 71.71 56.23 57.65 58.50 62.20	S2.05 SI. 04 72.26 72.16 70. S3 69.33	73.56 62.15 74.59:63.75 01.63 45.85 03.96;47.65 64.50146.50 67.23 '59.50		64.97 66.56 49.00 47.45 48.50 8<v50	66.53 66.48 51.45 52.05 52.00 61.06	OS. 68 71.27 57.00 56.40 57.nO 62.50	76.44 77.39 63.00 64.50 66.50 63.00	81.12 80.90 69.00 69.17 71.00 65.00	82.36 81.43 73.50 73.30 75.00 70.00	82.68 80.79 74.30 74.02 76.50 73.00	79.56 79.01 63.35 69.50 72.511 71.50	73.61 75.04 61.85 63.60 65.00 67.50	07.47 69.71 53.70 58.80 54.50 62.70	61.38 64.76 48.60 49.62 50.50 60.50
  The above table shows  very conclusively the  winter and spring months to that of the most
superiority of the climate of Florida  during the  celebrated places of resort abroad.]
  " The following table contains the result of the obser-
vations noted between Thebes and Asouan,  the upper-
most town in Egypt, and from  these an idea may be
formed of the winter climate in that region:
Date.	•J	Highest temp. by day. Diurnal range.		•5 bo a	State of weather.
Jan. 17. " is. " 10. " 20. " 21. " 22. " 23.	64 63 66 61 64 63 68	70 68 70 G) 71 72 72	6 5 4 5 7 3 4	7 7 5 12 7 6 10	I Cloudless sky and bright sunshine ev-J ery day; the firma-1 ment blazing with stars every night; no evening chills.
  "The benefit I derived from breathing the genial air
ofthe Thebaid was very decided.   The periodical night
attacks, though still occurring, were less violent and of
shorter duration; my breathing was greatly relieved;
and my strength was  so far recruited that I was able,
without fatigue, to make daily excursions, sometimes of
many miles, to the monuments with  which this part of
the valley of the Nile is studded.
  " At Thebes, which for several reasons should be made
head-quarters in Upper Egypt, the day temperature, from
the middle of January to the middle of February, ranges
from 68° to 78°, and after the latter date the  heat be-
comes rather toe great to be borne with comfort.   The
invalid should then commence  his  downward voyage,
and by the time he reaches the latitude of Cairo he will
find the climate there nearly as delightful as that which
he left at Thebes.  My register during the first week of
March at Cairo was as follows:
soothing influence of the desert air on delicate organs of
respiration, and its invigorating influence on a debilita-
ted frame, can be  appreciated by those only who, like
myself, have experienced its marvelous effects.  It is at
once balmy and bracing; and the invalid, while breath-
ing it, feels as if he were drinking in health at every
pore.  I quitted Cairo for the  desert of Ghezeeh on the
12th of March, and took up my abode in the neighbour-
hood of the Pyramids; and there a sudden change came
over me, as if by magic.  The second night I passed in
the desert was marked by sound and uninterrupted sleep,
and the absence of the periodical fit of dyspnoea, the first
occasion on which I had enjoyed the one or had been ex-
empted from the  other for more than two years.   My
appetite soon became excessive; both the flesh and  the
strength I had lost during my  illness were restored;  ev-
ery symptom of my complaint disappeared, and at the
end of a month I  returned to Cairo in perfect health.
The following table contains the meteorological register
kept by me while I lived in the desert:
		o. £		<i	
	6 J	6 • e		y	
					
					
Date.	S a	S? 1 ■	S	8	State of weather.
					
					
	J	S ■ S	e	O	
	o	° 1 °	O	o	
Mar. 1.	66	72 6	9		Gentle breeze, sunny.
u o	6.)	74 ' 5	4		Do. do. do.
" 3.	68	75 7	0	0	Fog.
" 4.	68	76 8	6		Calm and sunny.
" 5.	71	74 3		2	Haze.
" 6.	69	72 3	6		Cloudy and sunny.
" 7.	65	69 4	6		Drops of rain.
  " In a city like Cairo, with a dense population of more
than  two hundred thousand  people,  and with narrow
streets walled in by lofty houses, and constantly watered
to lay the dust, the air can neither he so pure nor so dry
as in the desert.  Accordingly, tne medical gentlemen of
Cairo are in the habit of sending almost all their conva-
lescent patients to reside for some time in the adjoining
de.«crt, to enjoy the benefit of its invigorating air.  In it
there is no water, either running or stagnant, to produce
humidity by evaporation, nor is there any decaying mat-
ter, either vegetable or animal, to taint the air with nox-
ious exhalations.  It is in the desert, therefore, that the
qualities of warmth,  equability, dryness, and purity,
which are characteristic of the Egyptian climate in gen-
eral, are to be found in the most perfect union.  The
	o.	6.	i		
	8j	su	g		
					
Date.	« °	st.	«	?	State of weather.
		■a «		b£	
					
	►J	X	a	Q	
	0	°	o	o	
Mar. 13.	63	69	6	10	High wind.
" 14.	63	70	7	12	Bright sunshine.
" 15.	63	6S	5	12	Do.
" 16.	63	68	5	13	Do.
" 17.	63	67	4	13	Do.
" 18.	63	70	7	12	Do.
" 19.	63	73	10	14	Do.
" 20.	67	72	5	17	Do.
" 21.	63	70	7	18	Do.
" 22.	63	71	8	18	Do.
" 23.	66	76	10	19	Do.
" 24.	71	76	5	16	Cloudy.
" 25.	67	71	4	10	Do.
" 26.	63	71	8	13	Bright sunshine.
" 27.	63	71	8	12	Do.
" 28.	64	73	9-	11	Do.
» 29.	63	74	11	15	Do.
" 30.	63	71	8	12	Do.
" 31.	66	71	5	12	Cloudy.
April 1.	6i	81	14	23	Khamseen.
" 2.	67	72	5	10	Cloudy and blowing.
" 3.	65	72	7	11	Bright sunshine.
" 4.	68	71	3	12	Do.
" 5.	65	71	6	16	Do.
" 6.	65	75	ia	18	Do.
" 7.	64	70	6	3	Rain.
" 8.	65	71	6	10	Bright sunshine.
  "The only other place in Egypt whose meteorology it
seems necessary to  notice is Alexandria.  When it is
borne in mind that this city is surrounded on three eid' s
by the Mediterranean Sea, and that on the land side it is
enveloped by the Lake  Mareotis, a moist atmosphere
may be expected, and accordingly the degree of humid-
ity indicated in the following extract from my register is
excessive.  In this respect the state of the atmosphere in
Alexandria, during the early part of May, will  be found
to contrast remarkably with that of Cairo and its vicinity
during the latter part of April; while the greater equa-
bility of temperature in  the former city, both from day
to day and during the twenty-four hours, is no less ob- ,
Bervable: 
1284
TUBERCULAR CONSUMPTION—Diet, etc, in.
   422. The diet in phthisis has been already dis-
cussed in general terms, and chiefly with respect
to my own experience (§ 299-301), but a few au-
thorities and particulars may be farther adduced at
this place.—a. Hippocrates advised, for phthisis,
animal food to be taken in  small  quantity, and
often, when fever is  absent;  and the opinion has
been followed by Salvadori, May, Rush, Vogel,
Rollo, and Kinglake.   Animal  fats, marrow,
and fat meats were recommended by Lange and
Bertin.  The circumstances in which these may
be adopted  have been stated above (y 299-301).
   [Many physicians ofthe  present day make but
little if any discrimination in prescribing the diet
and regimen of phthisical  patients.  The direc-
tions are to eat beef-steak,  mutton, fat ham, but-
ter,  cream,  and  drink porter, ale, brandy, using
I Place and | Date.	9St temp. night. est temp. day.		y 1 . 1 d. = 1" §			State of weather.
	J 5		6 "> S,			
Cairo.	O 1 0		l\t-			
April 19.	63 70					r
" 20. " 21.	67 ! 70 66 i 1-t.		3 5 .. 6 5.			A gentle breath of
" 22	67	7'}	51 41- -			wind and bright sun-
" 23.	69	74	5 9			< shine by day. Always ,
" 24.	70	77	7i 9			calm towards evening
" 25.	75	79	4 5			and during the night.
" 26.	72	75	3	4		_
Alexandria.						
April 28	70	73	3 ..		10	Sunshine and calm.
" 29	70	73	3i..		13	Do.
" ro	71	73	2l..		12	Do.
Mav 1.	72	74	2 ..		15	Do.
" 2.	72	74	2 ..		14	Do.
" 3.	73	75	2 ..		15	Do.
" 4.	72	74	'.'.'..		14	Do.
" 5.	73	76	3 ..		15	Do.
  "How far Alexandria, during the months of March and
April, may be a more suitable residence than Madeira or
Italy for those whose complaints require a climate  at
once warm, equable, and moist, I leave it to gentlemen
of the medical profession to judge;  but I do think my-
self fully warranted to denounce it as a most unsuitable
place for a bronchitic  patient.   During  all the  time I
was there I felt as if inhaling steam; my breathing was
excessively affected,  and  my whole system was languid
and relaxed.  These effects, however, by the time I had
been twenty-four hours at sea, were completely dispelled,
leaving no doubt whatever as to their cause.
  "I may add that dyspepsia is very prevalent among
the European residents in Alexandria; and I was inform-
ed that cases of pulmonary consumption, though not com-
mon, do occasionally occur  among  the  natives  of the
whole northern sea-board of Egypt; but the inhabitants
of Middle  and Upper Egypt, as far as I could learn, are
entirely exempted from that fatal disease.  The prevail-
ing maladies throughout all  Egypt are  dysentery and
ophthalmia, both induced, it is believed, by exposure of
the heated frame to currents of cold air.
  " These observations on the subject of Egyptian cli-
mate would be very incomplete if I failed to notice its in-
fluence in arresting haemoptysis.  Several  instances of its
efficacy in that respect were mentioned to me, and one
very decided case fell under my own observation.  A. B.,
a middle-aged gentleman, of a clear and florid complex-
ion, had been for years afflicted with this complaint to an
alarming extent.  He had spent a winter in Italy with-
out experiencing the smallest mitigation of his ailment.
He had next been sent to Madeira, and there the malady
was very greatly aggravated.   He was at Malta when I
went to  Egypt; but  finding no relief there, he came to
Cairo in the end of December, and took up his abode at
the hotel at which I lodged.   The effect  of the change
of climate was immediate. The spitting of blood ceased
at once,  nor did it ever recur during his stay at Cairo,
which was prolonged till the end of April.  He then
went to the south of Spain, and remained there till the
month of June, when he returned to England, apparently
in perfect health, and fully resolved to spend the whole
of the following winter in Egypt with the view of con-
firming his cure.
  " The transition  from the climate of Egypt to that of
all the exercise possible in the open air;  forget-
ting that the  diet  of consumptives  must, as in
oth"er diseases, be regulated by  the stage of dis-
ease and the  circumstances of each  particular
case; in the early stages enjoining usually a mild-
er diet, especially in cases complicated, as it often
is, with  inflammation.   If  the patient is able to
take active  out-door exercise, the food may be of
a more  nourishing  quality, and in larger quan-
tity, than if confined to the house ; but we have
almost invariably  found that  if the  patient was
chiefly confined in-doors, a rich diet  of animal
food excited fever, and aggravated the cough and
other symptoms.   Carbonaceous matters, how-
ever, must  be  supplied in  sufficient quantity to
combine with the oxygen taken in, otherwise the
waste and loss of weight will be rapid.  Sir James
 Britain is too violent to be hazarded by one whose respi-
 ratory organs are in a  delicate or dubious condition, es-
 pecially as the season at which it is necessary to quit the
 one country is far from being genial  in the other.  I
 therefore stopped in Spain on my homeward passage, and
 spent the latter part of May and the greater part of June
 in that country and in Portugal.  Having heard that the
 air of Malaga was remarkable for its mildness, I repaired
 thither, and was both delighted and surprised to find in
 Europe a climate scarcely inferior in any respect to that
 of the latitude of Cairo.   The register I kept while there,
 and from which J subjoin an extract, shows  a tempera-
 ture which  was probably only a few degrees lower than
 that of Cairo at the same date, while its equability  was
 greater than  I had noted any where except  at Alexan-
 dria ;  and, what is still more remarkable, the dryness of
 its atmosphere exceeds that of Cairo, and contrasts  sur-
 prisingly with the humidity with which the air of Alex-
 andria is loaded.
  '' The atmospheric conditions indicated by the following
 table are doubtless to be referred, partly to the geologic-
 al structure and the physical conformation ofthe country
 around Malaga, and partly to the latitude in  which it is
 situated.  I am persuaded that,  in a therapeutic point
 of view, the climate in this part of Andalusia is deserving
 of more attention than it seems hitherto to have received.
 Those who  take it for granted that the  climate of Italy
 must be the mildest and warmest in Europe seem to  for-
 get that Malaga is 248  miles farther south than Naples,
 318 miles farther south than  Rome, and 518 miles farther
 south than Venice; and those who have not adverted to
 the fact will probably  be surprised to find that it is 5
 mile3 farther south than Algiers.  Both Gibraltar and
 Cadiz are somewhat south of Malaga, but both have a
 great diurnal range of temperature, and  are nearly equal
 to Alexandria in the humidity of their  atmosphere,  the
one standing on an almost insulated rock in the Medi-
terranean Sea, and  the  other on  a narrow  spur of land
projecting into the Atlantic Ocean.
	n,		«		
	r, ,.■	ri .		fr	
Date.	~T/.	^•v	S	•a	
	%2	fi-°	t	u	
		s	a	a	
		o	o	o	
May 20.	70	72	2	9	Bright sunshine.
" 21.	10	'l'i	3	12	Do.
	71	73	2	12	Do.
" 23.	69	72	3	11	Rain.
" 24.	67	70	3	10	Do.
" 25.	66	69	3	10	Do.
" 26. " 27.	6S 69	70 72	2 3	14 16	Bright sunshine. Do.
" 2 s.	69	73	4	15	Do.
" 29.	69	73	4	16	Do.
" 30.	69	72	3	16	- Do- 1
    In the beginning of June I moved northward to Lis-
bon, but on its climate 2nd that of delightful Cintra no
information is needed.  In the end of June, 1853, I re-
turned to Scotland; and though I was threatened soon
after I reached home  with  a  recurrence of bronchitic
symptoms, these now yielded readily to medical treat-
Z* w  tam,most thankful to be able to add that during
nor iavo i tlT^tht I *iave enJ°yed e«ellent health,
nor have I been affected during that time by any of the

ieet Se8riW™"'V0 y£Sch  our variable cl^ate is sub-
£« n^  Climate of Egypt, by the Rev. Thomas Bad-
clay, D.D. 8vo.  Edinburgh, 1854           *°x""»- 
TUBERCULAR  CONSUMPTION—Bibliography  and References.         1285
Clark is of opinion that " the cases likely to be
cured by the  stimulating  plan of treatment—by
beef-steaks and porter—bear a very small propor-
tion to  those  who are injured by it."—Art." Tu-
bercular Phthisis," Cyclop. Pract. Med., Am.  ed.,
p. 570.   This statement  will hardly  hold good,
perhaps, when applied to the disease  among us,
although we are satisfied that more discrimination
should be used in regard to the diet  prescribed,
and that injury is often done from neglect of due
caution  on this subject.]
   6. A  fish diet is often of service, especially in
the more chronic and hemorrhagic states, or when
the biliary organs are congested ; but on all oc-
casions  the white kinds of fish should be select-
ed, and always be boiled.    Oysters were praised
by Tulpius and  Sims, but they ought to be taken
immediately upon being opened, and a small num-
ber only at one time.
   c.  Vegetable food has been advised by many
writers in preference  to any other, while as many
recommend a due proportion of animal and veg-
etable diet.  Of the more unusual articles, at least
in this climate, new figs, dates, the nuts yielding
the palm oil,  olives, &c, are the most likely to be
of service.  Grapes,  both recent and  dried, were
praised  by Riverius ;  pickled red-cabbage  by
Lange ;  and cucumbers, with vinegar and sugar,
by Schmalz, Frize,  Quarin, Marx ;  but these
last should be thus dressed without having  had
their outer rinds removed.   Of oranges, lemons,
limes, &c, the utility is manifest.
   423.  d. Milk has always  received great com-
mendation in phthisis, but  writers have differed
respecting that which is most beneficial.  Thus
Zacutus Lusitanus  and  Blegny prefer  human
milk;  Aret^eus, Burserius, and  Stoll, asses'
milk;   Diemerbroeck  and  Velschius, goats'
milk; Schenck, either asses'or goats'milk; Hip-
pocrates, either mares' or asses' milk ;  and Heis-
ter, the whey of cows' milk.  Stoll considered
that asses' and human milk should be diluted,  and
that they are injurious in the inflammatory com-
plications and in the last stage of the malady.
Whatever may be the diet and regimen adopted,
milk of various kinds, in suitable forms and states
of dilution, constitutes  an important part of the
treatment of phthisis.
   424.   e.  The  beverages  allowed the patient
should depend on the form  and stage of phthisis.
In an early stage whey is one ofthe best that  can
be taken.   At a far-advanced stage, or if diarrhoea
be present, it  is apt  to run off by the  bowels.
Fermented whey, or serum of milk, or the whey
of butter-milk, or recent butter-milk, may be given
according to circumstances.   In northern or Scan-
dinavian countries, and also among the Tartars,
the fermented serum  of milk is very  commonly
employed, and it has been recommended by Sie-
vers and others.   Spruce-beer is one  of the best
beverages that can be used ; weak tar-water is
also sometimes  beneficial.   Seltzer-water, with
milk, and lime-water or Carara-water, with milk,
when the  bowels are  much relaxed, are  also  of
service.
  425. /. In  recommendation  of exercise  in  the
open day, according to the strength and state of
the patient, it is unnecessary to add any thing to
what has already been  stated.  Of all kinds of
exercise, walking and horse-exercise are the best.
Although the latter was considered of little use
by Quarin, yet by Sydenham, Haller, Marx,
Darwin, and  others mentioned in the historical
sketch  (y214, et seq.), it was strongly recom-
mended.   Stoll advised it in the non-inflamma-
tory states, and when the abdominal viscera were
torpid or congested.   In the inflammatory com-
plications, active exercise, either on horseback or
otherwise, can  rarely be taken.
   426.  In concluding the above imperfect view
of the treatment of phthisis, it will be manifest
that no one plan of cure, class of medicines, kind
of diet, or regimen—no single method, whether
medicinal or regimenal, or both, is appropriate to
all cases, or even to the great  majority of cases,
of phthisis.   The rational physician, after having
endeavoured to ascertain the existing morbid con-
ditions, will merely select and combine, from the
stores above indicated, such means as he believes
to be most energetic in arresting, counteracting,
or removing  these  conditions, as far as circum-
stances may warrant the attempt or may promise
success.
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Treat, on Febrile Disease.-, 4 vols., Svo.  London, 1804,
iv., p. 460.— E. Peart, on Consump. of the^Lungs, with a
New Mode of Treatment, 8vo.   Lond., 1S03.— \\. Lambe,
Inquiry into the Origin, &c, of Constitutional Diseases,
especially Scrofula, Consumption, &c, 8vo.  Lond., 1S05.
—J. J. Busche, Untersuchungen ueber die Naturder Lun-
genscwindsucht, 8vo.  Duisb., 1805, et neber die nervose
Lungensucht, Svo.  Strasb., 1S07.—.P. G. Parrot, Physi-
calische Theorie der Schwindsucht, 8vo.  Dorpat, 1807.
—A. Weinholdt, Abhandlung ucber die Ansteckung der
Schwindsucht, Svo.   Brem., 1807.— M. Briende, Traito de
la Phthisie Pulmonaire, 2  tomes, Svo.  Paris, 1808.—J.
B. Demalet, Sur la Nature et le Traitement de la Phthisie
Pulmonaire, 8vo.   Paris, 1804. — Giraudy, Manuel de
Pht.hisiqucs.  Paris, 1804.—R. Bourne, Cases of Pulmo-
nary Consumption treated with Uva Ursi, Svo.  Oxford,
1805.—Salmade, sur la Contagion de la Phthisie.  Paris,
1805, — J. Reid, Treat, on the Origin, Progress, Preven-
tion, and Treatment of Consumption, 12mo.   London,
1806. — Wichelhausen, Ueber die Lungensucht   Manh.,
1S06. — W. Hamilton, Observ. on the Preparation, Utili-
ty, and  Administration  of Digitalis, Svo.  Lond., 1S07,
p. 61, 70-103__J. Sanders, Treat,  on Pulm. Consumpt.
and on the Medical Properties  of Digitalis, 8vo.  Edin.,
1808, p.  126.—W.  Woolcombc, on the  Frequency and Fa-
tality of different Diseases, and on the Increase of Con-
sumpt, &c, Svo.  Lond., 1808.—B. Gatpard, Recherches
Pathologiques sur les Phthisies, 8vo.   Chalons, 1809.— C.
Badham, Observ. on Inflammatory Affections of the Muc
Mem. ofthe Bronchise,  12mo.  Lond., 1S0S. —  R. Watt,
Cases of Diabetes, Consumption, &c, &c, 8vo.   Paislev,
1808.—J.  Russell, Treatise  on Scrofula, Svo ed., 180S, p.
39-116.—A. Portal, Mem. sur la Nature et le Traitement
de  Plusieurs Maladies,  3 vols., 8vo.   Paris, i.,  248 ; ii.,
p. 70, et sur la Nat. et Traitement de la Phthisie Pulmo-
naire, 2 vols., 8vo.   Paris, 1809.—B. Parr, London Med.
Dictionary, 2 vols.,  4to.   Lond., 1809, ii., 396.— J. Bux-
ton, Essay on the Use  of  a regulated  Temperature in
Winter Cough and Consumption, 12mo.  Lond., 1S10.—
W. Shearman, on Amenorrhoea as a cause of Consumption,
in Edin. Med. and Surg. Journ., vi., p. 75.—G. L. Beyle,
Recherches  sur la  Phthisie Pulmonaire,  Svo.   Paris,
1810.—J. B. Cayol, Recherches sur la Phthisie Trachealc,
4to. Paris, 1S10.— Wells, in Trans, of Soc.  for Improve-
ment of Medical and Chirurg. Knowledge,  iii.,  p. 471.—
Roberts, Med. Trans, of Coll. of Phys., v.  iv.,  p. 119.—
A. Duncan, Observ. on  the Symptoms of three  different
Species  of Pulmonary Consumption, 8vo.  Edin., 1813.
—T. Turton, Observ. on Consumption, &c, 8vo.   Lond.,
1812. — G. Rees, I'ractical Treatise on Haemoptysis, Svo.
Lond., 1813.—C. Pears,  Observations on the Nature and
Treatment of Consumption, 8vo.   Lond., 1814—H. H.
Southey, Observations on Pulmonary Consumption, Svo.
Lond., 1814. — T.  Young, a  Pract. and Historical Treat.
on Consumptive Diseases, &c, 8vo.   Lond., 1815.—J". A.
Gallup, Sketches of Epidemic Diseases in Vermont, with
Remarks on Pulmonary Consumption, Svo.  Bost, 1815.
— IP. Lambe, Addit. Reports of the Effects of a peculiar
Regimen  in Constitutional Diseases, &c, 8vo.   Loudon,
1S15.—H. H. Tullidge, Inquiry into the Nature  of Pulm.
Consumption, 8vo.   Lond., 1817.  — Lanthois, Theorie
Nouvelle de la Phthisie  Pulmonaire, Svo.  Paris, 1818.—
J. G. Mansford, an Inquiry into the Influence  of Situa-
tion on Pulmonary Consumption, Svo.   Lond., 1818.— F.
Magendie, Recherches sur l'Emploi de l'Acide Prussique
dans le  Traitement des Maladies de  Poitrine, &c, 8vo.
Paris, 1819.—T. A. Walther, Ueber das Wesen der Phthvs-
ischen Constitutionund  der Phthysis, 2 Bie., Svo.  Leip'z.,
1819-23.—D. A. G. Richter, die Specielle Therapie, &c,
B. iv., p. 588, et seq.—Cheyne, in Dublin Hosp.  Reports,
vol. v.   (Small Bleedings early in Phthisis.)—Hosack, in
American Med. and Philosoph. Register, vol. ii., p. 470.
(Small Bleedings.)—Baron, Notes on the Use of Iodine,
Midland Med. and Surg. Reporter, vol. i., p. 241.— Aber-
cromby  on the Pathology of Consumptive Diseases, in
Edin. Medical and Surg. Journ., vols. xvii. and xviii.—
Andral,  Archives  Gener. de  Medecine, t. ii., p. 205.
(Cases of rapid Phthisis.) — Roques, in  Nouv. Journ. de
d^V • •  lv-' f }51;   (The Use °f Tobacco as a Cause of
Phthisis.)—Andral, in Revue M.dicale, t. ii., 1825, p. 45.
—Several Authors, Review  of, in Medico-Chirurg. Rev.,
N,°ri3' P-.9T--41—,r- Stokes, in Trans, of  Irish College
of Physicians, vol. v., p. 303.-Storer, in Trans, of Med.
and Chirurgical Society  of Edin., vol.  iii., p 613 —P W
Philip, Trans, of Med. and Chirurg. Society, voi  vii' p' 
BIBLIOGRAPHY  AND  REFERENCES.                        1287
494. — A. B. Granville, a Historical and Pract. Treatise
on Hydrocyanic Acid in Consump., 2d ed., 8vo.  Lond.,
1820.—Maygrier, in Diet  des Sciences Medicales, t. xlii.
,Paris, 1820,  art. Phthisie Pulmonarie. — K.  A. Kock,
Darstellung des Verlaufs der Ursachen, &c, der Schwind-
suchten, 8vo.  Leipz., 1822. — A. Crichton,  Pract. Obs.
on the Treatment and Cure of the Varieties of Pulmon.
Consumption, and on the Effects of Tar Vapour in that
Disease, 8vo.   Lond.,  1823. — G. F. Weber, Grundzuge
der Consumtions-Krankheiten des Lungen-Organs, Svo.
Giessen., 1823. —J. F. Engelhard,  die Lungensucht in
ihren verschiedenen Formen und Zeitriinmen, 8vo.   Au-
ran, 1823.—Andral, Diet de Med., t. xvi., art. Phthisie.
—P.  C. A. Louis, Recherches Anatomico-Pathologiques
sur la Phthisie; translated from the 2d edition, by W. H.
 Walshe, for the Sydenham Society, Svo.  Lond., 1844.—
A. Hammersley, Dissert on the Remote and Proximate
Causes of Phthisis Pulmonalis, 2d edition, 12mo.   New
York, 1827.—J. Clark,  the Influence of Climate in the
Prevention and Cure of Chronic  Diseases, more particu-
larly of the Chest and Digestive Organs, &c, 2d ed., 8vo.
Lond., 1S30.—J. Murray, Treatise  on Pulmonary Con-
sumption, 8vo.  Lond., 1830.—E. Blackmore, a Practical
Treatise on Pulmonary Consumpt,  8vo.   Lond.. 1832.—
Carswell, in Cyclop, of Pract. Med., vol. iv.,  p. 253; and
Illustrations  of the Elementary Forms of Disease,  Fasc.
Tubercle.—J. Clark, Cyclop, of Practical  Medicine, vol.
iv., p. 272; and a Treatise on Pulmonary Consumption,
&c, 8vo.  Lond., 1S35.—Pagenstecher, Jour, des Progres
des Scien. Med., t. viii.,  p. 270. — R.  T. H. Laennec, a
Treatise on  the Diseases of the Chest, and  on Mediate
Auscultation, translated,  with Notes, &c, by J.  Forbes,
3d ed., 8vo.  Lond., 1829.—Cruveilhier, Archives Gener.
de Med., t. xviii., p. 293. —M. E. A. Naumann, Hand-
buch der Medicinischen  Klinik, 8vo.   Berl. 1829,  B. i.,
p. 660, et seq. — W. Stokes, a Treatise on  the Diagnosis
and Treatment of Diseases of the Chest, part  i.; Diseases
of the Lung and Windpipe, 8vo.  Dubl., 1838.—T. Da-
viss,  Lectures on the Diseases of the Lungs and Heart,
Svo.   Lond., 1835, p. 251, et seq. — T. Watson, Lectures
on the Principles and Practice of Physic, &c, 2 vols., 8vo.
Lond., 3d ed.,  1848, vol. ii., 177, et seq.—J. D. Morton,
Illustrations  of Pulmonary Consumption, 8vo.   Philad.,
1S34.—Bardsley, Hospital  Facts and Observations, p. 123.
—C. J. B. Williams, the  Pathology and Diagnosis of Dis-
eases of the Chest, &c,  3d ed., 8vo.   Lond.,  1835.—Rey-
vaud. Journal  Hebdomadaire  de Med., t. vii., p.  61.—
Lombard, Archives Gener. de Medecine, t. xxv., p.  60.—
Sasche, in Amer. Journ. of Med. Sciences, t. vi., p. 161.
— H. Roe, Lancet, Dec. 30, 1S37, p.  479. — D'Espine, in
Med. Chirurg.  Review, vol. xxviii., p. 270.—Bricheteau,
in Ibid.,  vol. xxviii., p. 264.—Costallat, in Ibid., vol.
xxviii., p. 267.—Home, in Edin. Med. and Surg. Journ.,
Jan., 1838, p. 1.—Fournet, in British and Foreign  Med.
Review, vol.  vi., p. 534. —Archibald Smith,  on the Dis-
eases of Peru, &c, in Edin. Med. and Surg.  Journ., vol.
liv., p. 6. — C.  E. Hasse, an Anatomical Description of
the Diseases ofthe Organs of Circulation and Respiration,
transl. by W. E.  Swaine,  Svo.   Lond., 1846.—P. Blakis-
ton, Practical Observations on Certain Diseases of the
Chest, and on the Principles of Auscultation, 8vo.  Lond.,
184 >, p. 283,  et seq.  (Many interesting Cases, and much
valuable Matter.)—S. Flood, an Exposition ofthe Pathol.
and Treat, of Tubercular Phthisis, 12mo.  Lond.,  1842.
— W. II. Madden, Thoughts on Pulmonary Consumption,
with an Append, on the Climate of Torquay, 8vo.  Lond.,
1849.—H. Green, a Treatise on Diseases of the Air Pas-
sages, comprising an Inquiry into the History, Patholo-
gy, Causes, and Treatment of Affections of the Throat,
Larynx, &c,  8vo. New York, 1846, p. 120, et pluries.—
W. T. Gairdner, on the Pathol, and Treatm. of Phthisis,
in Edin. Med. and Surg. Journ., vol. lxxxi., p. 396.—P.
L. Gellerstedt, Bidrag till  den Tuberkulosa  Lungsotens
Nosograpbie  och Pathologi, 8vo.  Stockholm, 1844; re-
viewed in Brit, and  For. Medical Review, vol. xxiii., p.
429.—J. H. Bennett, a Treat, on the Oleum lecoris Aaelli,
or Cod-liver Oil, as a Therapeutic Agent in  certain Fornrt
of  Gout,  Rheumatism,  and Scrofula, with  Cases, 8vo.
Edin., 1841. — On the Spontaneous  Cure of Pulmonary
Consumption, and the Indications for its Rational Treat-
ment, in Kdin. Med. and  Surg. Journal, 1845.—Also on
the Pathology  and Treatment of Pulmonary  Tubercu-
losis, and on the Local Medication of Pharyngeal  and
Laryngeal Diseases frequently mistaken for or associated
with Phthisis, Svo.   Edin., 1853; also various papers on
Tubercular Consumption in London and Edin. Monthly
Journal of Med. Science in 1842, 1849, 1850, and 1852.—
The Physicians, the First Report of the Hospital for Con-
sumption and Diseases of the Chest, &c, Svo.   Lond.,
1849.— J. Turnbull, an Inquiry how far Consumption is
Curable, with Observ. on  the Treatment and the Use of
Cod-liver Oil, &c, 2d ed., 8vo.  Lond., 1860. — W. M.
Burslem,  Pulmonary Consumption  and its  Treatment,
8vo.  Lond.,  1852. — T. Barclay, the Climate of Egypt,
&c, in Edin. Med. and  Surg. Journ., October, 1864.  (I
consider the account of the Climate of Egypt, Malaga,
tt-c., by my very eminent and able friend, so valuable to
the Medical Profession and Consumptive Patients, as to
induce me to give it above [p. 1282-1284] almost entire.)—
H. Ancell, a Treatise on Tuberculosis, the Constitutional
Origin of Consumption and Scrofula, 8vo.  Lond., 1852.
—R. P. Cotton,  the Nature, Symptoms, and Treatment
of Consumption, &c, Svo.  Lond., 1852. —J. Skoda, a
Treatise on Auscultation and Percussion, translated by
 W. O. Markam, Svo.  Lond., 1853.— J. Spurgin, the Phy-
sician  for  all,  his Philosophy, bis  Experience, and his
Mission, Svo.   Lond., 1855, p. 221.—T. Thompson, Clin-
ical  Lectures on Pulmonary Consumption, 8vo.  Lond.,
1855.—A. Clark, Microscopic Appearances of Expectora-
tion in  Phthisis, in Transact, of the  Pathological Society
of London, vol. vi., p. 74,  1855. — H. M'Cormac, on the
Nature, Treatment, and  Prevention of Pulmonary Con-
sumption, and  incidentally of Scrofula, with a Demon-
stration of the Cause of the Disease, Svo.  Loud., 18f:5.
(See also Bibliog.  and Refer, to art. on Scrofula and
Ttjbekcles.).
   [Am.  Biuliog. and  Refer.—Samuel G. Morton, Illus-
trations of Pulm.  Consumption, its Anatomical Charac-
ters, Causes, Symptoms, and Treatment, to which are
added some Remarks on the Climate ofthe United States,
the West Indies, &c,  with 13 col'd plates, 8vo.  Philad.,
1837 (one of the best works on this subject). — Benjamin
Rush, Medical Inquiries and Observations, 4 vols, in 2,
5th ed.   Phil., 1819.   Dr. Rush recommends particularly
long journeys on horseback for the cure of this disease;
also, in particular cases, stimulants  and tonics,  as co-
 paiva,  bals. Peru, oil  amber, turpentine, tar, garlic, elix.
vitriol,  dandelion, horehound, wild cherry bark, cinchona
bark, cold bath, &c.; also a cordial and stimulating diet,
dry air in elevated situations, remote from the sea in all
cases; appropriate clothing, blisters, and issues in the in-
flammatory stage, moderate use of the lungs, salivation,
and in  some cases bleeding,  For cough, demulcent teas,
sirups  and lozenges, opiates, tar vapour, &c ;  for night
sweats,  elix. vit. and lime-water;  for diarrhoea, chalk ju-
lep, with tinct.  opii and tinct. cinnamon, and astringent
injections.   The above are called palliatives.  The rad-
ical remedy is long-continued horseback exercise.— Wm.
Sueetser, a Treatise on Consumption, embracing an In-
quiry into  the Influence exerted upon it by Journeys,
Voyages, and Change of Climate, with Directions for the
Consumptive visiting the South of Europe, and Remarks
upon its Climate, 8vo.  Bost, 1836, p. 2C4.   This  work,
adapted for general reading, is written in a pure classical
style, and is one of the most instructive  on this subject
in our  language.  The remarks  on the best modes of
prevention and the climate of different places in Southern
Europe, the result of the author's personal observations,
are worthy of the particular attention of the American
reader.—John Bell and W.  Stokes, Lectures on the The-
ory and Practice of Physic, 2 vols., 8vo.   Phil., 1848,4th
edition. Dr. Bell has embodied a vast amount of facts
and  personal observations in  regard  to this  disease in
6even lectures devoted to it, which may be found  in th.'
2d vol.   The treatment recommended  is judicious, and
in accordance  with the present  prevailing  doctrines on
this subject.—Parish,  North Am. Med. and Surg. Journ..
vol. viii.  Dr. P., following in the footsteps of Dr. Rush,
recommends  the tubercular invalid "to rough it"  on
horseback, on long journeys and in all kinds of weather,
as the principal mode of cure.—Samuel Forry, The Cli-
mate of the United States and its Endemic Influences,
8vo.   New York, 1842.—Horace Green, a Treat, on Dis-
eases of the Air Passages, Svo.  N. Y., 1S46; also Report
on the Use and  Effect of Applications of Nitrate of  Silver
to the Throat, either in  local or  general disease, Trans.
of Am. Mud. Assoc, 1856; also Am. Med. Month, for Jan.,
1855, and March, 1856, and Trans, of N. Y. State Med.
Soc, 1855, &c.—Lemuel Shattuck, Report of the Sanitary
Commission of Massachusetts, 1850, Svo.  Mr. S. has em-
bodied in his report some very interesting facts in regard
to the prevalence of consumption in Massachusetts.  He
shows from the statistical reports that the seasons do not
exert much influence  upon the  disease, especially its
terminating period.  In four years, from 1845-S, there
were 3443 males and 5384 females died of this disease in
Massachusetts,  of whom 533 females were under 15, and
464 males;  over 60, 916 females, 753 males; from 20 to 30
the number of females who perish from it is nearly double
that of the males.  In the country towns the proportion
of the sexes is as 39.01 males to 60.99 females; in New
York city, as 42.08 to  57.92.  What are the  peculiar
causes affecting females in the country predisposing them
to the disease'/   The proportion of deaths from phthisis
in the western counties does not vary much from that on
the sea-coast, being 1 in 3.92 in Barnstable county, to 1
in 5.43 in Berkshire.  As 5.935, one tenth of the whole,
are returned without  a  specified  cause, the proportion
of deaths from  consumption in Massachusetts must be
somewhat greater than the above (loc. tit).—H. Huntt, 
1288                       BIBLIOGRAPHY AND  REFERENCES.
 Observ. on a Change of Climate in Pulm. Consumption,
 North American Med. and Surg. Journ., vol. i., J>. 2S2—
 Ttiomas Henderson, Cases of Pulm. Consumption, Am.
 Journ. of Med. Science, vol. viii.—A". S. Davis, in Trans.
 of Illinois Med. Soc, 1856, on Alcoholic Liquors in Tub.
 Consumption. — Win. M. Fahnedock,  in Am. Journ.  of
 Med. Sci., vol. v., p. 306. —John Spence, Case of Pulm.
 Consumption, showing the Influence of a Sea Voyage on
 that Disease, in Ibid., vol. ii.—G.  W. Stedman, Case of
 Tub. Consumption, in which  milky urine was voided, in
 Ibid., vol. ii., p. 295.—James Stewart, on the Lungs and
 their Diseases.  New York,  1849.   In this small work
 Dr. Stewart shows that in all classes of animals there is
 found a certain relation between the composition of the
 body and the development of the apparatus of respira-
 tion, which explains very clearly the production of scrof-
 ula and tubercle by breathing too  little  or too foul air.
 He shows that in the lowest form of organization albumen
 predominates greatly over all other animalized substan-
 ces, the proportion being diminished as animals rise in
 the scale of being.  In those of the lowest organization
 respiration is least  active, and  as they rise in the  scale
 respiration becomes more and more elaborate; so that the
 greater the proportion of albumen in the animal, the less
 important is the function of respiration, and the less the
 proportion, the more  complicated, more  developed, and
 more important is this function.  Now, as tubercle and
 scrofula consist almost wholly of albumen, Dr. S. supposes
 that from a want of sufficient oxygen, where too little air
 is respired, or from  inhaling an impure air, the albumen
 is not converted into healthy animal tissue, but deposited
 in the lungs,  glands, &c, in its nearly pure form, consti-
 tuting tubercular or scrofulous disease.  Hence the dele-
 terious influence of certain occupations which restrict the
 movements  of the  chest, as  tailoring, engraving, shoe-
 making, &c, as well as tight  lacing.—John H. Griscom,
 The Use and Abuses of Air, 12mo.  N. Y, 1850, p. 249.
 In this work Dr. G.  has most ably pointed out the influ-
 ence of air in sustaining life and producing disease, with
 remarks on the ventilation of houses, and the best meth-
 ods of securing a pure and wholesome atmosphere inside
 of dwellings, churches, court-rooms, workshops, and build-
 ings of all kinds.—Samuel Henry Dickson, Essays on Pa-
 thology and Therapeutics, 2 vols., Svo.  Charleston, 1845.
 —Austin Flint, Physical  Exploration and  Diagnosis of
 Diseases  affecting the Respiratory  Organs, 8vo, p.  636.
 Philad., 1S56.  The ablest work on  the subject yet pub-
 lished ; also Prize Essay " on Variations of Pitch," Trans.
 Am. Med. Asso., 1854.—George B. Wood, a Treatise on the
 Practice of Medicine, 2 vols., 8vo. Phil., 1847.— Meredith
 Clymer, Notes and Additions to "A  Practical Treatise on
 the  Diseases ofthe Respiratory Organs," &c, by C.J. B.
 WiUiams, 8vo.  Phil,, 1845. —Henry J. Bowdiich, " Re-
 visions and Alterations" of Pathological Researches on
 Phthisis, by  P. Ch. A. Louis, 8vo.   Bost, 1836; and the
 Young Stethoscopist, Cases of Anomalous  Development
 of Tubercles, &c, Am. Med.  Monthly, N.Y.,1855 (1 to 150
at base of lung).—Robley DungUson,  The Pract. of Med.,
 &c, 2 vols.,  8vo.  Phil., 1848.—Notes  to Am. edition of
 Cyclopedia of Practical Medicine.   Phila., 4 vols., 8vo;
 and "Human Health," &c, &c.—D. F. Condie, Notes  to
 Watson's Practice of Physic,  octavo.  Phil., 1844.—O.
 W. Holmes, Notes to Am. ed. of Marshall  Hall's Pract
 of Medicine,  8vo.  Bost., 1S45.—X.  Chapman, Lectures
 on the more  important Diseases of the Abdom. Viscera,
 Svo.   Phil., 1S45. —John A. Swett, on Dis.  of the Chest,
 Svo.   N.  Y., 1850.   Cases of Thoracic  Disease in which
 the  diagnosis was attended  with unusual difficulties, in
 New York Journal of Med., July, 1845.—David Hosack,
 Lectures  on the Practice of Medicine, 8vo.   New York;
 and in Am. Med. and Phil. Register, 4 vols.  New York,
 1813, '14, '15, '16.  Dr. Hosack was a strong advocate for
 bleeding, blistering,  and emetics, "in the first or inflam-
 matory stage," as he considered it, followed by mercurial
 salivation, and tonics in the  suppurative stage, in this
 respect following Dr. Rush. — George P.  Cammann and
 A. Clark, a New Mode of ascertaining the Dimensions,
 Form,  and Condition of Internal Organs by Percussion,
 in New York Journ. of Med., vol. iii., p. 62,1840.—R. L.
 Allen,  a  Historical, Critical, and Ther. Analysis of the
 principal Mineral Fountains at Saratoga Springs, togeth-
 er with General Directions for  their Use,  18mo,  p. 271.
 Saratoga, 1844.  Dr. A., though a resident at the Springs,
 remarks  as follows:  " I have  never seen a case where I
 thought there was even a degree of palliation produced
 by a use ofthe water in pulmonary  phthisis; but, on the
 contrary, always injurious, increasing all  the alarming
 symptoms of this  most  formidable disease."   Again:
 "My advice to all who are  labouring under the corrod-
 ing influence of this disease is, not to drink of any one
 of our mineral fountains, recently or remotely discovered
 and brought  into notice."—William A. McDowell, Some
 Physiological Evidences of the Curability of Tubercular
 Consumption, in New York Journ. of Med., vol. x., p. 32.
 Under the head of" Therapeutical Resources for Promot-
ing the Removal of Tubercles," Dr. McD. states that
"they must consist mainly of such articles as best pro-
mote the transformation of albumen ofthe blood into red
globules; and of these the most important are iron, aUn-
hoL naphtha, iodine, animal food, and common salt—W
H. Buford, on the Physiology of Exercise, Am. Journ  of
Med. ScieAce, vol. lix., 1855, p. 32. -J. P  Hall, Pulm.
Lesion treated  as  an event arising  in the I rogress  of
Constitutional  Decline under the Tubercular Diathesis,
in Ibid., July,  1S55, p. 50.—C. G. Comegys, on the Ltiol-
ogy and Curability of Phthisis Pulm., in Transact. Ohio
State Med. Soc, 1S55.—L. M. Lawson, Pract. Observat.
on the Diagnosis of Phthisis Pulmonalis, in Ibid,  lboo.
Dr. L.  doubts the existence of the supposed antagonism
between a miasmatic influence and the production of tu-
bercular diseases, and states that such diseases are not
infrequent in miasmatic districts.—Q. R. Grant, Report
to Am. Med. Asso. (in Trans, of Ibid., 1S53) on Epidemics
of Tennessee and Kentucky.  Dr. G. states that phthisis
pulmonalis is as common in  malarial as in non-malaria]
  One half of the 51 cases reported to have died of it oc-
 curred from July to October, the season when malaria is
 most prevalent."  He also remarks, that as far south as
 35th degree of latitude, in a region notoriously subject to
 malarial diseases, pneumonia and consumption occasion
 25 per cent, of the mortality. —D.  Drake, The Diseases
 of the Interior Valley of North Amer., 2 vols., Svo.  Cin.,
 1850.  (Dr. D.  also states .that " in  those regions where
 periodical fevers prevail, consumption is also a prevalent
 disease")—one of the most elaborate and able works on
 medicine ever published in our country. — W. A. Ham-
 mond, U. S. A., The Physiological Effects of Alcohol, &c.
 (As connected with the question of the use of alcohol in
 tuberculous diseases, the results of experiments on the
 healthy body  are  worthy of record in  this connexion.
 The chief  conclusions arrived at are, that alcohol  in-
 creases  the weight of the body by  retarding the meta-
 morphosis of the old tissues, promoting the formation of
 new, and limiting the consumption of fat.  Under the use
 of alcohol,  the carbonic acid and aqueous vapour given
 off in respiration were lessened in quantity, the amount
 of faeces diminished, the  quantity of urine reduced, and
 the urea, chlorine, and phos. and sulph. acids diminished
 in amount.)—D. D. Saunders and John C. Draper, on the
 Value of the Red  Line of the  Gum in  the Diagnosis of
 Consumption, New York  Journ. Med., Jan., 1867.  (The
 conclusions from an examination of several hundred cases
 of phthisis are: 1st, that the  red line, though it occurs
 frequently  in phthisis and chronic  blood diseases, is by
 no means characteristic  of them; 2d,  that in pregnant
 and recently delivered women the line occurs more fre-
 quently and better marked than in  any other cases; 3d,
 that age or sex exercises no influence on the existence of
 the line.)—S. B. Hunt, Editorial in Buffalo Med. Jour.,
 Nov., 1856, on  the Use of Alcohol in Phthisis.  (Dr.  H.
 advocates its use on the grounds that it is a carbonaceous
 food, that it stimulates the pancreatic secretion, that it
 acts as  a substitute for pancreatic juice, emulsionizing
 the fat in the stomach, and, lastly, that it improves the
 whole digestive function by its influence over the stom-
 ach, &c, through the cceliac plexus.) — George Barttett,
 Topical Treatment of the Respiratory  Passages, Boston
 Medical and Surg. Journal, 1850.—Jules Rochard, on the
 Influence of Sea Life and Warm Countries  on the Prog-
 ress of Pulmonary Phthisis, Am. Med. Monthly.  N. Y.,
 1856.  Dr. R., from much experience in the French Navy
 in various parts of the world, concludes that sea voyages
 accelerate  the  progress  of  pulmonary tuberculization
 much more frequently than they retard it; that it is a
 very common  disease among sailors, much more so, in-
 deed, than  in the army;  that phthisis progresses aboard
 ship much more rapidly than on  land.  He advises that
 young men threatened with phthisis should be interdict-
 ed the naval profession, and expresses  the  opinion that
 warm countries, especially within the  tropics, are very
 prejudicial  to consumptives, though there may be a few
 places on the confines of that region, and concentrated in
 a narrow space, which may be exceptions; and  that if
 change of climate ever does good in phthisis, it is in the
 first  stage. — W. W. Gerhard, Remarks on  Tuberculous
 Affections,  &c, Am. Journ. Med. Sci., N. S., vol.  xxi., p.
368.-4. Stille, Review of Fourcault on "Chronic Dis-
eases," in Am. Journ. Med. Science,  vol. x., N. S., p. 359.
—Charles Hildreth, on Cimicifuga and Iodiue in Phthisis
 Pulmonalis, in Ibid., vol. iv., N. S., p. 281.—T. B. S. Jack-
son,in New England Quart. Journ.  of Med. and Surg.,
 1842.  Dissections of 604 cases of persons dying of  all
diseases in 10 years in Boston.  Dr. J. states that intem-
perance  does not appear to develop phthisis, and that of
35 drunkards 26 presented no signs of tubercle. — An-
drew Hammersley,  Prize Essay on the  Remote and Ex-
citing Causes of Phthisis Pulmonalis, American Medical 
TYMPANITES—Definition  of.                            1289
 Recorder, 1826, p. 681. — John W. Gloninger, Cases of
 Consumption successfully treated by Mercury, in Amer.
 Med. Recorder, 1S22, p.  514. — Wm. C.  Wallace, Jewish
 Hygiene, in Bost. Med. and Surg. Journ., vol. xxxi., p.
 349.  On the Use of Charcoal in Consumption, Ibid., p.
 419. — J. Comstock, in Ibid., vol.  xxx.,  p. 489. — C. M.
 Durrant, on the Nature, Diagnosis, and Treatment of In-
 cipient Phthisis,  in Ibid., vol. xxviii., p. 409, 429, 449,
 469—S. D. Gross, Elements of Patholog. Anat, 2 vols.,
 1028.  Bost, 1839__H. G. Wiley, in Boston Medical and
 Surg. Journ., vol. xviii., 1848, p. 85.—Joseph Tuckerman,
 on the Climate of Santa Cruz, in Ibid., vol. xvi., 1837, p.
 357.—Thomas Glysnon, Ha.>morrhagic Phthisis, in  Ibid.,
 vol. xv., p. 16J,  1836. — S. W. Gold, on  the Causes of
 Phthisis  Pulmonalis, in  Ibid., vol. xiii., p. 181, 1835.—
 Charles Macomber, Thoughts  on Phthisis Pulm.,  Ibid.,
 vol. xii., p. '.8.1.—J. A. Brereton, U. S. Army,  Value of
 Chlorine Inhalations in  Phthisis,  in Bait.  Medical and
 Surg. Journal and Review, 1S34.—Andrew Anderson, on
 the Climate of St. Augustine as a resort for Consumptive
 Patients, in Boston Med. and Surg. Journal, vol.  ii., p.
 792; also Circular Letter, 1830.—Wm. P.  Dewees, a Prac-
 tice of Physic, &c, 8vo.   Phil., 1833.— John D. Fisher,
 Am. ed. of Forbes' Laennec, Svo.   N. Y., 1838. — ./. E.
 Coxe, Practical Treatise on Medical Inhalation. Phila.,
 1S41.—C. B. Coventry, Essay on Tuberculosis  and Tub.
 Pneumonia, New  York State Med. Trans., vol. xi., 1856.
 —See also the various works on the Practice of Medicine,
 viz., Wood's, Dunglison's, Dickson's, Eberle's,  Hosack's,
 &c — X Tessier, on Effects of Cold Climates in Pulmo-
 nary Consumption, New York Medical and Phy6. Jour.,
 vol. vii., p. 525.—Charles Drake, on the Effects of Respir-
 ing Cold Air in Pulmonary Diseases, Ibid., p. 199.—M.
 Mattson,  The Curability of Consumption, Boston Med.
 and Surg. Journal, vol. xliii., p. 429.—J. G. F. Wurde-
 mann, Climates of Florida and the West Indies, South-
 ern Journal of Med., vol. ii., p. 509. — George Hayward,
 Statistics of Pulm. Consumption in the Cities of Boston,
 New York, and Philadelphia, for 30 years, with  Remarks,
 New England Med. Journ., vol. i., p. 297.]
   TYMPANITES.—(From rvpnavov, a drum.)
 Tvpiravirnc,  rvpnaviac,  Hippocrates,  Celsus,
 Galen.   Tympanites, Tympanitis,  Auct. Latin.
 Tympanites,  Sauvages, Vogel,  Sayar,  Cullen,
 &c.  Affectio   Tympanitica,  Hoffmann.   Tym-
 panila,  Sennert.   Meteorismus, Sagar,  et  auct.
 var.  Emphysema Tympanites, Parr.   Tympa-
 nia, Ploucquet.   Emph. Tympamticum, Young.
 Emph. Abdominis, Good.  Hydrops  siccus, Auct.
 Windsucht,  Trommelsucht, Germ.   Tympanite,
 Ft.   Tympanitide, Ital.   Tympany, wind dropsy,
 dry dropsy, inflation of the abdomen.
   1.  Classif.—4th  Class,  6th Order (Cullen).
       6th  Class, 2d  Order (Good).   I.  Class,
       I. Order (Author in Preface).
   2.  Definit.—An inordinate generation and ac-
 cumulation of a gaseous fluid within the digestive
 canal, generally with retention of  it, occurring
 chiefly symptomatically, either terminating acute
 disease, or complicating chronic affections, and oc-
 casioning great  abdominal distention, and  a drum-
 like sound on percussion.
   3. I.  Pathology.—Tympany is  generally the
 result of greatly impaired vital power, as mani-
 fested chiefly through  the  organic or ganglial
 nervous system  upon the digestive canal, whereby
 not only is the tonicity of the  coats of the canal
 remarkably  impaired, but also  gaseous fluids are
 exhaled from the digestive mucous surface.  That
 the air is generally contained in the  canal, where
 it is  retained either by spasm in  parts of the
 canal near to its outlets, or by the inability of the
 muscular structure of the canal to expel it,  can-
 not be doubted.  It has been  supposed by some
 writers that the air may be on some occasions ex-
 haled into the peritoneal cavity.  If this occur-
 rence take place at all, it  must result from the
 decomposition  of matters  effused into the  cav-
 ity, as in cases of chronic peritonitis, or of puer-
 peral  peritonitis, or of  perforation  of the intes-
 tines, when some of the intestinal contents have
passed into this cavity.  The occurrence  of tym-
 pany from these changes is however, rare, but
 less rare when the intestines are perforated by
 any of the causes of this lesion of the intestines.
 (See art. Intestines, $ 29.)
   4.  Several varieties  of  tympany  have  been
 enumerated  by writers of  the seventeenth  and
 eighteenth centuries,  according as  the gaseous
 accumulation has occurred in the advanced course
 of acute maladies, or has  complicated chronic
 diseases, the primary affections, with which tym-
 pany is associated, furnishing the  basis of ar-
 rangement.   Of these  it is quite unnecessary to
 take any  notice,  as  such occurrences  of  tym-
 pany are merely contingencies of advanced and
 dangerous diseases, and are merely symptoms of
 these or of hysterical or uterine disorders ;  often,
 however, assuming very prominent and distress-
 ing characters, especially in the  last stages of
 peritonitis, of puerperal and malignant fevers,
 &c.  That the air which accumulates in the di-
 gestive  tube  in these and various other circum-
 stances  of disease cannot  arise, to  any  great
 amount, from the decomposition or retention  of
 alimentary materials, or of morbid secretions ac-
 cumulated or retained  in  the  canal, is demon-
 strated by the absence of these sources of the
 gaseous collection in  the  more  extreme cases.
 We are compelled, therefore, to view the accumu-
 lation of air as the result of a morbidly increased
 exhalation of it  from the digestive mucous sur-
 face, resulting from depressed vital or organic
 nervous power,  in connexion with lost or  im-
 paired tone of the muscular coats of the canal;
 this last condition, equally with the  augmented
 exhalation, proceeding from  the loss  of  vital
 power.   According  to  this view  tympany is
 merely an extreme state of flatulence  (see that
 article),  the  gaseous exhalation  having accumu-
 lated in the  former, so as to produce  extreme
 distention, but being discharged in the  latter at
 intervals or absorbed.
   5. That this exhalation must  necessarily pro-
 ceed from the blood, in great measure, or, in as
 far as it does not arise from the decomposition of
 alimentary matters, or  of  the  secretions, must
 necessarily be inferred, particularly  in the more
 extreme and sudden accumulation  ofthe gaseous
 fluid.  John  Hunter and Cullen believed that
 the fluid was  thus  generated, and Magendie and
 Gerardin endeavoured to prove the occurrence
 by experiment.   They included a  portion of in-
 testine between ligatures, returned it into the ab-
 domen, yet air, nevertheless, was found in it, al-
 though it contained no materials for the gener-
 ation of air.   That the air was exhaled from the
 digestive mucous surface had long been believed
 in, and  supported  by  observation and analogy.
 FABRICIUS filLDANUS,  HOFFMANN, PORTAL,  Vl-
 dal,  Gaspard,  Nysten,  Merat,  and many
 others,  have  contended  for  this  doctrine, and
 have adduced facts in support of it.  Bichat has
 shown that friction with sulphur communicates
 the odour of sulphureted  hydrogen  to the gas
which collects in the bowels.  The swimming-
bladders of fishes are known to be supplied with
air from the blood only ; and Blainville, Dumas,
Magendie, and others, have shown that a division
of the pneumo-gastric nerves is followed by gas-
eous distention of the stomach.
   6. Tympanitic  distention  of the  abdomen may
therefore be  referred,  firstly and  chiefly, to  the
extrication of air from the digestive mucous sur-
face, owing to the  states of organic nervous en- 
1290
TYMPANITES—Causes of.
dowment, or to the irritation or morbid action of
matters received into the alimentary canal, as in
various kinds  of poisoning, or to changes in the
blood itself; secondly, in a  small degree, from the
deglutition of air with the food or with the saliva ;
and  thirdly, and in a very variable degree, from
the decomposition or fermentation of alimentary
matters, or of secretions  and  excretions.   In
cases of weak digestion,  or when  the  organic
nervous influence is  much depressed,  the quan-
tity  of  air which  may be  formed, as shown  by
Dr.  Hales, from the fermentation of fruit or raw
vegetables in the  stomach is often very great.
   7. According as either of these sources of gas-
eous collections in the digestive canal predomi-
nates or is increased, so may the nature of the
gaseous fluid be supposed to vary.  The states of
the blood, the  nature  of the ingesta, whether ali-
mentary, medicinal, or poisonous, the seat of the
collection,  will severally modify the composition
ofthe gaseous fluid.  MM. Jurine and Chevreul
have shown that  generally the proportions  of
oxygen and carbonic  acid decrease, while that of
nitrogen increases, in descending from the stom-
ach  to  the rectum.*  Although there does  not
appear  to have been  any analysis of the air col-
lected in  tympany, yet there is every reason to
infer that it does not materially differ from that
usually  formed  in the  digestive canal, unless
under the  influence of acute  or malignant dis-
eases, when, with an admixture of carbonic and
nitrogenous gases, and a  little  hydrogen, sul-
phureted,   carbureted, and even  phosphoreted
hydrogen,  may severally exist  in  varying  pro-
portions.
   8. II. The causes of tympany—whether pre-
disposing,  exciting, concurring or determining—
are in some respects the same as those which are
noticed  under the head Flatulency ; but they
exist in the former, or are rather associated, with
one or more of the following pathological states :
1st, with mechanical  or other obstruction to the
discharge  ofthe gaseous exhalation from the ali-
mentary canal; 2d,  with impaired or lost  con-
tractile  power of the muscular coats of the canal;
3d, with alterations  of the blood from absorbed
matters or from vital changes, affecting the ab-
sorption of gases  from the air, or the generation
or extrication of them from the  blood; 4th, with
changes in the circulation in the lungs, and in
the respiratory functions.   Where one  or more
of these conditions are present, and in proportion

  *       ("Oxygen..............        11-
   In the  J Carbonic acid........        14*
 Stomach. ] Hydrogen............         3-55
          (^Nitrogen.............        71 -45
                                   100-
 In small  (Carbonic acid........  24-39  40-6  25-0
Intestines. •j"7dro8en............  55-53  51-15  8-4
          (Nitrogen.............  20-08   8-85 66-6
           In three cases.                   jn 0Jle
         1 Carbonic acid........        43-5  70-0
           Carbureted  hydrogen
            ^J7% ,of  8ul'
            phureted hydrogen .         5-47 11-6
           Nitrogen.............        51-03 18-4
           Carbonic acid........        jo• 5
           Hydrogen...........         7.5
           Carbureted  hydrogen        12-5
           Nitrogen.............        C7.5
                                   100-
  In the   (Carbonic acid.  .....        42-86
 Rectum.  •jCart.ureted  hydrogen        n-is
          (Nitrogen.............        45.1,(5
                                   100-
as they are increased by depression or exhaustion
of the vital manifestations or endowments of the
digestive  canal, in so far will the tympany  be-
come remarkable or extreme, and the possibility
of its removal be diminished.
   [There  are two principal sources of flatulence;
the first,  chemical  changes in the ingesta; sec-
ond, secretion,  or  exhalation from the mucous
membrane of the gastro-intestinal surface.  There
is also a third cause, not  usually recognised,  but
ofthe reality of which we are fully satisfied from
careful observation, and that is inefficient action
of the liver, and a want of bile in the intestines.
In a considerable proportion of the cases of flatu-
lence which  have come under our notice,  we
have found  it relieved by medicines which pro-
moted  the hepatic secretion,  as  small doses of
blue-pill or calomel.   These  cases are often  as-
sociated with  constipation, a furred tongue, foul
breath,  &c, all pointing  to  hepatic  torpor, and
the flatulence as well as the other symptoms  are
very certainly relieved by mercurials.  In retro-
cedent gout, where the disease is transferred to
the stomach and intestinal canal, attended, as it
usually is, with very painful cramp of the stom-
ach, colicky pains, constipation, and great  flatu-
lence, we have found large doses of calomel very
successful in  affording relief.   In a case of this
kind which recently came under our care, where
the disease  suddenly left  the extremities and
fastened on the digestive  organs, and where  the
pain, flatulence,  gastric  sensibility,  and cramp
were so severe as to threaten the life of the  pa-
tient, perfect and permanent relief was  afforded
by the administration of calomel, at first in large,
and  afterward alterative  doses, which  resulted
in  bringing  away large quantities of  thick,
black bile.   It is very  probable there may be
here, as in gastro duodenitis,  a complete tempo-
rary occlusion of the mouth  of the ductus  com-
munis  choledochus, from  vascular congestion of
the duodenal  mucous membrane, thus  causing
an obstruction to the flow of bile, and leading to
flatulence,  flatulent eructations,  &c.   In the
flatulence accompanying  ordinary dyspepsia, an
alterative  pill of blue  mass,  aloes, rhubarb, and
gentian, will generally afford relief.   The  flatu-
lence of low fevers may be due to exhalation, or
to the play  of the ordinary chemical  affinities in
the aliment or excretions  in the stomach or intes-
tines, from the  low condition or suspension  of
organic nervous power.   On  the same principle
we may perhaps account for the eructation of air
in gastritis, hepatitis, &c, although  it  is  more
probable that in such cases it is the result of ex-
halation or secretion]
  9- The  causes of tympanites, or rather the cir-
cumstances  in which  flatulent distention of the
abdomen  chiefly occur, are pathological, or con-
sist of antecedent  disorders  or most dangerous
organic changes.  While such disorders are pro-
ductive  of the less severe and dangerous states,
or those  which more  nearly  approach the con-
ditions described under the head Flatulence, the
most dangerous organic changes and malignant
maladies  give rise  to  the extreme instances of
meteonsmus or tympany.   The slighter cases of
flatulent distention are  produced by the nature of
the food,  especially by saccharine  and acescent
matters and vegetables, by indigestible and other-
wise injurious articles  of food, by  constipation
or the retention, by mechanical or  vital obstruc-
tion, of the  intestinal excretions, as in cases of 
TYMPANITES—Treatment  of.
1291
colic and ileus, and by hysteria or uterine and
spinal irritation.
  10. The extreme instances of tympany occur
chiefly after poisonous ingesta, more particularly
after poisonous meats,  poisonous fish and shell-
fish, and indeed during the last and most danger-
ous stage of poisoning by other deleterious agents
(see art. Poisons generally, and especially § 427
-528); in the advanced stages of puerperal fevers
and puerperal peritonitis; in gastritis and inter-
ims, particularly when perforation of the intesti-
nal canal  has  taken place, and then air may
escape  into, or be developed in, the peritoneal
cavity;  in  misplaced gout  of the  stomach  or
bowels; and in the last stage of adynamic and
typhoid  fevers, and of malignant continued and
eruptive fevers.  They also occur as terminations
of fatal ileus, of hernia, of intersusceptions and
strictures of the bowels, of lead colic, &c.   Even
a moderate degree of tympanitis in  adynamic or
typhoid  fevers should be viewed with  alarm, in-
asmuch  as  it is an indication of ulceration of
Peyer's glands.*
   11  III. The signs and symptoms of gaseous dis-
tention of the abdomen are very manifest, and even
the seat of distention may be correctly inferred,
especially when it is not extreme—A.  Palpation
and percussipn, in some cases even simple inspec-
tion, of the abdomen, are sufficient to show the
seat and nature of the morbid condition.   When
the distention is chiefly of the stomach, the region
of this organ is elevated above the margin of the
false ribs, and the ensiform cartilage is protruded,
the lower abdominal regions being less promi-
nent.  A similar elevation of the upper  regions
ofthe abdomen exists when the colon is the chief
seat of distention, but the course of the colon,
from the distended caecum to the termination  of
the bowel, may be observed on  inspection ; and
it is farther evinced by the hollow sound on per-
cussion, especially when the cause of obstruction
to the escape of flatus exists in or near to the
sigmoid  flexure or rectum.   In the extreme in-
stances  of tympany, arising from  any of the
causes stated above (y 8-10), the inflation is gen-
erally greatest in the small intestines, although it
may be  more or less in other portions  of the di-
gestive tube.   In cases of hysteria, the  distention
is more limited, varies in its seat, and in  the
sympathetic sensations and pain  it occasions ;
and owing  to the spasm and contractions, suc-
cessively affecting different portions of the tube,
occasions  borborygmi, and  the  propulsion of
flatus  into  the stomach  and oesophagus.   The
  {* Austin Flint, in an analysis of 56 cases of contin-
ued fever, reports tympanites present in 16 out of 28 hos-
pital cases of typhoid, and in 8 out of 13 cases of typhus
fever (Clin. Rep. on Contin. Fever, p. 84), being about an
equal  ratio in both, or as 4 to 6.   In private practice it
was less frequently observed. In typhoid fever it was
accompanied in a majority of cases with diarrhoea;  in
typhus the diarrhoea was uniformly absent.  In no case
was this symptom considered to be present, except where
there was obvious distention of the abdomen, as well as
resonance on percussion.
  In a second analysis of cases of continued fever. Dr. F.
found tympanitis present in 22 out of 39 cases of typhoid
fever, or in both collections 34 in 47 cases.  In 5 cases
the tympanitic distention was slight or moderate in 13,
and considerable in 4.  < )f 10 cases of typhus, tympanitis
was present in 8, being slight in  every case but one.  It
was less marked in typhus than typhoid.  Of 7 fatal cases
of typhoid, it was present in  6; in one fatal  case it was
Blight, in 3 moderate, in 2 considerable.  Of 4 fatal cases
of typhus, it was present in 3, but slight in each.  The
results show that this symptom occurs in  a much  larger
proportion of cases ending fatally than of those in which
recovery takes place.]
mechanical  effects of  abdominal  inflation are
chiefly  the  pressure  of the  diaphragm  on the
heart, lungs, and  large veins, and the arrest of
the peristaltic motions of the intestine  and of
the propulsive  efforts  by which the  intestinal
contents are excreted.  To these various subor-
dinate effects others may be added, consisting of
disturbance and arrest ofthe several secreting and
excreting functions,  of congestion of the lungs
and large vessels, and of imperfect oxygenation
ofthe blood, &c.
   12. B. The source  and nature ofthe abdominal
inflation are to be inferred chiefly from the history
ofthe case ; from the antecedent disorder; from
the seat, nature, and  duration of pain ; from the
indications  furnished  by percussion of the sever-
al abdominal regions, and from the states of the
excretions and ofthe pulse and tongue, with the
various constitutional symptoms.
   13. The  flatulent distention is generally that
of the intestinal canal,  and not of the peritoneal
cavity,  although I would  not say that this  latter
may not in  rare cases be its seat, especially if the
fluids effused into this cavity undergo more or less
of decomposition previously to dissolution;  but it
is not improbable that  the instances of gas thus
evolved in this cavity, as observed by Heister,
Dusseau,  Lieutand, Morgagni,  Portal, and
others,  are merely those in which the gas had
escaped into the cavity  owing to a perforation of
the digestive canal.   Tympanites has been occa-
sionally observed  in  most of the organic lesions
affecting the biliary  organs,  the  digestive  tube,
and tho abdominal and pelvic viscera.  It is often
an attendant on gout of the stomach or intes-
tines.
   14.  C. The appearances observed in fatal cases
are a very large proportion of those lesions which
have been very fully described  under the heads
Digestive Canal and Intestines.  In some cases
the distention of  the tube has been remarkably
great throughout the  greater part; and in others
it has been more limited ; as to the Cjecum and
Colon  (see  those articles).   It  has  rarely been
such as to rupture the bowel, sphacelation ofthe
more  distended  portions  being more common.
The small  intestines, especially the ileum, are
always remarkably distended by flatus, and the
glands, more  particularly Peyer's, are  often
more or less ulcerated,  &c.
   15.  IV.  The treatment of tympany is gener-
ally difficult, often hopeless, and always depend-
ent upon the pathological conditions of which it
is merely a symptom or contingent effect.  In
many cases it is  productive of so much and so
urgent  distress that  it becomes requisite to at-
tempt the removal, or the amelioration of it, be-
fore  the  moTbid  states, from which it  results,
should  occupy our attention with the view  of di-
recting the means of cure to them  more  espe-
cially.   The indications are, therefore,  1st,  to re-
move the tympanitic distention  by such means
as we  possess, when it is distressing and most
urgent; and, 2d, to subdue the pathological states
upon  which the distention depends, by appropri-
ate treatment, either when  this urgency is re-
moved or does not yet exist.
   16. i. The removal  of the flatulent distention of
the intestines by mechanical means was first rec-
ommended  by Dr. Darwin  to be attempted by
the introduction  of an enema-pipe into the rec-
tum,  in order to remove the resistance of the
sphincter ani to the  passage of flatus.  Trnka 
1292
TYMPANITES—Treatment of.
proposed that the gas should be removed by the
air-pump ;  and Dr.  Osborne, of Dublin,  adopted
this means, in the mode most likely to render the
recommendation successful.  After other means
had failed, he introduced a gum-elastic  tube of
nearly three feet in length, with a button and
hole at its  extremity, and, having applied to it  a
stomach-pump, he  proceeded  to  withdraw  the
gas, and " was enabled  to do so with few inter-
ruptions, which were speedily overcome either by
shifting the place ofthe tube in the intestine, or
by  injecting warm water to clear the holes by ac-
cidental stoppage.  In about an hour the abdo-
men was reduced to nearly the natural size."—
(Lond. Med. Gas., vol. vii., p. 825.)  Dr.  Graves
employed similar means  with success   in two
cases.—(Lond. Med.  and Surg. Journ.,  vol. ii.,
p. 781 )  I had recourse  to it  in one case with
temporary benefit, and have advised it in  consul-
tation  in two or three instances, but in neither
with permanent advantage.  It should not, how-
ever, be neglected,  as more or  less relief is pro-
duced by it.  In many of the more severe cases
I have prescribed enemata containing the extract
or confection of rue, or asafoetida, or both  rue and
asafoetida,  and enemata with  oleum  ohvoz and
oleum terebinthina,  or the other carminative in-
jections recommended for the  removal of obsti-
nate constipation.
  17.  While the  operation of  these and  similar
means  is expected, frictions over the abdomen
with either of the liniments referred to in  the Ap-
pendix (F. 311) may be resorted to,  and medi-
cines may be exhibited by  the month.  When the
tympany is not attended or caused by mechani-
cal  obstruction, and is to  be imputed rather to  a
paralyzed state of the muscular coats of the ca-
nal  than to either constriction or strangulation,
then the extract of nux vomica  in small doses, or
the  usual carminatives, especially rue, asafoetida,
capsicum, turpentine, &c, are often of  service.
Turpentine, either as a confection or as a draught,
with the oleum olivse, or ol. ricini, on the surface
of an aromatic water, or of common gin, in cases
of hysterical tympany, or of spirit-drinkers, if pre-
scribed  with discrimination, is the most effica-
cious, especially if enemata or liniments with this
substance be employed also.
  18.  When the tympanitic distention has arisen
from obstruction in the vicinity  of the caecum
or in  the large bowels,  then the injections into
the  latter should  consist chiefly of warm, oleag-
inous, and saponaceous substances.   Olive oil in
large quantity  may be thus employed, and this
oil  may be  taken in  small and frequent doses,
oleaginous  frictions being also resorted  to.  In
several instances where  tympany was caused by
the obstruction arising from hysterical pica—by
chewing paper in two cases, by  sealing-wax in
one case, and by bleached  wax and spermaceti in
another, the obstruction was removed, in all, by
these  means, the causes of the disorder  having
been made apparent, by the numerous balls of
these  substances, agglutinated  by the mucus of
the bowels,  and moulded  in  the cells  of  the
colon, which were voided.
  19. ii.  Having removed the more urgent symp-
toms, the Pathological conditions producing  the
tympany requires close attention and appropriate
treatment.   These  conditions  are so numerous
and so different that it is impossible to state all
that may be required to fulfil this intention. This
is, however, the  less necessary,  as the  circum-
stances under which tympanites occurs, and the
pathological causes producing it,  are duly con-
sidered, with the treatment required for each, m
the articles on Adynamic Fevers,  inflammations
of the mtestiAes and of other portions of the in-
testinal tube, hysterical affections, colic, ileus, and
on other disorders upon which tympania is often
contingent.   The  diverse sources of this allec-
tion, and the  very opposite pathological states
which  may  occasion  it, sufficiently explain the
success which has sometimes  followed very dif-
ferent or even opposite indications and means of
cure   Thus, when depending upon inflammatory
action, the antiphlogistic treatment and regimen,
as advised by J. P. Frank and others, are then
required ; but when depending upon a paralyzed
state of the intestines, consequent  upon either
organic lesion in some part of the digestive tube,
or upon a morbid condition of the blood, as  in
the advanced  stage of  low or  malignant fevers,
then stimulants, tonics, carminatives, and restor-
atives, as turpentine, camphor, musk, ammonia-
cum, asafoetida, galbanum, capsicum, myrrh, rue,
&c., are equally necessary.   In these latter cir-
cumstances, and especially when the bowels are
loaded by offensive sordes or morbid excretions,
then powdered charcoal,  as advised by Frank,
and employed  by myself  in such cases, in con-
junction with antiseptics or other means, or with
one or  more  of those just named,  may be em-
ployed.   The  carbon  may  be administered  in
doses of half a drachm  to a  drachm, twice  or
thrice daily, in the state of powder,  in  any suit-
able vehicle.   In the case of a very celebrated
general,  attended  some years ago  by Dr. F.
Hawkins and myself, this substance was  admin-
istered in that quantity and even  in more fre-
quent doses, and was conjoined with active medi-
cines ;  it having been adopted  chiefly for the re-
moval of the fetor characterizing the evacuations
and  tympania in the  advanced stage of low
fever.  For  inflation  of the bowels in  the last
stage of fevers, in dysentery, in chronic  diar-
rhoea, in misplaced gout, &c, the treatment al-
ready advised (§ 17) is often  beneficial;  and  in
many of these, especially in aged subjects, char-
coal is  often of use, and seldom fails of removing
the fetor characterizing these cases
  [When chronic, or owing to atony ofthe mus-
cular coat, electricity by the  electro-magnetic ap-
paratus has often been found  useful.  We have
known  also  the galvanic bell worn round the
body to afford much  relief, and exert a curative
action. Cold applications to the abdomen, the vari-
ous preparations of iron, sea-bathing, horse-back
exercise, a firm band about the abdomen, all may
prove advantageous in  cases where these reme-
dies are indicated   Articles of food prone to fer-
mentation, or  the extrication of large quantities
of air, must be avoided, such as peas, beans, tur-
nips, greens ; also fermented liquors, sweet wines,
pastry, &c.  The bulk of a meal should be small,
and condiments used, as pepper, mustard, &c]

  Biiiltog. and  Refer. — Celsus, 1. iii., cap. 21.—Aretx-
us, Chronic, 1. ii., cap. i.— Avicenna, Canon, 1. iii., Fern.
14, Fr. 4, cap. i. — Zacutus Lusitanus, Prax-admir., 1.
n., obs. 5X—Heister, Wahrnehmungen, 1. n. 15. (Ex aire
m cavum abdominis effusot)—Bonet, Sepulchret, 1. iii.
See xxi., obs 2,3. (Vitiaviscerum.)—Ballonius, Epidem.,
1. n., p. 111. — R. Blackmore, Dissert, on a Dropsy, a
Tympany, &c, 8vo.  London, 1721. - Willis, Pharmac.
Kat, P. n., sec  n., cap. i.—Brendel, Opera, t. ii.—Hoff-
mann, Med. Rat. Syst, t. iv.,  P. iv., c. 15.-1P. Combalu-
sier, Pneumatopathologia.   Paris,  1747. — Kaemvfer
Anican.  Exot., Fasc. iii., obs. 5, p. 543.—Haute8ierk,lie- 
URINARY BLADDER—Irritability of.                      1293
cueil, t. ii., p. 583.—J. B. Careno, de Aeris ingressu, in
ventriculum, 8vo.  Medio!., 1757.—Zeviani, Trattato del
I'lato, &c, 4to.  Veron., 1761.—C. F. Kadelbuch, de Tym-
panitidis Pathol, et Therap., 4to.  Leips., 1112.—Morgag-
ni, De Sed. et Caus. Morb., Ep. xxxvi., 23, 24,25.  (Tymp.
Intestinalis, T. Abdominalis.)—De Haen, Rat. Medendi.,
P. ii., c. v.; P. iv., p. 65.—Dusseau, Journ. de Med6cine,
1779.—Lieutaud, Hist. Anatom. Med., 1. i., 16.  (Intesti-
na enorruiter distenta), 270. (Air in cavo abdominis et in
intestinis), 1775.  (Aer extra intestina.)—M.Stoll, Prae-
lect, t. i., p. 89. — Trnka de Krozowitz, Historia Tym-
panitidis.  Vindo., 8vo, 1788.—Pleuker, De Meteorismo
ejusquc speciebus, in Eyerell, Coll.  Disser., 1. iii. — Sto-
erck, Ann.,  Med. ii., p. 191, 194, 199.  (Inflammathme
causata.)—Bang, in Acta Req. Soc. Med. Haun., t. i., p.
206. — Aaskow, in Ibid., t. i., p. 373. — G. L. Marugi, le
Malattie Flatuose, 4to.  Nap., 1786.—Bergius, Mat. Medi-
ca, t. i., p. 199. (Ascefoetidm enemata.)—Portal, Cours
d'Anatomie Medicate, t v., p. 142.   (Aer in cavo abdom-
inali.) — Odier, Manuel de Med. Pratique, p. 210.  (In
Febre adynamica et in F. Puerperale.)—J. P. Frank, De
Curand. Horn.  Morbis, 1. vi., P. i., p.  124.  (Carbo in-
terne), p. 117.  (Vena-sectio), p. 121.  (Frigus.)-X. V. A.
Gerardin, Recherches Physiologiques sur les Gas intes-
tinaux, 4to.  Paris, 1814.—J. G. Beutner, de quibusdam
Prscsidiis in pneumatosi abdominali  administrandis.
Heid., 1815.—Merat, Diet, des Sciences Med., t. xxxiii.,
art Mctiorisme.—Pinel et Bricheteau, in Ibid., t. iv., vi,
art. Tympanite. — Fradini et Santoli,  Med. and Surg.
Journ., vol. v.,  p. 167, et in British  and For. Med. Rev.,
Oct., 1836, p. 652.  (Camphor, Musk, et  Ammoniacum
pro Tymp.)—W. Kerr, Cyclop, of Pract Med., vol. iv.,
253.
  [See  various  Am. works of Prac. of Med. already re-
ferred to; also Flint's "Reports on Continued Fever,"
and Bartlett on  Fever.]
URINARY BLADDER.—Synon.—Festca  Uri-
   naria ; Vesica urinalis;  kvotic,  Cystis; Uro-
   cystis;—Vesica;—Vessie,   Fr.   Harnblase,
   Germ.
   1.  The  urinary  bladder  is  a musculo-mem-
braneous reservoir for the reception of the urine,
until the accumulation of a certain quantity so-
licits the discharge of this secretion.  This reser-
voir is situated in the hypogastric region, between
the pubes and rectum in man, and between the
pubes  and vagina in the female.  Its several con-
nexions with  the  urinary and sexual passages,
in both sexes, and its other anatomical relations,
need not be noticed at this place.   It is sufficient
that we bear in  recollection that, in addition to
the disorders and lesions which are seated in it
solely  or chiefly, it is liable, in consequence of
these connexions,  and of the nervous and vascu-
lar communications existing between it and other
parts,  to several  sympathetic affections, the most
important of which are those depending upon le-
sions of the kidneys and ureters, and upon those
of the prostate gland and urethra.   In all cases,
therefore, when  the urinary bladder appears to
be the scat of disease, our attention should be di-
rected  also to the states of these organs and pas-
sages ; and not be  limited to these, but be extend-
ed even  farther, and more especially to the com-
position and condition of the urine and of its de-
posits, with the several relations of digestion and
assimilation.
   2. I. Irritability of the Bladder.—Classif.
     —II.  Class, III. Order.   (See Preface.)
   3. Definit.—A frequent  and urgent desire to
micturate, independently of febrile symptoms and
of inflammation, and of organic  lesion of the urin-
ary bladder and prostate gland.
   4. i   Symptoms.—A person otherwise in good
health  feels  an  urgent desire  to void his urine
after very short intervals, and if the desire be not
gratified, either he is incapable  of retaining it, or
he retains it with great difficulty, and with more
or less pain.    The effort at  micturition is  some-
times  attended by pain  in the glans or  under
the frsenum, and by straining;  and although the
calls  are frequent, the quantity passed  at  each
call is very small.  These latter symptoms are
most frequent in old or aged persons, and in those
who have been addicted to masturbation or sexual
excesses, in whom the prostate is  more or less
tumid or enlarged.  Hysterical persons are often
liable to this disorder; but in these the urine is
more  copious and pale,  and contains less  than
the usual proportion of solid ingredients, the na-
ture of which are not altered.   When  irritabili-
ty of the bladder has continued long—the organ
having for a long period ceased to be distended
by the accumulation of urine—the  capacity of it
becomes permanently accommodated to the pau-
city of its contents, and incapable of containing
more  than two or three ounces.
  5.  Mr. Coulson, in his  admirable work on
Diseases of the Bladder and Prostate Gland, re-
marks that, notwithstanding this contracted state,
if there be no stricture or disease of the prostate,
the parietcs ofthe bladder are often thinner than
natural; and that it would seem that protracted
irritation produces absorption of part of the sub-
stance of the organ.  Opportunities of examining
after  death the bladder of persons who laboured
under this  affection in its  idiopathic form are
very  rare.   Mr  Coulson examined the body of
a gentleman of a very nervous temperament, long
a sufferer from this disorder, who was carried off
by disease of the lungs; but he could not detect
the least alteration in the appearance or structure
of the bladder, or of any of the urinary organs.
  6.  ii. The causes of this disorder require recog-
nition in each case which comes under treatment.
Old persons, or the aged, and next the very young,
are more liable to irritability of the bladder than
youths or the middle-aged; but the causes pro-
ducing it in the aged are generally  very different
from  those occasioning it in children.   The nerv-
ous temperament, weak, irritable and anxious dis-
positions, and gouty and rheumatic persons are
most predisposed to it.   Those subject to chronic
dyspepsia, to nervous giddiness, tremors, or to
scaly eruptions, are often also afflicted with this
complaint.
   When it occurs in females it is sometimes refer-
able to injury from pressure, either during preg-
nancy or in parturition, or to disorders or lesions
ofthe uterus, ovaria, or vagina.  It may be occa-
sioned in both sexes by haemorrhoids or irritation
of the rectum by ascarides, or by chronic states
of dysentery.  It may occur, in a slight form, even
independently of hysteria, in males as well  as in
females, from self-pollution, or from irritation of
the spinal nerves increasing the organic sensi-
bility of the bladder.
  7.  a. The most frequent causes are probably
those which are referable to the states ofthe urine,
arising either from the nature  of the ingesta, or
from  the changes consequent  upon primary or
secondary assimilation.  It has been well remark-
ed by Dr. Prout,  in his celebrated work, that cases
of irritable bladder, depending  on functional de-
rangement of the kidneys, usually result from the
unnatural properties of the urine.  All deviations
from  the normal condition  of the urine, whether
in deficiency, or in excess,  or in kind, are recog-
nised by the containing organs, and may prove a
source  of  irritation  in the bladder.  " Hence,
whenever the urine is very dilute  or very  con-
centrated, or is preternaturally acid or alkaline, or
contains any unnatural ingredient, the  urinary
organs in general, and the  bladder  in particular, 
ER—Irritability of.
1294                     URINARY BLADD]

though perfectly healthy, are liable to become ex-
cited and irritable, and the individual has no peace
until the unnatural secretion is discharged.   In
such cases the fault lies, not in the bladder, but
remotely in the kidneys and assimilating organs."
—(Op at., p. 366.)
  8  The use of various fruits, ripe or unripe, es-
pecially by children, and even by adults, and  dis-
orders of digestion and of assimilation, occasion-
ed by these  or by other causes ;  the elimination
from the blood of unwholesome substances, con-
veyed into it from the organs of digestion, wheth-
er subsequently altered or  unaltered by the kid-
neys ;  the excessive use of alkalis, or of these
combined with the  vegetable acids, and alkaline
states  of the urine  from these  or other causes ;
and  the prolonged use of acids, or of the  nitrate
of potass, or ofthe oxide of potassium, or of other
diuretics, may severally occasion this complaint
  9  b. The irritation of ascarides in the rectum,
and  morbid states of the urine, caused either by
unwholesome food, by unripe fruit, or by impair-
ed assimilation, or by spinal affections, or by rick-
ets, are the most common causes  of this affection
in children    Mr. Coulson met with cases in chil-
dren which were caused by so great a contrac-
tion  of the orifice of the prepuce as hardly to ad-
mit the point of a probe ; circumcision cured the
complaint.   When  irritability of the bladder oc-
curs in this class of patients about the periods of
dentition, it may generally be imputed to disorder
of the digestive organs, and to consecutive altera-
tions of the urine.  The connexion of irritability
with paralysis of the bladder is not unfrequently
met  with in children (§36)
  10. c.  Symptomatic irritability of the bladder is
much more common than the idiopathic disease.
Granular and other organic lesions ofthe kidneys
are generally attended, especially during the night,
with frequent and urgent desire to evacuate urine,
this  excretion being always more or less  morbid
even from an early period  Diseases of the pros-
tate  gland and of its vicinity, organic,  inflamma-
tory, or malignant very generally, and strictures
of the urethra not unfrequently, are accompanied
with this complaint.  Indeed, strictly speaking,
irritability of the bladder is merely symptomatic,
cither of disease of some adjoining or some close-
ly related organ, or of morbid conditions of the
urine; and this may  be the case even in those
considered  purely nervous, or  most devoid  of
manifest structural change.
  [Gonorrhoea and  masturbation are among  the
most frequent causes of irritability of the bladder,
the irritation being transferred from the urethra
to the neck ofthe bladder ;  causing frequent mic-
turition,  with  tenesmus, pain, bloody urine,  &c
All the stimulating class of diuretics may cause
the same difficulty; also those resinous cathartics,
like  aloes, which act on the lower portion of the
intestinal canal.   Turpentine,  cantharides,  and
nitrate of potass are the  most likely, perhaps, of
the diuretics, to irritate  the bladder ]
  11. iii. The diagnosis of this complaint is often
of importance; and  nothing tends more  to  de-
termine this  than a careful examination  of the
urine.   Irritability of the bladder will not be mis-
taken for diabetes, if the quantity and  quality of
the urine be ascertained.  Although  irritability
is a symptom  of inflammation of this viscus,  yet
it is necessary to ascertain its  independence of
inflammatory  action; and  this  is to be inferred
chiefly from the absence of those  local and con-
stitutional symptoms characterizing cystitis, ci-
ther in an acute or chronic form.   The absence
of pain in the region of the bladder, and of fre-
quency of pulse  or of other febrile symptoms, es-
pecially towards evening, will indicate  the  inde-
pendence of the recent state of the complaint of
acute inflammation ;  while the more chronic state
of irritability will not be imputed to chronic in-
flammation of the bladder,  if the constitutional
powers  of the patient be not very  sensibly im-
paired by it.  The dependence of the complaint
upon disease ofthe prostate gland may readily be
ascertained by an examination per rectum.   Not
only, however, may there be irritability, but also
pain of the bladder, without any manifest disease
of this viscus ; the mischief being confined to the
kidneys,  chiefly  in  the  form of calculi of  these
organs.    Instances of this kind are  adduced by
Morgagni, Prout, Coulson, H. J  Johnson, and
others, and have come under my own  observa-
tion.  Dr. Prout remarks that, in certain  renal
affections  in particular habits, even where the
urine is not very unnatural, the pain is confined
chiefly to the neck  of the bladder; but where
the urine is actually diseased, and especially when
it  is alkaline, we may be certain that the kidney
is  functionally, and if the patient be of a scrofu-
lous habit, and  the case  of long  standing, very
probably organically affected.*
   12 iv. Treatment —a.  In recent cases, the
states of the general health  and of the urine will
frequently indicate a successful treatment. When
the urine is very acid, or scanty, or furnishes a
red sandy deposit, and when the complaint ap-
pears in  connexion with either gout or rheuma-
tism, then bicarbonate of potash may be given,
with or without  the nitrate of potash, in tonic or
bitter infusions or decoctions ;  the carbonates of
soda and of ammonia being inappropriate, the for-
mer owing to its favouring the formation of urate
of soda,  the latter to its influence in generating
urea and uric acid.  Mr Coulson states that  great
relief will sometimes be obtained from cupping
on the perineum.  This will be more especially
the case  if any congestion of, or vascular determ-
ination to, the prostate gland be present.   Liquor
potassse, prescribed in bitter infusions, with hen-
bane or conium,  or with small doses of colchicum,
in the gouty or rheumatic/diathesis, is also of
great service.  Where the potash, in either ofthe
states now mentioned, is not productive of relief,
magnesia  may  be given  so as to preserve the
bowels in an open state, an occasional dose of
equal parts of the compound infusions of gentian
and senna being also  taken.
   13 6  In cases which manifest a nervous  char-
acter, or which seem  to be results of abuse of the
sexual organs, tonics are especially required, ei-
ther in combinations  already mentioned, or with
the mineral acids;  as the infusion  or decoction
of cinchona with the nitro-muriatic acids, and
with henbane or conium, or with a few drops of
tincture of opium, or with the compound tincture

  [* This disease 1ms sometimes been mistaken for 6tone
in the bladder. We have known two instances where the
operation of lithotomy has been  performed without find-
ing any calculus in  the bladder.   Dr. Gkosb relates  a case
of a boy four years of age, who had a constant desire to
micturate, complained of severe pain in the urethra and
neck of the bladder, pulled constantly at the prepuce,
and strained violently whenever he voided  his  urine,
which was occasionally tinged with blood. On sound-
ing, no stone could be found, and he was cured with al-
terative doses of calomel and rhubarb, with carb. soda,
and in the intervals quinine and Fowler's solution  ] 
URINARY BLADDER—Irritability  of.
1295
of camphor.  The mineral acids may also be given
with the decoction of pareira brava, or of uva ursi,
or with the infusion of buchu, and with the addi-
tions just mentioned.  I have prescribed the tinc-
ture of the muriate of iron in calumba or quas-
sia, and anodynes, with benefit, for cases of this
kind.   Mr. Coulson remarks that the decoction
of uva ursi and the infusion of wild carrot seeds
will occasionally give great relief; but that no
medicine is so generally successful in irritability
of the bladder as the infusion of diosma ;  and he
adds that, from time immemorial, the buchu leaves
have been  held in great esteem by the natives of
the Cape of Good Hope as a remedy for irritative
and inflammatory affections of the  urethra, blad-
der, prostate gland, and rectum, and also for rheu-
matism, indigestion, and gravel.  The natives of
the Cape and the Dutch are partial to the spirit
of buchu, made by distilling the leaves in the dregs
of wine, and call this  spirit buchu brandy ; and
they use it for all chronic diseases ofthe stomach
and bladder, especially colic, spasms, &c*  A
tincture of buchu  is ordered by the  Edinburgh
and Dublin Colleges ; and half a drachm  to  a
drachm of it may be given  for a dose.  In these
and similar cases of irritability an opiate supposi-
tory, or a  starch enema containing from one to
two drachms of sirup  of poppies, or about thirty
drops of tincture of opium, may be administered
at night;  or a pill with opium, or henbane, and
extract of colchicum, shortly before bed-time.
   [Dr. Gross (loc. at) speaks favourably of the
tinct. of canlharides in this disorder, and states
that he has used it with marked advantage in sev-
eral cases during the last few years, especially in
the irritation of the bladder in young children and
hysterical girls, when carried to the extent of pro-
ducing slight strangury.  Haerlcm oil has some-
times succeeded when every thing else has failed,
in doses of from 10 to 20 drops.   The saturated
tinct. of the Phytolacca decandra was often pre-
scribed in this disease by the late Dr. Physic, in
doses of two drachms every 7 or 8 hours.  The de-
coction of soot, f ij. to one lb water, and filtered, is
highly recommended by Dr. Gibrin (Bull. VAcad.
de Med., March, 1837).]
   14.  c. When this complaint is symptomatic of
granular or other organic disease of the Kidneys,
or of enlargement or other lesions ofthe Prostate
Gland (see those articles), then the treatment
must be based on the primary and  chief malady.
When it is connected with the gouty or rheumatic
diathesis, or with either of the scaly eruptions,
then the bicarbonate of potash, or the  solution of
potash, and small doses ofthe iodide of potassium,
in equal parts  of the compound tincture  of cin-
chona and ofthe fluid extract of sarsaparilla, with
one of the narcotics already mentioned, are often
beneficial.  If the urine becomes  alkaline, or  if
the iodide  appear to perpetuate the  irritability,
the alkali and the  iodide should be relinquished.
In this state of the disease, colchicum may be
conjoined with the above, or even a small quan-
tity of opium may be added to  them.  In most
cases, especially when the nightly rest of the pa-
tient is much disturbed, an  opiate in  some suit-
able form  should be given  in the evening or at
bed-time.
  15. d. When the complaint occurs  in hyster-
ical females, or  in connexion with the accession,
or with disorder of the catamenia, the prepara-
  [* The fluid extract is far preferable to the tincture.
Tilden's preparations are altogether reliable.]
tions of iron, or  of valerian, or of asafoetida, or
of aloes, the bowels being acted upon by prepara-
tions of the  latter, are  generally beneficial.   In
these cases also,  the tincture of sumbul, in doses
of twenty to forty drops, with five or six of the
tincture of opium, is often of service.
   16.  e. The incontinence of urine often afflicting
children, and  generally during sleep, seems to pro-
ceed from an association of irritability with par-
tial paralysis of the bladder, or at least with im-
paired tonicity ofthe sphincter vesicae.  In most
of these  cases the general health, the digestive
functions, and the state of the urine are more or
less disordered;  and  to these especially medical
treatment ought  to be prescribed.  In many in-
stances, while due means are employed for these,
stimulating liniments rubbed along the spine, or
sponging the back and sacrum with a strong solu-
tion of salt night and  morning, will prove of serv-
ice.   (See also §39.)
   17. /.  In all cases of irritable bladder the  diet
and regimen  of the patient should be duly regu-
lated, and with especial regard to the states of
the digestive functions, of the urine, and of the
organs most intimately related to the offices of
the bladder.   Fruit and vegetables are often inju-
rious.   Much animal food is even more hurtful,
especially in the  gouty, rheumatic, and uric acid
diathesis.  Malt  liquors and spirits are still more
injurious, and wine is very rarely of service. Sex-
ual excesses  ought also to be avoided, and sexual
intercourse seldom indulged in.  The calls  to mic-
turate should be deferred as long as possible, and
the mind be  diverted from it; for a constant re-
sponse to each early  call ultimately gives  rise to
a habit which increases and becomes  confirmed
from the want of opposition to it.
   [Neuralgia of the bladder may be noticed with
propriety under this head.  This is a painful af-
fection of the organ, generally referred  to  the
neck of  the  bladder, occurring  in  paroxysms
daily, or every other  day, at about the same pe-
riod of time.   It  is met with  most frequently in
miasmatic districts, and  in hysterical subjects,
though by no means confined to  females.   For
the most part it occurs in the old or middle-aged.
The attack is generally preceded by a sense of
uneasiness in the perineal region, with occasional
numbness, aching, or  a sharp, tingling pain ;  and
these symptoms, with remissions, may last sev-
eral days, the attacks becoming more distinctly
paroxysmal;  the paroxysms lasting from  two to
six hours, and the pain resembling that produced
by a fit of the  stone.   Dr. Gross  represents the
pain as extending to the neighbouring organs, as
the rectum and anus, the urethra and inside  of
the thighs.  In the female the uterus is some-
times  involved, and the spermatic cords  in  the
male.   The pain is generally  very severe in  the
sacral and lumbar regions  in both sexes.  The
desire to micturate frequently is strongly marked,
although attended with difficulty; and a  sensa-
tion of heat and burning is felt along the urethra,
but especially at the extremity of the penis, from
whence it frequently extends to the neighbouring
parts.   " The paroxysm,"  says  Dr.  Gross, to
whom we are indebted for this description, " gen-
erally goes off gradually, leaving no other  incon-
venience than a sense of soreness, or aching in
the neck ofthe bladder, perineum, and posterior
part of the urethra.  During the intermissions
the urine is voided without difficulty, and the pa-
tient feels comparatively comfortable, almost  as 
1296                        URINARY  BLADDER—Spasm of.
well, indeed, as if he had not suffered any pain.
When the attacks assume the quotidian type, they
usually occur in the evening, during the night, or
early in the morning.   Occasionally they make
their appearance soon after eating, and in a few
instances they occur twice in the 24 hours ;  thus
leaving the poor sufferer scarcely a moment free
from pain."*
   This affection is rarely accompanied with fe-
ver.   There is usually much derangement of the
digestive organs, with torpidity  of the bowels;
the sleep is disturbed, the pulse quick and irrita-
ble, the extremities cold, and the general health
greatly impaired.  In severe and obstinate cases
there is a gleety discharge from the bladder, with
soreness in the perineum and hypogastric region,
and  a sense of coldness, with numbness, in the
neighbouring parts.  The urine is generally nor-
mal  in quantity and quality, except in gouty or
rheumatic subjects, in whom it is generally acid,
scanty, and mixed with red sand.
   The diagnosis of this  affection is not always
easy, as its paroxysms closely resemble those pro-
duced by calculus in the bladder.   Dr. Gross ad-
vises sounding the bladder.  The most important
signs are the sharp  and darting pains, jhe parox-
ysmal character of the disease, the itching  and
scalding in micturition, the attempts at which are
frequent, urgent, and difficult, and the numbness
in the perineum, scrotum, groins, and thighs.
   The causes are obscure, though they are prob-
ably the same as excite neuralgia in other parts.
No doubt, masturbation,  venereal excesses, stric-
ture  of the  urethra, stone in  the bladder, piles,
uterine diseases, may excite it in nervous, irrita-
ble subjects;  and  malaria, indigestion, the  de-
pressing passions, and a morbid state ofthe urine,
may act  as predisposing, if not exciting causes.
Its seat is supposed to be, as in other cases of
neuralgia, in the nerves  of the part, though dis-
section has thrown  no light on this point.   The
prognosis of vesical neuralgia must be guarded.
Though it seldom, perhaps, terminates fatally, yet
it  is  apt to prove obstinate in  spite of the most
judicious management.   Sometimes it disappears
suddenly, like  other  neuralgias, but more fre-
quently  it  persists  for years, undermining  the
health, and terminating in serious  organic  mis-
chief.   The treatment of this affection must be
regulated by the predisposing and exciting causes,
if ascertainable.   In miasmatic regions, the usual
antiperiodics,  quinine, Fowler's solution, &c,
promise best.  If inflammatory symptoms be pres-
ent,  they are to be  combated  by the usual anti-
phlogistics.   Dr. Gross recommends early, copi-
ous,  general blood-letting, repeating it every day
or two till the  force of the attack is abated, and
this  to be followed by leeches to the perineum, or
over the seat of the pain.   Purgatives are also
advised, especially if the affection is of miasmatic
origin, trusting to those which produce free evac-
uations,  but avoiding  drastics.   Mercurials  are
useful adjuncts, but salivation is to be avoided.
" I am convinced,"  says  Dr. Gross, " that a sys-
tematic course of purgation is not only unequivo-
cally beneficial, but  absolutely indispensable to  a
speedy and permanent cure."
   The preparations of iron will sometimes prove
useful, but they are inferior to quinine and arsenic
in this affection.  These, as  well  as strychnine
and  aconite, with opium, arc  recommended by
  * " On Diseases of the Urinary Bladder," &c.  Phil.,
1855, p. 264.
 Dr. Gross in pill, according to the following form-
 ula :
  RAcid.  Arseniosi,  gr. ij.;  Strychnines,  gr. j.;  Ext
 Aconiti, gr. viij.; Pulv. Opii, gr. v.  M. ft 16 pills.  One
 pill to be taken every 6 hours.
 If opium  disagrees, lupulme  or hyoscyamus may
 be substituted for it.   If nausea results, the dose
 is to be  diminished,  or the  pills taken less fre-
 quently.  It is also advised  not to  continue the
 pills longer than a week or ten days  at a time, re-
 suming them in the course of two or three days.
 Under this course the disease is often cured;  and
 the same combination will prove useful in other
 forms of  neuralgia.  To relieve  the violent pain
 of the paroxysms, narcotics, in full doses, are nec-
 essary ; of which the salts of morphia will prove
 among the  best.   We have  found  stramonium,
 in the form of Tilden's fluid  extract, very  effica-
 cious  in  every form  of neuralgia.   It is to bo
 given in large doses, and the system kept under
 its influence for some time.   Belladonna supposi-
 tories are also worthy of a trial, if  other means
 fail.  When the disease occurs in a malarious dis-
 trict, and  is associated with hepatic or gastric de-
 rangement, an emetic will often arrest or cut short
 the paroxysm.  The wine of colchicum, with mor-
 phia, at bed-time, will be beneficial,  especially in
 rheumatic or gouty subjects, alternated with mer-
 curial purgatives.  If there be acidity of stomach or
 flatulence, a combination of bicarbonates of soda
 and potash  may  be advantageously  given, or an
 occasional dose of calcined magnesia.
  Dr. Gross condemns the use of bougies in ves-
 ical neuralgia, as advised by M. Civiale (Gazette
 Medicate, July, 1836), after considerable experi-
 ence in their use.   He thinks more favourably of
 injections of acetate of lead and opium, or of a
 watery solution of opium and hyoscyamus, em-
 ployed tepid, cool, or cold, as is most agreeable
 to the patient.  If the disease prove very intract-
 able, then counter-irritation to the perineum, the
 supra-pubic region, the  sacrum, the upper and
 inner parts of the thighs, by the moxa or Vienna
 paste, will be advisable.   When the disease de-
 pends on piles, stricture of the urethra, foreign
 bodies in  the bladder, &c., the treatment must be
 directed  to  the removal of  the original cause,
 which is always to be assiduously sought for, else
 it may be overlooked by the practitioner.  The
 warm bath is an important remedy in every form
 of the disease.  But,  as in all other diseases, al-
 though our remedies  be  carefully  selected and
 judiciously  applied, yet without strict attention
 to diet a cure can not be expected.   All kinds of
 alcoholic  liquor must  be  sedulously avoided, as
 well as acescent fruits and vegetables, new bread,
 strong coffee, cheese, &c.  The digestive organs
 must be strengthened, and all the usual hygienic
 appliances faithfully carried out.  If the patient
 reside in a malarious region,  a change to a more
 healthy district will be useful.]
  18.  II.  Spasm of the Bladder.—Classif.—
     II. Class, III. Order.   (See Preface.)
  19. Definit.—A sudden and violent attack of
 pain  in the region of the bladder, extending along
 the  urethra to the glans, with either involuntary
 expulsion  or retention  of the urine.
  20. A.  This disorder is most commonly symp-
 tomatic either of stone in the bladder or of gonor-
 rhoea, especially when this latter is treated by in-
 jections ;  or of organic  disease  of the kidneys,
or of parts adjoining the bladder.  Dr. Proot re-
marks that  it may be caused by acid urine, by 
URINARY BLADDER—Paralysis of.                      1297
 abscess ofthe kidney, by ulceration or other dis-
 ease of the prostate gland, bladder, &c, or by re-
 tention of urine, or by gout, or by venereal ex-
 cesses.  Irritating diuretics, cantharides taken in-
 ternally, the application of blisters, hysteria, mas-
 turbation, the irritation of ascarides in the rec-
 tum, dysentery, or tenesmus, may severally excite
 an attack.   When it is  connected with gonor-
 rhoea or the treatment of it, then the sphincter
 vesicae is thereby either irritated or inflamed, and
 spasm supervenes as 60on as urine passes into
 the bladder.
   21. B.  The sudden and violent attack of pain
 in this  viscus, characterizing this complaint,  is
 attended by a constant desire to void urine, with-
 out the ability to do so, and the agony felt dur-
 ing these attacks is excessive.  The contraction
 of the  bladder excites the muscular coats of the
 rectum, and occasions also a desire  to evacuate
 the  bowels,  or  more  or less  tenesmus.   Mr.
 Coulson remarks that the closure of the ureters
 at their  vesical  extremities  has  given rise  to
 dilatation of these ducts and of the pelices of the
 kidneys, and to serious changes in the kidneys ;
 and that, after an attack of spasm,  from which
 the patient  has  apparently recovered, it some-
 times happens that  a new  train of symptoms
 appears, indicating the injury which the tubular
 and  secreting structure  of the kidneys has re-
 ceived.  Frequent attacks of spasm also some-
 times injure the tone and  contractility of the
 bladder so much as  ultimately to induce a par-
 tial or  more  complete  paralysis of the organ
 (v 27).
   22  C. The diagnosis of spasm of the  bladder
 is not difficult; it may, however, be  confounded
 with inflammation ; but in this  latter the pain  is
 constant, commences with uneasiness, and gradu-
 ally becomes more and more  severe    Spasm oc-
 curs  suddenly; the pain is violent and constrict-
 ive ;  whereas  in inflammation  the pain, when
 greatest, is either lancinating or throbbing, and is
 attended by more or less  febrile action, of which
 the  former is generally  exempt.  In  both the
 urine is usually  retained, or passed in the latter
 in very small quantities, and  after  remarkably
 short intervals.  Spasm may, however, be asso-
 ciated with inflammation  of the mucous coat of
 the bladder, as spasm of the coats of the colon  is
 associated with inflammation of the mucous coat
 ofthe intestine.  In such  cases the spasm is only
 a  symptom aggravating the character of the in-
 flammation, febrile symptoms more or less mani-
 festly attending this latter.
   23. D. The  treatment of spasm of the bladder
 will appear  from the above  to depend  chiefly
 upon the pathological state occasioning it.  If it
 be consequent upon inflammatory action, either
 of the sphincter vesicae, upon suppressed gonor-
 rhoeal discharge,  upon the use of irritating injec-
 tions, or upon inflammation of the bladder, bleed-
 ing, according to the grade of morbid action and
 habit of body of the patient, should be prescribed,
 either by venaesection, cupping, or by leeches, and
 be repeated if required.  The warm bath, fomen-
 tations, cooling aperients, and diaphoretics should
 follow vascular depletion ; and demulcents with
 anodynes, emollient enemata with anodynes or
narcotics, &c, should also be prescribed.  If the
complaint supervene  on gonorrhoea or the use
of injections, the above treatment is appropriate;
local  bleeding, however, generally proving suf-
ficient.                                        I
     III.               82
   24. If spasm of the bladder occur in the gouty
 diathesis, or upon the suppression of a paroxysm
 of gout, or as misplaced gout, the  regular form
 of the disease should be  solicited by means of
 mustard pediluvia, and mustard  poultices to the
 feet, while the soothing and anodyne remedies
 above mentioned are exhibited.   In cases of this
 kind,  as well as in many others, magnesia and
 sulphur may be  takeYi, with small  doses of col-
 chicum, of camphor,  and of opium;  and if the
 former be given in decided doses, so as to act
 upon the bowels, a more rapid effect will be pro-
 duced upon the spasm than by any other means.
 If the state of the  urine occasion  or aggravate
 the  spasm, appropriate means should  be  used to
 correct this state.
   25. When the disease is symptomatic of a cal-
 culus in the bladder, or in the kidney,  or  passing
 the  ureter, the warm  bath, fomentations, demul-
 cents,  emollients,  and narcotics,  or  anodynes,
 taken by the mouth and administered in enemata,
 are  generally of service ; but when the  calculus
 is in the bladder, these means are only of tempo-
 rary benefit—permanent relief must  be looked
 for  only from the surgeon.  Cases of spasm af-
 fecting chiefly the sphincter vesicae, and causing
 retention of urine, are generally  symptomatic of
 irritation or of disease of adjoining parts,  and are
 relieved by the tinctura ferri sesquichloridi taken
 in doses of ten to twenty drops in water every
 quarter of an hour,  or by  a suppository contain-
 ing  the extract of belladonna,  or by a belladon-
 na plaster applied over the perineum, while the
 emollients  and  anodynes already  advised  are
 taken internally.  Mr. Coulson recommends  a
 poultice containing powdered camphor to be ap-
 plied over the perineum, or a liniment composed
 of camphor and opium ; and states that emollient
 clysters containing some of the watery extract of
 opium  often afford instant relief.
   26.  III.  Paralysis of the Bladder.—Clas-
     sif.—I. Class, II. Order.   (See  Preface.)
   27.  Definit.—Partial or complete loss of the
 contractile  power, and of the organic sensibility,
 of the  bladder; often also with loss of power of the
 abdominal muscles, whereby the urine is partially
 or completely retained.
   28  i. History. — Paralysis of  the bladder,
 whether partial or complete, whether temporary
 or permanent, depends on loss of power, either
 originating in the organ itself, or affecting it con-
 secutively upon injury or disease  of  the spinal
 chord, or of the brain, or of their membranes.—
 a. A partial form of paralysis sometimes occurs
 as a  symptom of extreme debility or exhaustion in
 the course of acute or chronic maladies, as of ty-
 phoid or adynamic fevers, of hectic, and ofthe last
 stage of organic diseases.   In these circumstances,
 the contractility and organic sensibility ofthe blad-
 der  is more or less impaired, and the  power of
 the abdominal muscles to aid by their contraction
 the  expulsive efforts of the detrusor  urinae,  is
 equally lost.
   29. b. In some cases the loss of power in both
 is general and complete, and this state of the dis-
 ease, especially in its advanced  or protracted
 form, may  be attended by a constant dribbling
of the urine, owing to the over-distention of the
bladder having overcome the resistance  of the
neck or sphincter vesicae.   Thus incontinence of
 urine is superadded  to retention, and  the latter
is sometimes mistaken for the former.   In such
cases examination of the abdomen and  region of 
1298
URINARY BLADDER—Paralysis of.
the bladder,  or  the  introduction of a catheter,
will disclose the state of matters; and strict at-
tention should be paid to the excreting functions
of the urinary organs in all fevers and constitu-
tional maladies.
  30. c.  Paralysis of the bladder, giving rise to
retention, may come on  gradually, especially in
advanced age; either in consequence of disease of
the kidneys, or ofthe prostate or urethra, or after
a prolonged neglect of evacuating the bladder or
the suppression of the desire to evacuate.    In
these circumstances, however, the paralysis and
the retention may be at once complete.  Although
this form of the affection is most frequent in aged
persons suffering from disease of some other parts
of the urinary apparatus, yet it may also affect
the middle-aged, especially when the desire  of
evacuation has been long suppressed ; the  conse-
quent over-distention having overcome the power
of contraction, the abdominal muscles either fail-
ing to expel  the urine,  or expelling it only par-
tially.  In these and similar circumstances a fre-
quent desire  to  micturate occurs, and after ex-
pulsive efforts made by the abdominal muscles a
small quantity  only is  expelled; and this state
may be mistaken for a form of irritability of the
bladder:  but upon a strict  examination  of the
abdomen, or upon the introduction of a catheter,
a  large  accumulation  of urine  is found  in  the
viscus.
  31. In  some  persons  even of middle  age, a
more or less manifest state of paralysis is  conse-
quent upon impaired health caused by anxiety,
fatigue,   excessive application to  business, and
neglect of calls  to micturate, or by venereal ex-
cesses  or  masturbation.    When  these   latter
causes have  existed,  a state of complete or in-
complete tabes dorsalis supervenes, with manifest
weakness of the loins and lower limbs , and if re-
lief be not obtained,  paraplegia, with complete
paralysis of the bladder,  ultimately  results.   In
both this and the immediately preceding cases, as
well  as in some others, the over-distention of the
bladder, or the distention of it to a certain extent,
occasions a frequent desire or effort to evacuate
the urine,  and  a small quantity only is passed,
the power of contracting farther  being lost, or
the contractions of the abdominal muscles being
sufficient only to expel that small quantity.   In
such cases the catheter is often required.
  32. d.  Injuries and diseases of the spinal cord
and  brain, and  their  membranes, occasion  the
most complete and severe instances of paralysis
of the bladder; more especially lesions seated in
the spinal cord or its membranes, and whether
in the cervical, dorsal,  or  lumbar regions.   In
this class of cases the effects produced upon the
bladder and upon the state of the urine are differ-
ent, or vary more or less  with the amount of in-
jury or disease, or with the rapidity of progress
of the latter in the nervous centres ;  but they are
generally remarkable according to the severity or
clanger of either.  At first, or immediately  after
the occurrence of these, the urine may be more
or less acid and free from mucus; but especially
after injury of the spinal cord it soon becomes
alkaline, turbid, and  ammoniacal, evincing this
state  at  its discharge; and when it cools it de-
posits much adhesive mucus.  After a short time
phosphate of lime is  found in the mucus, which
afterward is sometimes blended with blood.  The
urine collected  in the bladder is  altered, either
during the process of secretion or during its  re-
tention in the bladder, and is generally changed
in the following manner: The urea is converted
into  carbonate of ammonia,  which irritates the
mucous surface of the bladder, and  causes the
exudation of much viscid  mucus.  The neutral
triple phosphate of magnesia and  ammonia con-
tained in the secretion forms  prismatic crystals,
and  presents different degrees of transparency.
The  inflammation of the bladder consequent upon
paralysis of the bladder, caused either by injuries
or disease of the nervous centres, extends from
the mucous to the other coats of the organ, if the
patient live for some time ; and the parietes be-
come thickened  and incapable of contraction;
the urine requiring to be drawn off  and always
presenting  a fetid and  alkaline character.   The
question in these cases is whether the change in
the urine is  owing to the altered  nervous  power
of the kidneys, or is it the result  of retention in
the bladder 1   From some attention which I have
paid to this question, I conclude that the change
in the  urine takes place primarily and chiefly in
the kidneys, owing to the  loss of  that portion of
nervous power which the spinal nerves convey to
the renal ganglia ; and that it is increased during
the  retention  of the urine in the bladder, the
paralyzed state rendering this viscus  more prone
to inflammation, and to the more rapid superven-
tion  and  progress of  the changes  consequent
upon inflammation.
   33. As this state of disease proceeds, the pain
or uneasinesss of the neck  of the bladder  and
glans penis at first experienced subside and ulti-
mately disappear, although distention may con-
tinue or increase.  The desire to pass  urine is
not  expressed; and  while the local  symptoms
subside the  constitutional become aggravated.
The  pulse is much accelerated, thirst is increased,
and  restlessness  and anxiety of  mind are aug-
mented.  The fur on the tongue is thicker, deep-
er, and darker-coloured.   Delirium supervenes,
with a urinous odour  of the perspiration,  and
stupor or profound coma supervenes,  and the pa-
tient dies in this state ;  the complaint being, per-
haps, mistaken for typhus fever, if due attention
have not been directed to the states ofthe urinary
functions and bladder.   Patients, especially those
advanced in life, when attacked by  fever, owing to
the congested states of the nervous centres, may
experience similar changes in the urine,  and a
similar paralysis of the bladder , and if this unfa-
vourable complication of fever be overlooked, it
rarely fails of being the chief cause  of a fatal issue.
   34. Paralysis of the  bladder occurs chiefly in
the aged; and although in them, as well as in
some younger persons, it may be favoured oi
caused by the states  of the spinal cord or of its
membranes,  it  is  most  frequently  consequent
upon disease  of the  prostate gland  or  neck of
the bladder, or of the urethra, causing over-dis-
tention  of the  organ.    When   this complaint
affects females, especially from puberty  to the
decline  of life,  it  is generally connected with
hysteria, or with the advanced stage of spinal
congestion (hysterical paraplegia) caused by uter-
ine irritation.   I  have seen several cases of hys-
terical paraplegia  where a surgeon was required
to draw off the urine, the complaint having been
imputed to  masturbation.  When it occurs in
married females,  it may be either  a symptom of
pregnancy, or of injury experienced during labour
or delivery    In the fourth month of pregnancy,
or about that time, or near the period of confine- 
URINARY BLADDER—Paralysis  of.                       1299
mcnt, retention  of urine may occur, and if it be
neglected, a paralyzed state of the bladder may
supervene from  distention.   Similar results may
follow retroversion or anteversion, or prolapsus
of the uterus.   Imperforate hymen, and obstruct-
ed catamenia from this cause have even occasioned
this complaint.
  35. e. Hysterical paralysis of the bladder is be-
lieved by Sir B. C. Brodie, and very justly, in
many cases, to be owing to defective  efforts  of
volition.  He remarks that, in  the first instance,
it is not that the nerves are rendered incapable of
conveying the stimulus  of volition, but that the
effort of volition is itself wanting ; and this cor-
responds with what is observed in other affections
connected with hysteria.  " As the distention  in-
creases the patient begins  to be uneasy, and at
last suffers actual pain ,  and as soon as this hap-
pens volition is  exercised as usual, and the blad-
der begins to expel its contents."  If not relieved
by  means ofthe catheter, the hysterical retention
of urine is thus of short duration; but if the cath-
eter be  had recourse to, the natural cure is pre-
vented, and the disease  may be indefinitely pro-
longed.  "The general rule," Sir B Brodie adds,
" in the treatment of these cases, is to interfere
but little;" but  this rule  is not without excep-
tions , for, in  a  few cases where the bladder has
been  very  much distended, it loses its power of
contraction, and even though the patient endeav-
ours to micturate, no water flows.  Under  these
circumstances artificial aid should be obtained
   36. /.  The affection which sometimes occurs in
children, especially in delicate boys, and which is
characterized  by  the discharge of urine during
sleep, has  been  variously explained ;  by some it
has been imputed to irritability of the bladder, by
others to a morbid state of the urine, causing ir-
ritation  of this  viscus, and by some to paralysis
ofthe neck ofthe bladder, occurring during sleep
That  this last condition may obtain is not unlike-
ly, as the affection is not unfrequently associated
with prolapsus ofthe rectum after  a motion, and
with  deficient tonic contraction of the sphincter
ani  It may, however, depend, in different cases,
upon the association of all these  morbid  condi-
tions in different degrees, the  share that a mor-
bid state ofthe urine may have in its production
being ascertained by the examination  of this ex-
cretion.
   37 ii The  treatment of paralysis of the blad-
der is,  1st, constitutional, and, 2d, local; but in
many cases the latter should precede the former,
especially as respects the urgent necessity of ob-
taining immediate relief  As  to the best means
of attaining this end I must refer to surgical writ-
ers, and especially to the able and precise instruc-
tions of Mr Coulson,in his work on the  "Dis-
eases of the Bladder," <SfC.—A.  The constitutional
treatment must  chiefly depend upon the nature
of individual cases, upon the pathological condi-
tions occasioning this disease ;  but in most cases,
and particularly in  old  cases,  medical treatment
is  of little avail; surgical appliances, especially
frequent introductions of the catheter, being re-
quired during the life ofthe patient.  Trial, how-
ever, may be made of strychnine, gradually  in-
creasing the dose, and carefully observing its ef-
fects  on the  nervous and muscular systems.   I
have  generally preferred the extract of nux vom-
ica, in doses of a quarter of a grain, gradually in
creased to one grain, given twice or thrice daily,
and combined with the aloes and myrrh pill, and
purified extract of ox-gall, or with the compound
galbanum pill.   I have also prescribed terebin-
thinate  embrocations or epithems, to be applied
over the loins and sacrum.  In the great majori-
ty of cases, and especially in aged persons, seri-
ous lesions supervene in the kidneys and  in the
pelvis of these  organs, and thus  complicate  and
farther  aggravate the  disease, and render  recov-
ery altogether hopeless.
  38. B. Hysterical paralysis  of the bladder U
not unfrequently caused by masturbation, and a
moral discipline is required, although it may not
prudently be  either suggested or enforced, unless
with the utmost discretion.   Indulgence and sym-
pathy, on the part either of friends or ofthe phy-
sician, should be withheld, and the  most nause-
ous anti-hysterical medicines should  be exhibited,
especially asafoetida, turpentine, &c, both by the
mouth  and in  enemata.  In a case where  this
affection was rather simulated or feigned than
actually present, I recommended, in the hearing
of the patient, the actual cautery  to be  applied to
the sacrum;  but the complaint vanished soon af-
ter mention was made of the remedy, and direc-
tions given as to its employment.
   39.  C.  The  paralyzed or relaxed state  of the
neck of the bladder in children, noticed above (§
36), generally  disappears  as  the constitutional
powers ofthe patient improve.  I have found ton-
ics, stomachic  aperients, chalybeates, and  stimu-
lating embrocations applied over the  loins, the
spine and  sacrum being sponged every morning
with a strong  solution of salt, of great service.
The patient should sleep on a hair mattress, cov-
ered  with  a water-proof cloth.   Change of air,
sea bathing,  or sponging with sea or salt water,
where  the plunge-bath causes alarm, and exer-
cise in the open air,  are also beneficial, indeed
are almost essential in these cases.
   [The treatment of palsy ofthe bladder must of
course, as  in all cases, be regulated  by its patho-
logical  cause, and  the attending circumstances.
The urine must first be drawn off and care taken
to keep the bladder emptied by using the  cathe-
ter at stated intervals, as every four or six  hours.
This alone will often be all that is required to
effect a cure.   If the continued use ofthe instru-
ment be required, the patient may  be  taught to
introduce it  for himself.   In  exceptional  cases,
the  catheter may be  allowed  to remain in the
bladder, removing it, however, sufficiently often to
prevent any accumulations upon it.  Dr. Gross
(loc. cit.) advises not to remove all the water at
once, in cases of over-distention, for fear of severe
depression on the removal  ofthe  stimulus of dis-
tention, as a fatal result may  in  this way  be in-
duced.  This is good advice,  and so is that of
swathing the abdomen by a bandage, as  after tap-
ping in ascites.
   The use of the catheter should always be  dis-
continued at the earliest possible period, and the
patient  should  be urged, from time to time, to
make propulsive efforts, so that the use  ofthe in-
strument may be dispensed with  ; otherwise the
bladder, becoming accustomed to its use, may lose
entirely its contractile power.
   The  tone  of the bladder must,  in  the next
place, be restored, if possible ; and  this may be
done by cathartics, where the paralysis  is associ-
ated with paraplegia or great intestinal torpor
For this purpose calomel, with jalap or rhubarb.
will be  preferable.  The cathartic may be repeat-
ed  every other day, or, at first, every day, with 
1300
URINARY BLADDER—In;
flammation of--DESCRIBED.
decided benefit. Dr. Gross states, also, that emet-
ics are sometimes of signal benefit in this disease,
especially when associated with derangement of
the digestive organs and general torpor.   After-
ward, strychnia, cantkaridcs, and  arnica may be
used with advantage, unless the affection be of
an inflammatory form.  These may be given in
combination, one-sixteenth of a grain of strychnia,
one-eighth of cantharides, and three to five grains
arnica, in a pill, every six hours, watching close-
ly the effects.   We have used with great satis-
faction the extract of lgnatia Amara, in this and
other forms  of palsy, in doses  of one half to two
thirds of a grain, three or four-4imes a day.  Dr.
Gross recommends the arnica (forty to sixty
drops of tincture), especially, in palsy of the blad-
der consequent on typhoid and other fevers, mas-
turbation, and general exhaustion  The ergot of
rye has been strongly recommended in this dis-
ease by Dr. Allier of France (Jour, des Connais-
sances, Med. Chir., 1838), and Dr. Day  of London
(Treatise on the Diseases of advanced Age), by
whom  it is preferred to cantharides and arnica.
There can be  no doubt that ergot exerts a spe-
cific action on the bladder as well as uterus, ex-
citing the muscular contractility of both  organs,
and probably in an equal degree.
  The inflammatory form of this  affection must
be treated strictly  on antiphlogistic  principles,
viz., general and local bleeding,  fomentations,
warm baths, anodyne enemata, &c.   When the
disease occurs in the aged, or those debilitated by
other diseases, tonics of the chalybeate class will
prove beneficial.  Hysterical vesical palsy is to be
treated on the same general principles as other
forms of hysteria.   There can be  no  doubt that
the disease is  sometimes feigned, as many other
diseases  are, by hysterical subjects, for what ob-
ject, often, it would be difficult to say, unless to
gratify a morbid taste for notoriety, or to excite
the sympathy  of friends and relatives.  Asafoeti-
da, valerian,  musk, castor, iron, and morphia may
all be brought into play, and the patience of the
practitioner  well-nigh exhausted, before  an ac-
knowledged cure will be effected.  Dr. Gross
(loc. cit.) speaks  highly, also, of a succession of
blisters over the dorso-lumbar region, followed by
an emollient poultice, and the surface sprinkled
with one fourth of a grain of strychnia, after re-
moval of the cuticle and adherent  lymph,  and re-
peated every twelve hours ; and he remarks that
" there is hardly  any form  of vesical paralysis,
excepting, perhaps, the inflammatory, in which
this mode of counter-irritation will not prove more
or less advantageous."  For farther details in re-
gard to the treatment of this and other affections
of the bladder, we refer to the above-quoted and
most able work, passim."]
IV.  Inflammation  of the  Urinary Bladder.
  — Synon. — Cystitis (from Cystis, a  cyst or
  bladder),  Sauvages, Vogel, Cullen, &c.  In-
  flammatio vesica, Sennert, Hoffmann.   Cauma
  Cystitis, Young.   Empresma Cystitis, Good
   Uro-cystitis, Cystiphlogosis ; Inflammation de
  la Vessie,  Fr.  Entzundung der harnblase, bla-
  senentzundung, Germ.
     Classif.—1. Class, 2.  Order (Cullen).  3.
       Class,  2. Order  (Good).   Ill  Class, I.
       Order  (Author in Preface).
  Definit.—A sense  of pain in the region of the
urinary bladder, increased on pressure,  with a fre-
quent desire to micturate, generally preceded by
chills or rigors, and attended by inflammatory fever.
  40. i.  Structures and parts  primarily or
chiefly affected.—Inflammation ofthe bladder
most frequently commences in the mucous coat,
to which it  may be limited, or it may extend to
the external coats.   When it thus commences it
may be circumscribed, or it may  affect all this
coat.  When the former obtains, the  part cover-
ing the neck of the bladder and the cystic trian-
gle is  most commonly  affected;  but inflamma-
tion, whether limited to the mucous surface or
affecting the other coats  also, or even the whole
parietes  of  the  organ, generally commences in
this situation, owing to the irritation  of sabulous
matter, of calculi, &c.   The imperfect emptying
of the bladder, especially in connexion with en-
gorgement ofthe prostate, the contiguity of this
part to the prostate and urethra, the  liability of
the extension of inflammation to it  from these
parts, and the participation in  irritation of the
rectum and vagina, also account for the more fre-
quent  commencement of cystitis in this part.
From the extension of  disease, cystitis may be
consecutive  upon inflammation of the rectum or
vagina, upon metritis, and  upon  haemorrhoids;
and it is  often consequent upon and complicated
with inflammation of the prostate.  In addition
to these  modes of commencement, cystitis  may
primarily attack the peritoneal  covering of the
fundus.  This is comparatively a rare occurrence.
The fundus  ofthe organ is much less frequently
the seat  of  the  disease,  particularly at an early
stage, than the neck of the bladder and the parts
situated posteriorly between the  sphincter  and
entrance ofthe ducts.  When inflammation com-
mences in the peritoneal coat ofthe organ it  usu-
ally arises from the extension of the  morbid ac-
tion from adjoining parts, as the rectum, caecum,
colon, or omentum.  Uro-cystitis has thus been
observed in the course of colonitis or inflammato-
ry dysentery, of peritonitis, and of inflammation
ofthe generative organs in females , and the con-
nexion of these maladies has often been render-
ed  manifest by examinations  after  death.   In-
flammation  may also attack all  the coats of the
bladder either primarily  or consecutively.  The
former is of rare occurrence, the latter is much
more frequent, owing to its extension from the
mucous or serous surface ofthe organ, and to in-
juries and operations.
  41. Uro-cystitis, with reference to its seat, may
be viewed, 1st  As to its limitation  to the mucous
surface of the organ ; 2d. As to its extension to
the coats forming the parietes;  3d  As  to  the
part ofthe viscus most frequently  affected either
primarily or  secondarily; 4th.  As to the nature
ofthe morbid action ; 5th. As to its consequences;
and, 6th.  As to its complications.  Each of these
heads will be considered  in detail.
  ii. Inflammation of the Mucous Surface of
the  Bladder.—Synon.—Blennorrhagia  vesica-
lis, Swediaur   Dysuria  mucosa,  Cullen.   Ca-
tarrhus vesica, Lieutaud   Rheuma vesica, Stoll.
Pyuria mucosa, Sauvages.  Catarrhe de la vessie,
Fr   Muco-cystitis (Author).   [Cystorrhea]
  42. Inflammation  of the  mucous coat of the
bladder  generally  proceeds from  the  common
causes of inflammation, and from those which are
usually productive of cystitis ($ 84, et  seq), espe-
cially the extension  of inflammation  of the  ure-
thra  to the neck and internal surface of the or-
gan, the use of irritating injections, of irritating
diuretics  and aphrodisiacs, the irritation of calcu-
li, &c.  This form of cystitis is of frequent oc- 
URINARY BLADDER—Inflammation of—described.               1301
currence, and presents every degree of activity,
from the most acute to the most chronic, owing
to the diathesis and habit of body, age, and mode
of living ofthe patient, and to its causes.
   43. A. The acute form ofthe disease is char-
acterized by  severe pain, increased by pressure,
sense of heat or tension in the hypogastric re-
gion, and uneasiness in the perineum, and by fre-
quent urgent calls to discharge the urine, attend-
ed by difficulty and increased pain.  These symp-
toms are often preceded  by chills, horripilations,
or rigors, and are followed and attended by febrile
reaction and  its usual concomitants.  Sometimes
neither chills nor horripilations are felt, especially
when the disease has extended from the prostate
gland or the urethra, the pain in the region ofthe
bladder, and the frequent desire to urinate being
the invading  symptoms.  The urine is passed oft-
en and in small quantities, with much smarting
heat and repeated efforts.   It is generally acid, of
a deep lemon or orange colour; at first clear, but
in a day or two numerous small shreds of lymph
or mucus are seen floating in it.  Sometimes the
urine is reddened and turbid, and deposits a thick
sediment, consisting chiefly of a muco-puriform
matter.  In a few days the irritation and febrile
disturbance are  diminished; the severity of the
pain in the region of the bladder is abated; but
often, even when this abatement is well marked,
the quantity  of mucus or of muco-puriform  mat-
ter in the urine is increased  The local and symp-
tomatic irritation, and the frequency and the dif-
ficulty of urinating, generally more or less  sub-
side about the same time.
   44. B. The consequences and terminations of
acute muco-cystitis vary with the  severity, the
causes, and the nature of the attack, and the  con-
stitution and other circumstances of the  patient.
If the inflammation proceed no farther  than the
mucous surface of the neck of the bladder and of
the  parts in the immediate vicinity, the above
symptoms  diminish  gradually,  and the disease
terminates  in resolution.   But very different con-
sequences occasionally ensue.   If the inflamma-
tion be very  acute, it may rapidly  extend to all
the tissues of the organ,  and even partially to
others in the vicinity, the  disease becoming ex-
tremely dangerous or even fatal.  In this case it
passes  into a state of uro-cystitis, to be noticed
hereafter.  More frequently, however, the acute
inflammatory symptoms gradually subside, espe-
cially the febrile  action, but the local ailment sub-
sists for some time, or continues with greater ob-
stinacy, the disease becoming chronic.
   45 C. Chrome inflammation ofthe mucous sur-
face of the bladder sometimes supervenes on the
acute, as just stated ; but it often occurs in a pri-
mary form. — In this latter case its invasion is
slow, and it is not accompanied with any or much
febrile disturbance, unless  the  inflammation as-
sume an intermediate grade between the acute
and chronic.  Sometimes the febrile action is  very
slight or remittent, and the local symptoms are
chiefly  remarkable, especially irritability  of the
bladder, pains in its region, or at the extremity of
the urethra, previous  to and at the time of pass-
ing the urine.   This excretion furnishes, espe-
cially as it cools, a mucous or muco-fibrinous de-
posit, of various shades of colour  in different
cases, and often an ammoniacal odour.   A sense
of weight in the perineum,  or of heat in the blad-
der and along the urethra,  frequent calls to  mic-
turate, and shooting pains  to the anus,  are  also
often experienced.   The discharge of mucus in
the urine is more or less considerable—hence the
term catarrhus vesica—but varies much in differ-
ent cases and at different times.
  46. a. Sometimes  the disease is  slight;  but in
old cachectic subjects, and when complicated with
disease of the kidneys or of the prostate, or with
both, it  is often  dangerous, or even proves fatal.
In this latter state, or when the disease has gone
on to ulceration, the  heat in the bladder and ure-
thra amounts to scalding, the desire to pass the
urine becomes iriore  frequent and urgent, and the
efforts more violent or straining.  The expulsion
of the last portion of urine is more or less pain-
ful ; and retention of urine is not infrequent, ow-
ing to the obstruction caused by clots of mucus
or fibrinous exudation lodged in the passage.
Pain is  felt at the extremity of the penis, in the
perineum and anus, sometimes in the loins and
thighs.   There are thirst, costiveness, or irregu-
larity of the bowels, uneasiness or restlessness,
wasting of flesh, and loss of strength.         >.
   47. b. The  mucus discharged in the urine va-
ries much in quantity and  appearance.   It  is
sometimes small, at  other times or cases it is so
great as to amount to pounds in the  twenty-four
hours.  In small quantity  the urine is rendered
turbid or flaky by it, and it settles to the bottom
of the vessel.   It is occasionally  stringy, ropy,
or of a  lumpy or viscid consistence.   The urine
is generally acid early in the disease, but it be-
comes neutral or alkaline as the mucous secretion
is increased.   When acute muco-cystitis passes
into the chronic the quantity of mucus is often
considerable, in some cases extremely great, form-
ing glairy or ropy streaks in the urine, which are
afterward deposited.   When the disease has not
been of long duration, the mucus in  the urine is
generally  whitish-gray  or  yellowish-gray,  tena-
cious or stringy, inodorous,  and  presenting no
distinct appearance  of pus.   But in the more
chronic or obstinate cases a purulent matter  is
evidently  present, mixed with and often more or
less predominating  over the  mucus.  In  these
cases the morbid matter is less abundant, less te-
nacious, of a yellowish colour, more  readily mis-
cible with  the urine, and is sometimes streaked
with thin bloody filaments.   It is also sometimes
fetid, is not so  readily  deposited  at the  bottom
ofthe vessel as the mucous secretion, nor is it so
tenacious.  It does not form  albuminous flocculi
when boiling  water  is poured upon  it, nor does
it coagulate, or  but imperfectly, when boiled.
When these  appearances are seen in cases of
considerable duration, ulceration of the mucous
surface, affecting chiefly the follicles, and the ex-
tension  of inflammation to the connecting cellular
tissue, may be inferred.  This inference  will be
still more  fully borne out if there be  slight fever
assuming  a remittent, or  intermittent, or  hectic
form, constant pain in the  organ,  emaciation,
restlessless at  night,  and the undoubted presence
of pus in the urine, with  more or less alkales-
cence.
  48. c. Pus may be distinguished from mucus
not only by the above appearances, but  by its
being miscible with  the urine, which it renders
opaque.   If the urine contain pus as well as mu-
cus,  the former is deposited upon the latter, and
is yellower in tint, and opaque, the mucus being
translucent.  The microscope aids the diagnosis
in these cases by showing the presence of pus-
globulea of the diameter of l-2500th part of* an 
1302              URINARY BLADDER—Inflammation of—described
inch.  If the  urine be  acid, the nucleus of the
pus-globule may be seen  without the aid of re-
agents ; but, as it is more frequently alkaline, the
addition  of a drop of acetic acid will bring the
nucleus  into view by rendering the corpuscle
more transparent.  A copious sediment resem-
bling pus is sometimes produced by a large quan-
tity  of triple phosphate in the urine.   But the
nature of this is shown by its solution  in nitric
acid, and by the shape of the crystals under the
microscope.   When  the  urine  containing  pus
presents  an acid reaction,  pyelitis may generally
be inferred ; when it is  alkaline, cystitis may be
considered to exist.    Purulent urine  becomes
clear on  standing, a more or less abundant sedi-
ment is formed, the supernatant fluid is  often of
a greenish-yellow tint, and contains albumen.
  49. Dr. Prout states that, in the advanced
stage of the disease, the mucus in the  urine is
diminished, it becomes opalescent and of a green-
ish tint, and can in part be easily diffused through
the urine, rendering it glairy or opaque, or milky
like  pus, the morbid matter  being in fact muco-
puriform.   The urine  is now generally deep-col-
oured, or serous, or alkalescent, having an ammo-
niacal odour, and effervescing with an acid.   In
this  latter case there is an  excess of carbonate of
potash or of soda in the urine, derived from the
serum  of the blood.   " When these symptoms
have continued for a longer or shorter period, the
urine becomes scanty, still more high coloured,
and occasionally even  acid ; the mucus, and even
the pus,  gradually diminish, and almost disap-
pear ; and  after a short period of comparative
ease the patient expires."
  50. d. Intermediate grades of muco-cystitis, be-
tween the acute and chronic  states ofthe disease,
are occasionally met  with in practice.  These
have often been termed  sub-acute.   They are to
be distinguished by more or less of the symptoms
already adduced, generally all of them, but in dif-
ferent degrees of severity, and attended by remit-
tent  or hectic febrile  action.  They may occur
primarily or follow the acute, which may subside
into the sub-acute, and ultimately into the chronic
state, terminating at last in ulceration and thick-
ening of the organ or some other structural le-
sion.  The chronic form of the disease may even
pass into the acute, although not so often as the
converse, either having  presented an intermedi-
ate  grade of morbid action, or having, owing to
some exciting cause, suddenly assumed the acute
form.  In this latter  case the  extension of in-
flammation  still farther should be dreaded  and
guarded against.
  51. e.  The  duration  of muco-cystitis is  ex-
tremely various : it may  may be from one month
—it being seldom much less in the acute—to two
or three  months in  the  sub-acute, to several
months to two or three years in the chronic.  It
depends entirely on the  cause, the age, and con-
stitution  of the patient, on the degree to which
the inflammation may have extended to the other
coats of the viscus and to adjoining parts, and on
the complications the  disease may have  present-
ed.   The same circumstances also influence the
prognosis and treatment (y 83, 89).
  iii. Inflammation of all the Coats of the
Bladder.—Cystite profonde, Cloquet ;  Cystitis
vera—true  Cystitis.
  52. This form of cystitis is not often met with
as a primary disease.  It much more frequently
supervenes on one or other ofthe forms of muco-
cystitis, and it occasionally occurs from  the ex-
tension of inflammation from contiguous viscera ;
as from inflammation of the uterus and ovana or
Fallopian tubes, or ofthe rectum, colon, caecum,
peritoneum, omentum, &c.; from extensive hffim-
orrhoids, and from diseases of the  prostate.  It
will be seen that  true cystitis, in some of these
consecutive states of occurrence, commences in
the peritoneal surface of the fundus, and that it
extends to all the coats.   It is, indeed, extremely
rare for true cystitis  to commence in this part of
the structure of the  bladder, unless when it su-
pervenes in the manner now alluded to.
  53.  True Cystitis  is thus more frequently sec-
ondary or  consecutive, and but  rarely primary.
But whether originating in the one way or in the
other,  it is a severe and dangerous disease; and,
owing to  its consequences, is often speedily fol-
lowed  by the most  serious effects.   While the
mucous coat only is the seat of inflammation, the
function of the muscular  coat is  seldom affected
in such a manner as to allow inordinate accumu-
lations of urine within the viscus, unless the dis-
ease is attended  by  an obstruction to the dis-
charge of the urine by associated disease of the
prostate or urethra, or by the impaction of a cal-
culus or fibrinous clot in the neck ofthe bladder.
When, however, these obstructions occur,  the in-
flammation of the  mucous coat soon extends to
the other coats;  the previous irritability of the
muscular coat is overcome by the distention con-
sequent on obstruction, and rapidly passes into
almost total paralysis or incapability of contrac-
tion, one ofthe most dangerous states  of the or-
gan in cystitis.
  54.   When true  cystitis follows muco-cystitia
or  catarrhus vesicae, the  abundant  mucous or
muco-purulent secretion which characterized the
latter is either much  diminished  or ceases  alto-
gether.  This arises  from the transfer of  the in-
flammatory  action chiefly to the more external
coats of the bladder,  and the  diminution of it in
the surface, which was  formerly its only  seat.
The occurrence of this change has led Dr. Prout
to think that the inflammation of all the coats of
the viscus is of a different kind from that  of the
mucous coat; but  I infer that the difference con-
sists merely in the different functions ofthe parts
affected in both these forms of cystitis.
  55.   True Cystitis  presents various grades of
activity, from the most acute to the chronic.  The
pathological  states through  which  the  disease
passes, and the consequences to which they lead,
are  also diverse, and  not always referable to the
violence of the attack, but are dependent upon
a number of circumstances connected with the
causes, complication, and other  peculiarities of
the case.   Thickening of the coats  of the blad-
der, owing to an  infiltration of  an  albuminous
serum  into the connecting cellular tissue, is  very
frequent, especially  when the inflammation is
sub-acute  or chronic, or has  extended from  the
mucous coat and is dependent upon obstruction
to the discharge of urine or the presence  of cal-
culi.  In these cases  the distention of the bladder
is a frequent occurrence; and even  when this
form of the disease is primary, and is not accom-
panied with obstruction to the discharge of urine,
a loss  of the power of the muscular  coat, and
consequent retention of urine, is a frequent at-
tendant upon it.   Although true  cystitis  affects
all the  coats of the bladder, a part  of the organ
may be more particularly  affected by it than the 
URINARY BLADDER—Inflammations of the.
1303
rest, especially the parts near the neck, and ex-
tending thence to the ureters.   This is especially
the case when the  disease has followed inflam-
mation or other morbid  states of the  prostate
gland, urethra,  rectum; or has proceeded  from
haemorrhoids, or from injuries caused by the use
of the catheter, by lithotomy, lithotrity, or other
operations.
   56.  A. Acute Cystitis.—a.  The symptoms of
this state of the disease are, generally after chills
or  rigors, severe pain, at  first behind, afterward
above the pubes, a sense of uneasiness in the per-
ineum, heat and tenesmus, and heat and smart-
ing in the course of the  urethra.  The patient
has frequent  calls to pass  urine, which are al-
ways attended  by more or less difficulty, often
amounting to dysuria.  The urine at last escapes
only by drops, with more or less scalding and
pain, and ultimately with unavailing efforts to
discharge it.    When the symptoms arrive at this
pitch much  anxiety  and tension of the abdomen
are experienced.   The distended bladder  rises
above  the pubes,  and the  hypogastric region is
very tender.   The frequent calls to pass the urine
and the dysuria may mislead the physician,  a
large quantity of water accumulating and causing
injurious distention ofthe bladder before the cir-
cumstance is suspected.  This accumulation may
be explained by the irritable state of the sphinc-
ter vesica?, the tumefaction of the inflamed parts
having diminished the outlet of the bladder, and
by the want of due action  in the muscular coat,
owing to the inflammation in which it and the
other coats are involved.  Hence it is thrown into
frequent and inefficient action, a portion of urine
is often passed ; but as soon as it reaches the ir-
ritable and inflamed parts  immediately below the
sphincter, spasm of these parts, and ofthe sphinc-
ter itself, takes place, which the contractions of
the fundus are unable  to overcome.   The secre-
tion of urine proceeding, distention so great as to
destroy the powers of reaction results, and com-
plete paralysis of the muscular coat supervenes.
If in this state a portion of the urine passes off,
it is owing  to partial relaxation ofthe sphincter
for a moment, and to the position admitting of
the discharge by gravitation.   This difficulty of
voiding the  urine and the consequent accumula-
tion are not owing  to the muscular coat of the
bladder only; for in many cases the parts near
the neck of the bladder are chiefly affected, the
tumefaction of these being so great as nearly to
obliterate the canal, and mechanically to obstruct
the flow of urine and the introduction ofthe cath-
eter.  In complications of the disease, with en-
larged or inflamed prostate, this is obviously the
case, a circumstance tending materially to influ-
ence the prognosis.  Independently of this com-
plication, there is every reason to infer, from the
nature ofthe morbid secretion and structure of
the parts, that this swelling contributes its share
with the other lesions  to the  production of this
very unfavourable symptom.  In cases of cystitis
produced by injuries of the spine, the paralytic
state ofthe  muscular parts of the bladder is the
cause of the accumulation of urine and of the
consecutive  inflammation ; but in other cases the
inflammation is the cause ofthe retention and of
the loss of muscular power, as above stated.
  57.  When the disease has reached this stage,
and the accumulation in the bladder is manifest,
the symptoms soon run on to a dangerous height,
if relief be not soon afforded by medical or surgi-
 cal treatment.   The patient is anxious, distress-
 ed, and fevered, the pulse is frequent and hard,
 the tongue white and loaded, the appetite is lost,
 thirst is great, costiveness with frequent calls to
 stool, painful tenesmus, and difficulty of passing
 a motion, especially when the disease is seated
 chiefly  about the neck of the bladder, or is com-
 plicated with disease of the bladder, as  frequent-
 ly is the case, especially in old men, are also ex-
 perienced.    In these cases,  and in others pro-
 ceeding from some irritation acting in  a  special
 manner on the bladder, as when  the cystitis  has
 arisen from the  improper use of cantharides, the
 presence of calculi, &c, the urine which is pass-
 ed is often sanguineous, or contains a considera-
 ble quantity  of blood.
   58.  The disease, having reached the state now
 described, will often evince signs of diminution,
 or rapidly present those of a still more dangerous
 character.   If accumulation  of urine and over-
 distention  of the bladder have been prevented,
 and the treatment otherwise judicious, the former
 will generally be the result.  But when the blad-
 der still continues over-distended, great prostra-
 tion of strength, with extreme restlessness, takes
 place ;  the pulse becomes small, frequent, inter-
 mittent, constricted, and at last weak and  scarce-
 ly perceptible ; the skin is hot and dry, afterward
 moistened with  a urinous or fetid  perspiration ;
 the tongue is dry, the thirst extreme ;  and to
 these sometimes supervene cardialgia, vomiting,
 hiccough, stupor or low  delirium,  cold extremi-
 ties, sometimes convulsions, coma, and death.
   59. b. Cases of true cystitis occasionally occur
 wherein little or  no urine accumulates  in  the
 bladder, owing  to the inflammation and  conse-
 quent tumefaction of that part ofthe viscus sur-
 rounding or in the vicinity ofthe opening ofthe
 ureters into  it, or to the effusion of coagulable
 lymph having entirely shut up their outlets.   In
 these cases inordinate distention of  the ducts  and
 pelvis of the kidneys must occur, and, in addition
 to the  above symptoms, those of dangerous dis-
 ease ofthe kidneys and suppression of urine  su-
 pervene, especially fulness, pain, and tenderness
 in the loins, numbness of the limbs, vomiting,
 constant hiccough, cold or urinous perspirations,
 rigors, subsultus tendinum, coma, &c.
   60. c. When  cystitis'has followed the healing
 of old eruptions or ulcers, or the sudden  stoppage
 of accustomed  discharges, as the haemorrhoids,
 the catamenia, or fluor albus, or if it have aristn
 from the misplacement or metastasis of rheuma-
 tism or gout, or if it have attacked persons of
 these diatheses, the several tissues ofthe bladder
 are liable to be affected nearly at the same time ;
 but the  symptoms are generally less severe than
 in the strictly primary and phlogistic form of the
 disease, and more frequently assume a sub-acute
 form, or some grade  intermediate between this
 and the chronic form next to be described.
  61. d. The duration of the disease in persons
 of the  phlogistic diathesis, and at an early age,
 often is extremely short.  True cystitis may reach
 its height as  early as the third or  fourth day, and
 its termination in the course ofthe first or second
 week.   But in more delicate or less inflammatory
constitutions, or in those  weakened by  previous
disease, if it  assume  the  acute form, it is more
 inclined to lapse into a sub-acute or chronic state,
and to  continue an  indefinite time.   It may,
moreover, assume, from the commencement a sub-
acute or intermediate character between the acute 
1304                   URINARY BLADDER—Ulceration of the.
and chronic.   But in all cases of this form of cys-
titis very much depends upon the nature of the
exciting and concurring causes, the complications
which certain  cases present,  and the attention
paid to the unloading the bladder of its contents,
and to other indications and means of cure.
   62.  e. Terminations  of Acute Cystitis.—True
cystitis terminates—1st. In resolution, with a
gradual amelioration of all the symptoms; 2d. In
the chronic state, with relief of the most urgent
symptoms, and continuance of a dull pain, uneas-
iness, and tenderness in the region  of the blad-
der, dysuria, &c. (§ 65, et seq.); 3d. In suppura-
tion, when the disease is very acute, this issue
generally occurring within twenty-four hours aft-
er the disease  has reached its acme; 4th, and
very rarely, in  gangrene; 5th, and still  more
rarely, in rupture of the viscus.
   63. (a) Suppuration is preceded and  attended
by pain and throbbing in the region of the blad-
der, or  behind  and above the pubes, and  occa-
sionally referred to the  seat of the rectum, by
horripilations, chills, or rigors, followed by flush-
es of heat, and sometimes by perspiration.  There
are often also painful tenesmus, costiveness, and
fever.   The urine afterward has  a turbid, puru-
lent appearance, or  contains  a  whitish-yellow
matter,  sometimes streaked with blood, and has
the odour  characteristic of pus.   In many of
these cases the purulent secretion proceeds from
the internal surface of the bladder, but small ab-
scesses formed  in the parietes  ofthe viscus have
opened internally and  furnished  this secretion.
This latter is more frequently the case when the
parts near the neck of the organ are more espe-
cially affected.   Chopart has  recorded several
instances of this occurrence, as well as of anoth-
er, more unfavourable, when the abscess is form-
ed more exteriorly, and makes its way, externally
to the bladder, into the loose adipose cellular tis-
sue at the bottom of the pelvis.  If in such cases
the patient survives, the abscess ultimately points
in the perineum, or near the margin ofthe anus.
Abscess of the bladder is seldom so situated as
to break into the peritoneal cavity.   In  all cases
of abscess of this viscus the danger is great, par-
ticularly in the latter cases.
   64. (b)  Gangrene may supervene in the most
acute cases, or  in cachectic constitutions ; but it
is a very rare occurrence, and  is never met with
unless  the disease be  attended by retention of
urine of two or three days' duration.  In these
circumstances an eschar or small  sphacelated
spot is formed  at one or more situations in the
organ.   This advances, and at last  the  bladder
bursts, and the urine is effused, generally  into
the abdominal cavity.  M.  Cloquet thinks  that
the rupture may occur without the previous sphac-
elation, from the distention, the greater tenuity
of the  bladder, and the  deficient support of its
parietes at this situation.  Admitting that rup-
tures of the bladder are generally in the  fundus,
yet they are less to be imputed to want of sup-
port in this  situation,  and to greater  tenuity,
than to previous ulceration and deficiency of vital
cohesion characterizing the advanced stages of
acute inflammation, although these circumstan-
ces may contribute to the event.   But very few
of the cases of rupture  that occur depend upon
previous sphacelation, which is an extremely rare
occurrence in this disease.
  65. B. Chronic Cystitis.—When the acute form
of true cystitis has not  terminated completely in
 resolution, it frequently  passes into a chronic
 state of the  disease.  But this form may exist
 from the commencement,  and, appearing in a
 mild state, it is often neglected, and hence  be-
 comes an enduring disease.  As in other inflam-
 mations, cystitis is observed of every intermediate
 grade of severity and of duration,  from the most
 acute to the most chronic, according to the nature
 of the exciting and concurring causes and the
 peculiarities  of the individual.   The consequen-
 ces resulting from the sub-acute or chronic forms
 of cystitis also vary with the severity of the at-
 tack.  When the chronic is merely a continua-
 tion ofthe acute in a less severe degree, the na-
 ture of the disease is  manifested by the persist-
 ence of the local symptoms especially, which are
 of a nature  readily to be  recognised and under-
 stood, and are chiefly those already adduced, but
 in a milder form.
  66.  When chronic cystitis occurs primarily, its
 accession is sometimes slow, and scarcely so  se-
 vere at first  as to  excite the anxiety of the pa-
 tient.  In other cases it is of a much more mark-
 ed character, and more nearly  approaches a sub-
 acute or  an  acute  form.    But in general it is
 characterized by permanent pain referred to some
 part of the viscus, by frequent calls  to  void the
 urine, attended by difficulty, as if occasioned by
 stricture ofthe urethra;  by the presence of mu-
 cus or purulent matter in the urine ;  by tenesmus
 at stool and costiveness ; by slight fever, especial-
 ly in the evening, and sometimes by fever of a  re-
 mittent or intermittent form ; by a loaded tongue;
 by inability to retain much urine at  a time ; and
 by an exacerbation of some or of all the symp-
 toms after fatigue, exposure to cold, or errors of
 regimen, especially after drinking spirituous, vin-
 ous, or malt  liquors.  These  symptoms vary in
 degree, and one, more, or  even all of them, are
 more severe the more nearly the disease  ap-
 proaches a sub-acute or acute form.
  67. The duration of this form of cystitis varies,
 according to  the severity of the symptoms, from
 two or three months to as  many years, or even
 longer.  An  acute or sub-acute state may super-
 vene upon the chronic and shorten  its duration,
 or the same result may follow the extension  of
 disease to adjoining parts  and the  presence  of
 serious complications.   When it arises from cal-
 culi  in the bladder, or from disease of the pros-
 tate  or urethra, thickening of the walls of the
 viscus is a common consequence.  It may, when
 it approaches the acute or sub-acute forms, term-
 inate in  abscess, in ulcerations, or perforation,
 or give rise to other lesions by extension of the
 inflammation to adjoining parts, as noticed in re-
 spect ofthe acute disease (§ 63).
  68.  C.  Ulceration of the  urinary bladder may
 result from any one ofthe forms of inflammation
 ofthe mucous coat ofthe  organ already noticed,
 but most frequently from the sub-acute, chronic,
 and  most protracted  states.  It may,  however,
 also  follow the acute form and  the more chronic
 states of true cystitis.  It is often difficult to de-
cide  as to the existence of ulceration ; but when
disease ofthe bladder has been of long duration,
the pain severe and continued,  with a frequently
recurring  desire to micturate, and  an increasing
difficulty and pain in passing the urine, then the
existence of this lesion should be suspected, and,
if the urine presents the appearances stated above
($ 48), especially if it contains pus streaked with
blood, it need not be doubted.   Ulceration of the 
URINARY BLADDER—Complications  of  Cystitis.                1305
 bladder may take place differently: it may com-
 mence in the mucous follicles, especially in the
 more chronic cases;  or it may follow the acute
 form, lymph being first exuded from the inflamed
 surface, and subsequently detached, leaving this
 surface tender and susceptible of irritation from
 the urine, and liable to experience ulceration from
 the continuance of the irritating cause.  In acute
 cases the mucous surface may thus be nearly all
 destroyed by the softening and ulcerating proc-
 esses produced and perpetuated by the urine on
 the inflamed surface, the walls of the viscus be-
 coming thickened, even although the muscular
 coat may be laid bare in parts.
    69.  When the  ulceration  is  seated or com-
 mences in the follicles, perforation of the bladder
 may result, the disease having assumed most fre-
 quently a chronic form.  When ulceration or de-
 struction ofthe mucous  coat follows acute cysti-
 tis, all the coats forming the parietes ofthe organ
 rapidly become implicated, and the disease soon
 terminates  fatally.  The more limited states of
 ulceration,  especially when commencing in the
  follicles, may perforate  the coats of the  viscus,
 and, having reached the peritoneal surface, occa-
 sion the exudation of lymph,  by  which the blad-
 der becomes united to  adjoining parts, thereby
  preventing the escape of urine, or forming a fis-
  tulous opening into some other viscus.   In  this
  manner a fistulous communication may be form-
  ed between the fundus ofthe bladder, the sigmoid
  flexure ofthe colon, or the caecum, or the ileum,
  &c.  When a fistulous opening is thus  formed
 between the bladder and any  portion  of the bow-
  els, faeces may pass into the  bladder, unless the
  opening be formed between the under surface of
  the bladder and the rectum,  and then the urine
  is usually voided with the faeces.  Fistulous com-
  munications between the bladder and the  rectum
  are more frequent, especially in females, than be-
  tween the former and other portions ofthe intes-
  tinal canal.   When communications are  formed
  in this situation, either by ulceration commencing
  in the bladder or in the rectum, an abscess below
  the  reflected  portion of  the peritoneum often
  forms, owing to the inflammation ofthe connect-
  ing cellular tissue caused by  the urine or by the
  faeces.   Mr. Coulson (op. att, p. 140) has  record-
  ed some  interesting  cases of fistulous openings
  between  the bladder and  intestines, to which I
  may refer the reader.   Ulceration and perforation
  are always  attended by hypertrophy or thickening
  ofthe coats ofthe bladder, whether they be con-
  sequent upon  muco-cystitis or the more chronic
 or  sub-acute states of true cystitis.  When the
* ulcer is seated in  the posterior and inferior part
  of the bladder, it may penetrate the coats  so  that
 the  urine will pass into the  cellular tissue be-
 tween the  bladder and rectum,  producing the
 most destructive effects.
    70.  iv. Complications of  Cystitis.—One or
 other of the forms of cystitis may be associated
 with some  other  disease or structural  lesion.
  These diseases may be the causes ofthe  inflam-
 mation ofthe mucous coat ofthe bladder, as well as
 its complication.  This is especially the case with
 gonorrhoea, gleet, stricture ofthe urethra, syphilis,
 calculus  in the bladder, rheumatism, gout,  &c.
  Gonorrhoea  often induces a severe and obstinate
 form of muco-cystitis, the discharge from the ure-
 thra being  diminished as  that from the bladder
 becomes more copious and the other symptoms
 more distressing.   On the other hand, the chron-
ic forms of muco-cystitis, especially when they
go on to ulceration, perforation, &c, induce dis-
ease of the kidneys, most frequently of the left
kidney (Rayer, Richter, P. Frank, Coulson,
&c).   In these latter cases  a dull pain  is felt in
the loins, is increased by pressure, and is usher-
ed in  by chills, rigors, sickness at stomach, and
an albuminous urine, which also contains large
quantities of puriform matter, often tinged with
blood.
  71.  With ulceration of the mucous coat, hy-
pertrophy of the muscular coat, contraction and
thickening of the parietes of the organ generally
result. The bladder, owing to its irritability, is con-
stantly contracting upon the urine poured into it;
and spasm of the  sphincter often causes  a re-
gurgitation into, or an obstruction of the ureters ;
which thus become distended  and tortuous, and
still farther changes are thereby induced.  " The
mucous membrane, extending upward along the
ureters to the pelvis and the infundibula of the
kidneys, becomes inflamed and rough, and pours
out a quantity of pus.  The glandular structure
ofthe kidney undergoes from pressure  slow ab-
sorption.  The capsule adheres with preternatural
firmness to the exterior of the gland.  Upon mak-
ing a section of a kidney  so diseased, we find
that, although apparently of large size, it consists
in great part  of dilated tubes, and that  the true
vascular or secreting part is  in smaller proportion
than usual."—(Op. at., p. 144.)
   72. The complications either  of muco-cystitis
or true cystitis are chiefly with diseases of adjoin-
ing parts, and arise from the extension of inflam-
matory action, either to these parts from  the blad-
der, or from the latter to the former.   Inflamma-
tion of the urethra, prostate gland, strictures of
the urethra, calculus  vesicae, haemorrhoids, co-
lonitis or inflammatory dysentery, inflammations
of the rectum and of the uterine organs, and kid-
neys, &c, may severally extend to, or excite in-
flammation  of the bladder.  On the  other hand,
this latter may involve  the adjoining parts:  it
may extend from the fundus to the omentum, or
to some of the convolutions of the intestines, or
it  may occasion peritonitis.  This is not a fre-
quent occurrence ;  but firm adhesions of one or
other of these parts to the fundus of the bladder
have  been found on rare occasions, where, from
the history of the cases, the  bladder was  the orig-
inal seat of disease.
   73. Inflammation may extend from the mucous
coat of the bladder to the ureters, and along their
course even to the kidneys ;  but  this very fre-
quent and important complication of uro-cystitis
is most probably not often produced in this man-
ner, but much more frequently by the occlusion
ofthe ureters where they pass through the coats
of the bladder, owing to the  tumefied state of the
inflamed parts at this situation.  In this case the
urine is secreted for a while, but cannot pass into
the bladder, owing to this condition of parts.  In-
ordinate distention of the ureters, pelvis, and tu-
bular  structures is the consequence, and serious
disease and  disorganization, not only  of these
parts, but also of the constitution, result.
  74. The extension of inflammation of  the blad-
der to the uterine organs is not infrequent; oc-
casioning not merely  adhesions  between the se-
rous surfaces, but also, particularly when cystitis
is  consequent upon, or is attended by retention
of urine, retroversion or obliquities ofthe uterus,
leucorrhoea, &c. The most frequent complication 
1306                  URINARY  BLADDER—Diagnosis of Cystitis.
 of cystitis is stone in the bladder, the inflamma-
 tion being consequent upon, and generally occa-
 sioned by the solid concretion.  The frequent
 connexion also of the several forms of uro-cys-
 titis with gout and rheumatism, either as conse-
 quences of the misplacement or metastasis  of
 these, or as occurring from other causes, owing
 to the predisposition to  urinary disease occasion-
 ed by them,  should not be overlooked when as-
 certaining the causes and the relations of cystitis,
 or when determining the indications and means
 of cure.
   7."). v. Appearances  after  Death. — These
 vary much in different cases, and are more gen-
 erally the consequences than the states forming
 the early, or even the advanced, states of the dis-
 ease.—A. After acute muco-cystitis, the inner sur-
 face of the bladder is thick, rough, of a reddish-
 pink hue, from capillary distention, with small
 ecchymoses, owing to exudation from the con-
 gested capillaries.  The inflammation in  most
 fatal cases is found to extend over the whole in-
 ner surface, although greatest in some parts, es-
 pecially near the neck of the organ.   Coagulable
 lymph is sometimes found covering or attached
 to the mucous coat.   This tunic,  in the  most
 acute cases,  may be detached from the muscular
 in parts, or even  throughout, forming a grayish
 layer resembling a false membrane.  In many in-
 stances the mucous coat has been destroyed  by
 ulceration ; " sometimes, however,  round  ulcer-
' ated spots, the size of a sixpence, are found in
 different parts, with elevated edges and a red sur-
 face."   Ulceration generally commences  at  or
 near to the neck of the bladder, and extends more
 or less to the fundus ; but it sometimes begins in
 the latter, and advances to the former.   In the
 most severe cases the muscular coat is involved
 in the inflammation, presenting gangrenous  or
 disorganized spots.  One or other of the kidneys
 is also generally diseased, the pelvis being dilated
 or ulcerated, containing pus, and the ureters also
 being dilated and ulcerated at  their vesical ex-
 tremities.
   76. B. In the slighter or early states of chronic
 muco-cystitis the mucous coat is found, in cases
 of death from  other diseases consequent on the
 former, injected, discoloured, thickened, and soft-
 ened, and its follicles enlarged and inflamed.  It
 separates readily from the adjacent coat, is abraded
 in parts, and is even detached in spots by extrava-
 sations underneath.  The parietes of the viscus
 are thickened and contracted, the muscular coat
 is greatly hypertrophied, and ulceration of the
 mucous coat penetrates to the muscular, or even
 farther (§ 68, 69).  When the  ulceration is ex-
 tensive, the hypertrophied muscular fibres appear,
 and resemble the columnae  carneae  of the  heart,
 presenting a purplish-red colour;  the  mucous
 coat between the columns thus formed being pale,
 soft, and swollen.  Pouches, or sacs, generally
 coexist, with dilated ureters, between these  mus-
 cular  columns, and are  formed by  the contrac-
 tions of the  bladder and of the abdominal  mus-
 cles, in expelling the urine, forcing the mucous
 coat in places between the muscular fibres.  These
 pouches are lined with a diseased mucous coat,
 which secretes an alkaline mucus, and are " some-
 times the receptacles of a mortar-like matter, and
 finally  of calculi, consisting  generally of phos-
 phate of lime."  As the disease proceeds in the
 mucous coat it extends to the ureters, to the pel-
 vis, and to the tubular structure of the kidneys ;
and pyelitis supervenes.  Ultimately the ureter
leading to  the  kidney affected becomes dilated,
tortuous, its lining membrane inflamed, granu-
lated, or ulcerated, or sometimes covered with
lymph.   The pelvis and infundibula are much di-
lated, while the secreting structure ofthe kidney
is reduced to a  thin layer.
  77. C. In the more  chronic states and  other
cases of muco-cystitis, patches of a red colour,
more or less deep, or from a bright red to a violet
shade, are found in the mucous coat;  and small
ulcerated specks  or points,  apparently  affecting
the mucous follicles, are seen in these patches.
In the more chronic cases the ulcers are of con-
siderable size.   When numerous they  are gen-
erally small.   Sometimes an albumino-puriform
matter, adhering at points of the mucous surface,
gives it an ulcerated aspect on a superficial view ;
and occasionally this surface appears elevated at
numerous points, owing to an albuminous exuda-
tion  in the subjacent cellular tissue.   The whole
internal surface is but  rarely affected,  although
the greater part generally is, in the form of large
irregular patches.  In protracted cases the mu-
cous surface is thickened, and this change often
extends to the  connecting cellular tissue ; while
the blood-vessels are  more  numerous and more
engorged than natural.  With these appearances
the bladder is generally contracted, and the mu-
cous  coat forms  a number of large  wrinkles  or
folds, is often  softened, and is occasionally in-
crusted, or  covered in parts with a calcareous de-
posit.  The prostate gland is often  enlarged  in
these cases, is  somewhat diminished in consist-
ence, and readily admits of being divided.
  78. D. In true cystitis, especially when chronic,
in addition to increased vascularity, more marked
in some places than in others, the parietes of the
bladder are much thickened,  and more or less con-
tracted ;  but the  extent of these  changes varies
greatly, being generally greatest in cases of chron-
ic cystitis  arising from the presence  of stone.
In some cases the thickening is moderate, yet at-
tended by  a varicose  state of some of the  veins
of the viscus.   Adhesions to adjoining parts of
the fundus of  the bladder,  ulcerations, &c, are
also sec i in the circumstances and complications
of the disease described above (y 63-69).
  79.  vi. Diagnosis. — A.  Muco-cystitis, when
acute, may be mistaken for inflammation of all the
coats of the bladder; but in  the latter the desire
to void the urine is much less frequent than  in
the former, and sometimes is not experienced un-
til a large accumulation has taken place, and then
it occurs in most severe paroxysms.   The sense
of scalding along the urethra felt in muco-cystitis
is either slight, or absent when all the  coats are
inflamed.   Occasionally the power  to  pass the
urine is lost in this latter form ofthe disease, even
when the desire is most urgent, and the act can
be accomplished only after repeated efforts, or by
surgical aid.
  80. Many of the symptoms of acute  muco-
cystitis are experienced when stone is present in
the bladder.  But in  cases  of stone the pain is
chiefly felt after  the bladder has  been emptied;
whereas in acute muco-cystitis the pain is most
intense when the bladder contains urine, and it
subsides when  the viscus is empty ;  in cases of
stone, also, larger quantities of blood are passed
than in muco-cystitis, and the urethra is seldom
so irritable.  (Coulson.)
  81. B. Irritability ofthe bladder is to be dis- 
URINARY BLADDER—Prognosis—Causes  of Cystitis.
1307
tinguished from muco-cystitis  and true cystitis
by  the  symptoms noticed above (y 11), and  by
the severity of the local affection, and of the con-
stitutional disturbance.  When, however, the  ir-
ritability depends upon organic disease of the kid-
ney, the diagnosis is more  difficult.  Mr. Coul-
son remarks that the intense pain which attends
inflammation and ulceration of the mucous coat
ofthe bladder soon exhausts the patient, while in
irritable bladder from diseased  kidney there is
sometimes, but  not  always, pain in voiding the
urine ;  that the frequency  of micturition is the
most distressing symptom ;  and that, even when
pain exists, it is never so severe as to  wear the
patient out, but  may be, and often is, endured for
years.
   82.  C. The chronic  states of muco-cystitis are
readily recognised.  When mucus is passed in
the urine in small or moderate quantity it may be
mistaken for the involuntary discharge of semen,
or ofthe prostatic fluid, which accompanies the
evacuation of the faeces  or  of the urine in some
persons ; but semen  differs from  mucus  in  its
color, in its property of liquefying on cooling, in
its insolubility in water when recent and  thick,
and its solubility when liquid, and in the  radia-
ting crystals which it produces after evaporation.
The prostatic fluid may be distinguished by  its
remarkable transparency, by its stringy and slimy
properties, and  by its retention  of these condi-
tions until it is dried.  The prostatic secretion is
often mistaken for the seminal in cases where it
is discharged, both being passed immediately after
the bowels and  the bladder are evacuated ; but
the prostatic fluid is passed much more  frequent-
ly than the seminal, which  is thus voided  much
more rarely than is often believed to be the case.
Chylous urine is different from the urine voided
in muco-cystitis, in being of a uniformly whitish
hue, and the sediment formed by standing readily
mixes with the  urine  on shaking; whereas the
urine in this form of cystitis is at first turbid, and
on standing the sediment becomes viscid, ropy,
flocculent, or muco-puriform, or even  purulent,
and it has  the appearances  already noticed
(v 47-49).
   83.  vii. The  Prognosis  depends much upon
the age, constitution, diathesis, and habits ofthe
patient, and on the exact seat, severity, and dura-
tion of the disease.   It  may even still  more de-
pend upon  the  consecutive lesions already pro-
duced, and upon the presence or absence of com-
plications.  If the disease be primary and uncom-
plicated, and the patient young or middle-aged,
and of a sound constitution, or has not  previous-
ly been subject to disease of the urinary organs,
the prognosis is favourable;  but, on the  contrary,
if he be aged, cachectic, has been subject to pre-
vious disease of the urinary organs, to  stricture,
or to any of the complications mentioned above
(y 70, et seq.), especially to disease of the kidneys,
and still more particularly to this latter, occurring
consecutively upon  chronic muco-cystitis, the
prognosis is unfavourable  In the  more  acute
cases, as well as in the subacute  and chronic, if
the pain  continue, notwithstanding a judicious
practice;  if the  micturition  be still frequent;  if
the urine be loaded with a muco-puriform matter,
epithelium, and  a little blood; if a dull, heavy,
and continued pain be felt extending from above
the pubes to the sacrum or sacro-iliac symphyses,
and especially if it be experienced in the  loins and
extend to the thighs ; if emaciation and hectic
be marked; and if vital exhaustion be rapid or
extreme—ulceration of the bladder, and  conse-
quent  disorganization  of the kidney, may be in-
ferred, and a fatal issue be expected.  If the states
of true cystitis be followed by retention of urine,
or if either form be followed by suppression, re-
nal symptoms supervening, and no urine being
found in the bladder, the danger is generally ex-
treme.  Whenever any of the severe  symptoms
mentioned above (v 56, et seq.) occur, whatever
may be the stage, form, or progress of the dis-
ease, a most cautious prognosis should be formed.
  84. viii. Causes of Cystitis.—A. The  several
forms  of  cystitis are  most frequently met  with
in persons advanced in age, and in adults—par-
ticularly in the former.   MM. Lesaive and Bois-
seau  have, however,  seen them in children be-
tween two or  three years of age, and I have met
with them as early as four and five years; but
instances at this age are very rare, unless when
accompanied  with  calculus  in the bladder, or
after injuries and operations.  Cystitis  frequently
occurs in cold and humid climates, especially that
form  of it which is limited to the mucous coat;
and it is common in persons addicted to ferment-
ed  or spirituous liquors.   Sedentary habits  and
occupations also predispose  to it, especially in
aged persons who are either confined to a sitting
posture or to bed.  An habitual neglect of imme-
diately attending to the first desire  of voiding the
urine is a usual  predisposing as well as exciting
cause; the retention of  this  excretion occasion-
ing irritation of the mucous surface and over-dis-
tention and diminution of contractility ofthe mus-
cular coat.  Females are less subject than males
to muco-cystitis; but they appear quite as liable
to the acute  form of true crystitis, while  they
are less frequently affected with its chronic state,
and to the complication  of the disease with cal-
culus and with disease ofthe kidneys.  This par-
tial immunity is owing to calculous concretions
being less frequent and  more easily removed in
females ; while diseases of the prostate and of the
urethra are very frequent causes of the forms of
cystitis in the male sex.
  85.  There  are, perhaps,  few  causes  which
more  frequently predispose to inflammations  of
the bladder than long-neglected disorder of the
digestive organs, and especially to those states of
cystitis which are complicated with calculous
formations.  There also seems to be a predispo-
sition constitutionally inherent  in  some persons
to diseases of the urinary organs, and  conse-
quently of the bladder, and especially in those of
a gouty diathesis.  Indeed, both  the gouty and
calculous diatheses often originate in the same
sources, namely, in deficient vital energy,  and
long-continued disorder of the digestive functions
connected  with  an excessive use of animal  food
relatively  to the amount of exercise in the open
air.  The connexion of the former state  of the
system with disease ofthe bladder is very evident,
and the  intimate relation  which both diatheses
hold to each other in respect  both  of their com-
mon sources and of their exciting causes,  are
satisfactory proofs of predisposition independent-
ly of the evidence furnished by experience of the
frequency of cystitis in  gouty habits.   Persons
of a scrofulous diathesis, or who have been ad-
dicted to venereal excesses or to the habitual use
of highly seasoned dishes, to much animal food,
and to sedentary occupations, are generally dis-
posed to cystitis. 
1308
URINARY BLADDER—Treatment of  Inflammation of.
  86. B. The most frequent exciting causes are,
too long retention of the urine, exposure to cold
and moisture, sitting on damp couches, sofas, or
seats, or on cold stones, or on the ground;  damp
clothes on the lower extremities ; damp feet; cold
drinks while the body is perspiring ; the abuse of
diuretic and lithotriptic medicines ; the excessive
use of common gin; the incautious exhibition of
emmenagogues ; the internal use of cantharides
or turpentine in too large or too frequent doses ;
the abuse of aphrodisiacs ; the introduction of a
catheter or sound, especially by unskilled hands;
irritating or improper injections thrown into the
bladder;  the irritation caused  by calculi  or  by
morbid states of the urine; external injuries, or
blows on the hypogastrium, especially when the
bladder is  full; coitus when  the  viscus is dis-
tended with urine; horseback exercise, with  in-
attention  to the evacuation of the urine;  the
pressure ofthe foetus upon the unemptied bladder
during labours; protracted labours and the  use
of instruments to facilitate the process ; opera-
tions performed on the bladder; the suppression
of accustomed discharges, as of fluor albus, haem-
orrhoids, catamenia,  and  the sudor pedum, to
which some persons are subject;  the  incautious
suppression, without suitable internal  treatment,
of  cutaneous eruptions, or healing of external
sores or ulcers ; the retropulsion or misplacement
of gout and rheumatism ; inflammations of adjoin-
ing parts ; obstructions to  the discharge of urine
from strictures of the urethra, or from enlarge-
ment or abscess of the prostate gland; repelled
gonorrhoea, and the use of injections for its cure.
   87.  Ambrose  Pare,  Cabrol,  and  Chopart
have recorded some cases in which large quan-
tities of cantharides had been taken as  a cure for
agues, and had occasioned cystitis of uncommon
severity  and  fatal issue.   The same  result has
followed the use of this substance as  an aphro-
disiac.  Cystitis may also be the extension of in-
flammation from the pelvis of the  kidneys  to  the
bladder, or it may  arise from the irritation of a
calculus  in that part of the ureter which passes
between the coats  of the bladder.  It may also
supervene in the progress of fevers, particularly
of those characterized  by stupor, coma,  or  de-
lirium, or  by congestion  of the spinal cord, ow-
ing to the  accumulation of urine of a highly irri-
tating property ; the local  affection failing to ex-
cite the sensibility of the  patient in thesis states,
or the attention of the physician.   The frequency
and importance of this complication in  fevers and
in  diseases of the brain and spinal cord should
attract attention to it on  every occasion, and on
every  visit.
   88.  Injuries and diseases of the  spinal cord,
its membranes, &c.; compression of,  or haemor-
rhage on,  the cord; concussions of the brain or
spinal cord, &c, are frequent causes of  reten-
tion of urine, and thereby of cystitis.   Even sud-
den jerks,  as missing steps on descending  stairs,
coming with a jerk upon the feet when the body
is erect,  falling from a height on  the  feet, espe-
cially when much water is in the bladder and a
predisposition to inflammation of it exists, are oc-
casionally  causes of the disease.   It may  be re-
marked, that a single cause will in some persons
more certainly produce its effects than the con-
current operation of several causes where little or
no predisposition to the disease exists.
   89.  ix. Treatment.—A. Of Acute Muco-Cys-
titis.—The antiphlogistic  regimen and  treatment
are required in all their details in this form of the
disease.  General and  local bleeding should be
prescribed, and even repeated,  according  to the
age, habit of body, and constitution ofthe patient.
Cupping over  the sacrum,  or leeches applied
above the pubes or on the perineum, and repeat-
ed when circumstances indicate the propriety of
the measure,  are requisite;  and in the  milder
cases,  and  in the  less robust subjects, the local
may supersede general bleeding.  In some cases,
especially when the symptoms indicate congestion
or torpor of the abdominal viscera, or accumula-
tion of sprdes in the prima via,  an  emetic will be
given with benefit.  After its operation has been
freely  promoted the bowels should  be sufficiently
moved by means of cooling  aperients, as the in-
fusion of senna with magnesia, the  neutral salts,
or  the carbonate  of magnesia and  sulphur, &c.
Bleeding ought not  to be carried too far, espe-
cially  in the inhabitants of large towns, and in
the aged,  cachectic,  or  delicate.   Nor   should
those  purgatives which are  liable  to irritate the
rectum or colon  be  employed; but the  bowels
ought to be kept  regularly  open.   A warm gen-
eral bath, or hip-bath, is  always of service, and
should be resorted to as early in the disease as
possible after the above means have  been em-
ployed, and should be repeated as often  as the
state  of the  patient will indicate.  When the
bowels have been evacuated, opiates, and  demul-
cents or emollients are  required, both to support
the patient and  to allay   the local  irritation.
These may be variously combined and exhibited,
and may be conjoined with the alkaline carbon-
ates.  Morphia,  or the preparations of opium,
may be used, according to the medicines intend-
ed to be given along with either of them or at the
same time.   I have generally preferred the soap
and opium pill, conjoined with  an equal quantity
of Castile soap.   If these fail or lose their effect,
emollient enemata should be administered, with
either the sirup of poppies or compound tincture
of camphor added to them.  When these  also
prove insufficient to allay  the local  irritation,
opiate suppositories may  be resorted  to, and a
belladonna  plaster be applied above the pubes, or
over the perineum,  or a suppository containing
some  extract of belladonna may be tried.  The
state of the urine must be  daily tested, and, as
long as  it continues acid, the carbonates  of the
fixed alkalies may be given, in demulcent vehicles,
with such other medicines as the peculiarities of
the case may suggest.  As the  disease lapses
into a subacute or chronic state, the warm  or hip-
bath, opiates with soap or alkalies, the infusion of
pareira or of diosma, the preparations of cubebs,
small  doses of copaiba or of the other balsams,
and the infusion or tincture of hops, may be
severally prescribed.
   90.  The  acute  form of muco-cystitis will be
protracted,  or pass  into the subacute, and ulti-
mately into the chronic form, if the regimen and
diet of the patient  be not  duly regulated.   All
spirituous,  vinous, and malt  liquors should be
relinquished, as well as acidulated or sweetened
drinks or fluids.   The food ought to be farinaceous,
demulcent,  and  vegetable,  and prepared  in as
bland a form as possible.   The  drink should con-
sist entirely of linseed-tea, barley-water, or toast-
water, gum-water, or marsh-mallow tea taken in
moderate quantities.
   91.  In severe  or  obstinate cases  some prac-
titioners have recommended  the injection of oil 
URINARY BLADDER—Treatment of  Inflammation of.
1309
and opium into the bladder by means of a gum-
elastic catheter.  As to this treatment, Mr. Coul-
son has very justly remarked, that the pain and
irritation  caused by the introduction  of any in-
strument  along the urethra are  so  severe as  to
deter him from resorting to this treatment; for,
unless there be retention  of urine, the use of
the  catheter,  sounds, and  bougies  should be
avoided.
  92.  B.  Treatment of Chronic Muco-Cystitis.—
This form of the disease is often complicated with
stricture  of the urethra,  or with disease of the
prostate  or kidneys; and it often also is conse-
quent upon the acute form of the disease, owing
either to neglect or to the constitution of the pa-
tient.  In all cases the treatment of this form of.
muco-cystitis  is difficult,  and  more especially
when it  is complicated,  and in the aged and
cachectic.  When  the disease is simple, or con-
sists  chiefly  of an  abundant  secretion of mucus
(cystorrhoea), the decoction of pareira, or the in-
fusion of buchu, with opium or morphia, or with
the dilute phosphoric or  nitric or nitro-muriatic
acids, and the  decoction or extract of  uva ursi,
are generally  of service; but,  where there are
also  much irritability and pain  of the  bladder,
opiates given  by the mouth or in enemata are
most  requisite, and  should  be  conjoined with
every other method of cure.  Sir A. Cooper rec-
ommends the balsam of copaiba, in doses of eight
or  ten drops thrice daily, with  mucilage, sweet
spirits of nitre, and  camphor  mixture.  Mr.
Coulson advises small doses of copaiba, or  of
the  essential  oil of  cubebs with  hyoscyamus,
either to be given  alone, or with  the infusion  of
buchu, or with the  decoction  of  pareira.  He
adds,  however, that  both copaiba  and  cubebs
should be given with care; for, after the pro-
longed use of  these remedies, an aggravation  of
the disease may result. He frequently, therefore,
gives the compound tincture of benzoin, in the
dose of a tea-spoonful, three times daily; and,
when the urine is alkaline,  and contains much
mucus with the phosphates, an infusion of the
dried Alchcmilla arvensis (one ounce to a pint of
boiling water), the dose being two ounces of the
infusion three times in the day.  The  muriated
tincture of iron, the ammoniated tincture of iron,
the balsams, Chio  turpentine, and other kinds of
turpentine, uva ursi, with camphor and nitre, the
sulphates of iron  and of zinc,  have  also been
severally employed in this state of the disease,
and are  generally  of service when aided by opi-
ates, and when the digestive organs and bowels
are  duly  regulated.    Dupuytren  relied much
upon turpentine when the mucous secretion was
great; and I  have had occasion to  observe  its
good effects ; but it should not be long continued,
although it may be given at intervals, or altern-
ately with other means.*
  [* The  copaiba is much employed  in this country in
cases of vesical catarrh, and often with decidedly benefi-
cial effects. It should be given in moderate doses, as 10,
15, or 20 drops every four hours, in emulsion of gum ara-
ble and sugar.  If it  gripes, nauseates, or purges, tinct.
opii or morphia should be combined with it; and if pyro-
sis or acid eructations be present, bicarbonate of soda is
a very useful adjunct.   Its  use must be continued in
chronic cases several weeks,  the patient using at the
same time the fluid extract of uva ursi.  If its taste be-
come  disgusting, turpentine  may be  substituted for it.
We have  in many cases used the uva ursi, in  connexion
with alkalies, with a  successful result The chimiphila
umbeUata is also  very useful in this disease.  The epioea
repens (May-flower) is extolled by Dr. Ives, of New Ha-
ven, as a highly useful remedy in this affection.  A wine-
  93. Persons of a scrofulous diathesis, or those
addicted to venereal excesses, or who have  suf-
fered from syphilitic affections, or who are subject
to haemorrhoids or to gout, are liable, when they
are  attacked, to an obstinate form of this disease.
For these the treatment should have more or less
reference to the state  of constitution, while the
local affection  also obtains sufficient attention.
The aged and cachectic also require to have their
constitutional powers supported while the urinary
disease  receives requisite care.  But in these lat-
ter  persons palliation alone can be hoped for ; and
the  prolongation of life, by means of a restorative
or tonic treatment,  opiates, and  a regulated diet,
is often the  whole amount of benefit  that can be
expected.
  94. When chronic muco-cystitis is associated
with stricture ofthe urethra, or is produced by it,
the, treatment is extremely difficult.   Mr. Coul-
son remarks that " the pain and irritation along
the  urethra are often  so great  as to render the
use  of catheters and bougies impracticable ; and,
unless the state of the urethra improve, no mate-
rial  benefit  can be  expected from internal reme-
dies."   Under these circumstances, having calm-
ed the pain and irritation by means  of sedatives,
he proceeds to dilate the urethra with bougies or
the gum-elastic catheter;  and, if the stricture be
of long standing and very narrow, he commences
with armed bougies, introducing them once in
three or four days.
  95.  The  frequency of this, as well  as  other
forms  of cystitis in the gouty,  and even also in
the rheumatic diathesis, and ofthe occurrence of
the disease  in connexion with, or upon the disap-
pearance of gout, suggests the propriety of modi-
fying the treatment conformably with this con-
nexion.  In these cases 1 have  found the opium
and soap pill, with the extract of colchicum, taken
at bed-time, and a sufficient dose of magnesia and
sulphur, or magnesia  and  rhubarb, early in  the
morning, to prove of great service.   One or other
of the  other means already mentioned, avoiding
the  acids, may also be given in  the course of the
day, as circumstances  may indicate.
  96. Other means, which more especially belong
to the province ofthe surgeon, have been advised
in the  more severe  and protracted cases of muco-
cystitis.  Sir B. Brodie states that when "the
symptoms  are at their greatest  height, the mild-
est injections (into the bladder), even those of te-
pid water, will do harm  rather than good.   They
are especially to be avoided when the mucus de-
posited by the urine is highly tinged with blood.
When, however, the symptoms are abated,  the
injection of tepid water, or decoction of poppies,
is, in many instances, productive of excellent ef-
fects."   The fluid should be allowed to remain in
the bladder about thirty or forty seconds, and not
more than  two ounces  should be injected each
time.   Distention of the bladder by  the  injection
so as to cause  pain is  injurious, and should be
avoided.  The operation may be repeated once or
twice in the twenty-four hours.  When the symp-
toms have abated and assumed a still more chron-

glassful of a decoction, made with two drachms to half a
pint of water, is to be given every two hours.  In its ef-
fects it is closely allied to the uva ursi and buchu (Trans.
Amer. Med. Assoc., vol. iii., p. 314).   See also a paper by
Dr.  La Roche on copaiba  in this affection, in Am. Jour.
Med. Science, vol. xiv.  Dr. GK06S speaks very favoura-
bly of the benzoic acid, given alone, or in combination
with bals. copaiba, in doses of 15 to 20 grs. three or four
times a day, or with a few drops of Haerlem oil.] 
1310
URINARY BLADDER—Treatment of  Inflammation  of.
 ic  form, and the  mucus is free  from blood, then
 one minim ofthe strong, or ten minims ofthe di-
 luted nitric acid, to two ounces of distilled water,
 may be used as an injection; the proportion of
 the acid  being afterward increased.   Mr. Coul-
 son remarks that the tenacious  mucus produced
 in  this state ofthe disease deposits phosphate of
 lime ;   and when phosphate  of lime from  this
 source coexists, as  it often  does, with the triple
 phosphate in the urine, a compound salt is form-
 ed ; and in  such cases a weak solution  of nitric
 acid (beginning with one minim of strong  acid,
 increasing  the  quantity to  two, to  two ounces
 of distilled water) injected into  the  bladder  acts
 as  a  salutary  stimulant.  As to Lallemand's
 cauterization of the mucous membrane of the
 bladder with solid nitrate of silver, in cases of
 chronic catarrh, and as to Devergie's injections
 with balsam of copaiba and narcotics, I must re-
 fer the reader to the work ofthe  author just men-
 tioned, and to other surgical works.*
   97.  It should not be overlooked that excessive
 mucous secretion from the surface ofthe bladder,
 if neglected, or treated too long with some of the
 more heating  substances which have been ad-
 vised, may be followed by  a chronic inflammation
 of all the  coats  of the bladder, and ultimately by
 a subacute or an acute form ofthe disease, which
 may destroy the  patient.  This result  is most
 likely to occur when the diet and regimen so req-
 uisite to the success of treatment have been  neg-
 lected.  In the milder form  of the disease, ani-
 mal food in very moderate quantity may be taken.
 The diet  should be chiefly  farinaceous, but the
 white kinds offish, boiled, may be allowed.f   In
 the severer states animal food should be still more
 sparingly taken.  If in these the vital powers be
 much depressed, sufficient light nourishment may
 be given, and tonics with the  alkaline carbonates,
 opiates, &c, may be prescribed.  Spirituous, vin-
 ous, and malt liquors should  be  strictly prohibit-
 ed, and all irregularity of diet and regimen care-
 fully avoided.  When there is great  debility, dry
  [* Dr. Gross (loc. cit.) recommends, in obstinate cases
 of this disease, counter-irrit ition in the form of a seton,
 i>sue, or tartar-emetic pustulation, over the perineum
 or the suprapubic region.   If there is reason to suspect
 renal disease, the counter-irritation should be over the
 sacrum or in the loins by means of a seton, and the dis-
 charge  kept  up for  a  long  time. When irrigation is
 practised, a better mode than that recommended  is to
 use a double catheter, and gently inject a pint of tepid
 water, so as to wash out the bladder thoroughly : and it
 may be repeated twice a day, unless the urine is bloody,
 or there are symptoms of cystitis present.  With regard
 to the various medicated injections for a local alterative
 effect on the mucous membrane, we greatly prefer a  solu-
 tion ofthe nitrate of silver, in combination with the fluid,
 watery extract of opium or hyoscyamus, beginning with
 a weak solution, and gradually increasing its  strength,
 throwing in about two ounces each time, and allowing it
 to be retained from five to ten minutes; the patient plac-
 ing himself in different attitudes  to bring it in contact
 with every part of the bladder, and repeating the injec-
 tion once a day, or every third day, according to circum-
 stances.
  Where every thing has failed, it has been proposed by
 Sir. Guthrie to open the neck of the bladder by an incis-
 ion, as in lithotomy, so as to allow a free outlet to the
 mucous secretion as fast as it is poured out, and thus af-
 ford the  bladder comparative repose ;  on the same prin-
 ciple as  the knife is recommended for anal fistule  and
 fissure.   This operation has been performed by Dr. W.
 Paeker, of New York, with evident relief of the symp-
 toms, but the patient succumbed  four weeks after from
 organic disease of the  kidney and bladder.  (See New
 York Journ. of Med., 1350.)]
  [t We have generally found an entire abstinence from
 animal food the preferable course, and only allow mild
 broths when convalescence is fully hogun.   Vegetable
acids are always prejudicial in this disease.]
 sherry may be allowed, especially if acidity ofthe
 prima via be not experienced.   In all cases the
 functions  of the  skin as well as  of the  bowels
 should be duly promoted.
   98. C.  Treatment of Acute Cystitis—of Acute
 Inflammation of all the Coats ofthe Bladder (y 56).
 —It has been above (Y 55) stated that the inflam-
 mation may affect one of the tissues of the blad-
 der more than the others, or may implicate them
 all, chiefly through the medium ofthe connecting
 cellular  tissue, and that a portion  of the bladder
 may be thus affected, or the whole of the organ;
 that when the inflammation is seated in the neck
 ofthe bladder, the urine is retained by  the tume-
 faction occasioned by it; and that when the parts
 through which the  ureters pass into the bladder
 are  chiefly affected, the swelling  which  results
 more  or less obstructs the passage of the urine,
 and occasions dilatation ofthe pelvis, ureters, dec.,
 by its accumulation in these parts and suppres-
 sion of this excretion.   The consequences of the
 retention on the one hand, and of the suppression
 on the other, are always most serious, and  should
 be prevented by a most active treatment as soon
 as these important  and always dangerous states
 are  present.   The  former may  be removed by
 surgical aid ; the latter by prompt and judicious
 medical  treatment.  But in most cases the treat-
 ment  should have reference to the cause of the
 disease and the diathesis of the patient.   When
 the  malady is produced by cold in any form, then
 the  phlogistic form may be inferred, and suppu-
 ration may take place, especially in  the phlogistic
 temperament and full habit of body.  When it is
 occasioned by spirituous liquors,  aphrodisiacs, or
 the  suppression ofthe gonorrhoeal  discharge, al-
 though all the coats may be implicated, the mu-
 cous will generally be chiefly affected, and reten-
 tion or suppression of urine less frequently re-
 sult.  If the disease occur in the gouty or rheu-
 matic  diathesis,  or follow upon  suppression or
 metastasis of either gout or rheumatism, all the
 coats may be affected, and neither the fundus nor
 its peritoneal covering escape.
   99.  In all these  circumstances the treatment
 should be prompt and decisive, and the quantity
 of urine retained in the bladder carefully watch-
 ed, by examining the hypogastrium  and the quan-
 tity  excreted.  If the patient be young, or robust,
 or plethoric, although advanced in  life, venaesec-
 tion should be prescribed and even  repeated, and
 be followed by the local depletions, which may be
 sufficient for the delicate or weak, by cupping on
 the perineum, or by  leeches applied to the part or
 to the pubes.   Hot baths; warm  fomentations
 above  the pubes or on the perineum ;  the remov-
 al of the  urine by means of the  catheter when-
 ever it may be required ; emollient, laxative, and
 anodyne injections ; cooling saline aperients, pre-
 ceded  by calomel and  opium  when  the febrile
 symptoms are severe and the biliary  functions
 are impaired ; and demulcents with diaphoretics
 —are the means of cure which may be safely re-
 sorted to  in all the  circumstances of the malady
 just noticed   If the disease be consequent upon
 gonorrhoea, oleaginous  or mucilaginous demul-
 cents,  with small doses  of camphor, nitrate of
 potash and henbane, in  addition to appropriate
 depletions, diaphoretics, aperients, &c, will gen-
erally remove the  more  urgent symptoms.   If it
be connected with gout or rheumatism, magnesia
and  sulphur in equal parts, either alone or with
demulcents, and smail  doses of colchicum, will 
URINARY BLADDER—Treatment of  Inflammation of.             1311
be found very beneficial, by moderately promoting
the abdominal secretions and the functions ofthe
skin ;  this latter being too generally overlooked,
especially in gouty affections.   Under the above
treatment the symptoms generally subside grad-
ually ; but if retention of urine be long neglect-
ed, or if the urine be suppressed, owing either to
delay  in adopting the above means, or the con-
stitution ofthe patient and violence ofthe attack,
delirium, coma, and death will  generally result.
It may be asked, What should be done in cases
where the urine has become suppressed ! I would
answer, after the above means have been judi-
ciously employed, that warm flannels, or  stupes,
moistened with  spirits of turpentine, should be
applied over the hypogastric region  and  perine-
um, and that emollient enemata, containing equal
parts of this substance and castor oil, and one or
more ounces of olive oil, be administered  and re-
peated as  they  may be  required, while diapho-
retics should be assiduously continued.
   100. When the inflammation ofthe fundus of
the  bladder implicates the peritoneal coat, or is
associated with inflammation ofthe uterine organs
or peritoneum, the treatment is not then material-
ly different from that recommended above. Cup-
ping over  the sacrum, leeches to the hypogastri-
um, &c, the warm  terebinthinate embrocations,
 or stupes, in these situations, calomel and opium,
 followed by the enemata and diaphoretics  already
advised, are  the  means most generally appropri-
ate.*  If cystitis be  complicated  with haemor-
rhoids or inflammation ofthe rectum or colon, or
with fistula, calomel should be withheld, as it gen-
erally increases these affections, and thereby pre-
vents  the resolution of the uro-cystitis ; but the
other means ought to be employed.
   101. D. Treatment of Chronic Uro-Cystitis.—
Chronic uro-cystitis  is often consequent upon the
acute, but it  is oftener a consequence of stricture
of the urethra, of enlargement of the prostate, of
 stone in the bladder, of prostatic calculi, of the
abuse of spirituous liquors, especially of common
gin ; of the  use  of  cantharides, or  of cubebs or
copaiba ; or protracted gout and rheumatism, es-
pecially the  former, and of the retention of the
urine in the bladder after the desire to pass it.
The nature of the cause influences more or less
the treatment to be  adopted.   In strong,  young,
or plethoric subjects, and especially when consid-
erable pain is  experienced, local  depletion,  fol-
lowed by warm baths, the  semicupium, fomenta-
tions, &c, is always required.  In many cases
, the removal of the primary disease should be the
first indication, especially in the case of stricture
of the urethra ;  and with this indication the em-
ployment of means which act more or less direct-
ly on the  bladder should  also  be adopted.   In
most instances   the  selection  of  these  means
should be guided by the state  of the urine.   If
this be  acid or  scanty, the bicarbonates  of the
fixed alkalies with nitrate of potash and sweet
spirits of nitre, in demulcent or emollient vehicles,
will be generally of great service ;  and anodynes,
such as the  sirup  of poppies,  tincture of hen-
bane, compound  tincture of camphor, tincture of
hop, opiate suppositories, &c, will  also be pre-
scribed in many cases with advantage.  The prep-
arations of pareira brava, or of the diosma, or of
uva ursi [or Epigea  repens, or chimiphila  umbel-
lata] may, in the  more obstinate or chronic cases,
  [• Anodyne suppositories are better suited to this dis-
ease than enemata.]
 be given with the above, or the decoctions or in-
 fusions of these latter may be the vehicles for the
 exhibition of the former.   When the disease oc-
 curs in the gouty or rheumatic diathesis, or ap-
 pears after the suppression of either of these dis-
 eases, then the extract, tincture, or wine of col-
 chicum in small doses, may be prescribed with
 the alkalies, and a small dose of opium or of mor-
 phia ;  and when the pulse presents much strength
 or hardness, the tincture of aconite, in the dose
 of one, two, or three drops, may be resorted to,
j although this  latter is more  appropriate in the
 more acute cases, and when the peritoneal cov-
 ering of the viscus is implicated in the  disease.
 The infusion of parsley-root is sometimes of serv-
 ice in chronic uro-cystitis, especially when made
 the vehicle for some of the medicines mentioned
 above.   Mr. Coulson states that he has tried the
 infusion of wild-carrot seeds in this form of the
 disease with advantage, but that it should not be
 given if there be any irritation of the  mucous
 membrane; and he adds that, as in these cases
 the  bladder is, by  its own efforts, seldom  com-
 pletely emptied, a catheter should be introduced
 from time to time, and the patient be instructed
 to do this for himself.  Unless this direction be
 strictly attended to, the patient will become worse,
 and serious consequences ensue.
   102. E. When inflammation is extended to the
 peritoneal coat of the bladder,  either from the in-
 ternal coats, or from parts in the vicinity of, or
 in contact with the peritoneal, the symptoms may
 then be very acute, and become chronic from neg-
 lect or injudicious treatment.   This form of the
 disease is most frequent in females, especially
 after parturition or in some period of the puer-
 peral state, and is generally contingent upon the
 occurrences which sometimes take place during
 this state.  In some cases it is strictly a partial
 peritonitis, confined chiefly to the pelvic perito-
[ neum ; the symptoms, local and general, being
 distinctive of its nature and seat.   (See art. Peri-
 toneum,  inflammation of,  § 76.)   The seat of
 pain, tenderness, and tension, the rapidity ofthe
 pulse, the position of the patient, the expression
 of the countenance, &c, indicate the  nature of
 the disease, which may be limited to  the pelvic
 peritoneum, especially when coagulable lymph is
 thrown out, which forms adhesions between the
 opposite surfaces, and prevents the extension of
 the malady.   In unhealthy constitutions, and in
 females in the puerperal states, the inflammation,
 instead of being thus  limited, generally extends
 over  the peritoneum; in place  of coagulable
 lymph, a serous fluid, of varied  appearances, is
 thrown out, and the morbid action, commencing
 in the hypogastric region, extends  through the
 abdomen, which becomes tender and tympanitic.
 The pulse is so rapid as hardly to be counted ;
 hiccough supervenes, and the disease presents the
 course and termination described in the article
 Peritoneum (y 19-36).  In these cases the treat-
 ment is the same as I have advised in that article
 (y 137-159, et seq.).
   103.  In rare instances an abscess forms below
 the  peritoneum, between  the bladder and the
 symphysis pubis, or some other adjoining part, as
 in a case related by Dr. Elliotson.   Sometimes
 also a pseudo-abscess is seated within the pouch
 ofthe peritoneum, between the posterior wall of
 the bladder and the rectum.  Lymph, in these
 cases, agglutinates some folds of the intestines,
 or the sigmoid flexure ofthe colon and the fundus 
1312        URINARY  BLADDER—Malignant  and Organic Diseases of  the.
of the bladder, and pus collects in the pouch form-
ed by these parts.  The contents of this pseudo-
abscess may be absorbed,  if in small quantity,
old adhesions alone remaining; or they may find
their way into the peritoneal cavity, and occasion
general peritonitis and death.   Cases of this na-
ture are mentioned by Mr. Coulson, and they
have been seen by myself, but only in females,
and as consequences of pelvic peritonitis after
parturition (see art. Peritoneum, y 76, et scq.,
and Puerperal Diseases,  y 221, et seq.).
   104.  V. Malignant and other formations
are sometimes  found in or attached to the pari-
etes of the urinary bladder.—A.  Tubercle is oc-
casionally deposited in the parietes of this viscus,
generally either under the peritoneal coat, at the
fundus, and in the. mucous membrane, near the
urethra.  In this latter situation the small gran-
ular deposits pass rapidly to ulceration.  Tuber-
cle of the vesical mucous membrane is, according
to Rokitansky, rare, and is not always formed in
connexion with tubercular affections  of the uri-
nary and sexual organs.   Tubercle on the exte-
rior of the bladder is generally seen associated
with the  same formations in  the vicinity, espe-
cially in the female sexual organs.   Mr. Coulson
remarks that the morbid deposit may be so great
as to glue together the different organs, and thus
interfere with the free action of the detrusor uri-
nae ; but this can only occur when the tubercular
cachexia  is inordinately developed.  The most
frequent appearance  of tubercle in  connexion
with the bladder is in cases of tubercular peri-
toneum, that part ofthe membrane covering the
bladder partaking in  the general alteration, the
deposit being commonly in small distinct masses,
the  membrane  being spotted,  dark-coloured, or
rugous, or otherwise altered.   (See Peritoneum,
y 111, et seq.)
   105.  B.  A polypous excrescence  from  the in-
ternal  surface  of the bladder  is very rarely ob-
served.   Dr. Baillie  saw only one example of
it, and that filled up the greater part ofthe cavity
ofthe viscus.   An instance of it occurred to Mr.
Crosse, of Norwich, in a child.   Other cases of
polypus vesicae have been recorded by Mr. War-
ner and others,  but they require no particular
notice.  The very interesting and instructive case
published by the late Mr. Crosse will be found
in Mr. Coulson's work.
   106.  C. Malignant formations in the bladder
are not very rare.  The worst form is that de-
scribed  by Mr. Travers and others as the malig-
nant medullary fungus, which arises  from the
sub-mucous tissue, and  projects into  the cavity
of the viscus as a soft, vascular, and cauliflower-
like mass, which bleeds upon the slightest touch.
Mr. Travers states that it springs from " the
mucous coat of the bladder, and  resembles that
of the nares and uterus, breaking, bleeding, and
reproduced as quickly as it is displaced.   It is of
very extensive attachment, and gradually reduces
the cavity to very small dimensions.   Portions
of fungus and coagula of blood become plugged
in the urethra, and form firm pellets, so as to pro-
duce retention of urine.   It is a very painful dis-
ease.  It keeps the patient in constant anxiety to
void urine, which is more or  less  tinged with
blood, and frequently he passes blood alone.  He
dies hectic and wasted."   Mr. Coulson states
that this malignant fungus is generally first de-
veloped near the  neck ofthe bladder, the trigon,
or the posterior surface ;  and that cases occur in
which the vegetations fill a diverticulum or sac-
culus, where  they form a  tumour which  may
cause retention of urine by  its pressure.  These
tumours vary  in size, some being, when solitary,
as large as a  goose's egg;  others are small, es-
pecially when they are numerous.   Another form
of medullary cancer has been described by Roki-
tansky  as occurring in small masses between
the muscular and mucous  coats  of the bladder.
It may make  its  way through the mucous coat
and form  a deep carcinomatous  ulcer, or  may
protrude  externally through  the  muscular and
peritoneal coats.   Fibrous  or  scirrhous cancer,
although sometimes affecting the uterus and ova-
ries,  very rarely attacks  the urinary  bladder.
These malignant formations cannot be assigned
to any local cause of irritation, or to any other
cause beyond the cancerous diathesis, hereditary
or acquired.   (See art.  Cancer, y 23, et seq.)
   107.  a. The symptoms of malignant tumours
of the bladder frequently resemble those of stone.
Warren states that the first sign of this disease
is a  discharge of blood with the urine.   The
quantity is at first so small as scarcely to tinge
the urine, but it  gradually  increases until it be-
comes an exhausting symptom.  The amount of
pain attending it varies in different cases, being
slight or moderate in some,  and severe in others.
Constant desire to pass urine  is one of the most
common  symptoms,  accompanied with sympa-
thetic irritation ofthe rectum and inclination  to
stool.   When blood passes  from the bladder aft-
er the introduction of a  sound or catheter, or after
the flow of urine has terminated,  or very nearly
terminated, there is much reason  to infer that it
proceeds from the coats  ofthe bladder; and when
this occurs in connexion with the other signs,
and especially with the  sense ofthe existence of
a body  or substance in the bladder, felt either by
the patient or the operator when a sound is in-
troduced, the  existence of a malignant tumour,
fungus, or polypus may be inferred.  Ultimately,
in these cases, consecutive disease and disorgan-
ization  of the  kidneys, with  more or less marked
disorder of the stomach and bowels, and exhaus-
tion of the powers of life, is followed by a fatal
issue.  I may refer the  reader to Mr. Coulson's
work for some instructive cases and post mortem
appearances of this disease.
  108.  Disease of a disorganizing nature may
extend to the bladder from malignant disease of
the rectum in men, or ofthe womb in females;
and by means  of ulceration a communication may
be established between the rectum and the blad-
der, or  between the bladder and  vagina.*  Mr.
Travers, however, doubts whether the ulceration
of the bladder in  these cases be truly cancerous.
In this  doubt  Mr. Coulson  appears to partake.
I have  seen a few cases of extension of malig-
nant disease from the neck  of the uterus to the
bladder, but in most of them have  had reason to
infer that the disease in the  latter  partook of the
same  character as that of the former.
  109.  b. The treatment of malignant disease of
the  urinary bladder is chiefly palliative, by means

m£wefiT,de £f trueatment by suture, in cases of vesico-
Zllfl *Lstule'.has.be<3n in ™g"e since the 17th century;
sl „A!  v0,l,8,unlder Breat obligations to Dr. J. M.
onrratf™  J°,!'k- f0riJi8 imProvement ofthe ordinary
and ?n »'JL h »  ™ffic,enU*'  easy, simple, and  safe,
scrinHon Ti-J STef d?gree ««'«Mrful.  For a full de-
GazVetl'y0\ v" ^m! °f/roc?dure^ Kew York Medical
1854-and r7r!' 1854.\ A™™™ Medical Monthly. Feb.,
1804, and Gross on  " Diseases of Bladder," p. 156.] 
URINARY BLADDER—Bibliography and  References.               1313
of narcotics, sedatives, &c, administered by the
mouth, or in enemata, or in suppositories, as ad-
vised when treating of Cancer, and of diseases
ofthe Uterus, &c.   In many of these cases the
haemorrhage from the bladder is so excessive that
means are required to  arrest the discharge and
to  sustain the  powers of life.   For these the
tincture of the sesquichloriue of iron, the decoc-
tion of pareira brava, with nitric, or hydrochloric,
or  sulphuric acid, if the  urine be  alkaline; the
uva ursi, with the alkalies, if the urine be acid ;
the  secale cornutum,  spirits of turpentine, and
other anti-haemorrhagics and astringents, the re-
cumbent posture, &c,  are the means  chiefly  to
be confided in, conjoined with opiates, &c.
   110. VI. Abnormities  of  the  Bladder are
sometimes observed, either alone or in connexion
with malformation of other parts of the urinary
or sexual organs.   They are generally congeni-
tal,  and proceed from irregularities  of foetal  de-
velopment.   Numerous cases and  various forms
of irregularity of formation are on record ; but as
respects any treatment which may be adopted for
them, they concern  the surgeon more than  the
physician, and sufficient reference may be  made
to them in the subjoined Bibliography.
   111. Foreign  bodies are often  found in  the
bladder, having been introduced  at some previous
period, or having passed into it  from the rectum
or  some part of the intestinal  canal, through  a
perforating ulcer  or sinus  formed between the
bowel and bladder.*   In many instances, when a
foreign body has been found in this viscus, it had
become incrusted by  the urinary  deposits to  a
greater or  less  extent.   This   subject  will be
found more  appropriately  discussed in  surgical
works, where also rupture of the bladder, hernia
of  the  bladder, and  wounds and injuries of the
bladder, are most ably treated of by their respect-
ive authors.

  Biiilioo.  and Refer. — Aretoms, Curat. Acut.,  I. vii.,
cap. 9; Chronic, 1. ii., cap. iv. — Oribasius, Synopsis, 1.
ix., cap. 26, 31.—Alexander Trail., 1. iii., cap. 3fi.—Pau-
lus jEgin.. 1. iii., p. 45.  (Injections into the Bladder, &c.)
—Avicenna, Canon, 1. ii., fin. 19.  Tract, i., cap. 14.—J.
F. Arma, De Vesicae et  Renis affectus Dignotione et
Medicatione, 8vo.   Bugella, 1550.—Rufus Ephesius, De
Vesica; Renumque  Morbis, 8vo.  Park, 1554.—Augenius
Horat., Epist., 1. x., n. 5.—Boyvin, Ergo Renum et Vesi-
ca;  affectus per Dijectionem expurgantur.  Paris, 1599.
—Amatus Lusitanus, Cent, v., cap. 79. — Zacutus Lusi-
tanus, Med. Pract. Hist.,  1. ii., n. 130. —J. M. Midler,
Dissert, de Inflammatione Vesica? Urinarise, 4to.   Altd.,
1703.— Voter, Dissert, de Ulceris Vesica; Signis et Reme-
diis.  Witeb., 1709.—Bonet, Sepulchret., 1. iii., sec. xxv.,
obs. 18; sea xxix., obs. 10.—Warner, in Philos. Trans.,

  [* Worms, chiefly ofthe ascaridic genus, have not un-
frequently  been found in the human bladder, having
crept thither from some part of the intestinal canal, ei-
ther by perforating its coats or through some ulcerous
opening.  Mi-. Lawrence and T. B. Curling, of London,
have both described instances of this  kind (Medical Clin.
Trans, of London, vol. ii., p. 385, and vol. xxii., p. 279);
and  in this country, among several   others, Dr. Bard-
well, of Indiana (West Journ. of Med. and Phys. Sci.,
vol. vii., 1834), and Dr. Campbell, of Conn. (Am. Journ.
of Med. Sci., vol. xxi., p. 130).  In the former case, many
thousand worms were passed in the course of six months,
of a lumbricoid kind, from six to  nine lines in length,
and about the thickness of a horsehair, with a black and
rather large head, the body of a dark, dirty white.  Some
of them lived 24 hours after they had been voided.   The
patient, a man aged 30, recovered under the use of tur-
pentine.  In the latter case the worms were small, red-
headed, and about half an inch long, the bodies com-
posed of many minute cartilaginous rings, and furnished
with a number of legs, arranged in two rows from one
extremity to the other.   They were hard, very active,
strong, and  tenacious of  life.  See also  a case in Dr.
Gross's work, 60 often quoted  (p. 332, 2d ed.), with  a
history of symptoms, treatment, and  all there is known
on the subject.]                                      I
     III.                   83
 n. 495.   (Sarcomatous Excrescence removed by Ligature
 and Excision.) —F. Lallier, a Dissertation on Disorders
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 (Opera,  Sup. ii., 2, 4to.)   Hal., 1724.1— C. Barrere, Obs.
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 Cumin, in Cyclop, of Pract. Med., vol.  i., p. 502.   Lond.,
 1832.—R. Willis, Urinary Diseases and their Treatment,
 8vo.   Lond., 1838.—G. J. Guthrie, on the Anatomy and
 Diseases ofthe Urinary and Sexual Organs, 8vo.  Lond.,
 1836.—B. C.  Brodie, Lectures on the Diseases ofthe Uri-
 nary  Organs, 3d ed., 8vo.   Lond., 1842.—W. Prout, on
I the Nature and Treatment  of Stomach and Urinary Dis- 
1314        URINE  AND URINARY  DEPOSITS—Pathological Relations  of.
eases, being an Inquiry into the Connexion of Diabetes.
Calculus, and other affections ofthe Kidney and Bladder
with Indigestion, Svo.  Lmd., 184-3, 4th edit—IK Coul-
son, on the Diseases of the Bladder and Prostate Gland,
4th edit, 8vo.  Lond., 1S52.   (See also Biblioo. asd
Refer, to the next Article.)
  [Am. Biuliog. and Refer. — S. D. Gross, a Practical
Treatise oa the Diseases, Injuries, and Malformations of
the Urinary Bladder, the Prostate Gland, and the Ure-
thra, 2d ed., Svo, p. 925.  The ablest and most compre-
hensive work, on the subjects of which it treats, hitherto
published.   It is remarkably full, clear, and accurate in
its statements, and the medical and surgical treatment
recommended for its various affections is in the highest
degree wise and judicious.  There are numerous articles,
reports of cases, essays, &c, relating to the bladder and
its diseases, scattered throughout the American medical
journals, many of which are worthy of special mention.
We shall, however, refer to only a few, as the book of
Dr. Guoss  supersedes the necessity of more particular
mention.—J. B. S. Jackson, Descriptive Catalogue of the
Anatomical  Museum of the Boston Society for Mutual
Improvement, 8vo, p. 352.  Bost, 1847.  (See Malforma-
tions of the Bladder.)—C. P. Johnson, Medical Examiner,
July, 1S50, p. 3S6. — E. R. Peaslee, Case of Rupture of
Bladder, Am. Journ. of Med. Science, N. S., vol. xix., p.
383, 1850.—Stephen Smith, Case of Rupture of Bladder,
N. Y. Journ. of Medicine, N. S., vol. vi.,  p. 374,1851.— W.
Walker, Lithotomy, Med.  Com.  of Mass. Med. Soc, vol.
vii., 1845.  For a full description of Dr. Sims's mode of
operation for vesico-vaginal fistula, see Gross on Urinary
Organs—A'. R. Smith, Surgical Works.  Phil., 1844.—
A. Brighton, Worms in the Bladder, simulating Stone,
Am. Journ. of Medical Science, vol. xx., p. 59.—Joseph
Bossuet, New Eng. Journ. of Med. and Surg., vol. vi., p.
134, 1817.  (Case of Fatal Remains in tlie Bladder.)—P.
S. Dorsey, System of Surgery, 2 vols.  Phil., 1813.  (Re-
tention of Urine, &c.)—Dr. Le Seur, Am. Journ. of Med.
Science, 1854, Ap., p. 403.  (Case of inter-pubic puncture
of Bladder.)—W. Parker, S. Cooper's First Lines of Sur-
gery, N. Y.—P. F. Eve, Southern Med. and Surg. Journ.,
1849.  (Case of Lithotomy, in which 170 calculi were re-
moved from the Bladder.)—In Gibson's Surg., vol. ii., p.
220, may be found an account  of Dr. Piiysick'b opera-
tion for lithotomy on Chief Justice Marshall, in which
upward of 1000 calculi were removed from the bladder.
—G. Blackman, N. Y. Journ. of Med. and Surg., 1852, p.
109.  (Litfiotrity.)—G. S.  Pattison, Am. Med. Recorder,
vol. v.  (Anatomical Cause of Infiltration of Urine aft-
er Lithotomy.)—George McClellan, Surgery, Phil. Other
references will be  given under "Urine and Urinary De-
posits."]

URINE AND  ITS  DEPOSITS.—Classif.—
  General and Special Pathology, and Ther-
  apeutics.
  1. The urine is one of the chief depurating se-
cretions in the animal  economy, and one which,
when interrupted  or arrested, rapidly terminates
existence.   This secretion in some form or other
occurs in all  animals, either by a distinct appara-
tus, or  by  a  vicarious or associated function, in
which latter form it also takes place even in the
vegetable creation ; and in  all it is characterized
as the excretory function of nitrogenous elements
and compounds, variously associated with other
substances.  In  the human subject and in the
more perfect animals the conditions of the urine
depend upon the states of the frame  generally,
upon the states of the  urinary organs, and upon
the food and drink  of the individual.   Hence
these conditions are of the  greatest importance
to the pathologist, by enabling him to recognise,
1st, those states of the system with which they
are severally connected; 2d, those lesions, func-
tional  and structural, of the kidneys, of which
they are often the symptoms and effects; and,
3d, the influences produced by   the  food  and
drinks of the individual upon his system  and
urinary organs.
  2. The urine is derived from the blood—is a dep-
urating secretion performed  by the kidneys from
the blood as long as these  organs are actuated
by the organic nervous influence  distributed to
them, aided by whatever share of influence may
be  transmitted  to  them  or their ganglia by the
spinal nerves   The urine being derived irom the
blood, and being one of the chief depurating se-
cretions by which  the blood is preserved in due
or healthy quantity and quality, it must be mani-
fest that the phenomena connected with the urine
and its secretion become important indications,
not merely of the  states of the blood  itself, but
also of the several  sources by which the  blood is
altered or contaminated.
  3.  It was stated in the first part of this work,
and then explained (in  1832), that  the  kidneys
conveyed from the blood the fluids carried into
the blood, and with these fluids the  effete mate-
rials, the ultimate results  of animalization, and
various other elements and substances resulting
from indigestion and mal-assimilation, or other-
wise absorbed  into the circulating mass.   As
long as the kidneys discharge their functions, an
excess ofthe fluid elements ofthe blood, and of
various saline and  nitrogenous materials, are pre-
vented from  accumulating  in the blood; these
functions being strictly  depurating, as respects
the purity  or quality  of the  blood, and elimi-
nating, or excretory, or  excrementitious, as re-
spects not only the quality but also  the quantity
of the circulating mass.
  4.  It is thus  obvious  that the urine consists
chiefly of the fluids and  of the fluid  parts of the
aliments taken into the stomach, and carried into
the blood;  and  that it contains not only saline
and other ingredients derived  from  the  ingesta,
and from the changes which the ingesta undergo,
in the digestive canal, and  in their  passage  into
the blood, but also the effete nitrogenous mate-
rials  resulting from the waste and absorption of
the tissues, which are  first conveyed into the
blood by the absorbents and veins, and afterward
eliminated from the blood, with the fluids in ex-
cess, by the action of the kidneys.
  5.  Such being the source of the urine, it may be
inferred that the quantity and condition of this
excretion will depend upon a variety of  circum-
stances which require the recognition  of the pa-
thologist in  his  investigations  of disease—upon
the states of the digestive and assimilating func-
tions ; upon the states of the circulating organs
and ofthe blood ; upon the states ofthe urinary
apparatus;  and  upon the states of the other dep-
urating and eliminating  functions—upon those
of the skin, lungs, liver, and intestines.   In re-
cent times,  and in  recent writings, the conditions
of the urine have  received  a due, if not an ex-
cessive, share of attention, especially  from the
chemical  pathologists ;  yet these conditions have
been insufficiently  investigated in their relations
to the other depurating functions, and especially
to that ofthe skin, this particular function being
either altogether overlooked, or very imperfectly
inquired into.   When treating of the Blood (see
y 115-160), and when giving a succinct view of
pathology under the head of Disease (see y 94-
104, and 163, ct scq.), I there stated the same doc-
trines as  those now enunciated, but more explic-
itly and  fully than I have now done; and since
then (published in  1832) the same views have re-
ceived the approval of, because they have been
altogether adopted  by, more recent  writers, al-
though without  acknowledgment of their long
previous existence  in the pages of this work.  I
may request those who are curious in this matter
to read what I have stated  in the articles and in
the sections just referred to, and to peruse the 
URINE  AND URINARY DEPOSITS—Pathological Relations  of.        1315
fundamental  doctrines  in  Dr. Golding  Bird's
work on "Urinary Deposits," where the subject
of urinary pathology has been very ably discussed,
and where not only the views, but even the terms,
first  adopted  by me have been followed and em-
ployed.  I should not have referred to these prin-
ciples of urinary pathology if it had not been
necessary, by asserting my  own priority in re-
spect of them, to defend myself from the contin-
gent imputation of adopting the ideas of others.
  6.  b. The  doctrines insisted upon in the early
parts  of this work  respecting the  depurating
functions of the kidneys  and of other organs,
have been much more recently carried out by Dr.
G. Bird, as regards those  of the kidneys, and in
many places  so conformably with these doctrines
—although with too manifest a leaning to chem-
ical  pathology and neglect of a controlling vital
influence—as to induce me to refer to his evi-
dence on several topics, where I believe it to be
accurate, or  to  support  my  own views.  The
fundamental  principle  he  has laid down  is cor-
rect as far as it extends, but it is too limited, in-
asmuch as it is •onfined to the functions of the
kidneys.  He states that" it is, indeed, a general
law, that any substance which has entered the
circulating mass, and not been required  for the
nutrition ofthe body, nor  forming a normal cle-
ment of healthy blood,  always escapes from the
system by the kidneys, providing it exists in a
state of complete solution.   Hence  these  most
important emunctories have the duty of removing
any imperfectly assimilated elements ofthe food
which  had been absorbed while  traversing the
small intestines, and entered the circulating mass,
as well as excreting the often noxious results of
unhealthy digestion.   To  effect  these most im-
portant conditions, it is essential that the sub-
stance to be removed  should be soluble, or at least
capable of being readily  metamorphosed into a
body soluble  in the water of the urine, as nothing
can be excreted from the kidneys, without breach
of  surface, unless  in a state of  solution.  The
third function performed by the kidneys is their
serving as outlets to evolve from the animal or-
ganism those elements ofthe disorganization of
tissues which cannot perform any ulterior process,
nor be got rid of by the lungs or skin.  The dis-
organization of tissues  here alluded to is a neces-
sary result ofthe conditions for  the growth and
reparation of the body."   " The old and effete
atoms of the animal structure are not excreted in
the  form of  dead tissue, but,  becoming liquefied,
they re-enter the circulation, their elements being
rearranged.    One  series  of combinations thus
produced, rich in  nitrogen, is excreted  by the
kidneys, while those products which contain a
preponderance of the inflammable elements, car-
bon,  hydrogen, and sulphur,  are called upon to
perform, chiefly through the medium of the liver,
an  important office previous to their final elimi-
nation from  the  system.   Thus the blood is not
only the source of the elements derived from the
food which serve for the  nutrition of the body;
but  it  also  serves, like a  sewer, to  receive the
matter arising from  the waste and liquefaction
ofthe old and exhausted tissues."  (P. 256.)
  7.  Now all the ideas contained in this quota-
tion will be  found  fully and explicitly stated, as
referred to above (y 3-5) and in other places, but
more correctly and more conformably with path-
ological conditions than  in the above passage,
in the first volume  of this  work, published many
years before the appearance of " Urinary Depos-
its."  Besides, Dr. G. Bird has overlooked the
functions of the skin in relation to those of the
kidneys, and has not taken a correct view of those
of the liver in  connexion with the functions of
the lungs, while those of the follicular apparatus
of the intestinal canal and of the skin  have been
altogether neglected.   Yet all  these  functions,
as  I  have elsewhere  shown  (see  the articles
Blood,  Crises, Disease, and  Excretions and
Excreting Functions, &c), are more or less
intimately related to each other and to the  depu-
rating functions of the kidneys, and often evince,
even  in health, a vicarious  increase when one or
more of the  others  are  impeded or diminished,
and a marked diminution when they are augment-
ed.  It should also be recollected, when estimating
the source and nature ofthe functions  ofthe kid-
neys and of  other eliminating organs, that it is
not only the materials mentioned in  the  above
quotation which  are eliminated from  the  circu-
lation by the kidneys, but also a portion of those
resulting from the waste of the red globules and
fibrin of the  blood, and that the kidneys are not
the only depurating organs, the functions  of the
skin, liver, bowels, &c, being generally more or
less  impaired  or otherwise disordered in  those
diseases which evince the most remarkable alter-
ations in the state ofthe urine, these functions,
especially that of the skin, being too generally
neglected by modern physicians in favour  ofthe
popular attractions furnished by the functions of
the kidneys.
   8.  It is obvious, from what I have  stated now
and in  earlier  parts of this work  respecting the
sources ofthe urine, that this depurating secretion
will vary in  quantity and sensible appearances
and physical properties, and even be remarkably
altered, by a variety of causes—1st, by the quan-
tity and  nature of  the  ingesta,  alimentary and
liquid;  2d, by  the imperfect and disordered prod-
ucts  of indigestion  and mal-assimilation result-
ing from impaired vital power or simple or com-
plicated ailments ; 3d, by the metamorphosis and
waste of the several tissues and of the blood—
the removal of effete materials into and from the
blood—during the healthy processes going on
throughout the frame; 4th, by the  waste and
metamorphosis of the structures and of the blood,
when accelerated by local or constitutional dis-
eases ;  5th, by the  absorption of morbid  secre-
tions, and deposits or formations carried into the
blood, and partially, chiefly,  or altogether  elimi-
nated by the  kidneys and other emunctories;
6th, by the varying states ofthe other depurating
functions—by  the increase and diminution of one
or more of these, diminishing, increasing, or al-
tering more or less the functions of the kidneys.*
   f* " In morbid states of all the principal organs the
urine is remarkably  liable to change.  This arises from
various causes.  If the stomach be the primary  scat of
disease, or if its condition be disturbed through sympa-
thetic influences of other diseased  organs, as is almost
constantly the  case, digestion is imperfectly performed,
and the  chyle, in consequence, becomes more or less un-
fitted for the purposes of nutrition  and seen tion.  The
kidneys, therefore, cany off more than their wonted
quantity of excrementitious matter, while this matter ap-
pears under conditions more or less varied from the nat-
ural product.  The whole office of appropriation is, also,
more or less impaired, which farther modifies the condi-
tion of the blood  and the formative action of the kidneys;
though a part of the  office of excretion, under these cir-
cumstance s, devolves upon the skin and lungs.  A third
great cause of the variableness of the urine consists in
unusual vital decomposition or wasting ofthe body, or
of some  of its parts,  when it devolves upon the kidneys 
;IXS—Pathological Relations of.
1316        URINE  AND URINARY DEPOS

  9. Dr. Prout considered that the elements of
the albuminous tissues of the frame are  so  ar-
ranged, during the processes of metamorphosis or
waste, as to be converted into uric acid, or urate
of ammonia, and that the atoms or elements not
composing these bodies form  certain ill-defined
principles.   The ulterior  changes which the ge-
latinous tissues undergo during destructive assim-
ilation this very celebrated physician supposed to
be  intimately connected  with their conversion
into urea, and some  saccharine principle, or its
close ally, the lactic acid.   Baron Liebig follow-
ed in the path pointed out and first trodden by
Dr. Prout, and has been in several matters sup-
ported by the researches of Mulder, Taylor, 13.
Jones, and others. According to Liebig's theory,
the elements of muscular tissue  are  carried into
the circulation, combined with water and oxy-
gen ;  the latter, by its union with the carbon of
the effete tissue, supports the temperature of the
body.  On reaching the structure of the liver, 50
atoms  of carbon, 1 of nitrogen, 45 of hydrogen,
and 10  of oxygen,  with  an unascertained  but
considerable  proportion of sulphur,  are filtered
off from  the portal blood in the form of bile.  The
more highly nitrogenized  elements of the meta-
morphosed or wasted tissues are separated by the
kidneys  from the blood,  chiefly  in the  form of
urea and uric acid, while the carbonic acid form-
ed by the slow combustion of the carbon  of the
original  atoms of muscle  in  the capillaries is
exhaled from  the surfaces of the skin, and bron-
chi, and  air-cells.
   10.  It is manifest  that the atoms  or elements
of tissues, which have become worn out, or which
have given place to new deposits in the  course
of nutrition, are carried into the circulating mass,
where they undergo  progressive  changes under
the influence  of vitality, and are  ultimately elim-
inated from the blood by the depurating organs.
It has been supposed that the states in which the
several materials are found on their elimination
are such as may be altogether imputed to the ac-
tion of the excreting organs ; but it is more prob-
able that the  atoms  or elements  composing  the

to co-operate, beyond their natural habit, with the lunga
and skin,  in removing the redundancy of waste materials.
A fourth cause of the urinary changes, and an important
one, lies in actual morbid states of the kidneys them-
selves.  The kidneys, however, are not often the seat of
morbid affections beyond those of a simple functional and
transient  nature, as induced by sympathetic influences
exerted by the  diseases of other parts, but to which in-
fluences the  kidneys are ex'remely liable, and therefore
to consequent, modifications ofthe urinary product. Brief-
ly, then, every alteration ofthe natural action of the kid-
neys, whether primary or sympathetic, and every defect
in assimilation and appropriation,  is  attended by some
change in the urine; while an endless variety is imparted
to it by the qualities and quantitiesof the ingesta.  From
this circumstance, which should have prompted 'other
conclusions, has arisen the belief that the state ofthe urine
supplies some of the most important signs of pathological
conditions, not only of the kidneys themselves, but of re-
mote organs with which they may sympathize.  From
Hippocrates to our day, elaborate disquisitions have ap-
peared concerning the changes of the urine as indicative
of particular forms of disease, of their special seats, of the
different stages of their rise and decline, and of their de-
grees of severity and danger.   The humoralists were apt
to regard the unusual  conditions  of this product, and
other ' vitiated secretions,' as the disease itself; and in
this respect they are imitated by the humoralists of the
19th centuiy.  Chemistry has been also brought to bear
upon the fluctuating states ofthe urine, and has increased
the factitious importance of a symptom which is often as
likely to denote some alimentary substance, or diverse
forms of disease, or imperfect digestion, or some remedial
agent, as the source from which it emanates."__" The In-
stitutes of Medicine," by Martyn Paine.  8vo, N. Y., 1847.]
materials removed from the structures, as well as
those composing the blood, more especially the
albumen, fibrin, red globules, and even the saline
ingredients, undergo  a  succession of changes or
modifications during their circulation through the
body, until the great or ultimate change is pro-
duced by the organs  which discharge them  from
the economy.   It is not, however, conformable to
the laws of the human frame that each organ
should perform so simple and definite a function
as the chemical pathologists believe.  The skin
certainly exhales carbonic acid ; but it also dis-
charges other materials by means of its follicular
apparatus ;  while the bowels, chiefly by the same
or a similar apparatus, also excrete effete mate-
rials from the circulation ; and, although the com-
binations which are found  during their elimina-
tion may be viewed as chemical, they are the re-
sults of vital  action  in health, are  more or less
modified in disease, and are such as rapidly un-
dergo  farther  changes after their  discharge, or
after death, which changes are more decidedly
chemical, and  such as  their individual elements
chemically dispose them to assume.
   11.  I. In health, the urine presents certain
conditions, a., especially as respects specific grav-
ity, at different periods and in different circum-
stances.  These have  been  distinguished  into,
first, the  urine which  is  excreted  shortly  after
drinking freely of fluids, the nature of the fluids
modifying the appearances and odour of the se-
cretion.   This (the unna potus) is generally pale,
and of a  specific  gTavity varying  from 1003 to
TOIO.  Second, the urine  secreted  shortly  after
the digestion of a full meal (urina chyli), varying
in physical characters with the nature ofthe food,
and other circumstances, and presenting consid-
erable density, its specific gravity  varying  from
1020 to 1  030.  Third, the urine  passed after a
night's rest (urina sanguinis): this is of inter-
mediate density, and varies from 1015 to 1025.
In  order to ascertain the specific gravity ofthe
urine, in health or in disease, the portions pass-
ed before retiring to rest,  and on  rising in the
morning, should be  separately  tested by the uri-
nometer, and the average density ofthe two will
be a near approach to accuracy.  Dr. Prout as-
signed  1 020  as the average  gravity of healthy
urine.  M. Becquerel stated that it is 10189 in
men, and  10151  in women, the mean  in  both
sexes being 1  017 ; and Dr. Routh  that the  aver-
age of 18 healthy cases gave a specific gravity
of 1-021.
   12.  The specific gravity ofthe urine at differ-
ent periods of the day varies in disease, as well
as  in health,  although  in  a less marked degree,
and in  some diseases more than  in others; but
this part ofthe subject has not been sufficiently
investigated, and it is,  moreover, liable to  many
sources of fallacy, as emotions ofthe mind, arti-
cles of diet, the beverages or  drinks employed,
the medicines taken, &c, all combine to render
the results of observation uncertain. _ The nature,
the stages, states, and  course  of disease, as  of
hysteria and other nervous disorders, febrile dis-
eases, &c, also remarkably increase the difficulty.
   13. b. The  quantity of urine passed in the 24
hours, as well as its density and inoredients, va-
nes very much in health, but still  more remark-
ably in disease.   The  quantity and quality are
modified by temperature, by exercise, by the func-
tions of the skin, &c, by modes of living, cloth-
ing, &c.  Dr. Prout estimated the quantity at 
URINE  AND  URINARY DEPOSITS—Pathological Relations  of.        1317
30 to 40 ounces in  the 24 hours.  Dr. Routh
found the average of 18 cases to be 35 ounces.
M. Becquerel considered the quantity to be 43
ounces  in men, and 47 in women, the general
use of soups and weak sub-acid wines in France
being productive ofthe increased discharge ; but
among  the  beer-drinkers  of this  country the
amount given by Drs. Prout and Routh would
be found much below the average.
  14. c. The quantity of the urine is, however,
no measure ofthe depurating actions ofthe kid-
neys ;  for 20 ozs. of urine in the 24 hours may
carry off as much solid  materials as 40 ozs. at a
different time or in a different person ; for a dens-
ity  of the former amounting to 1030 will fur-
nish an equal quantity of those materials to those
afforded by  the latter  at 1015.   Dr. Day  has
shown that the formula for calculating the solids
contained in the urine given  by Dr. Christison
is the most correct; and the following table, cal-
culated from  it  by Dr.  G. Bird, will show at a
glance the quantity of fluid and of solids existing
in 1000 grains  of urine of  different densities.
The gravimeter  having  shown the specific grav-
ity, the proportion of solid matter  is at once  in-
dicated by this table :
                  TABLE I.
[ formula a very useful table for showing the num-
 ber of grains of solids in, and the weight  of, a
 fluid ounce of urine, of every density, from 1010
 to  1040.
TABLE ill.
Sp. Gr. looi-	Solids.	Water.	Sp. Gr. 1021	Solids. 48 93	Water.
	2 33	997-67			951 -07
1002	466	9! 5-34	1022	51-26	948-74
1(103	6 99	993 01	1023	53 5i	946 41
1004	9-32	99(168	1024	55 92	944-18
1005	1165	f 88-35	1025	5S-25	941 -75
1006	13'. 8	986-02	1026	CH-5S	939-42
1007	16-31	983 69	1027	C2-!.'l	937-09
1008	18-64	f,81-36	1028	65-24	934-76
10:9	20 97	979 -('3	1029	67-57	932-43
1010	23 30	976-70	1030	69 90	930-10
1011	25 63	974 37	1031	72-23	927-77
1012	27-96	972-04	1032	7456	9-25-44
1013	30 29	96T-71	1033	76 89	923-11
1014	32 62	967-28	1034	79 22	920-78
1015	34 95	965 05	1035	81 55	i:18-45
1016	37 23	962-72	1036	83-88	91612
l'H7	39-61	9i'.0 30	1037	86 21	913 79
1018	41 -94	958 06	1038	S8 54	911-46
1019	44 27	955 73	1039	91 87	90913
1020	46 0	953-40	1040	93 20	906-80
  15. By measuring the quantity of urine pass-
ed in a given time, the weight of solids excreted
by  the  kidneys may readily  be calculated  by
means ofthe foregoing and the following tables,
a pint of distilled water weighing 8750 grains.
The following table is given by Dr. G. Bird :
                 TABLE II.
Specific Gravity.	Weight of one Pint.	Specific Gravity.	Weight of one Pint.
1010 1011	8837 grains. 8846 "	1023 1024	8 51 grains. 8960 "
1012	8S55 "	1025	8968 "
1013	8'63 "	1026	8977 "
1014	8872 "	1027	8986 "
1015	8S81 "	1028	89- 5 "
1016	8S90 "	1029	9003 "
1017	88' 8 "	1030	roi2 "
ldl.S	K907 "	1031	9021 "
1019	8916 "	1032	9030 "
1020	8925 "	1033	9038 "
1021	8933 "	1C34	9(147 "
1022	8-^42 "	1035	9056 "
   16. It may readily be calculated from these ta-
bles, that if 1000 grains of urine, of the specific
gravity of 1020, hold 46 6 grains of solid matter
in solution (Table I.), a pint ofthe same specific
gravity, weighing 8925 grains (Table II.)  will
hold 415 9 grains solid matter;  and that, if two
pints and a half of urine be passed, 1039 72 grains
will  be discharged in the 24 hours.   Dr. Gold-
ing Bird has  calculated from Dr. Christison's
Specific Gravity.	Weight of one fluid Ounce.	Solids in one fluid Ounce.	Specific Gravity.	Weight of one fluid Ounce.	Solids in one fluid Ounce.
		grains.			grains. 26-149
1010	441-8	10-283	1025	448-4	
1011	442-3	11-336	1026	448-8	27188
1012	442-7	12-377	1027	449 3	28 265
1013	443-1	13-421	1028	449-7	29-338
1014	443-6	14-470	1029	450-1	30-413
1015	444(1	15517	1030	450-6	31-4!'6
1016	414-5	16-570	1031	451-0	32-575
1017	444-9	17-622	1032	451-5	33-663
1018	445 3	18-671	1033	451-9	35146
1019	4458	19-735	1034	452-3	36-831
1020	446-2	20-792	1035	452-8	37-323
1021	446 6	21-852	1036	453-2	38 014
1022	417-1	22-918	1037	453-6	39-104
1023	447-5	23-981	1038	4541	40-206
1024	448-0	24-951	1039	454-5	41-300
   17.  By multiplying the  number of ounces of
 urine passed in the 24 hours by the two last fig-
 ures of the specific gravity, the quantity of solids
 excreted will be obtained.   Thus, if three pints,
 or 60 ounces, be discharged in the 24 hours, and
 the density ofthe several specimens give an aver-
 age  of 1020, the 60 ounces multiplied by 2079
 would give a product of 1247 grains, the quantity
 of solids excreted in the 24 hours.  Dr. G. Bird
 estimates the average amount of solids  excreted
 by the  kidneys of the healthy adult to be from
 600  to 700 grains in  the  24 hours ; numerous
 circumstances  connected with  occupation, exer-
 cise, diet, regimen, &c, modifying the results.
   18.  d. The tints presented by the urine in dif-
 ferent diseases  are of great importance in respect
 both of diagnosis and of treatment.  These tints
 vary with the degree of dilution and the nature
 of the ingredients from nearly colourless, to the
 usual pale amber colour, to deep brown.   When
 very watery, urine presents a faint greenish tint,
 as in early infancy, and in hysteria and chlorosis.
 If bile or blood be present in the urine, a variety
 of colours, from red to brown, blackish-green, or
 apple-green are produced, the latter hue being
 sometimes indicative of cystine.  A  reddish tint
 may be caused by purpunne or by blood;  if by
 the former, congestion  of the portal circulation,
 or disease ofthe liver or spleen, may be inferred ;
 if by the latter, haemorrhage in some part ofthe
 urinary passages has occurred.  In the former
 case the specific gravity is moderate, and  heat
 produces no change ;  in the latter, heat and nitric
 acid  occasion turbidity, and blood-disks are seen
 under the microscope.   A brownish tint is caused
 by a concentrated or dense state of the urine, as
 in fevers, the specific gravity being high ; or by
 obstruction to the discharge of bile in some part
 ofthe biliary apparatus, and the presence of some
 or all the elements of bile in the circulation ; or
 by the existence of blood in a less degree or alter-
 ed state, and  shown by the tests just mentioned.
 Blood  and bile  may occasion  a greenish-brown
 tint,  the former when the  urine is alkaline, the
 latter when the urine is very acid.  A grass-green
 hue ofthe urine indicates excess of sulphur and
 the presence of cystine.   It is unchanged by heat
 or nitric acid.   It should not, however,  be over-
looked that numerous articles of diet and of med-
icine affect the appearance ofthe urine.  Chima-
phyla, hsematoxylum, indigo, rhubarb, senna, &c,
produce this change in a marked degree. 
1318
URINE AND URINARY DEPOSITS—Pathological Relations  of.
  19. e.  The fluidity of the urine sometimes va-
ries.  It  is more or less viscid, owing to the pres-
ence of mucus or pus, or both, especially when
alkaline,  and in the layer formed at the  bottom
ofthe vessel;  and in a slight degree in diabetes
mellitus,  when the frothiness caused by agitation
continues for some time.  Although fluid while
warm, it becomes in rare cases jellatinous  on
cooling, owing to the presence of self-coagulating
albumen  or fibrin.  This state indicates severe
organic disease ofthe kidneys.  I have, however,
met with it at advanced stages of pregnancy.
  20. II. The  chemical composition  of the
urine has engaged the attention of chemists and
physiologists for many years ;  and even now the
elements contained in this fluid, although nearly,
if not altogether, ascertained, are still topics  of
controversy, as respects either the origin of cer-
tain of them, or the successive changes of which
they may be the ultimate products.  As to the
general principle, that the urine is an excretion
by which the blood is depurated from the effete
materials carried into  the circulation  from the
metamorphosis and  waste of the  tissues, &c,
as stated above (Y 3-10) and in the commence-
ment of this  work  (see Blood, § 115-160), no
doubt can now exist; but the successive changes
which these elements or materials undergo dur-
ing their absorption  and passage from their ori-
gins and sources, during their  circulation, and
during their ultimate discharge—from  their ori-
gins to  their  elimination from the body—have
been long topics of research and discussion, espe-
cially by  the chemical physiologists and patholo-
gists of recent times, who have been more dis-
posed to  view them as  altogether chemical, than
as vital and as modified, and even more  or less
altered, by the states of vital power and vascular
action.   To the specialist in medicine the chem-
ical doctrine presents itself in its most favourable
 aspect, as placing urinary pathology in an so-
 lated yet scientific position.   To the general or
 legitimate physician, the conditions of the urine.
 in"all their phases, and in the successive changes
 from their origins to their ultimate  results, arc
 viewed as ever-varying effects ofthe influence of
 vitality throughout the frame, as manifested by
 the functions of digestion, assimilation, nutrition
 metamorphosis, waste, and depuration ; all which
 are not only under the complete and constant do-
 minion of life, but are also the necessary agen-
 cies of the continuance of life ; this  department
 of pathology being inseparable, in its philosophic
 as well as in its practical relations, from all oth-
 ers which comprise  the whole range and circle
i of morbid actions.
   21. The urine in health  contains :  1st, certain
 organic products, namely, urea, uric acid, creatine,
 creatinine, colouring  and odorous elements; these
 more  especially result from the metamorphosis
 and waste of the tissues and of the blood, and are
 separated from the  latter by  the  kidneys;  also
 other ingredients, more particularly lactic and
 hippuric acid,  developed during the process of
 assimilation, and  accidental  matters  carried into
 the  circulation;  2d, inorganic  products, being
 saline combinations,  derived from the food, espe-
 cially sulphates, phosphates, chloride of sodium,
 and soluble salts taken with the ingesta, and often
 decomposed in their transit into  and from the
[ blood ; also  saline substances, generated chiefly
! from the processes of destructive metamorphosis
 and waste, and of depuration, as  sulphates and
 phosphates ; 3d, matters derived from the urinary
 passages, being chiefly mucus, debris of epitheli-
 um, and a minute quantity of phosphate of lime
 present in mucus.   M. Becquerel gives the fol-
 lowing  as the  average composition  of urine in
 males and females, and the quantity discharged
I in the 24 hours.
	Urine in Men.		Urine of Women.		Moan of Both.	
	In 24 Hours.	In 1000 Grs.	In 24 Hours.	In 1000 Grs.	In 24 Hours.	In 10.10 Urs.
	19516 10189 610-	311	21124 1-0151 526-8	24 95	20320 10170 568-	28-
						
						
Constituents of Solids.	270-7-6 ISO-	128 0391 763 9-26	240-86 126-145-	10366 0406 614 8'	255-81 138-1605	12 0398 1 69 8-6
						
						
Organic matters and vola- ) tile saline combinations. >						
   22.  a.  Urea.—This important excretion, com-
 posed of C 2, N 2, H 4, O 2 = 60, is the form in
 which a large quantity of nitrogen is eliminated
 from the  body;  270  grains of urea being  dis-
 charged by a healthy man in the 24 hours.  This
 substance is the product of the destructive meta-
 morphosis or waste of organized parts (§ 9, 10);
 but it is so rapidly carried  out of the blood by the
 kidneys as to admit of only minute quantities of
 it escaping by the skin, unless when the func-
 tions of the  kidneys  are interrupted, and then it
 is discharged both by the  skin and by the intes-
 tines in greater quantities.  The food has a re-
 markable influence upon the quantity of urea in
 the urine.  Dr. Lehmann  found the quantity of
■ urea excreted by his kidneys while  living on
	Animal Food.	Vegetable Food.	Mixed Diet.	Non-nitro-geniied Diet.
Urea in the urine ) in 24 hours.... |	819-2	346-5	500-5	237-1
strictly animal food, and while restricted to vege-
table diet, as shown by the preceding table.
  [Urea has  been  repeatedly detected in the
blood under ordinary circumstances, and  espe-
cially after  extirpation of the  kidneys in the
lower animals;  but  it is removed  with such
rapidity by the kidneys, that there is  probably
never more  than a fiftieth of one  per  cent, of
the circulating blood.   Though its source is sup-
posed chiefly to be  found in the  food and the
waste of muscular tissue,  yet both creatine and
mosic acid produce it in their descending  meta-
morphosis.  From the fact that caffeine and other
substances increase its amount, the seat of its pro-
duction  would seem  to be  the blood itself.  Dr.
J.  C. Draper, of New York (Inaugural Disser-
tation, 1856), from experiments on the urine of
persons in different conditions of motion and rest,
and by an examination ofthe diurnal and noctur-
nal variations in the  amount of urea voided, com- 
URINE AND  URINARY DEPOSITS—Pathological Relations  of.
1319
pared with an invariable standard, gives reasons
for concluding that the differences in the amount
of urea excreted are almost entirely attributable
to the influence of the food, an individual in such
a state of comparative rest as is observed during
treatment for a fractured  leg  not  excreting by
any means so much less urea as might have been
anticipated when  compared  with another indi-
vidual who walked thirteen miles at the  rate of
four and a half miles an hour.   But on examin-
ing the influence of the food it appears to be well
marked.  The greatest amount of urea is excret-
ed within a few hours after dinner.  Another max-
imum occurs also just after breakfast; but during
the eight night hours far less is excreted than
during the same period in the afternoon.   The
ingestion of food  thus exercising  so rapid and
marked an influence on the quantity of urea, he
refers to it as the cause of the increased excre-
tion of that substance during the course of the
day rather than to the increased  motion of exer-
cise then indulged in; and in view of this con-
clusion, it becomes probable that the nitrogen of
the wasting muscular tissues escapes, not under
the form of urea through the kidneys, but through
the skin, or  perhaps  even as free nitrogen  from
the  lungs.   (" Human Physiology," by  J.  W.
Draper, 8vo, New York, 1856.)]
   23. According  to  Lecanu,  the  quantity of
urea and of uric acid  excreted in the 24 hours is
very much  influenced by age.  The following
are  the results of his experiments,  as  to the
amounts of these substances excreted in the 24
hours:
	Urea. | Uric Acid.	
	431-9 grs. 294-2 " 124-8 " 138-2 "	13-09 grs. 10-01 " 6-77 " 3-98 "
		
Very old men (34 to 86 years) Children (under 8 years)....		
  [To detect urea, Dr. Bird recommends to place
a drachm of urine in a  watch-glass, and  add
about half that quantity of colourless nitric acid.
If a normal  proportion of urea exist, no change,
except a darkening in tint, and the evolution of a
few bubbles, will be observed, unless the weather
be very cold, or the glass be placed in a freezing
mixture, and then a delicate plumose crystalliza-
tion of nitrate of urea will commence at the edges
of the  fluid.  Under ordinary circumstances no
crystals of urea will  appear, unless the urine be
concentrated by previous evaporation.   In some
cases an excess of urea exists, and then a rapid
formation of crystals of nitrate  of urea occurs,
sometimes so copious that the mixture becomes
nearly solid. Dr. B. thinks it important, when this
is the case, to measure and ascertain the specific
gravity of the whole quantity of urine passed by
the patient in 24 hours ; for unless this equals or
exceeds the average proportion of health, there is
no proof that an actual excess of urea is excreted
by the kidneys.  A particular specimen of urine
may appear richer in urea than natural, from the
diminished amount of water present]
  24. b.  Uric Acid.—Uric or lithic acid, composed
of C 70, N 4, H 4, 0 6 = 168, is excreted by the
kidneys to the amount of 81 grains in the 24
hours.   Dr. Prout's opinion, confirmed by Dr.
B. Jones and Dr. G. Bird, is that the greatest
portion  of the uric acid always  exists  in the
blood in combination with  ammonia; for  this
acid  requires 10,000 parts of water at 60° for so-
lution, while there does not exist quite 2500 times
its weight.  Urate of ammonia is soluble  in 480
times its weight  of water; and as it occurs in
urinary deposits,  it requires for solution  2789
parts of urine, according to the researches of Dr.
B. Jones, who has shown that the presence of a
moderate quantity of saline matter increases its
solubility.  Dr. G.  Bird states the following as
the mode in which uric acid exists in  healthy
urine.   " Uric acid, at the moment of its separa-
tion  from the blood, comes in contact with the
double phosphate of soda and ammonia, derived
from the food, forms urate of ammonia,  evolving
phosphoric acid, which thus produces the natural
acid  reaction of urine.   If the whole bulk of the
urine be to the urate of ammonia formed, not less
than about 2701  to  1, the secretion will, at the
temperature  of the air, remain clear, but if the
bulk of fluid be less, an  amorphous deposit of
the urate will occur.  On the other hand, if an
excess of uric acid be separated by the  kidneys,
it will act on the phosphate of soda ofthe double
salt, and hence, on cooling, the urine will deposit
a crystalline sediment of acid sand, very probably
mixed with  amorphous  urate of  ammonia, the
latter usually forming a layer above the crystals,
which always sink to the bottom of the vessel."
(Op. at., 84.)
  25.  Without referring to Liebig's views as to
the physiological origin of uric acid, which are
contradicted  by the experiments  of Lehmann,
and  merely stating  that these views are not cor-
roborated by any subsequent  researches, I may
give the results of the  researches of this  latter
physician:
Diet.	Quantity excreted in 24 Houre of		Proportion of Uric Acid
	Uric Acid.	Urea.	to Urea.
Exclusively animal Mixed animal ; and vegetable. \ Exclusively veg-) Food free from i	22-64 grs. 18-17 " 15-7 " 11-24 "	819-2 grs. 505 0 " 346-5 " 237-1 "	1: 36-1 grs. 1:27-5 " 1:22- " 1:21- "
Dr. Bence Jones, who has investigated this and
other subjects connected  with the chemico-pa-
thology of the urine, with great scientific acumen,
has shown the immediate influence of food on the
quantity  of uric acid contained in the urine to
be as follows:
	Specific	Grains. |
	Gravity.	Uric Acid. |
In 1000 Grains of Urine :		
	1027	1022
	1024	0049 ;
After vegetable food ..	1025	1010 1
Before " " ..	1024	0049 !
From these and other researches and consider-
ations, it may be inferred that uric acid is derived
from the nitrogenized elements ofthe effete mole-
cules of the tissues, and  from the elements of
food abounding in nitrogen, which are not as-
similated into the healthy  constituents of blood ;
and  probably from  the latter source,  in  larger
proportion ; and thus these nitrogenized elements
are excreted from the blood in the states of uric
acid, of  uric acid combined with ammonia, and of
urea; the causes of the preponderance of either
of these being not satisfactorily explained.
  26. c. Lactic acid and lactate of ammonia were
said by Berzelius to exist in the urine, but were
denied by Liebig.  That lactic acid exists in the
blood, and is excreted by the skin in health, and
more largely in some diseases, is admitted.   It is, 
1320        URINE AND URINARY DEPOSITS—Pathological  Relations
however, found in the urine of herbivorous ani-
mals ;  and it  probably  undergoes some change
before it is excreted by the kidneys in the human
subject.  Dr  G. Bird considers  that what was
mistaken for lactic acid in urine is really a mix-
ture of creatine and  creatinine, these substances
being forms in which the nitrogenized  elements
of worn-out structures, especially muscular  tis-
sues, are removed from the system.   Dr. Prout
believed that several of the constituents of urine
were derived from the destructive metamorphosis
of distinct and separate tissues,  and these sub-
stances appear to support his views.
  27. d. Hippuric, or urobenzoic acid, exists chief-
ly in the urine of herbivorous animals, and occa-
sionally in that of man.  Its quantity in health is
not constant, probably owing to the nature of the
food.  It is, next to  bile and purpurine, the rich- j
est in carbon of any of the products of vital chem-
istry ; and hence its  abundance in urine may de-
pend upon the states of biliary secretion and of
the respiratory functions, impairment of these in-
creasing its excretion by the kidneys.*
  [Though  we are  not disposed to deny that
chemistry has been of great service in  the diag-
nosis of calculous and urinary disorders generally,
yet there is reason to believe that the treatment,
to be successful, is not always  to be regulated by
the chemical indications present.   The  alkalies,
especially the bicarbonate of potash and  bicar-
bonate of" soda, when given freely,  especially at
or near the times of eating,  interfere  with the
process of digestion, by neutralizing the gastric
acids,  and thus aggravate  the difficulty by de-
ranging this important function.   These, as well
as other alkaline substances, should  be given at
least two hours from the time of meals, in con-
nexion with  the  vegetable tonics.   Prof.   M.
Paine, in his very  able work, " The Instit. of
Medicine" (p. 233), thus speaks ofthe aid derived
from a knowledge  of the chemical constitution
of the  urine :  " Coming to  the bed-side, we  find
that all that is  practically  useful in relation to
the  urine is generally  best ascertained by mere
inspection ; and upon this subject  we have  all,
and more  than  is desirable, from Hippocrates
himself.  Those philosophers,  however, who  are
employed  in  interrogating disease by chemical
analysis, are not often, or long, in the chambers
of the  sick.   They carry on the investigation of
morbid processes in the laboratory of the chemist,
and then and there  fabricate the  appropriate re-
agents.   He who studies organic nature accord-
ing to the method  of solidism and  vitalism, has
neither the leisure  for these most difficult, unat-
tainable, and  laborious analyses, nor would they
have any  influence on his judgment as  to  the
pathology or treatment of disease in the midst of
such a multitudinous variety as is presented by the
vital phenomena of disease.   Of one thing, also,
we may rest assured, that nature has supplied all
those  ready means  for interpreting disease  that
may be necessary for immediate action; nor can
we  often delay the treatment of acute disease
  [* To detect hippuric acid, evaporate a few ounces of
urine to a sirupy consistence, and then add an excess of
hydrochloric acid; a mixture of hippuric and uric acids
will then be separated and fall to the bottom of the ves-
sel.  After a  few hours' repose, the supernatant fluid
should be decanted, and the deposit washed in a very
little cold water.  On boiling the residue in alcohol, in
which uric acid is insoluble, the hippuric acid will be
dissolved, and by spontaneous evaporation is left in thin,
delicate needles, strongly coloured from adhering impu-
rities.]
for consultation with the laboratory.   In respect
to the blood, were it even practicable to learn from
analysis its variable conditions in disease, it would
reflect no light upon morbid states of the  organs,
since the qualities of that fluid vary with every
varying  change in  the  vital conditions of the
solids, and therefore, too, would fail to indicate
in the least the appropriate remedies.   11ns  is
also  true, in a general sense, of the urine and all
other excretions and secretions.  The ready sight,
their sensible properties, the vital phenomena,
physical  signs, experience, and general principles,
must be  our guide.  These may  sometimes be
facilitated by extraordinary modes of observation,
but which are always within the  reach and clear
understanding of every practitioner,  such as the
usual mode of examining the blood in inflamma-
tory  diseases, evaporating  the urine  in diabetes,
&c.   On the contrary,  were the  humoral  doc-
trines correct, the teaching  and  the practice of
medicine should be  restricted to chemists alone,
since there is no branch  of inquiry so difficult as
organic analyses,  while  their uncertainty would
soon prove that the vis mcdicatrix natura is the
only ordination of nature for the maladies of the
urine race."]
  28. e. Butyric acid is sometimes found in the
urine, and may be  either  referred to the butter
used in food, or to the imperfect assimilation of
saccharine matter.  It is seen also in the creamy
deposit formed in  diabetic urine.   This acid may
also  be derived from protein compounds.
  29 /.  The colouring matter of urine has been
differently accounted for by Simon, Prout, Hel-
ler, G  Bird, and Scherer.   The  last-named
physician  attributed it to  the destructive meta-
morphosis or waste  of red-blood corpuscles.  Dr.
G. Bird investigated its nature and composition,
gave it the name  of purpurine, and viewed it as
a principle of urine chiefly in disease, and as a
result of impaired  excretion of carbon by the
lungs and liver, this element being,  when exist-
ing  in excess in  the blood, partly  eliminated by
the  kidneys in this form (y 27, 28).
   30  g  Sulphur extractive exists in urine, and
is derived from the metamorphic destruction of
albuminous and  fibrinous  tissues, which contain
sulphur  and traces of phosphorus.   " While the
greater  quantities of their protein elements are
converted into creatine and its allies and urea, a
small proportion  containing  the sulphur and
phosphorus is eliminated by the kidneys in the
form of this  peculiar extractive matter."  The
taurine,  a constituent of bile, may also be one of
the  sources ofthe sulphur extractive  ofthe urine.
The nature  of the  food may also contribute ma-
terially to the quantity of this constituent
   31. h. Ammonia exists  in urine "combined
with uric acid, and probably with phosphoric acid
and soda, forming the triple compound known as
microcosmic salt."
   32  i. The fixed salts  of urine are  those which
are  left  after the  other ingredients are destroyed
by a red heat. They amount to nearly 140 grains
in the 24  hours, and consist of  combinations  of
chlorine, sulphuric and phosphoric acids,  with
soda, lime, magnesia, and  potass.   Of these the
combinations of chlorine and phosphoric acid are
probably derived  from the  food.   Dr  G.  Bird
considers that the  phosphoric acid  and  soda in
the  urine exist in the state ofthe common rhom-
bic  phosphate unless it be combined with the
phosphate of ammonia.  The soluble phosphates 
URINE  AND URINARY DEPOSITS—Pathological Relations  of.        1321
far exceed in quantity the insoluble salts, and are
derived directly from the  food, as well as from
the albumen and other elements of the  blood.
The  insoluble  phosphates, forming part of the
structure of the body, and  derived from the blood
during the  process  of nutrition, are  conveyed
back to the blood during the metamorphosis and
waste ofthe structures, and are eliminated by the
kidneys.   " Some portion  of the phosphoric acid
of the  urine is in all probability  generated from
the action of oxygen on many of the  structures
ofthe body, into  the composition of which phos-
phorus largely enters, as the brain and nervous
system generally.  But the  greatest part  of the
phosphoric  acid  is derived  ready formed from
without; the  phosphates of lime and  magnesia
abounding in milk and most varieties of vegetable
food; while the  basic alkaline phosphates exist
in flesh, in  wheaten flour, leguminous seeds, as
beans, peas, &c." The interesting researches of
Dr B. Jones  have shown that the quantity  of
phosphates, in a given quantity of urine, bears
some relation to  the periods of taking food, and
to the nature  and composition of the  food.  He
found the quantity of phosphatic salts to be much
greater after a diet  restricted to vegetable, than
to animal food.  The  quantity of phosphates of
lime and magnesia in  the urine is considerably
increased after the ingestion of soluble salts  of
these two  earths.  The alkaline phosphates are
most abundant shortly after a meal composed chief-
ly of bread, and are not materially affected by the
circumstances which influence the excretion  of
the  earthy  salts.  "A part  only ofthe earthy
phosphates contained in the food is absorbed into
the circulation, the greatest  proportion escaping
by  the intestines."  Berzelius  found in three
ounces of human faeces six grains of earthy phos-
phates.  The insolubility of the salts in water ac-
counts for their presence in the faeces.  A small
quantity of phosphorus also  exists in the urine
in a non-oxidized form.  The  excess of phos-
phoric acid often found arises from the oxidation
ofthe phosphorus ofthe urine.
   33.  k. The quantity of sulphuric acid  in the
urine is too great to be accounted for by its pres-
ence in the food as saline combinations ; and sul-
phuric acid has been found in the urine while food
quite free from sulphates  has alone been  taken.
According to G. Bird and Mulder, the origin of
this acid is to be referred to  the oxidation  of the
sulphur  which exists  with phosphorus in those
tissues which contain albumen and fibrin.   Dur-
ing the metamorphosis or waste of tissues, oxi-
dation of the sulphur  occurs, and explains the
presence of at least a portion of the sulphuric acid
met with in the  urine.  The existence of more
than twenty per cent, of sulphur in taurine—one
of the products  of the metamorphosis of bile—
accounts for a portion  of the sulphuric acid, by
referring it to the oxidation of the biliary sulphur
during the  recrementitious offices of  bile  in the
economy.   As a portion of sulphur  is excreted
from the body in  a non-oxidized form, a part only
of the sulphur not required for the purposes of
the animal economy undergoes  oxidation.   Pro-
fessor Ronalds found, in five specimens of urine
of healthy persons, the proportions of sulphuric
acid, and of the non-oxidized sulphur, existing in
1000 grains, to be as follows :  106; 0  17.—146 ;
018—142; 018— 2 44; 0 153—132,  0165.
   34.  Dr. Bence Jones has shown, by his inter-
esting researches connected with the subject, that
the salts of this acid are increased in the urine by
any kind of vegetable or animal food ; that exer-
cise does not appear to increase them, nor the
administration of sulphuric acid, unless in large
quantities ;  and that the ingestion  of sulphur, or
of  the  sulphates  of  soda or  magnesia, always
greatly  augments  the quantity of  the  sulphuric
salts in  the urine.
  35. /. The chloride of sodium of the urine  is
obviously derived  from  the  common salt taken
with the food.   Some of the saline constituents
of the urine may  be readily recognised by the
crystalline forms they present  when the urine is
evaporated  on a glass plate.   MM  Regnault,
Reiset, and Burral have shown that the chloride
of sodium increased the excretion of nitrogen, as
evinced by the augmentation of urea and the ni-
trogenized compounds  in the urine   It may be
inferred that common salt produces  salutary ef-
fects : 1st, by furnishing hydrochloric acid to the
stomach; 2d, by furnishing soda to the bile ; 3d,
by aiding the metamorphoses  of the blood glob-
ules and of the tissues ; and, 4th,  by promoting
the depuration  of the  blood   The  absence or
diminution  of chloride of sodium in the urine of
patients labouring under pneumonia, noticed by
Redtenbacher, was  attributed to  the  alteration
of diet  during  this  disease.   But  Dr. Lionel
Beale has established the following propositions,
which show the insufficiency of this explanation :
1st. Chloride of sodium is totally absent from the
urine of pneumonic patients at the period of com-
plete hepatization ofthe lung.  2d. The chloride
reappears afterthe resolution of the inflammation.
3d. The chloride exists  in the blood in the largest
quantity when  most  abundant  in the urine, and
vice versa   4th. The chloride exists in very large
quantity in the sputa of pneumonic patients.  5th.
There is  reason to believe that the chloride in
pneumonia  is  determined  toward the  inflamed
lung, and is reabsorbed and removed on the res-
olution  of the  inflammation.   (Transactions of
Medical and  Chirurgical  Society, vol. xxxv., p.
374, &c.)  I may, however, remark that the quan-
tity of chloride in  the expectoration is increased
beyond that existing in healthy pulmonary mucus,
and is diminished in the urine, in acute bronchitis,
in pleurisy, and in phthisis, although not so re-
markably as in  pneumonia.
   36. III. The Formation of  Urinary Depos-
its.*   Et seq.—"When  the  several constituents
   * Clinical Examination ct the Urinf.—Dr. Gold-
ing Bikii has given  the following  recommendations for
ascertaining the state of the urine in disease, provided
that it be an average specimen of that paseed in the pre-
ceding twenty-four hours, or that resulting from the first
micturition after a night's rest, unless the urine secreted
at other times be required.
   A. Urine without Deposit or poured from the Sediment.
—After ascertaining the acid, alkaline, or neutral states
ofthe urine by means of test-papers, a little of the urine
should be heated in a metallic spoon over a lighted can-
dle, or in a test-tube over a spirit-lamp;  and if a deposit
occurs, albumen or an execs- of the earthy phosphates is
present; the former  if a drop of nitric acid does not re-
dissolve  the deposit,  the latter if it does.   " If the urine
be very highly coloured, and be not rendered opaque by
boiling, the colouring matters of bile or purpurine are
present.  To  determine this, pour a thin layer of urine
on  the back of a white plate, and  allow a few drops of
nitric acid to fall in the centre; an  immediate and rapid
play of colours, from bluish-green  to red, will be ob-
served, if bile; but no 6uch change will be observed if
purpurine alone exists.  Should the high-coloured urine
alter in colour or transparency by heat,  the pretence of
blood should be suspected.   If the addition of nitric acid
to deep-red urine, unaffected by heat, produces a brown
deposit, an excess  of uric acid exists.  If a specimen of
urine be  pale, immerse the gravimeter, and  if the spe- 
1322
URINE AND  URINARY  DEPOSITS—Pathological  Relations of.
of the urine are in due relation to each other, the
urine is clear, and of a pale  amber colour.   Its
transparency is but slightly affected on cooling by
the gradual subsidence of a slight mucous cloud
sometimes entangling a few microscopic crystals
of uric acid; but when one or more of these con-
stituents " exist  in real or comparative excess, or
a new  substance is  superadded, the urine does
not generally remain clear, but either immediate-
cific gravity be below 1012, there is a considerable excess
of water; but if above 1025, the presence of sugar, or a
superabundance of urea, is indicated.  To determine the
existence of either of these conditions, place a few drops
of the urine in a watch-glass, add an  equal quantity of
nitric acid, and allow the glass to float in some cold wa-
ter ; crystals of nitrate of urea will appear in two or three
minutes if the latter exists in excess.  Should this change
not occur, the urine mu>t be examined specially for sug-
ar, which, it must be remembered, may exist in  small
quantities, without raising the specific gravity of the flu-
id." For this purpose, boil a small portion with an equal
bulk of liquor potassae, in a test-tube, and the develop-
ment of a brown colour will show the  almost certain ex-
istence of sugar.  An excess of colouring matter, rich in
carbon,  should always be sought after on account  of its
pathological importance.   " This  is readily done by
boiling  some  urine in a tube, and, while hot, adding a
few drops of hydrochloric acid. If an average proportion
of the pigment exist, a  faint red or lilac colour will be
produced; but if an excess is present, it will be indicated
by the dark-red, or even  purple tint assumed by the mix-
ture.  Should the urine  be alkaline, add a drop of nitric
acid; if a white deposit occurs, albumen is  present; if
brisk effervescence follows the addition of the acid, the
urea has been converted into carbonate of ammonia" (p.
16, 17).
  B. Examinition ofthe Sediment deposited.—" If the de-
posit is flocculent, easily diffused on agitation, and scanty,
not disappearing on the addition of nitric acid, it is chief-
ly made up of healthy mucus, epithelial debris, or occa-
sionally, in women, of secretions from the  vagina, leu-
corrhoeal discharge, &c.   If the deposit is ropy, and ap-
parently viscid, add  a drop of nitric  acid ; if it wholly
or partly dissolves, it is composed of phosphates; if but
slightly  affected, of mucus.   If the deposit falls like a
creamy layer to the bottom of the vessel, the supernatant
urine being coagulable by heat, it consists of pus.  Urine
sometimes appears opaque from the presence of a light
flocculent matter diffused through it, presenting neither
the tenacity of mucus nor the dense opacity  of pus.  Al-
though scarcely sufficient  in quantity to interfere with
the perfect fluidity of the urine, if a little be placed in a
test-tube, and  agitated with an equal  bulk ot liquor po-
tassaj, the mixture will often become a stiff, transparent
jelly.  This peculiar appearance is demonstrative of the
presence of the exudation, or large organic globules form-
ed under the influence of irritation, providing the  urine
does not coagulate by heat; for should it do so, the ex-
istence of minute quantities of pus may be suspected."
  " If the deposit is white, it may consist of urate of am-
monia, phosphates,  or cystine; the first disappears on
heating  the urine, the second on the addition of a drop
of diluted nitric acid, while the third dissolves in ammo-
nia, and the urine generally evolves an  aromatic odour
like the sweet-briar,  less frequently being fetid.   If the
deposit  be  coloured,  it may consist of red  particles of
blood, uric acid, or urate of ammonia stained with pur-
purine.  If the first, the  urine becomes opaque by heat;
if the second, the deposit is  in visible  crystals;  if the
third, the deposit is amorphous, and  dissolves on heating
the fluid.   Oxalate,  and, more rarely, oxalurate (?) of
lime, are often present, diffused through  the urine,  with-
out forming a visible deposit; if this be suspected, a drop
of the urine, examined microscopically, will detect the
character of the crystals.  If the urine be opaque, like
milk, allowing by repose a cream-like layer to form on
the surface, an emulsion  of fat with albumen is probably
present.   Agitate some  of the urine, with half its bulk
of ether, in a test-tube, and, after resting a few minutes
a yellow etherial solution of fat will float on  the surface
of the urine, a tremulous coaguluin of albumen generally
forming  beneath it."
  Dr. G. Bird adds, that much of the little time required
for the investigation  thus sketched may be saved by re-
membering the following facts: " If the deposit be white,
and the urine acid, it, in tlie great majority of cases, con-
sists of urate of ammonia;  but should it not disappear by
heat, it is phos:>hatic. If a deposit be of any colour in-
clining to yellow, drab, pink, or red, it is almost sure to
be urate  of ammonia, unless visibly crystalline, in which
case it consists of uric acid'' (p. 18-21).
ly upon being voided, or at least on cooling, be-
comes more or less turbid."   When the urine, on
cooling, becomes covered with a thin membrane-
like scum,  a pellicle is said to exist.  When the
substance causing opacity floats between the sur-
face and the lower portions of the fluid, it is said
to form a cloud.  And when this falls toward the
bottom ofthe containing vessel, the appearance
was termed encorema.   When a positive deposit
collects at  the bottom  of the  vessel, the  term
sediment, the hypostasis of the  ancients, is com-
monly  applied.   The terms  pellicle, cloud, and
deposit, or  sediment, are those commonly used in
describing  the states of the urine.  These appear-
ances are generally not fully  developed until the
urine is cooled  down to the temperature of the
air.  This  is especially the case with those de-
posits which are soluble in warm water ; as the
urates, particularly the  urate  of ammonia, which
constitutes the  chief part of reddish and  fawn-
coloured amorphous sediments.
   37.  Urinary deposits, including  all substances
which  disturb the  transparency of urine by their
presence, whether they subside to the bottom of
the vessel  or not, have been divided by Dr. G.
Bird into:  1st. " Deposits composed essentially
of ingredients derived, directly or indirectly, from
the metamorphoses of tissues—(to which I would
add, from  the metamorphosis and waste also of
the red globules, fibrin, and  other  constituents
of the blood)—or from  the organic  elements of
food ;  namely, uric acid and urates, uric oxide,
oxalate of lime,  oxalurate of  lime,  and  cystine.
2d.  Deposits  composed of ingredients  for the
most part of inorganic origin, including phosphate
of  lime, ammonio-phosphate of magnesia, car-
bonate  of lime, silicic acid.  3d. Highly-coloured
deposits (black or  blue) of doubtful origin; viz.,
cyanourine, melanourine, indigo, Prussian blue.
4th. Deposits consisting of non-crystalline organic
products, including—organized: blood, pus, mu-
cus, organic globules, epithelium,  spermatozoa,
confervoidbodies.vibriones;  non-organized, milk,
fatty matter, stearolith."
   38.  i. Deposits of Uric Acid and of its Com-
binations—Uric acid, uncombined  with a base,
forming  a  deposit, is  invariably in crystalline
forms.   But the crystals  are  seldom so large as
to admit of their figures being recognised without
the aid of the microscope.  Uric acid presents a
yellow  or amber colour, unless when mixed with
urate of ammonia, which is frequently the case,
and then it is of a  much paler hue.  These de-
posits present  every shade of colour, from the
palest fawn to the deepest amber or orange-red.
The deeper the colour of the urine the darker are
the deposits
  39/1 Diagnosis of Uric Acid Deposits —When
heated  in the  urine, the uric  acid deposit is not
dissolved ;  the crystals  merely become  opaque
When mixed with urate  of ammonia, Dr. G  Bird
recommends the urine to be warmed in a watch-
glass ;  the  acid then becomes visible at  the bot-
tom ofthe  glass  as soon as the urate  dissolves.
Heated with liquor potass®, the uric acid deposit
dissolves, forming urate of potash of ready solu-
bility in the alkaline fluid.  » Hydrochloric and
acetic acids are without any  action; but  nitric
acid readily dissolves it, and by careful  evapora-
tion a residue of a beautiful pink colour, becom-
ing ot a rich purple on being held over the vapour
of ammonia, is left.  This coloured residue is the
murexid of Liebio, the purpurate of ammonia of 
URINE AND URINARY DEPOSITS—Pathological Relations of.         1323
Prout.   Fxposed to heat in a platinum spoon,
the uric acid deposits  readily burn, evolving an
odour of bitter almonds, and finally leave a  small
quantity of a white ash, which contains phosphate
of soda, or lime, or both."
  40. When urine contains an excess of uric acid
it generally forms crystals on cooling, uric acid
being seldom deposited before emission.  Some-
times, especially  in. the urine of gouty persons,
many hours elapse before any is deposited, al-
though a large quantity is present. Occasionally
the acid is not deposited, but remains on the sur-
face as a crystalline  pellicle, presenting an iri-
descent play of colours in a bright light.  Urine
of a deeper amber colour  than natural, or of a
reddish-brown colour, usually deposits the largest
amount of this acid ; but very high-coloured urine
seldom deposits uric acid until after the addition
of a stronger acid; and  urine  does  not deposit
all its uric acid until decomposition  has  com-
menced.   Urine depositing this acid always red-
dens litmus paper, and often contains an excess
of urea, so as to crystallize when mixed with nitric
acid.  Its specific gravity is generally above 1 020,
excepting in infants, in whom  deposits of uric
acid are common, although the urine may be pale
and of  a much lower density.   These deposits
" appear as a yellow crystalline sand, while the
supernatant urine is of low specific gravity, often
1006, as pale as water, and  contains  very  little
urea."  This circumstance admits of explanation
from the small proportion of alkaline phosphates,
the presumed solvent  for uric acid in the  urine
of infants.  For the various microscopic*charac-
ters of uric acid deposits, which can only be satis-
factorily shown by engravings, I must refer the
reader to Dr. G. Bird's interesting work.
   [Microscopic Characters.—All the varieties of
uric acid crystals may be traced to some modifi-
cation ofthe rhombic prism,  the  normal crystal-
line form  of this substance.  The rhomboidal
crystals are sometimes so thin as to  be merely
pale, lozenge-shaped  laminae; more  generally,
however, they are thicker.  Many of them appear
nucleated, as if one crystal included another.  It
seldom  happens that the  angles of  these  are
sharply defined, the two obtuse angles being most
generally rounded off, and sometimes  the  acute
angles are blunted, so that the whole crystal ap-
pears elliptical.   Where the deposit has  been of
long  continuance, the rhomboid outline of the
crystal is replaced by a square one.  Several ac-
cidental varieties of these rhomboid and square
crystals exist, the most curious of which presents
a  spindle - like  figure, the obtuse  edges being
rounded, and the margin on either side excavated;
and some appear to be composed of flattened cyl-
inders.   Some  are very thin, longer than broad,
representing square tables, with  smooth or ser-
rated sides  and edges.  Another variety forms
thick, rhomboidal, cohering prisms, and  another
still, aggregated lozenges in  spinous  masses.
When the urine cools very suddenly, or a strong
acid is added to it, uric acid is sometimes precip-
itated in irregular masses resembling irregular
fragments of yellow quartz.  We have observed
this appearance this very day (June 28, 1857) in
the urine of a patient labouring under renal cal-
culus ofthe uric acid kind.]
   41  B. Diagnosis of Deposits of Urate of Ammo-
nia—These vary in colour, from white, through
every tint, to a pale fawn (the oftenest met with),
brick-red, pink,  or  purple    All  these deposits
have certain characters in common.  They never
take place until the urine has cooled, and quickly
disappear on the application of heat.  The dark-
er coloured deposits require a higher temperature
for solution  than the paler ;  and when the urine
is scanty and concentrated, as  in acute rheuma-
tism, the addition of a little water may be required
before they  quite disappear.   The  addition of
liquor ammoniae or  liquor  potassae quickly  dis-
solves deposits of urate of ammonia, rendering
the urine a little turbid from the  precipitate of
earthy phosphates.   Deposits of urate of ammo-
nia always contain small quantities of the urates
of lime and  soda, and often  of magnesia  and
potass.
   42.  Urine depositing  urate  of  ammonia  pre-
sents several modifications:  1st, a pale  urine of
low specific  gravity (1012) with a nearly white
deposit, which, instead of entirely falling, forms
masses in the fluid, and appears as  a mucous  pus.
The application of heat shows at once its real na-
ture by causing its  disappearance.  2d. A  pale
amber-coloured urine, of a specific gravity about
1018, which, on cooling, deposits a copious fawn-
coloured substance  resembling powdered bath-
brick mixed in  the water, but very readily disap-
pearing on applying a gentle heat.   This deposit
occurs often, readily disappears, and frequently
attends a cold,  obstructed perspiration,  or slight
indigestion.  3d.  A  deeper coloured urine,  of a
higher specific  gravity (from  1022 to 1026), and
deposits, on cooling,  a reddish-brown sediment—
the well-known brick-dust or lateritious sediment.
This variety  generally is present  during febrile
excitement, and becomes turbid on the addition
of a drop of nitric acid, " not from the coagula-
tion ofthe albumen, but from the precipitation of
uric acid in very minute  microscopic rhomboidal
crystals."  4th. Urine of a very deep colour, ap-
proaching to a  copper or purplish tint, or to  pur-
plish  hue.   This colour Dr. G.  Bird attributes to
the presence of purpurine.   He adds that,,when-
ever a deposit of urate of ammonia  occurs in such
urine, either spontaneously or by immersing it in
a freezing mixture, it combines with the pink pig-
ment, forming a kind of lake, and which is often
so abundant  as not to entirely disappear by heat,
until the urine  is diluted with water.  This state
ofthe urine is  often observed in acute  rheuma-
tism,  gout, in diseases of the liver,  spleen,  &c,
and has been attributed to the obstructed elimina-
tion of carbon.
   [Microscopic Characters.—Dr Bird states that
when a drop of urine, turbid from the presence
of urate of ammonia, is placed between two pieces
of glass and examined  with  the  microscope, a
mere amorphous precipitate is first seen ; but, on
minute examination, this is seen to be composed
of myriads of excessively minute globules adher-
ing together, forming little linear  masses, often
mixed with  crystals of  uric acid.  Sometimes,
especially if the urine has  been long kept, the
minute particles cohere, and form small opaque
spherical bodies, appearing black by transmitted
light, on account of their opacity.  When exam-
ined by reflected light, on a  black ground,  they
present a buff or fawn colour.  On the applica-
tion of slight heat to the drop of urine, the parti-
cles of urate of ammonia dissappear, again be-
coming visible  on cooling.   A good mode is to
place a drop  of the turbid urine in  a watch-glass
and gently warm it.   As soon  as it  has become
clear, add a drop of  almost any acid (the hydro- 
1324 URINE  AND URINARY DEPOSITS—Pathological & Therapeutical Relations of.
 chloric is perhaps the best) ;  the muddiness pre-
 viously produced by the urate will, on examina-
 tion, be found to be replaced by lozenges of uric
 acid of a rhomboidal form.  Very rarely the urate
 of ammonia occurs in large globules mixed with
 crystals of uric acid.   This  is  occasionally  ob-
 served in albuminous urine, and by its opacity is
 best observed by reflected light.]
   43.  ii.  Pathological  Relations of Uric
 Acid  and Urate  of Ammonia.—Independently
 of changes in the quantities  of these substances
 in the  urine, caused by the quantity and nature
 of the food, very important alterations of the pro-
 portions of these substances accompany and char-
 acterize various pathological  conditions  of  the
 frame.  Uric acid and its combinations have been
 attributed to two sources, viz., the waste or disin-
 tegration  of the tissues, and  nitrogenized food.
 But it appears to me that too large a share of
 these  sources has been  imputed to the  former
 (which is more correctly the  nutritive metamor-
 phosis, and waste of the tissues), while the meta-
 morphosis and waste of the globules, fibrin, and
 albumen ofthe blood, as contributing to the form-
 ation of these substances in the  urine, have been
 overlooked.  In  disease, especially  in acute dis-
 eases, as long as the kidneys are enabled to dis-
 charge  their functions, an  increase of uric acid
 and its compounds appears in the urine ; and this
 increase is to be imputed chiefly to the waste of
 the tissues and of the hsemato-globuline, for little
 or no nitrogenized  food  is generally taken in
 these cases, but emaciation, and with this more
 or less of anaemia supervene.  The anaemia, which
 is  often remarkable, especially in the advanced
 progress of these  diseases, is often overlooked
 In acute rheumatism, gout, fevers, diseases of the
 liver,  spleen, &c, the elements  and sources  of
 uric acid and its  compounds are abundantly sup-
plied  by the states of the blood  to the kidneys,
and uric acid, both pure and combined, is  greatly
in  excess in  the urine.   MM. Becquerel and
L'Heretier found, in eleven  cases of inflamma-
tory fever and twelve of continued fever, the uric
acid more than double that in health.
	Acute In-flammations.	Fever	Health.
Specific gravity of the' Uric acid in the urine.	1-0216 1041	10229 1 312	1017 0 3T1
  44. That uric acid and its combinations may
be formed to some extent in the blood, at least in
some diseases, especially gout, rheumatism, ery-
sipelas, &c, and eliminated by the kidneys, is
rendered probable by the circumstance  of urate
of soda having been detected in the blood by Dr
Garrod.   But the presence of this combination
in the blood does not preclude the elaboration of
a portion of the uric acid and its compounds, or
the  modification and metamorphosis of one or
more of them, or their elements, by the kidneys
  45. In diseases of debility, especially  in those
characterized by depressed  or exhausted organic
nervous power, and by a poor or anaemied state
of the circulation in hysteria, chlorosis, disorders
of irritation, &c, uric acid and its compounds are
greatly reduced in the urine, unless the quantity
of urine passed be remarkably diminished, and no
deposits are formed.
  46. The  state of the perspiratory function is
too  often overlooked by those who attend espe-
cially to the urine.  Whenever the functions of
the  skin are impeded or interrupted, those  of the
 kidneys are augmented; and the results  are re-
 versed when  the  perspiratory  actions  are in-
 creased.   But the increase  or  diminution of ei-
 ther does not consist  merely in the watery ele-
 ment, but also in the nitrogenized and  other ma-
 terials held in solution. This reciprocative or vi-
 carious function, and more especially the frequent
 want or  imperfection  of compensation existing
 between these functions, are most intimately con-
 nected with the origin  of many diseases, and are
 not the less productive of most dangerous results
 in the progress of others.   I have always insist-
 ed, in my lectures  (delivered from 1826 until
 1842), upon the influence of an insufficiently dep-
 urated blood—of effete materials circulating in
 the blood—owing to impaired function of either
 the kidneys, the skin, or  the  intestinal mucous
 surface and follicles, or of two or all of these ; or
 to an imperfect compensation of function  of the
 others, when one is impaired or interrupted, in
 causing diseases not only  of a serious and acute
 character, but also of a chronic and obstinate, al-
 though not dangerous kind.  Most of the dis-
 eases ofthe skin, especially those which are most
 disposed to become chronic, are induced, or  per-
 petuated, or both, not only by impaired depura-
 ting function of the skin  and  its follicles, but
 more especially  and remarkably also by imper-
 fect action of the kidneys, and  of the  intestinal
 mucous  surface and follicles;  the effete and ni-
 trogenized elements and materials, and their com-
 binations, retained and accumulating in the blood,
 irritating the cutaneous capillaries, and  the capil-
 laries oY predisposed and sensitive surfaces  and
 tissues  The crises of fevers and inflammatory
 diseases are merely the returning functions of
 depurating organs,  and the  free discharge by
 these emunctories of effete nitrogenous elements
 and materials and their compounds, chiefly  by the
 kidneys, bowels, and skin.  This  doctrine  has
 been fully elucidated in the articles Blood, Cri-
 ses, and Disease (published in 1832 and  1833),
 and has been applied to the illustration of the
 causes and phenomena of Crises (see $ 15-20).
 Long after the publication of my views, Professor
 Liebig referred the products of elimination from
 the blood by the emunctories, and especially those
 discharged by the kidneys, to chemical changes,
 but his explanations are opposed to clinical ob-
 servation, while the researches of M. Becquerel
 (Semeiotique des Urines, <£c, 8vo, Paris,  1841)
 tend to confirm the opinion contained in the ar-
 ticles now  referred to.
   47. (a) Excess of uric acid, or of its  combina-
 tions with bases in the urine, the quantity of this
 fluid being natural, occurs  in fevers, acute rheu-
 matism, gout, erysipelas, inflammatory  diseases,
 hepatic and cutaneous  complaints, &c, chiefly
 from the waste and absorption ofthe tissues, and
 the metamorphosis ofthe elements and  materials
 derived from these sources, and  from the  blood
 aided by oxygen conveyed into the circulation by
 the red globules,  (b) A similar excess  may also
 arise from an excessive indulgence in animal food,
 especially in highly  nitrogenized flesh-meats, or
from  an indulgence  in  this kind of food beyond
what is required for the nutrition of the several
 structures,  or  from a more moderate use of this
food, due exercise, especially in the open air, be-
ing neglected,   (c) Excess of these  substances
may occur in  the urine, although the supply of
nitrogenized food is very moderate, owing  to" im-
paired digestive, assimilative, and nutritive func- 
URINE AND URINARY DEPOSITS—Pathological & Therapeutical Relations of. 1325
tion.  (d) Excess may also occur in consequence
of impaired or arrested action of the  skin  and
bowels;  the kidneys discharging a more or less
compensating function, and eliminating a portion
or the whole of those elements and their combi-
nations usually discharged by these other emunc-
tories.
  48. Calculous  Deposits of Uric Acid and the
Urates.—An abundance of uric acid and of the
urates in the urine may occur without producing
much disturbance to the  urinary or other func-
tions.  This is especially  the case with urate of
ammonia, which can hardly be ascribed to disor-
der, but rather to the healthy discharge ofthe  dep-
urating function ofthe kidneys.  But,  as Dr. G.
Bird has justly remarked, " Uric acid  or urates
may be deposited in an insoluble form in the kid-
neys or  bladder, and, aggregating, form a mass,
on which, by a kind of imperfect crystallization,
great quantities of the  acid or its salts may be
deposited, giving rise to the formation of a calcu-
lus   Uric  acid is  of more serious importance
than most other elements of calculous formations,
not only from its constituting a large proportion
of all urinary calculi,  but even when  they are
chiefly composed of other ingredients, the nuclei
on which they are deposited are, in the  great ma-
jority of cases, composed of uric acid.  Of 374
calculi contained in the Museum of Guy's Hos-
pital, at the time I examined them, the nuclei arc
in 269 composed of uric acid or urate  of ammo-
nia.   On account of its solubility, urate of am-
monia is not a frequent component of entire cal-
culi, although it often enters with other ingredi-
ents into their composition. Indeed, calculi whol-
ly composed of this compound are almost pecul-
iar to childhood ; in Guy's  Museum  there  are
but  eight concretions entirely consisting of this
substance, although it constitutes the nucleus in
eighteen.  It is hence very probable that if ever
by medical treatment we can  succeed in over-
coming a calculous diathesis, or dissolving a stone
in the act of growth, it will be by means directed
to the solution  of the uric acid or its combina-
tions "   (Op «j , p. 154)
   [The symptoms attending the crystalline Iithic
acid deposit are sometimes  severe, and chiefly
met  with among those who use considerable ani-
mal  food and take but little exercise.   The tend-
ency to such deposits is often  marked by sharp
lancinating pains in the extremities, and by lum-
bar pains, combined with  more or less irritation
during micturition ; and these symptoms are gen-
erally absent if the deposits  are of a lateritious
character, unless they occur in rheumatism, fever,
or gout, when they may be expected to be pres-
ent.   Such crystalline deposits are to be suspect-
ed, when transient but sharp pains are experi-
enced by the patient, and a sensation of scalding
or irritation is felt after or during micturition, and
no other symptom of constitutional disturbance is
observed. The patient may labour under more or
less derangement of the digestive organs, but not
so strongly marked as in the  phosphatic and ox-
alic forms of deposit, which are usually charac-
terized by severe dyspeptic symptoms and consti-
tutional disturbance.]
  49  iii  Treatment of Deposits of Uric Acid
and  Urates.—From the  foregoing, it  is appar-
ent that excess  of these materials in the  urine,
and the deposit of them, either in some part of
the urinary apparatus, or  after the urine is  dis-
charged,  are contingent upon a variety of ante-
cedent disorders or pathological conditions, which,
in individual cases, require due recognition and
appropriate  means;  and not upon those alone,
but also, in different cases, or in different circum-
stances, upon  an excessive or improper diet and
regimen, or  upon insufficient exercise.   One of
the most important and most generally prevalent
of these conditions, more especially when  these
materials are deposited in large or unusual quan-
tities, and still more particularly when they are
deposited  in any of the urinary organs, is de-
pressed or exhausted organic nervous power, oc-
casioning impaired digestion,  assimilation, and
nutrition.   This condition suggests the employ-
ment of such means as  experience has shown to
be most efficacious in restoring the organic nerv-
ous power to  its former energy, throughout the
organs devoted to digestion, assimilation, and nu-
trition.  This  indication of cure should be fulfill-
ed, 1st, by medicinal  treatment; 2d, by  suitable
diet and regimen ; and, 3d,  by exercise in the
open air, and residence  in a healthy locality.
   50. a. Medicinal treatment comprises  the sev-
eral means  of cure already recommended under
the separate heads of Indigestion, Gout, Pyro-
sis, &c.;  but  there are substances to which spe-
cial reference may be made for removing and dis-
solving the deposits above noticed, and for coun-
teracting the disposition to their formation.   The
medicines which may be employed in these cases
are either restoratives and tonics, or are  solvents
of uric acid ; and others may be so combined as
to operate in this double capacity.   The first of
these consist chiefly of the tonic vegetable infu-
sions and decoctions ; the second of alkalies and
alkaline salts; the former being generally  made
the vehicles  for the exhibition ofthe latter—more
especially ofthe following,viz., the liquor potas-
sae, Brandish's  alkaline solution, the carbonates
of potass and soda;  the citrates,  acetates, and
tartrates of potass and  soda ; magnesia, and the
citrate and carbonate of magnesia ;  the biborates
of potash and of soda; the phosphates of soda
and of ammonia, and the benzoic and citric acids.
Certain mineral  substances are  likewise of use,
especially the alkaline  preparations of iron, the
nitrate and  oxide of  silver or  bismuth,  and the
sulphate and oxide of zinc, which  may be given
in various states of combination, and in the form
of pill.   It  may be remarked respecting certain
of the foregoing, that the preparations,  especially
the carbonate  of the fixed alkalies and the liquor
potassaj, are  often most beneficially  conjoined
with the iodide of potassium, and prescribed in a
tonic bitter  mixture ;  that the phosphate of soda
may be taken  freely in gruel, so as to act gently
on the bowels  ; that magnesia will be most bene-
ficial when  given with sulphur, and so as to act
upon the bowels, kidneys, and skin, which it will
generally do when taken at  night; and that the
biborates may be prescribed  in stomachic  infu-
sions with salts  ofthe vegetable acids.   Benzoic
acid was recommended by Mr. A. Ure, to prevent
the formation  of uric  acid.   It  may be given in
doses of five to ten grains, thrice a  day, with car-
bonate or phosphate of soda,  or with the carbon-
ate of ammonia,  dissolved in  boiling water.   Cit-
ric acid was strongly recommended by Dr. Owen
Rees for  diseases, especially gout and rheuma-
tism, in which  uric acid and urates  are abundant-
ly formed;  and  whether it be given as an  addi-
tion to the patient's drink, or in combination with
the alkalies, it is often  of great service.  With 
1326 URINE  AND URINARY DEPOSITS—Pathological & Therapeutical Relatio
 magnesia, either in the form of citrate, or as re-
 cent lemon-juice or lemonade taken immediately
 after the magnesia, it is equally beneficial.
   51.  Most of the diseases, or slight states of
 disorder in which uric acid and the urates are
 deposited, are characterized by deficiency of the
 cutaneous excretion, and insufficient attention is
 directed to this function in many cases.  The res-
 toration of this excretion  by means ofthe warm
 bath, or the vapour bath, followed by frictions of
 the surface, by walking, or other active exercises
 in the open air, is a most important indication of
 cure where these deposits  appear  in the urine,
 both in preventing and in permanently removing
 the complaints in which they are the general con-
 comitants.
   52.  b. The mineral  waters which contain the
 alkalies, or sulphur, as those of Vichy, of Ems, or
 of Harrowgate, will also be resorted to with ben-
 efit.  But whatever be the  treatment, the quan-
 tity  of the  flesh-meats used as food should be
 abridged,  and farinaceous and vegetable substan-
 ces, or the white kinds of fish, boiled, be partly
 substituted, more especially when active exercise
 in the open air is not enjoyed, and when the func-
 tions ofthe skin are imperfectly performed
   [We have generally been in the habit of rec-
 ommending the  free use of the Saratoga (Con-
 gress-water), fresh from the spring, if possible,
 in uric  acid gravel, and have rarely failed to find
 it beneficial.   It should be used as freely as pos-
 sible, short of exciting purgation, and taken at
 different times in the  course of the  day.   The
 Sharon and Avon sulphur waters, as well as those
 of Virginia, have also  considerable  reputation in
 the treatment of these  cases ; and they would be
 far more beneficial were proper attention paid to
 the diet.]
  53. c. Uric Oxide—Xanthic Oxide—Xanthine,
 Pathological Relations of.—This  substance is a
 very rare ingredient of calculous deposits or  con-
 cretions, and it has been observed only in  single
 instances  by  Marcet, Langier,  Langenbeck,
 Dulk,  Berzelius, and Morin.  The chemical
 constitution and the diagnosis of uric oxide are
 given by Dr. G. Bird, to whose work I may refer
 the reader.   The  character  of urine  depositing
 this  substance is not  known.   The microscopic
 examination of a fragment of calculus consisting
 of uric oxide did not furnish any information as
 respects a crystalline arrangement.  The only re-
 corded cases of the formation of this deposit oc-
 curred in  children, and the  calculi  formed by it
 did not exceed a few grains  in weight.
  54. iv.  Purpurine, its  Pathological Rela-
 tions.—Deposits of urate of ammonia coloured
 by this substance (v 39-42) present tints varying
 from pale  flesh-colour to  the deepest carmine
 " The presence of purpurine interferes with the
 ready solubility of the deposit with which  it is
 combined  on the application of heat, and free di-
 lution with water is often required  to aid its so-
 lution."  Dr. G. Bird  states that he  has  never
 seen purpurine colouring any other deposits ex-
 cept those of urate of ammonia, and hippuric  acid
 when precipitated from concentrated urine by hy-
drochloric acid.   Uric  acid  scarcely appears to
have any affinity for it.  It cannot  be mistaken
 for blood, on microscopic examination, owing to
 the absence of blood-disks.  The  chemical com-
position of purpurine occurring in disease is not
exactly known.  Scherer states that that gener-
ated by the action of hydrochloric acid on urine
 consists of 62 51  of carbon, 5 79 of hydrogen,
 and 31 70 of nitrogen and oxygen.  Urinary cal-
 culi sometimes  present layers of urate of ammo-
 nia stained with purpurine.  Dr G. Bird remarks
 that all the deposits with which it is  combined
 were,  as far as he  had observed, amorphous
   55.  A. The Characters of the Urine containing
 Purpurine.—When an excess of urate of ammo-
 nia is present, it falls to the bottom ofthe vessel
 as the urine cools, carrying with it a great part
 of the purpurine.   " If this excess be not pres-
 ent, the urine simply presents  a pink or purple
 colour, and on dissolving white and pure  urate
 of ammonia in it  by heat, it is precipitated  on
 cooling, deeply coloured by the purpurine  The
 presence of the  yellow  extractive which yields
 purpurine can be readily discovered by the action
 of hydrochloric acid.  On evaporating urine con-
 taining  purpurine  to the  consistence of an ex-
 tract,  and  digesting it m alcohol, a fine purple
 tincture is obtained—the  intensity ofthe  tint be-
 ing rather heightened by acids and diminished by
 alkalies."  The specific gravity of this high col-
 oured  urine, when the colour is as deep  as that
 of brandy, varies from 1 022 to 1 030
   56  B The pathological indications of an ex-
 cess of purpurine  are important  Dr G  Bird
 remarks that the existence of purpurine in urine
 appears to be " invariably dependent upon some
 imperfection in the excretion of carbon by these
 organs, whose  special function it is to eliminate
 this element  from  the blood, as the liver and
 lungs, but especially the former   It is hence al-
 most always connected with some functional  or
 structural mischief of the liver or spleen, or some
 other  organ connected with the  portal circula-
 tion "   I have for many years ascribed the pres-
 ence of this colouring substance in the urine  to
 an increased waste ofthe red globules ofthe blood,
 or of  the hasmato-globulin by the kidneys, and
 that the diseases in which  it most remarkably
 occurs, as fevers, gout, acute rheumatisms, phthi-
 sis, &c , are characterized not  only  by a rapid
 waste  ofthe tissues, but also of the globules of
 the blood, giving rise in  most  cases to marked
 anaemia  There  can be no doubt of biliary disor-
 der, torpor, &c .ofthe liver—enlargements ofthe
 spleen, &c , being  often associated  with these
 and other diseases  in which purpurine exists in
 the urine; but m these the  waste of the blood-
 globules is not the less remarkable, this substance
 disappearing from  the urine when the waste  is
 diminished to the natural amount by restoration
 of vital power, by due  oxygenation of the blood,
 and by improved  digestion and assimilation
   57. v  Cystine, its pathological Relations.
 —This substance does not exist in healthy urine,
 and rarely occurs in morbid urine  It is proba-
 bly derived from the sulphur extractive of urine
 (y 30)    In its chemical composition it contains
 no less than 26 per cent  of sulphur   Cystine,
 Dr. G  Bird states, has been found in urinary sed-
 iments by very few observers, and it was not rec-
 ognised in this form until a long period after its
 discovery in calculi by Dr  Wollaston.   In the
 rare cases in which it has been observed, it form-
 ed a nearly white or pale fawn-coloured pulveru-
 lent deposit, resembling pale urate of ammonia.
 The greatest proportion of cystine may be infer-
 red to  be merely  diffused  in  the urine while in
the bladder, as at the moment of discharge the
urine is turbid, and immediately deposits a copi-
ous sediment.  Dr G. Bird states that, on apply- 
URINE AND URINARY DEPOSITS—Pathological & Therapeutical Relations of. 1327
ing heat to the urine, the deposit undergoes no
change, and very slowly dissolves on the subse-
quent  addition  of hydrochloric  or nitric acid.
'• Pure cystine is soluble in the mineral, and in-
soluble in the vegetable acids ; with the former,
it  forms imperfect  saline  combinations, which
leave by evaporation gummy masses or  acicular
crystals.   It is readily soluble in ammonia and
the fixed alkalies and their carbonates, but insol-
uble in carbonate of ammonia.  Heated on plati-
na foil it burns, evolving a peculiar disagreeable
odour "  Cystine  may be distinguished from a
deposit of urate of ammonia by not disappearing
on heating the urine, and from the earthy phos-
phates by being soluble in very dilute hydrochlo-
ric or strong acetic  acid.  " The best character
of cystine is its ready solubility in ammonia, mere
agitation of some of the deposit with liquor am-
monias being sufficient to dissolve it; and a few
drops of the fluid, when  allowed  to  evaporate
spontaneously on a slip of glass, leaves six-sided
tables  of cystine.   The ammoniacal  solution,
when kept for some time in a white glass bottle,
stains it black, from the combination of the sul-
phur ofthe cystine with the lead in the  glass."
   58 a. The character of urine  depositing cys-
tine  is that of a pale yellow, or more of a honey-
yellow than of an amber tint, presenting an ap-
pearance like diabetic  urine.  It is below the av
erage specific gravity,  is passed in larger quanti-
ty than usual, and is  often neutral, seldom acid
to litmus paper, and soon becomes alkaline.  The
odour of this urine is peculiar, and resembles that
of sweet-brier   It is more rarely fetid, and when
it is, the colour is generally greenish or greenish
yellow.  " A certain portion of cystine exists in
solution in  the urine, as the addition of acetic
acid always precipitates a small quantity." Even
when this  deposit has vanished  for  some days
together, crystals of cystine are then precipitated
by acetic  acid.  Urea and  uric acid are present
in very small quantities, and in some instances
the latter is nearly absent.
   59 b  Calculi  composed of cystine  are  gen-
erally pale yellow or fawn-coloured, but by  long
keeping they become greenish-gray, or a fine
greenish-blue, probably owing to the action of
light  The microscopic characters of cystine are
very obvious.  When it occurs  as a deposit, it
is always crystallized, never being amorphous
Among the crystals a few regular six  sided lami-
na; arc often seen, but the great mass is composed
of a large  number of  superposed plates, so that
the compound  crystals thus produced appeared
multiangular; but I must refer the reader to Dr.
G. Bird's  work, where  this topic  is well illus-
trated by wood-cuts.
  60. c The pathological origin  of cystine is no
farther known than that it is inferred to proceed
from the waste of tissues, [especially the albu-
minous,] and probably also ofthe haemato-globu-
lin, or rather of some derangement ofthe normal
course of this waste connected more especially
with an excessive elimination of sulphur; every
ounce  of cystine containing  more  than  two
drachms of this element.   Cystine  may thus be
formed from those elements of the tissues nor-
mally producing urea and uric acid with an ex-
cess  of sulphur, owing probably to a deficiency
of the  process  of oxidation in connexion with
impaired vital energy.   That these latter states
obtain is evinced by the occurrence of cystine, or
or cystin-uria, in scrofulous, chlorotic, and anae-
mied  subjects.  The hereditary  nature of this
condition of the urine has been  noticed by Dr.
G. Bird, who states that in one family alone sev-
eral members were affected with cystin-uria ; and
that one instance exists in which it can be traced
with  tolerable  certainty through  three genera-
tions.   In one  case under the care of Mr. Luke,
extensive disorganization of the  kidneys  co-ex-
isted  with a cystine calculus.   Dr. Prout has
seen fatty matter mixed with the urine in cystin-
uria, and suggests the probability of its connex-
ion with fatty  liver.   Dr. G. Bird thinks it not
unlikely that the excretion of cystine may be a
means,  under certain circumstances, of compen-
sating for deficient action of the liver quoad the
excretion of sulphur.  The  existence of cystine
in the urine of chlorotic and debilitated females
has been met with in several cases by Dr. Shear-
man, of Rotheram.
   [According to our observations, cystine is not
often met with in the urine ofthe human species,
though  very common in the dog.   Dr. Wollas-
ton called it cystic oxide, because peculiar to the
bladder, and resembling some few of that class of
substances in being  soluble in both acids and al-
kalies   In  calculi it exists in a  perfectly pure
form    It dissolves in dilute nitric, hydrochloric,
sulphuric, oxalic, and phosphoric acids, but will not
combine with the tartaric, acetic,  or citric acids.
It is dissolved by caustic ammonia, but not by the
carbonate of that alkali; also by  the fixed caus-
tic alkalies and their carbonates.   A dark brown
colour is produced by evaporating nitric acid on
cystine.   It is insoluble in alcohol, and nearly so
in water.   The carb. of ammonia is the best pre-
cipitate  for it, when in solution in  acids, and the
acetic acid from alkalies.  The best mode of de-
tecting  cystine is to dissolve the  calculous mat-
ter in caustic potash, then add a solution of ace-
tate of lead in such proportions that the oxide of
lead  shall not precipitate, but be  retained in so-
lution by the excess of potash.  This liquor be-
comes black when boiled, if cystine is present, a
reaction dependent on the presence of sulphur in
the cystine.  Before the blowpipe it is consumed,
yielding a very peculiar fetid smell.  It may be
easily distinguished  from the  other components
of calculi by its being soluble in dilute hydro-
chloric acid, and a solution ot carb. of potash.]
   61. d. Indications  of Cure.—Dr. Prout ad-
vises the prolonged use of nitro-hydrochloric acid,
and found it of benefit in some cases.  Having
viewed the existence of cystine in the urine as a
result of debility in connexion with imperfect ox-
idation  of the blood-globules, I have in one case
prescribed the chlorate of potash with tonic infu-
sions   This view of the pathology of cystine  is
suggestive  also of the employment of the tinc-
ture ofthe chloride of iron, ofthe iodide of iron,
of chalybeate mineral waters, and of other tonics,
for its removal, aided by a generous diet, by act-
ive exercise in  the open air, and by due attention
to the functions of  the skin and  bowels.  (See
also  the Treatment of Debility, of Chlorosis,
and of Scrofula.)
  62. vi.  Hippuric Acid—Hippuria.—This acid
is  constantly present in the urine of the  horse,
and generally  also  in that  of herbivorous ani-
mals.—a. Lehmann  found it in  diabetic  urine,
and Liebig detected it in healthy urine, although
in minute quantity.  As this substance never ap-
pears as a sediment until after the addition of a
stronger acid, the diagnosis of it entirely depends 
1328  URINE AND URINARY DEPOSITS—Pathological & Therapeutical Relation:
upon the characters of the urine containing it.
The urine containing an excess of hippuric acid
is either very slightly  acid, or neutral.   It may
be even  alkaline.   When this state of urine  is
caused by the ingestion of benzoic acid, it is then
very acid.  Its odour is commonly that of whey,
and its specific gravity  is below the healthy state,
varying from 1006  to 1008.  Deposits  ofthe
triple phosphate of magnesia are not infrequent
in it.  For the modes of detecting this acid, and
for its microscopic characters, I  must refer the
reader to Dr. G. Bird's work.
   [To detect hippuric acid, evaporate a few ounces
of urine to a sirupy consistence, then add  an ex-
cess of hydrochloric acid, when a mixture of hip-
puric and uric acids will be  separated and fall  to
the bottom ofthe vessel. After a few hours' repose,
decant the supernatant  fluid, and wash the depos-
it in a little very cold water; boil the residue with
alcohol (in which uric acid is insoluble), when the
hippuric  acid will be dissolved, and,  on evapora-
tion, will be found in thin, delicate, strongly-col-
oured needles.  Hippuric acid requires nearly 400
times its  weight of cold water for solution]
   63. b. The pathological stales causing this state
of urine  are not always obvious.  In the  lower
animals it proceeds from vegetable food, it being
constant  in such as are  not exercised, and re-
placed by benzoic acid  in those that  are worked.
When in excess in human  urine, it is ascribable
to diet; thus it has been found after a prolonged
milk diet, after an excessive use of apples, and
in the urine of infants.   This acid does not nec-
essarily interfere  with the  production  of uric
acid, but generally it is attended  by  a deficiency
of urea.   It has been found in urine containing
albumen.   Dr. G. Bird ascribes it to a diet defi-
cient in nitrogen, or to the mal-assimilation ofthe
carbon in the food, and infers "that hippuric acid
may be one of the agents by which  the kidneys
perform a vicarious function for the liver,  in re-
moving an excess of carbon from the system."
In this respect it may be viewed as an analogous
result  to the production of purpurine and bile-
pigment, each removing 63 93, 62 0, and  6818
per cent,  of carbon, respectively, from  the sys-
tem.   It  should be looked for in  the  urine when
the functions of the liver,  lungs, and skin are
defective, when the food is deficient  in nitrogen,
and  when the urine is copious, is slightly acid
or neutral, and of low specific gravity.
   64. vii. Oxalate  of Lime—Oxaluria.—Ox-
alate of lime often exists in  the urine, and is fre-
quently a constituent  of calculous  concretions.
Its chemical and pathological relations have been
ably investigated by Dr. G.  Bird, who contends
for its frequent appearance as a crystalline de-
posit in the urine, in fine and well-defined octa-
hedral crystals, and for " the connexion between
the occurrence of this  substance and the  exist-
ence  of  a certain series of ailments  generally
characterized by nervous irritability."  He con-
siders that the depressing influences, always pres-
ent in densely populated cities, are more product-
ive of this than of earthy  phosphatic deposits ;
and that traces of oxalate of lime, in the minutest
microscopic crystals, may be detected in the urine
of persons free from any apparent disease.  Hence
he regards it as  one of the common results of
metamorphosis of tissue.  But this is very differ-
ent from  its  presence  in large  crystals and  in
considerable quantities, these constituting a truly
pathological condition.
  65. a.  For the detection of oxalate of lime in
the urine, I must refer to the work already quoted
for the full  details; generally, however, the ex-
istence of this substance may be ascertained by
pouring off the upper six sevenths ofthe water
passed a  few hours after a meal, having given it
time to repose in a glass vessel.  A portion of
the remaining seventh may be warmed in a watch-
glass to dissolve the urate of ammonia.   Having
removed  the greater part of  the  fluid, and re-
placed it by  distilled water, a white glistening
powder like  diamond dust now becomes visible;
and this  under the microscope will  be found to
consist of crystals of oxalate of lime  in  trans-
parent octahedra, with sharply-defined edges and
ano-les.   Dr. G.  Bird states that, out of a great
number of specimens of urine containing  the
oxalate, it has scarcely ever appeared in the form
of a distinct  deposit, but  has  remained diffused
in the urine, even when present in so large a
quantity  that each drop, when placed under the
microscope,  was loaded  with  its crystals.  But
if any substance capable of being a nucleus were
present, the oxalate would be  deposited around
it, although  scarcely in cohering masses, and in-
variably  colourless and beautifully transparent.
The oxalate of lime, although absolutely insolu-
ble in water, must be soluble in urine, for its lus-
trous crystalline form  sufficiently indicates its
previous  solution, and  it is  not until  after the
urine has been  voided  several hours  that  the
crystals of oxalate can be  detected.
  66. Occasionally some  remarkable  crystals of
the oxalate  resembling dumb-bells, or  two kid-
neys  with their concavities  opposed,  are met
with, their surfaces being finely striated.  But
it is doubtful whether or no these are an oxalate
of lime.  Dr. G. Bird considers them an oxalu-
rate of lime, a salt which differs from the oxalate
in ultimate composition only in the  presence of
the elements of  urea and absence of the constit-
uents  of water.   Dr. Bacon  has investigated
these crystals minutely, and has concluded that
the dumb-bell crystals consist of a " salt of lime
containing either oxalic,  oxaluric,  or perhaps
some other  organic acid easily  converted into
oxalic acid;  but the exact nature ofthe acid re-
mains to be  determined  by future examination."
   67. b.  The characters  of urine containing the
oxalate of lime  are  those of a fine  amber hue,
sometimes darker than in health, in  a few cases
paler than natural, and  of a lower specific grav-
ity, the odour being generally natural,  or  rarely
aromatic like mignonette.  Frequently  a deposit
of urate  of  ammonia, sometimes tinted pink by
purpurine, falls during  cooling.   The specific
gravity of oxalic urine varies extremely.   Of 85
different  specimens, Dr.  G. Bird found 9 in which
it ranged from 1009 to  1015; in 27 from 1016
to 1020; in 23 from 1021 to 1025; and in 26
from  1 025  to 1030.   Generally  the  heaviest
specimens contained most of the  oxalate.  The
quantity  passed  seldom exceeded the  average,
instances of positive diuresis being  rare.   Irri-
tability of bladder was sometimes complained of.
Acidity ofthe urine was well marked, even more
so than in health, and always present.   An in-
crease in the quantity  of urea was frequently
found.  Mr. Stallard discovered in  oxalic urine
a  great  increase  of the  indeterminate organic
matters (v 21), often as much as double the av-
erage proportion in twenty-four hours.
  68. c.  The complications of oxalate of lime with 
URINE AND URINARY DEPOSITS—Pathological & Therapeutical Relations of.  1329
 other deposits are of some  importance.   Dr. G.
 Bird found the oxalate of lime unmixed with any
 other saline deposits in more than one half of the
 specimens  of oxalic  urine.   " In a  very  few,
 crystals of uric acid were found from the  first,
 mixed  with the  octahedra  of  oxalate  of lime ;
 and in nearly all the successful cases this acid
 appeared in  the course of treatment, and  ulti-
 mately replaced the oxalate altogether," at a pe-
 riod generally contemporary with convalescence.
 " Much more rarely* prisms and  stellae of the
 ammoniaco-magnesian  phosphate were found
 mixed  with  the oxalate, and occasionally re-
 placing it in the course of treatment; and  still
 less frequently, the phosphate was observed in
 the urine some time before the appearance ofthe
 oxalate."   Very few well-marked  instances of a
 complication ofthe oxalic-acid urine with gran-
 ular degeneration of the kidneys were observed
 Of the 85 cases referred to above (y 67), 43  were
 unmixed cases of oxalate ;  15 were cases of ox-
 alate mixed  with urate of ammonia;  15  were
 mixed  with uric  acid ; 4 were mixed with triple
 phosphate;  and  8 with  phosphate deposited by
 heat.   Dr. G. Bird constantly found a very  large
 quantity of epithelial cells  and scales in oxalic
 urine, indeed so  constantly, that a white deposit
 of epithelium led to the suspicion of the presence
 of oxalate of lime.
   69.  d. The pathological  source  of oxalate of
 lime in the urine is of great interest.   It is well
 known that a physiological  connexion exists be-
 tween  sugar and oxalic acid;  that the former
 substance is a common constituent  of our ali-
 ments ; and that most of the  farinacea  are par-
 tially converted into this  substance during diges-
 tion.    Under certain circumstances the sugar
 thus formed is carried into the blood, and is elim-
 inated by the kidneys.   In certain  morbid states,
 a large proportion of the food may be converted
 into sugar in the stomach, which  passes rapidly
 into the circulation, and is  excreted by  the kid-
 neys as diabetic urine.*   Recollecting the facility
 with which sugar and its chemical allies are, un-
 der the influence of oxidizing agents, converted
 into oxalic acid, it might be inferred that the ex-
 istence of oxaluria is due to the presence of sug-
 ar  in the blood.  Dr. G. Bird, however, argues
 against any connexion or relation  subsisting be-
 tween  oxaluria and diabetic urine, inasmuch as
 sugar  very rarely exists in  the  former; and as
 the latter rarely contains, in  a given quantity, an

  [* The best tests for sugar in the urine are Frommer's,
 Capezzuoli's, and Moore's.  Frommer's Test—Add to the
 suspected urine, in a large test-tube, just enough of a so-
 lution of sulphate of copper to communicate a faint blue
 tint; a slight deposit of phosphate of copper generally
 falls.  Then add liquor potass<v. in great excess; a pre-
 cipitate of hydrated oxide of copper first falls, which re-
 dissolves in the excess of alkali, if sugar be present, form-
 ing a blue solution like ammoniuret of copper.  On gen-
 tly heating the mixture to  ebullition, a deposit of red
 sub-oxide of copper falls, if sugar be present.
  Moore's Test.—Place in a test-tube about two drachms
 of the suspected urine, and add nearly  half its bulk of
 liquor }x>tassa>.  Heat the whole over a spirit-lamp, and
 allow actual ebullition to continue for a minute or  two;
 the previously pale urine will become of an orange-brown,
 or even bistre tint, according to the proportion of sugar
 present.
  Capezzuoli's Test consists in adding a few grains of
 hydrated oxide of copper to urine contained in  a conical
 glass vessel, and render  the whole alkaline by adding
 liquorpotassm.  If sugar be present, the fluid assumes a
reddish colour, and in  a few hours the  edge of the de-
posit of oxide assumes a yellow colour, which gradually
extends through the mass, from a reduction ofthe oxide
to a metallic state (sub-oxide?)]
    III.             84
 excess of urea, uric acid, or urates, and  is re-
 markably free from saline deposits, the high spe-
 cific gravity depending upon the large proportion
 of sugar.  In oxaluria, on the other hand, a large
 excess of urea, of uric acid, and urates is present,
 and is as characteristic of this state of urine  as the
 oxalate of lime itself.  Hence he infers that there
 is no relation between oxalic acid and saccharine
 urine.   From  the symptoms  present  in  cases
 where oxaluria is observed, there can be no doubt
 that the primary cause of this state of urine must,
 as Dr  Prout has shown, be imputed to an  un-
 healthy condition of the digestive and  assimila-
 ting functions.  That the oxalic acid is formed
 from its elements, either  in  the digestive  canal
 or in its course to and in the blood, must  be in-
 ferred, since Dr. Garrod detected,  beyond any
 doubt, octahedral crystals of oxalate of lime in
 the serum of blood from a patient affected with
 albuminuria.  " It is difficult to explain the pres-
 ence of so  insoluble a  salt in solution in  the
 blood ; but it is probable that the opinion of  Dr
 Schmidt, of Dorpat, may be correct.   He  has
 assumed that there exists in the animal economy
 a tendency  to  the formation of a soluble  triple
 compound  of oxalic  acid,  lime,  and  albumen,
 which, by its decomposition, allows oxalate of
 lime to crystallize."  Probably such  a compound
 exists  in the blood in  disease ; and when  the
 acetic acid is added, as in Dr. Garrod's process,
 the albumen is separated and the oxalate set free.
   70.   The  chemical relation existing between
 uric acid, urea, and oxalic acid, and the readiness
 with which the former of these substances is con-
 vertible into the latter, suggest the idea that  ox-
 aluria may be regarded as a  form of what  has
 been termed by Dr. Willis azoturia, of which
 an excess of urea is the  prevalent indication, part
 ofthe urea,  or of its elements, having been con-
 verted  into  oxalic  acid.   It  may be  inquired,
 Whence are the  elements which  form oxalic
 acid ]   Are  they derived from  the metamorphic
 changes of the structures, like  healthy  urea and
 uric acid 1    Dr. G Bird infers that  they are
 " Hence oxalate of lime  must be regarded as one
 of the common results of metamorphosis of  tis-
 sue."   (Op. at., p. 210.)   I am more disposed to
 agree with the opinion he has subsequently stated,
 viz., that although it is  probable that such may
 be the origin of oxaluria (in the waste of  the
 tissues), yet, the quantity of oxalate of lime  being
 greatest after a full meal, and often absent in  the
 urine passed in the morning, frequently disap-
 pearing when the diet is  regulated, and reappear-
 ing on the use of unwholesome food, it is equally
 probable that this salt is derived from  the mal-
 assimilated elements of food.   It  is sufficiently
 obvious, from the nature of the complaints in
 which oxaluria occurs, that it is always the result
 of imperfect assimilation of the  aliments, owing
 to impaired  organic nervous power,  the mal-as-
 similated, or rather the non-assimilated, elements
 forming the  product in question, aided by oxida-
 tion, which  product is  rather eliminated  than
 formed by the kidneys.    However minute and
 laborious may be the researches of organic chem-
 ists in  endeavouring  to show  the  elementary
 combinations and the atomic affinities  of these
 elements, in  the  production  of urinary deposits,
 the vital endowment, and the  states of function
depending upon this endowment, more especially
demand attention;  the chemical constitution  of
the urine being generally only a sign, but  an 
1330 URINE AND URINARY DEPOSITS—Pathological & Therapeutical Relations of.
important one, of the  state of this endowment,
particularly as manifested by the organic nervous
system.
  71. e.  The symptoms accompanying the excre-
tion of oxalate  of lime have been minutely de-
scribed by professors  of the  urinary  specialty;
and conformably with the importance they attach
to an urinary deposit,  they view it as  the actual
disease, or at least as a diathesis, instead of being
merely a sign, or at most a result, of pre-existing
disorder  or disease, to  which more especially ra-
tional  medication  should be directed.   Oxaluria
is not a sign of one, or even of two disorders
merely, but of several, the chief morbid mani-
festations being depressed vital endowment ofthe
digestive and assimilating organs, with lowness
of spirits, irritability or nervousness,  hypochon-
driacal feelings, impaired nutrition, anaemia, and
often loss of sexual power.   Pains in the loins,
irritability of bladder,  and high specific  gravity
of the urine—generally from 1 025 to 1030—
with various symptoms of impaired health, are
also commonly experienced.  The  urine is in-
variably  acid, often excessively so;  and there is
a marked tendency to eruptions of boils.   Dr
G. Bird  remarks that  he has seldom  met with
phthisis  in cases with oxalate of lime deposit,
and that  in very few instances has he  seen  oxa-
luria terminate in the  formation of a calculus.
He again states that the source of this deposit is
to be imputed to metamorphosis of the  tissues,
and that  this is the only way  that the  attending
emaciation can be satisfactorily  accounted  for.
I  have already stated my belief that this deposit
as well as the emaciation are the results of im-
paired or morbid  assimilation of the  food, and
the consequent  imperfect  nutrition  of the  tis-
sues (y 70).
  72. f.  Causes.—This state  of the urine is fre-
quent in  those who are subject to mental anxiety
and to laborious mental occupations, more espe-
cially in  men on  the stock-exchange, in  medical
men,  in  barristers  and solicitors, and in  those
who are engaged in occupations attended by
much mental anxiety, and are excessively devoted
to business or study.   The exciting  causes are
chiefly neglect of health, chronic dyspepsia,  hyp-
ochondriasis, exhaustion from disease, from syph-
ilis or  mercurial courses; venereal excesses,  mas-
turbation, involuntary  seminal emissions, excess-
ive discharges, and prolonged lactation, previous
acute diseases, injuries affecting the spine, &c,
&c.
   73.  g. The treatment of oxalate of lime deposits
is generally successful, if the diet and the  regi-
men of both mind and body  be duly  regulated.
The food should be digestible, properly cooked,
and the  animal and vegetable  in due proportion.
Malt  liquor ought to  be  avoided; and  either a
small  quantity of brandy  in  much  water,  or a
glass of  dry sherry in two of water, may be taken
with  dinner.   The medicines most appropriate
are the nitric or nitro-hydrochloric acid (one part
of the nitric to two  of the hydrochloric) given
in  tonic  infusions or decoctions.  If anaemia or
chlorosis exist,  the tincture  of the muriate of
iron, with preparations of calumba  or quassia;
or the mistura ferri composita, or the ammonio-
citrate or ammonio-tartrate of iron,  should be
prescribed.   If the bowels be  costive, the extract
of taraxacum  may be  given with  the former
medicines ; or the decoction of aloes be conjoined
with the mistura ferri composita; or the mistura
gentiana composita may be given alone, or with
tincture  of serpentaria,  &c.   The  sulphate  of
iron, or of quinine, or of zinc may be prescribed,
where  the foregoing fail,  combined with small
doses of camphor and henbane,  or of conium.
Dr. G. Bird recommends recourse to colchicum
for oxaluria, and states that, under the influence
of this drug, copious deposits of oxalate  of lime
have become replaced by uric acid and the urate
of ammonia, thus  inducing a condition of urine
much more amenable to treatment.
   74. viii. Chemical  Pathology  of  Earthy
Salts  in the  Urine.—Phosphuria—Phosphate
of Lime,  Ammonio-phosphate of Magnesia, and
Carbonate of Lime.—Phosphoric acid is excreted
in considerable quantity from  the blood by the
kidneys, combined with soda, ammonia, lime, and
magnesia; forming, most  probably,  ammonio-
phosphate of soda, phosphate of magnesia, phos-
phate of lime.   The first of these is soluble in
water,  and Dr.  G. Bird considers  it to be the
solvent of uric acid,  and indirectly the source  of
the acidity of urine.  The other two salts  are
insoluble, but the  presence of  a minute  portion
of an acid,  even the carbonic, enables water to
dissolve a considerable quantity.  They are also
soluble to some extent  in hydrochlorate of ammo-
nia.   " In  healthy urine, the earthy phosphates
are held  in  solution by the acid of  the super-
phosphates, produced  by the  action of uric (or
hippuric) acid on the tri-basic alkaline salts ; and
these salts are also, according to Enderlin, capa-
ble of dissolving a certain quantity of phosphate
of lime."   The earthy  phosphates  are  always
abundant after  a meal, the reverse applying to
the alkaline salts.    Phosphoric acid may be ex-
creted in large excess without forming a deposit,
owing  to its  combination with  an alkaline base;
and hence, when the excretion of an excess  of
this acid is looked for, it is not indicated by the
amount of earthy  salts deposited, for there "is
always three or four times more phosphoric acid
in a given specimen of urine,  in the form of a
soluble alkaline salt, than is precipitated as  an
insoluble earthy compound.  The presence of an
excess of lime and magnesia has more to do with
determining  a deposition of insoluble phosphate
than an excess of  phosphoric  acid."  The cir-
cumstances under which the earthy phosphates
are deposited often are of so great importance as
to require a recognition of their existence,  as
well as of the quantities of these phosphatic de-
posits.
   75. A.  The Diagnosis of earthy Phosphates.—
a. Deposits of these phosphates are white, unless
coloured with blood, are soluble in dilute hydro-
chloric acid,  and insoluble in liquor potassae and
in ammonia.  On heating the  urine, the deposit
merely agglomerates into little  masses.  A small
quantity of a solution of sesqui-carbonate of am-
monia added to a large quantity of healthy urine
causes  turbidity,  from  a  deposit of the triple
phosphate mixed with  some phosphate of lime.
" On placing a drop  of this turbid urine under
the microscope,  myriads of minute prisms of  the
triple salt, mixed with  amorphous granules of
the phosphate of lime, will be seen floating in  the
fluid ;  these disappear on adding a drop of any
acid.   As  these earthy  salts   are  insoluble in
water, they must be held in solution in the urine
by the free acid which generally exists.  If from
any cause the quantity of solvent acid falls below
the necessary proportion, the earthy phosphates 
 URINE AND URINARY DEPOSITS—Path

appear diffused through the urine, disturbing its
transparency,  and subside,  forming  a  deposit.
Hence, whenever the urine is alkaline, phosphat-
ic deposits are necessary consequences.  If urine
be secreted with so small a proportion of acid as
barely to redden litmus paper, a deposit  of triple
phosphate often occurs within a few hours after
emission ;  probably owing to the  presence of
mucous matter, which induces the decomposition
of urea and the formation of carbonate of ammo-
nia, which, by  neutralizing the solvent acid,  pre-
cipitates the phosphates.   The triple phosphate,
which occurs spontaneously in prismatic crystals,
is  a neutral  salt,  "and may coexist as a deposit
with  very sensible acidity of the  supernatant
urine   It by no means follows that the existence
of a deposit  of this salt involves the necessarily
alkaline  state  of the urine."   Another triple
phosphate, differing from the former in  contain-
ing an excess of base, is of frequent occurrence
in the urine when in an  alkaline or putrescent
state.  It cannot be present in urine having the
slightest  acid  reaction  on  litmus  paper.   Its
crystals are invariably stellar or foliaceous.  This
salt is termed the basic phosphate.  " When the
triple or calcareous phosphates are separately ex-
posed to the  heat of a blow-pipe  flame, they fuse
with  great difficulty, and not until  the  heat has
been  urged  to the  utmost.   If, however, the
phosphate of lime is  mixed with a triple phos-
phate in  about equal proportions,  they readily
melt  into a  white enamel.   These mixed salts
constitute  what is hence termed the fusible cal-
culus, and they can readily be detected by this
property in concretions;  a character  very avail-
able in the examination of gravel and calculi, as
the two phosphates generally  occur together."*
  76. b. The physical appearance of deposits of
the earthy phosphate varies remarkably.   Some-
times they appear as a white  crystalline gravel,
especially when the triple salt  is the chief part of
the deposit.  But if a small quantity be present,
it  may  readily escape detection by remaining a
long time diffused in the urine.   After  a repose
of a few hours, some of the crystals collect on the
surface, forming an iridescent pellicle, " reflecting
coloured bands like a soap-bubble or a thin layer
of oil.  If then the lower layers of the  urine be
placed on a watch-glass, and held obliquely over
the flame of a candle or any strong light, a series
of glittering  points will  become visible from the
reflection of light from the facets of the minute
prisms ofthe salt."  (Op.  cit., p. 269.)
  77. The phosphates often subside to the bot-
tom ofthe vessel like a dense cloud of mucus, for
which they may  be mistaken.   Sometimes they
form,  in very alkaline urine, dense masses, hang-
ing in ropes, like the thickest puriform mucus,
from  which it is  impossible to distinguish them
by the unaided  eye.  Their disappearance on the
addition of hydrochloric acid shows at once their
nature.   The examination of a few  drops  of the
urine between two plates of glass, by the micro-
scope, will detect the characteristic crystals of
  [* Some writers speak of calculi composed of the "acid
phosphate of lime."  By this is meant, not the super-
phosphate, but the neutral or di-phoxphate of lime. When
the di-phosphate  of lime calculus is digested with water,
it is decomposed  into an insoluble sub-phosphate and n
soluble super-phosphate, which possesses an acid reac-
tion; and this fact led Fouroroy into the mistake of de-
scribing these  concretions as composed of a super-phos-
phate of lime.  Di-phosphate of lime constitutes the ac-
cidental bezoar, an intestinal  concretion found in the
stomach of the ox, deer, &c.].
)logical & Therapeutical Relations of. 1331

 the phosphates.  Occasionally they are mixed in
 a deposit with the urate of ammonia, this latter
 being pale or nearly white.   As phosphatic urine
 is usually very pale, it follows that any  urate  of
 ammonia deposited from it will be nearly  white
 from the absence of colouring matter.
   [Microscopic  Characters.—According to Bird,
 the neutral triple phosphate occurs : 1st, in well-
 defined colourless prisms, the angles and edges of
 the crystals being remarkably sharp and perfect.
 The triangular prism is most frequently met with,
 but it presents every variety of termination, some-
 times  merely truncated, often bevelled  off, and
 not unfrequently the terminal edges are replaced
 by facets, presenting a very beautiful microscopic
 object of great transparency, or of an  enamel-
 like opacity, so that they can only be viewed  as
 opaque objects  ; 2d,  the triple phosphate forms
 minute calculous concretions, composed of colour-
 less acicular prisms, cohering at one end, so as to
 represent  simple Stella, or rosettes; 3d,  Penni-
 form crystals, resembling striated feather-like crys-
 tals, two being often  connected,  so as  to cause
 them to resemble  wings; 4th,  Stellar and foli-
 aceous crystals.  Dr. Bird regards  this as usually
 a secondary product taking place out of the body,
 generally occurring in the form of six-rayed stars,
 each ray being serrated, or irregularly crenate, re-
 sembling a taraxacum leaf.]
   78. c.  States of Phosphatic  Urine.—Although
 it may  appear necessary for the urine to be alka-
 line  for a deposit of phosphates  to exist, yet
 generally urine which deposits the triple phos-
 phate is acid at the time of its excretion.   Some
 neutral salts  redden  litmus paper, and  yet con-
 tain no free  acid; and  this fact may  in some
 cases explain the occasional acid reaction where
 deposits of phosphates exist.  Dr. O. Rees has
 shown  that  hydrochlorate  of ammonia may  in
 some cases  be  the solvent of the earthy phos-
 phates  when in excess.   Occasionally urine does
 not  contain  any visible deposit, and  yet  on the
 application of heat appears  to coagulate  from the
 deposition of earthy phosphates.   The  addition
 of a drop of nitric acid immediately dissolves this
 deposit, and distinguishes it from albumen.  The
 precipitation  of the earthy phosphates by heat
 has  been ascribed by Dr. II. Brett to the exist-
 ence of carbonic acid in the urine in a free state.
 Dr.  B. Jones has, however, shown  that, if  to
 any  urine  rich in phosphates, as  that  passed
 shortly after a meal, a minute portion of an  al-
 kali be added to neutralize any great excess  of
 acid, the  subsequent application of heat precipi-
 tates the earthy phosphates.
   79. Generally, where phosphatic deposits, mag-
 nesian, calcareous, or both, exist for a consider-
 able  time, the  urine  is pale,  often  whey-like,
 passed  in  large quantities,  and of low specific
 gravity—from 1005  to 1014.   "This  is espe-
 cially the case where  organic  lesion of the kid-
 neys exists."   On  the other hand, when the de-
 posits recur and disappear in the course  of a few
 days, the urine  is generally of a deep amber col-
 our, is of high specific  gravity (from  1020  to
 1 030),  often contains an excess of urea,  and pre-
 sents an iridescent pellicle on its  surface  by  re-
 pose.   This  form  of  phosphatic  urine  is often
 met with in  connexion with irritative or inflam-
 matory dyspepsia  and  with  mal-assimilation.
 Sometimes prisms  of  triple  phosphate are seen
 entangled  in the meshes of a mucous cloud  for
 a day or  two, and then disappear.  Phosphatic 
1332 URINE AND URINARY DEPOSITS—Pathological & Therapeutical Relations of

                                               served by this emanation of vital influence from
                                               those changes to  which their constituents are
                                               chemically disposed.  But  if these fluids are re-
                                               tained for an unusually lengthened period, or if
                                               vital energy, to which they owe their original nat-
                                               ural character, be much impaired, those changes
                                               which their constituents are chemically disposed
                                               to undergo take place more rapidly after their dis-
                                               charge  from the body, and  in  many instances
                                               even while they still remain in those  receptacles
                                               or cavities which are provided for their reception
                                               and temporary retention.   But with  the various
                                               manifestations of depressed vital power, changes
                                               in the secretions are not only such as take place
                                               after these secretions are produced, but also those
                                               which occur during their production, and which
                                               depend  upon the existing state of vitality through-
                                               out the body, and upon the manifestations and
                                               modifications of vitality in the organs especially
                                               destined to the formation  of these  secretions.
                                               When vital energy is impaired, or. in other words,
                                               when debility is manifest, whether  constituting
                                               the only or chief pathological condition or asso-
                                               ciated with others, as with nervous susceptibility
                                               or  irritability, or with febrile action,  or with or-
                                               ganic change, or  with other alterations  farther
                                               impeding or disturbing the functions  of a secret-
                                               ing organ or organs, results will be furnished by
                                               the secretions varying with the manner in which
                                               the general impairment of vital power affects the
                                               functions of dio-estion, assimilation, nutrition, and
                                               waste—the successive conditions of nutritive sup-
                                               ply, of vital cohesion and resistance, of molecular
                                               dissolution, of vascular depuration,  and of ulti-,
                                               mate discharge.
                                                 83. This doctrine, which, as I have shown, has
                                               been published  and taught by me with reference
                                               especially to the several secretions and excretions
                                               —recrcmentitious,excrementitious, or depurating
                                               —is  altogether applicable to the urinary excre-
                                               tion, and to  the deposits which  form in it, both
                                               after and previous to its discharge from the body,
                                               and in  a more particular manner to the urine
                                               which  furnishes the phosphates in great or un-
                                               usual excess.  The deposit of earthy phosphates
                                               may be viewed  as resulting more especially from
                                               depression or exhaustion of vital power, as mani-
                                               fested chiefly by the nervous system, and is hence
                                               most frequently met with in the aged,  and in those
                                               who labour  under disease  of the cerebro-spinal
                                               nervous system, or have experienced injury ofthe
                                               spine, or have suffered  much from tear and wear
                                               of  mind and body.  The pathological conditions
                                               giving  rise to the deposits of phosphate  of lime
                                               are similar  to  those producing the triple salt.
                                                Indeed, they often occur simultaneously, espe-
                                               cially when  the urine is alkaline.   Dr. G  Bird
                                               considers that, when  the  deposit has consisted
                                               chiefly  of the calcareous salt, the patients have
                                               presented more marked evidence of exhaustion,
                                               and of the previous existence of some drain on
                                               the nervous system, than  when the triple salt
                                               alone existed, unless its source is strictly local.
                                                  84. When the triple phosphate occurs in small
                                               quantities, nearly or quite free from the phosphate
                                               of  lime, the urine being acid or neutral at the time
                                               of  emission, the cases are then  the slightest of
                                               this class of disorders.  Nevertheless, severe dys-
                                               pepsia, irritability, restlessness, impaired assimi-
                                               lation,  and  emaciation  are constantly present.
                                               When  there is an  excessive discharge of urea,
                                               the symptoms are more severe, and the exhaus-
                                               tion and nervous depression greater.   The urine
urine occasionally varies from a whey-like hue to
a deep  brown  or greenish brown,  is very  fetid,
generally  alkaline,  "and  loaded with  a dense
ropy  mucus  often  tinged with blood,  and  in
which large crystals of the triple phosphate and
amorphous masses  of phosphate of lime are  en-
tangled    This variety is almost always met with,
either under the irritation of a calculus, or even
of a  catheter worn in the bladder," or where
actual disease of the mucous coat of this organ
exists.
  80. d. For the microscopic characters of earthy
phosphates, I must refer to Dr. G.  Bird's work,
where they are fully illustrated.  I can only men-
tion,  1st, the prisms of neutral triple phosphates;
these are well defined, the triangular prism  being
the form  most frequently met with, but it pre-
sents every variety in its terminations ; 2d, simple
Stella of the neutral salt, the radii being more or
less distinct or crowded ;  3d, penniform crystals
of neutral salt; this variety presents the appear-
ance  of striated feather-like crystals, two  being
generally connected, resembling a pair of wings ;
4th, stellar and foliaceous crystals  of basic salt ;
this variety  is  chiefly formed after the  urine is
discharged,  and, when rapidly formed, it gener-
ally appears as six-rayed stars, each ray  being
serrated.  Phosphate of lime generally presents
no  appearance of crystalline structure;  it  either
resembling an amorphous powder, or being  col-
lected in  rounded  particles, often  adhering to
prisms  of triple phosphate.
  81. B. Pathological Relations of the Phosphates.
—I  have  many years ago contended, and more
recently, in various parts of this work, alluded to
the fact, that the secretions are endowed, to a  cer-
tain extent, with an emanation of vitality which
for a time resists  the changes which they are
disposed to enter into, either when  organic nerv-
ous influence is  much depressed or when they
are removed from the body.   " Indeed,  the vital
influence  modifies  their physical conditions, in
a more or less marked manner, as long as they
continue  subjected to its operation.   From  this
source, also, they are imbued  with a vital ema-
nation,  the presence of which is indicated by the
continuance, for a time, of the specific characters
of  each  This emanation, being no longer re-
quired when they are removed from the body, is
soon dissipated.   The secretions,  while within
the sphere of the animal system, and for a short
time  afterward, possess this  emanation of the
vital  influence, to  an amount  sufficient to  give
them certain  characters,  and  to preserve them
from the  chemical changes to which their con-
stituents  are naturally prone;  but  when this in-
fluence becomes depressed, or ultimately ceases,
they then undergo dissolution  as unequivocal as
that evinced by the textures of the body.  In con-
firmation  of this view, I need only refer  to the
comparative conditions  of the more  perfectly
elaborated secretions immediately after their for-
mation and excretion, and after periods of various
duration have elapsed from the time of their dis-
charge from the body."   (Physiol. Notes by the
Author, p. 636.)
   82. The above  doctrine was published by me
in  1824 ;  and  both then and subsequently I have
 insisted upon its importance, and upon the obvi-
 ous deductions which follow from  it.  While vi-
 tal energy  is  perfect, or  at least not materially
 impaired, the secreted fluids, especially while
 they remain undischarged from the body, are pre- 
 URINE AND URINARY DEPOSITS—Path

is then of a rich amber colour, generally deposit-
ing phosphates on the  application of heat, and of
a specific gravity varying from 1 025 to 1030.
In mild cases of dyspepsia, especially in the gouty
diathesis, an iridescent pellicle of triple salt, the
urine being rich in urea and either acid or neu-
tral, is often observed.  This state ofthe urine is
not infrequent in  dyspeptic females at or about
the climacteric period.   Crystals ofthe triple salt
occur in very old persons, especially in the ill-
fed ; in persons recovering  from acute diseases,
especially from rheumatic fever
  85 Early in continued fever the urine is high-
coloured, and loaded with uric acid and urates
It is then generally acid , but after the end of the
second week, or earlier, in the lower types of fe-
ver, the acidity often vanishes, and  the urine be-
comes alkaline and deposits the phosphates.  This
is, however, more frequently seen in some types
and states of fever than in  others, especially in
the typhoid and putro-adynamic, and when coma-
tose symptoms appear.  The treatment, particu-
larly the use of alkaline medicines, or ofthe salts
of the vegetable acids, has some influence in fa-
vouring  the change to an alkaline  state of the
urine   In these cases, as well as  in  other dis-
eases where the nervous energy is remarkably
depressed or exhausted, more  especially in  the
low forms of insanity, in cases of debility from
venereal excess, masturbation. &c, after injuries
ofthe spine, as remarked by Pkout, Brodie, and
others, the elements of urea become rearranged,
or obedient to ordinary  chemical affinities, and
form carbonate of ammonia.
  86 When the deposit of phosphates is copi-
ous, the two phosphates  are generally mixed, ei-
ther falling to the bottom ofthe vessel, or remain-
ing suspended in the urine like mucus; the urine
is then generally alkaline, and the odour ammo-
niacal or fetid   This  kind  of urine is  most re-
markable in organic disease ofthe urinary organs,
or serious affections of the  spinal cord followed
by such disease.   Conformably with the doctrine
above insisted upon  (y 81-5), the impaired vital-
ity of these  organs depending upon depressed vi-
tality of the frame generally, as in typhoid  and
putro-adynamic fevers, or of the urinary organs
especially, as after  injuries or diseases of  the
spine, its cord, &.c ,  so affects the urinary secre-
tion, both during the performance  of this func-
tion and while the secretion is retained, as to fa-
vour the occurrence of those changes, even before
it is discharged, which its ordinary chemical af-
finities dispose it to  assume.  The change thus
produced in  the urine may be followed by  the
formation of calculi in any part ofthe urinary ap-
paratus, but most frequently by irritation of the
urinary mucous surfaces and by the secretion of
a quantity of viscid mucus, which  .may become
puriform or changed, by the carbonate of ammo-
nia formed in the urine, into a viscid and almost
gelatinous or tenacious ropy  fluid, sometimes pre-
venting the discharge ofthe urine, and increasing
the sufferings ofthe patient.  Mr Curling's view
of this subject is different from that now stated.
He believes  that the  result ofthe spinal lesion is
the loss of the natural sensibility of the bladder
The  effect of this is the secretion of unhealthy al-
calescent mucus, which acts chemically upon  the
urine, renders it alkaline, and leads to the depo-
sition of the earthy phosphates.   He thinks that
the  urine may subsequently  be secreted in an al-
kaline state by the extension ofthe irritation from
jlogical & Therapeutical Relations of.  1333

 the bladder to the kidneys, or by the latter  sym-
 pathizing with the former.   It should not,  how-
 ever, be overlooked, that injury of the spine not
 only deprives the urinary apparatus of that share
 of nervous power reinforcing the organic or gan-
 glial nervous influence which endows this appara-
 tus, but thereby also modifies the secreting func-
 tion ofthe kidneys.  Whether the result be im-
 pairment only, or a modifying action also, there
 can be no doubt that the chief result of these in-
 juries  is paralysis of the  bladder, especially as
 respects its contractile powers, causing retention
 ofthe urine, which, whether it be secreted in an
 altered or morbid condition, or rendered such aft-
 er its secretion, owing to impaired vital influence,
 more readily irritates the urinary mucous surface
 than in its healthy state, and gives rise to mucous
 discharge and the consecutive lesions ofthe uri-
 nary organs.
   87  The urine may be alkaline  and loaded with
 phosphates, owing to disease ofthe Urinary Blad-
 der (see that article), more especially of its mu-
 cous surface.  This state of the urine thus arises
 from three important pathological conditions  : 1st,
 from vital depression, as  manifested  chiefly by
 nervous debility and irritability; 2d, from injuries
 and diseases implicating the spinal  cord or its
 membranes ; 3d, from disease of the urinary or-
 gans   But it should not be overlooked that the
 second condition affects the  urine by first -disor-
 dering the functions and subsequently the struc-
 ture of these organs.  It is important to be able
 to distinguish between these sources of alkalinity
 of the urine, especially between the presence of
 a general  morbid condition  and a strictly  local
 disease.  Dr Bence Jones has  established that
 urine is alkaline from ammonia when the cause
 is local, and from a fixed alkali when the ailment
 is general.  Hence urine may be alkaline, and not
 ammoniacal, although when the latter it is neces-
 sarily the former   The urine is sometimes  alka-
 line after breakfast, owing to the presence of a
 fixed alkaline  carbonate.   The  urine, in  such
 cases, turns red litmus paper blue, whatever may
 be the  alkali present; but if it be a fixed alkali,
 the paper  remains blue  after being dried before
 the fire; but if it be the volatile alkali, the paper
 resumes its red tint when  thus exposed.   When
 the urine is alkaline from ammonia, Dr. B. Jones
 has  farther shown, abundant  crystals of triple
 phosphate are always found, while, when  ammo-
 nia is absent, these crystals are  rarely present,
 and are replaced by a copious and dense deposit
 of phosphate of lime.  He  has arrived at the fol-
 lowing conclusions  as to  the  relation borne by
 phosphatic salts to certain  pathological states :
   88. 1st. No determination of an excessive se-
 cretion of phosphatic acid can be furnished by the
 deposit of earthy salts, unless the quantity of lime
 and  magnesia in the food be taken into account;
 2d No real increase of phosphatic salts occurs in
 spinal diseases, notwithstanding the existence of
 deposits ; 3d. In fever and  in most acute inflam-
 mations, the phosphatic salts are not increased;
 4th  In old cases of mania, melancholy, paralysis
 of the  insane,  or  in chronic diseases in which
 nervous tissues are  influenced,  no conclusions
 can be drawn ;  5th. In fractures ofthe skull, the
 phosphatic salts increase only when any inflam-
 matory action occurs in  the  brain, and in acute
 phrenitis an excessive increase takes place ; 6th.
 In delirium tremens there is a marked deficiency
 of phosphates,  unless they are introduced  with 
1334 URINE AND URINARY  DEPOSITS—Pathological & Therapeutical Relations
the ingesta ; an excess is, however, met with in
some functional affections ofthe brain.
   89.  In some instances the urine is copious,
pale, and freely deposits the phosphates, the pa-
tient being  emaciated, and the urinary  organs
free from disease.   In these the formation of a
calculus may be dreaded.  But when this does
not exist, it will often be found that tabes dorsa-
lis from masturbation  is the  cause both of the
constitutional and  of the urinary disorder.   Dr.
Golding Bird  states that the deposits of phos-
phates, where no organic disease exists, are often
absent, not only for hours but for days together;
and this fact will often indicate a favourable ter-
mination of the case ;  and he comes to the fol-
lowing conclusion : " that, where the presence of
a deposit of phosphates is independent ofthe irri-
tation  of a calculus, or of organic disease, it is
most abundant  in the urine passed in the even-
ing, and absent  or replaced by uric acid or urates
in the  morning, the urine being always of a toler-
ably natural colour, never below, and often above
the mean density.  Where the presence of phos-
phatic salts depends upon the irritation of a cal-
culus,  or upon  organic mischief in the  urinary
passages, the urine is  pale  and whey-like, of a
density below the average, often considerably so,
and the earthy deposit is nearly equally abundant
in the night and  morning urine." (Op. at., p. 293.)
   90.  C. Therapeutical  Indications.—a. When
phosphatic deposits depend upon  irritative dys-
pepsia, or upon  nervous or febrile disorder, inde-
pendently of affection ofthe  spine  or ofthe uri-
nary organs, the treatment  should be directed
rather  to the constitutional, digestive, and assimi-
lative  disorders, than to the  state of the urine,
which  ought to be viewed only as a symptom.  In
these cases, depression of spirits, hypochondria-
sis, and various dyspeptic symptoms, are present;
and  the urine has  a high specific  gravity, con-
tains an excess of urea, and deposits crystalline
or amorphous phosphates.  In these the  urinary
deposits should  be viewed as the results of defect-
ive vital and nutritive powers, and as exhausting
the nervous energy ; and the treatment ought to
be directed to the functions of the  stomach and
bowels, and to the  improvement of the  general
health, by means of stomachic or tonic aperients,
by a light, digestible, and  generous  diet, and by
bitter  infusions or  decoctions.   To  remove the
more painful symptoms, the oxide of bismuth or
of zinc may be given with the extract of ox-gall,
and  the extract of henbane  or the  pil.  saponis
composita.  In these cases the means advised in
the articles Debility, Hypochondriasis, Indi-
gestion, &c, will generally be appropriate.
   91.  b. When the phosphatic deposits  depend
upon exhaustion or  injury of the spinal cord—
upon tabes dorsalis, &c., then the medical means
require modification.  In these, great emaciation,
copious phosphatic deposit, the phosphate of lime
predominating remarkably, pain and weight  in
the lumbar region,  copious pale urine and low
specific gravity, and dryness of the  skin, require
not only the restoratives and tonics already ad-
vised,  but also  a recourse to opiates, conjoined
with aromatics, diaphoretics,  &c.   When these
cases proceed from a blow or other injury ofthe
spine,  or wrench of the  back, then the terebinthi-
nate liniments  or embrocations  along the  spine
(see Form. 296, 311), the cold salt-water douche
on  the loins, followed by frictions  or liniments,
the emplastrum roborans, &c, will  be of great
service.   In  many of  these (especially  when
caused by masturbation) the preparations of iron,
the nitro-muriatic acid in  tonic  infusions, the
tincture ofsumbul or of musk, or of serpentaria,
with tincture  of opium, are severally productive
of more or  less benefit.   In mild  and prolonged
cases of this kind, a calculus is not unfrequently
insidiously  formed in the  pelvis of the kidney.
For these, the mineral acids  have been recom-
mended, as they hold the phosphatic salts in so-
lution :  of these, nitric or nitro-muriatic acid may
be preferred; but it has been doubted whether
they reach the kidneys or  act upon the deposit.
However, when  given  judiciously  or conjoined
with  bitter tonics, they  improve  the general
health, and thereby either  prevent  or arrest the
increase ofthe deposit.*
   [Believing, with Dr. Prout, that a  perfectly
healthy condition of the urine is not only one of
the most  natural, but probably also  one of the
most  powerful  solvents for all  the ingredients
likely to exist in urinary calculi that we  can hope
to possess, and that there is scarcely any form
of stone that will long bear the continued action
of healthy urine without becoming more or less
dissolved or disintegrated,  we direct the patient
to drink very largely of pure rain-water, some-
times aiding the diuretic  effect by parsley-root
tea, infusion of juniper, the  cucurbitaceous seeds,
&c, in order to a copious secretion of healthy
urine.   Urinary deposits are often thrown down
from  the  amount  of urine being  too  small to
hold them in solution ;  increase the quantity se-
creted, and  the  urine again becomes limpid and
free  from  sediment.  Great water-drinkers, as
Bouchardat says, are never afflicted with urina-
ry calculi.]
  92. c. When  phosphatic  deposits proceed from
lesion ofthe urinary organs, their connexion with
a morbid secretion from the mucous membrane
of the bladder is well known.  The  disposition
of the phosphates to adhere to this surface gen-
erally increases the difficulty of treatment.   For
this state of phosphatic cystitis, weak acid  injec-
  [* B -RV.Ei.irs believed that he had proved by his ex-
periments that the mineral acids never reach the kid-
neys in a free state, and never increase the acidity of the
urine.   This is doubtless  the case generally with the
vegetable acids  also, which undergo decomposition  or
combustion in passing through the circulation.  It cer-
tainly is very difficult to acidify alkaline urine.  Orfila,
however, states that he detected nitric, sulphuric, hydro-
chloric, oxalic, and perhaps acetic acid in the urine of
dogs poisoned by these acids, but never in a free  state.
Woiiler concludes from his  experiments that oxalic,
tart trie,  and benzoic acids (and probably, therefore, all
acids)  are never eliminated in the urine in a free  state,
but always  in  combination  with  a base.  Dr. Bkspk
Jones states that,  in  his experiments with sulphuric
acid, given freely many days in the form of lemonade,
it does, after a while,  pass off with the  urine; but 364
grs. of dry tartaric acid, given after eating, were not suf-
fieient to render the urine acid.  Changes, however, in
the condition  of the digestive and  assimilative organs
 eadily affect the urine, as in  the experiment of Bebze-
lit/s, where he gave phosphoric acid freely for a consid-
erable time without acidifying the urine; but as soon as
it purged the patient,  the urine lost its alkalinity, and
deposited uric arid.  Mr. Brande states verv truly that,
when mineral acids are given to relieve  phosphatic de-
posits, they are apt to induce red gravel (uric acid); that
the vegetable aci !s are less apt to cause the deposition
of red  gravel in the urine  than the mineral ones.  We
conclude that all acids are very uncertain remedies in
phosphatic gravel or calculi;  that, at best, they are only
palliative; and that, for the  most part, when they do
prove beneficial, it is by a tonic influence on the digest-
ive organs and improving the functions of as>-imilation.
When employed, it should always be in conjunction with
the bitter tonics.} 
URINE AND URINARY DEPOSITS—Pathological & Therapeutical Relations of. 1335
tions into the urinary bladder have been advised,
in order to wash away the phosphatic formation.
A few drops of the hydrochloric acid, with as
many of the vinum opii in tepid barley-water,
may be injected daily.   Dr. G. Bird  advises, in
almost every case where phosphatic alkaline urine
exists, to wash out the bladder  by injections of
warm water.   (See aUo the treatment of muco-
cystitis in art. Urinary Bladder, y 89-97.)
   93. ix. Deposits of Carbonate  of Lime.—
Carbonate of  lime sometimes  occurs in small
proportions in deposits of earthy phosphates,
when the  urine is decidedly alkaline, owing to
the decomposition  ofthe phosphate of lime by the
carbonate of ammonia which replaces the urea.
Its appearance is that of an amorphous powder ;
and its presence may be recognised by the addi-
tion of any dilute  acid, which dissolves it with
effervescence ;  but the deposit  should be prev-
iously washed  to deprive it of any adherent car-
bonate of ammonia.
   94. x.  Deposits of Blue or Black Matters.
—Certain  colouring matters, communicating to
the urine a blue or black tint, the products of dis-
eased  action, are  met with on  rare occasions.
Three blue  pigments, viz.,  cyanurine, indigo,
and percyanide of iron ; and two black, melano-
urine and melanic acid, have been distinguished.
These colours, as well as green, have been men-
tioned by many ofthe older writers noticed in the
bibliography, and have doubtless been owing to
the presence of blood or bile altered by the urine.
— (a)  Cyanurine  was discovered by Braccon-
net, and noticed by several more recent observ-
ers.   Urine containing it is of a deep blue colour,
the colouring matter being deposited by rest, and
readily separated by  the filter.   The origin of
this substance, as well as its pathological indica-
tions, if any, are obscure, and merely furnish a
subject of conjectural discussions to chemical pa-
thologists.
   95. (b) Indigo is sometimes prescribed empir-
ically in  some diseases, as epilepsy ; and it may
thus pass into  the urine, and form a blue depos-
it.   Prout and Simon have shown that it may be
generated in the economy, the urine acquiring a
dark blue colour, and depositing a substance of
the  same hue, which, when  collected on a filter,
presents all the characters of indigo.   The origin
and pathological indications  of this  substance,
when not taken internally, are unknown.
   96. (c) Prussian blue, or sesqui-ferro-cyanide
of iron, has been found in the urine after taking
the ferro-cyanide of potassium upon preparations
of iron.  It furnishes no pathological inferences.
  97. (d) Melanourine anil melanic acid are black
pigments which have been rarely met with in the
urine.  It is probable  that they  are merely the
colouring matters ofthe blood altered by the state
of the  urine.   Many years ago  a clergyman in
London, with whom I was well  acquainted, ex-
perienced a dangerous  immersion in the river,
and  was  saved with difficulty.   He  soon after-
ward began to  pass black urine, for which I was
requested to visit him.   He complained only  of a
slight weight in the region ofthe kidneys.  The
urine was quite black, was passed in about the
usual quantity,  and was retained nearly the usual
time.  The lower extremities were not affected.
A portion of the colouring matter was deposited,
but the supernatant urine was not materially al-
tered from its black colour.  I attributed the  col-
our to  the  escape  of red  globules of blood with
the urine, owing to congestion of the kidneys,
and  their alteration by the state of the  urine.
Conformably with this  view, I  directed  blood to
be taken from the loins by cupping.  The urine
soon  afterward resumed its healthy appearance,
and no farther complaint was made.
  98. xi. Organic Deposits in  Urine.—The de-
posits in the urine which have been noticed above
are recognisable by their forms and chemical prop-
erties ; those which remain to  be  mentioned ei-
ther possess or have possessed  organization, and
can be distinguished only by an examination by
means of the microscope or of tests.
  99. A.  Blood and  its elements are often
seen in the  urine, and suggest  important patho-
logical and therapeutical indications.  The urine
may contain  only the serum of the blood, or li-
quor sanguinis ; or with this a  considerable pro-
portion of red globules;  or it may contain  a very
large proportion  of blood, hardly or not at all
changed from its normal characters.
   100. (a) Serous or albuminous urine is readily
indicated by heat, and by adding a drop of nitric
acid,  which coagulates the albumen contained in
it.  Urine containing much albumen is eitlier free
from, or contains but  a very small amount  of,
colouring matter.  The reddish urine in granular
disease of the kidneys furnishes less albumen by
heat than the straw-coloured.   Nitric acid and a
mixture of one part  of nitric and three of hydro-
chloric acids are  more delicate  tests of the pres-
ence  of albumen than heat.  Several  sources of
fallacy have been pointed  out  by  writers which
should not be overlooked when resorting to these
tests.  1st. Heat will produce a white precipitate
in urine containing an excess of earthy phos-
phates, but this will disappear on  adding a drop
of nitric acid, and distinguish it from albumen.
2d. Nitric acid will produce white deposits in pa-
tients taking copaiba, cubebs, or other resinous
substances; but  heat has  no such effect.  3d.
Nitric acid  will,  in  some  instances,  produce a
buff-coloured amorphous deposit in the high-col-
oured urine in fever, but heat does not cause this
change.   4th. Albumen combined with alkalies
does not coagulate by heat; therefore nitric acid
should be used if the urine be alkaline.  5th. Al-
bumen in an incipient state may not be detected
by heat, but readily by means of the acids.
  101. Albumen is sometimes found in the urine
in a coagulated  state, presenting  a tubular ver-
micular appearance, being casts  ofthe uriniferous
tubules of the kidneys, often with portions of
epithelium adhering to  them ; and, according to
Dr. G. Johnson, loaded with fatty globules.  These
casts, when recently passed, appear  like large
hairs, but form after a  time a  dirty-white sedi-
ment, which a solution of potash gelatinizes, and
distinguishes from  mucus.  This  deposit is pa-
thognomonic of the  changes which terminate in
granular disorganization ofthe kidneys.
  102. Blood passed in  considerable quantity in
the urine  may either be more or less intimately
mixed in the urine, or it may have coagulated in
blackish masses like pieces  of black currant-jelly,
linear masses like leeches being passed through
the urethra with great suffering.   In the former
case the blood generally is poured out  in the kid-
neys or their pelves ; in the latter  it is most fre-
quently effused in the  bladder.  In either case
the urine is always more or less coloured, often
so deeply as to present  a Port-wine colour;  the
microscope showing some entire blood-globules, 
 1336 URINE AND URINARY DEPOSITS—]

 and others with their investing membrane broken
 down, and their coloured contents diffused in the
 urine.  If the quantity of urine be small, the
 urine may appear like the washings of meat, or
 of a dirty or dingy hue, the red globules being still
 recognisable  by  the microscope.  The  coagula-
 tion of the urine by repose seldom occurs : it is
 owing to the presence of fibrin, which, however,
 is very rarely effused without an admixture of
 blood-globules, giving the coagulum a reddish
 colour, or of a fatty matter,  imparting to it a
 whitish or opaline hue.
   103. Hamatosin, or the colouring  matter con-
 tained within the sacs of the blood-globules, im-
 parts to the urine  a deepness of tint in proportion
 to the quantity ofthe  colouring matter which has
 escaped from the  sacs of the  blood-globules, or
 rather to the  number of these globules which are
 ruptured.   Generally, however, the urine, when
 recently voided, contains some globules that re-
 main entire; and, with the colouring matter,
 more or less albumen, which is affected, as shown
 above, by heat and nitric acid, excepting that the
 coagula are  more or less brown, owing to the
 presence  of  haematosin.   When, however, the
 urine is much loaded with purpurine, or uric acid,
 or with bile, these  may be mistaken for haemato-
 sin.   The first of these will not be affected in
 colour or transparency  by a boiling heat; the
 second is not  affected by heat, and is at once dis-
 tinguished by the  characters of the deposit; the
 third may be  detected by pouring a thin  layer of
 the urine on  a white plate or sheet of writing pa-
 per, and letting a drop or two  of nitric  acid fall
 upon it, when a change of colours, in which green
 and pink predominate, will be produced.  Hama-
 toxylon, pareira, chmaphila, and senna,  the for-
 mer especially, will impart a reddish or brownish
 hue to the urine;   but these will be distinguished
from haematosin  by the  knowledge of their hav-
 ing been taken, by the black precipitate produced
 by sulphate of iron when the  first of these has
 produced the redness ; and by the absence of al-
bumen and haematosin as regards all of them.
  104. The   presence of blood-globules in  the
 urine is best  determined by the microscope.   If
the blood be  recently  effused, they will either be
found adhering in  rouleaux, or  unaltered in fig-
 ure.  But if it have been effused for  some time,
 or if the effusion has been slow, or the exudation
 of an asthenic character, the linear arrangement
of the globules is lost, the investing membrane,
 being ruptured, is collapsed around their corpus-
cles or nuclei, and  ultimately the globules appear
irregular in their margins.
  105. (b) The pathological indications  of the
presence of the elements of blood, or of blood in
 any  form, in  the urine,  has always been of im-
 portance ; but it has become of even greater im-
 portance  to the physician since the enlightened
investigation  by* Dr. Bright ofthe diseases ofthe
kidneys.   When pure blood, or even  the admix-
ture of its globules in  large quantity,  is observed
 in the urine,  it may be presumed that active or
passive haemorrhage from some part ofthe urina-
ry passages  has occurred;  the  more pure the
blood, and the less intimately  mixed with the
urine, the more probable is the effusion to have
taken place in the lower passages of the appara-
tus.   If the  quantity  of haematosin be so small
as only to tint the urine, it is to be presumed that
both it and the albumen  also present result from
the congested state ofthe kidneys connected with
'athological & Therapeutical Relations of.

 the cachectic inflammation of these organs, which
 terminates in the organic changes which render
 them incapable of eliminating  the nitrogenized
 elements of urine  and of depurating the  blood,
 although the secreting power is so far preserved
 as to separate the albumen and water, this latter
 element being ultimately very  incompletely re-
 moved.  (See art. Kidneys, y 83, ct seq.)
   106.  When  the  presence  of albumen in  the
 urine was first shown to be a proof of granular
 disease  of  the kidneys, I contended (see  art.
 Dropsy, y 36, ct seq) that this state of urine ex-
 isted in several other diseases,  especially in  the
 febrile and exanthematous maladies of children,
 and when congestion ofthe kidneys is occasion-
 ed by other affections or circumstances, although
 not always or continuously observed, that  yet it
 was a contingent and occasional or temporary oc-
 currence.  Since this statement was made, from
 a varied observation, the truth of it has been con-
 firmed  by many subsequent observers.   When
 blood is voided in large quantity, or when coag-
 ula are passed with the urine, breach of surface
 or lesion of a blood-vessel may  be inferred ;  but
 the  particular  cause  of lesion, whether  conges-
 tion, rupture of a vessel, or injury, or irritation of
 a calculus, or malignant or fungoid disease, and
 the seat of either of these morbid conditions can
 be ascertained only from a careful examination
 of existing  symptoms, in connexion with  the
 changes in the urine just mentioned (y 105,106),
 and with the circumstances attending the reten-
 tion and calls to void this excretion.
   107  (c) Therapeutical Intentions—These  are
 varied, or even opposite, according to the conclu-
 sions at which the physician will  arrive after
 due examination and  consideration ofthe peculi-
 arities of each case, respecting the seat, cause, and
 vital conditions of haematuria, as  fully set forth
 under this  head in  the  article Hemorrhage.
 (See  Hamorrhage  from  the  Urinary  Organs,
 y 204-220.)
   108  B Purulent Matter  in  the Urine.—
 Pus  is  seen  in the urine  consequent upon sup-
 puration in the kidneys, or  in  any part of the
 urinary organs, or in parts communicating with
 the urinary apparatus.  It is also contended that,
 in cases of abscess of internal viscera, the puru-
 lent  collection  is sometimes absorbed and dis-
charged with the urine  But it is  more probable
that  pus-globules, when absorbed, are metamor-
phosed, either during their passage into or dur-
ing their circulation in the blood,  and that they
cannot be eliminated by secreting  organs unless
thus metamorphosed  or reduced to simpler ele-
ments.
   109. a. The appearances of purulent urine vary
with the seat of the disease   This urine is gen-
erally acid or neutral.  The pus falls  to the bot-
tom ofthe vessel by repose, and forms a dense
homogeneous deposit, of a pale greenish or cream
colour.   It never hangs in a stringy form in the
urine like mucus, unless the  urine be alkaline,
and it becomes uniformly  diffused in the  urine
by agitation.   If the  deposited  pus be agitated
with an equal quantity of liquor potassse, a dense
translucent gelatinous mass,  of a  thick mucous
appearance,  is  formed. When  the  pus is agi-
tated with ether, fat is dissolved, and  left in the
form of butter-like globules, when the  ether is
allowed to evaporate.  The urine decanted from
the purulent deposit yields albumen on the appli-
cation  of heat  or  nitric acid.   When purulent 
URINE AND URINARY DEPOSITS—Path
ological & Therapeutical Relations of.  1337
urine is alkaline, the deposit is viscid, and is not
readily diffused by agitation through  the  fluid,
resembling some mucous deposits.  The presence
of albumen in the  purulent urine, "and the con-
version of the deposit into a white granular mass,
destitute of its previous viscidity, by the addition
of acetic acid," indicate the  nature ofthe depos-
it.   In females, the urine may contain a puru-
lent matter derived from the vagina, in cases of
leucorrhoea—a circumstance requiring considera-
tion
   110. b. Microscopic  Characters.—Pus consists
of round globules, somewhat larger than blood-
globules, floating in an albuminous fluid, or liquor
puns, which  differs from the  liquor  sanguinis
chiefly in the  absence  of fibrin, and consequent-
ly in the inability  of coagulating spontaneously.
Under  the  microscope, the  globules  appear
" white,  roughly  granular  exteriorly, and are
much more opaque than blood-globules.  On the
addition  of a drop of acetic acid, the interior of
the globule becomes visible, and is  found  to be
filled with several transparent bodies or nuclei."
Hence the pus-globule is a regularly  organized
body, consisting of a  granular membrane envel-
oping transparent nuclei, being, in other words, a
nucleated cell.  (See  Disease, y  131, 132, and
the Microscopic Characters more fully in the art.
Pus, and in Urinary Bladder, y 48.)
   111. C. Mucus is present in healthy urine  in
very small quantity.   When irritation exists  in
any part of the urinary apparatus the  mucus  is
greatly increased,  and  generally in proportion  to
the amount and extent of it, this secretion  vary-
ing  from a flocculent cloud in the urine to the
production of a fluid so viscid as to form a copi-
ous  ropy deposit.   This condition of the urine is
generally alkaline, and undergoes  a  putrefactive
change soon after  it is passed, or even  before be-
ing voided if it be  long retained.  Although it be
acid  when passed, it rapidly becomes ammoni-
acal.  Mucus  contains no albumen admitting of
coagulation by  heat or  nitric acid (y 100), and
hence mucous urine simply " can never be  albu-
minous like pus, unless the albumen be derived
from some other  source.  Agitated with ether,
mucus gives merely traces of fat, and in this re-
spect also differs from pus."  (For the patholog-
ical  and  therapeutical relations of Mucous Urine,
see the art. Urinary Bladder, y 47, et pluries.)
   112. D. Epithelium.—Exfoliation of the epi-
thelial covering ofthe genito-urinary mucous sur-
face is constantly taking place, but with very dif-
ferent rates of rapidity.  This covering is some-
times partially  detached, so as to  appear like
patches of membrane-like mucus; some of the
epithelial cells being irregularly lacerated, others
entire, and readily recognised by the aid of the
microscope.   When distended by fluid they are
oval cells, which become irregularly angular and
flattened  when  partially empty   When quite
empty they present in each a central nucleus pro-
jecting above the  surrounding surface.  These
cells are  said sometimes to contain fat-globules,
especially in the Morbus Brightii.  When the ex-
foliation  of epithelium is copious, a  deposit is
thereby formed in  the  urine, resembling mucus,
but differing from  it in the absence of viscidity.
With  liquor  potassae  this  deposit  gelatinizes
nearly as perfectly as when pus is present.  When
an abundance  of epithelium is found in the urine,
oxalate of lime often also is present; the irrita-
tion  of the mucous surface of the urinary pas-
sages, especially in the kidneys, very probably at
the same time that it detaches the epithelium,
converts the uric acid and urates into the oxalate.
   113. E. Spermatozoa, or what has been called
spermatic animalcules, are sometimes found  in
urinary deposits, when  the  urine  of the  male
adult has been allowed to repose for a time.—a.
The only means of distinctly determining the
presence of semen in the urine is by ascertaining
the existence of spermatozoa by the aid of the
microscope.   " These minute bodies never occur
living in urine, unless protected by the presence
of a deposit  of pus, in  which  they retain  their
power of moving a long time after  emission."
In the microscope, " the spermatozoa will be ob-
served as minute ovate  bodies, provided with a
delicate bristle-like tail, which becomes more dis-
tinct on allowing a drop of urine to dry on the
glass.   Mixed with these are  generally found
round granular bodies, rather larger than the body
of a spermatozoon, and nearly opaque from the
numerous asperities on the surface ofthe invest-
ing  membrane.   These appear to be identical
with the seminal granules described by Wagner
and others "   (Op. at,  p. 359.)
   114. b. The presence of spermatozoa in the
urine furnishes  certain pathological  indications
of much importance.  They may be present ow-
ing to the discharge of urine immediately or soon
after  seminal emission,  the urine washing away
the portion of semen which  may remain in the
urethra; or  owing  to a costive motion having
pressed upon the spermatic receptacles, so as  to
press out a portion of their contents.   However
the presence  of these bodies in the  urine may  be
accounted for, the fact that they are  commonly
observed in  persons who have weakened  their
sexual organs, either by excessive  female inter-
course, or by  the unnatural vice of masturbation,
is indisputable;  and in  such persons chiefly  or
only spermatozoa, and the much-discussed affec-
tion of spermatorrhoea, is observed.  The patho-
logical and therapeutical indications furnished by
this condition of the urine are  considered under
the head of Impotence, and more fully under that
of Pollution, voluntary and involuntary.
   115. F. Fatty or oily  matter has not un-
frequently been  found  in  the  urine, generally,
however, in  minute traces only, and very rarely
in any considerable quantity.   It is most proba-
ble that some of the instances in which oil has
been said to have existed in the urine have been
those in which the oil-like pellicles  ofthe earthy
phosphates have  formed on  the  surface of the
urine.  The  genuine states  of fatty urine  have
generally resembled milk in  colour and opacity,
and have gelatinized on cooling.  The term chyl-
ous urine has been applied to these stales by Dr.
Prout.   Dr.  Eichholz and Dr G Johnson con-
tended that oil or fat existed in the urine in gran-
ular disease of the kidneys, owing to the super-
abundance of fat in the epithelial cells ofthe tu-
bular  structure ofthe kidneys, and to the escape
of these cells from the tubuli and admixture with
the urine.   But the quantity of fatty matter thus
mingled with the  urine is rarely such as to give
rise to appearances indicative of its existence, un-
less the deposit be  examined under the micro-
scope, when the  cells containing oil, sometimes
presenting casts  of  the tubes  from which they
have been detached, may be observed.
  116. In most cases of chylous urine, albumen
is  present in very varying quantity,  and forms 
1338  URINE AND URINARY DEPOSITS—Pathological & Therapeutical Relation
with the fat an intimate admixture or emulsion.
The fat may be obtained by agitating the urine
with an equal quantity of ether in a tube.  The
presence of fat in albuminous urine may be view-
ed  as  a  strong  indication of organic disease of
the kidneys;  but the combination rarely exists
in such a manner as to give rise to the  chylous
appearance of the urine.  It should not be over-
looked that instances sometimes occur in which
hysterical females, to create interest in their cases,
or to obtain other ends, have imparted a morbid
appearance to  their urine, by adding to it milk,
or small quantities of blood or other matters, by
which the medical attendant has been deceived.
Such instances  have come before me and other
physicians with whom I am acquainted.   I have
rarely seen cases of chylous urine.   The most
remarkable instance of it which I have observed
was in a mulatto young man from the West In-
dies.   Dr. G. Bird  states that, in the  chylous
urine he has examined, he has failed in detecting
under the microscope the slightest appearance of
oil-globules, blood-disks, or pus-granules;  the
opacity appearing to depend upon the presence
of particles so minute as to present no defined
form.  M. L'Heritier  has, however, remarked
that oily globules can always be detected in fatty
urine; and Dr.  Simon, of Berlin, has made the
same remark, and has  stated that he has  met
with three varieties  of fatty urine :  one in which
the fat is merely diffused through it, and collects
on its surface by repose, as in cases recorded by
Dr. Elliotson ;  the other in  which  the fat  is
combined with albumen; and a third, in which
the fatty matter existed with casein as an emul-
sion, forming  the true milky  or chylous urine.
Dr. Bence Jones has investigated this state of
the urine,  and has arrived  at the following con-
clusions respecting it:
   1st. The fat on which the milky aspect ofthe
urine depends  appears  after the  absorption of
chyle, but the albumen, fibrin, blood, and  alkaline
salts may be found  even when  no food has been
taken, and consequently no chyle formed.   2d.
During absolute rest, albumen  disappears from
the urine, and does not reappear in any quantity,
even after taking food, unless active  exercise  is
employed.  A short time before rising early, the
urine gelatinizes  by repose, but  is free from  fat.
3d  This state of urine does not  depend upon the
presence of an excess of fat in the blood, as proved
by actual analysis.  4th. The seat of this disease
is probably some slight alteration in the structure
of the kidneys, by which, when the  circulation
through these organs is most active, one  or more
ofthe constituents ofthe blood exude from the
capillaries and escape into the urine.
   Dr. G. R. Bouyun, of Demerara  (Dr. G. Bird
states), has observed cases  of chylous urine so
frequent  in Creoles  and negroes  as  to be often
epidemic in that country.  This state ofthe urine
appears to be attended by irritative fever and ema-
ciation, as in diabetes.   He attributes the disease
to lesion  of the assimilative functions;  and he
treats it by the free administration of a decoction
of  the  mangrove bark  (Rhizophera  racemosa).
This medicine acts freely on the skin, increases
the secretion and alters the character ofthe urine,
and improves the general health.*

  ["* Kiestine.—In  1831, Nalche, of Paris, described a
peculiar gelatino-albuminous ingredient, found, as he
supposed, only in the  urine of pregnancy. When the
urine of a pregnant female was allowed to stand  in a
   117.  G. Confervoid Growths.—Torula Ce-
revisia—Fungoid Growths—Vibnones, &c, have
been  described  as existing in the urine, in  cer-
tain states of the frame, chiefly  characterized by
remarkable depression of vital power.   The ex-
istence of these may be imputed to the presence
of  albuminous, fibrinous, saccharine,  or other
matters in the urine, and to changes which have
taken place in these after the urine has been dis-
charged, although they may  possibly  be formed
in the bladder,  when the urine  is long  retained
in these morbid states  in this viscus, especially
when the vital energies are very  much depressed,
and the other circumstances favourable to these
productions, already adverted to (y 82), arc pres-
ent.
   118.  H.  Hydatids have been passed in the
urine;  but cases in  which they thus  have been
observed  are extremely rare.   Instances have,
however,  been  recorded in  the Philosophical
Transactions (No. 273), and  in  the Medical  Ob-
servations and Inquiries by Mr. Russel (vol. iii.).
A case came before me many years ago, in which
a  number, varying in size from a small pea to
that of a large  bean, were passed in the course
of two  or three days.   Soon afterward  the case
passed  from under my observation, without be-
ing able to ascertain  its issue.
   119.  xii. Foreign Bodies—Worms, &c, have
been  often  found in  the  urine, in some  cases in
consequence of having been  introduced into the
bladder, in others from having been put into the
urine with the  intention of deception ,  and in
more instances  owing to their passage by ulcer-
ation, penetration, or otherwise, through the pa-
rietes of some portion of the digestive canal, or

glass vessel, a cotton-like, cloudy deposit first appeared,
afterward oblong points or specks, which, increasing in
number  and  agglomerating, covered the surface of the
fluid and the sides of the vessel, in  the form of a firm,
tenacious pellicle.  Eqiihifb followed, sustaining the
same positions.  In 1S40, Dr. G. Bird published the re-
sults of his observations on the urine of thirty pregnant
females, and came to the conclusion that the pellicle no-
ticed by Nauche - as composed of the triple phosphates,
with some granular and oily matter; and though fur-
nishing a strong corroborative test of pregnancy, is not,
however, an entirely reliable one.  Our distinguished
countrym:-.u, the late Elisha K. Kane, in his inaugural
dissertation (Am.  Journ. of Med. Science, N. S., vol. iv.,
1842), from a great number of experiments and observa-
tions, came to the following conclusions:
  "1st. That the kiesteine is not peculiar to pregnancy,
but may occur whenever the lacteal elements are secreted
without a free discharge at the mammae.
  11-2d. That though sometimes obscurely developed, and
occasionally simulated by other pellicles, it is generally
distinguishable from all others.
  " 3d.  That where pregnancy is possible, the exhibition
of a clearly-defined kie<teinic pellicle is one of the least
equivocal proofs of that condition ; and,
  "4th.  That when this pellicle is not found in the more
advanced stages of supposed pregnancy, the  probabili-
ties, if the female be otherwise healthy, are as 20 to 1
(31  to 4), that the prognosis is incorrect."
  More recently, Dr. G.  'P. Klt.iot. Jun., of New York
(.V. 1'. Journal of Med.,  Sept., 1858), has published the
results of his experiments on the urine of 16!) pre  nant
females, and concludes that there are no recognisable pe-
culiarities in the urine of pregnancy, that there is noth-
ing oositive in the indications furnished by kiesteine,
and that its appearances can  scarcely ever  be called
"corroborative" of pregnancy (Loc. cit, p. 181).  On the
whole, the opinion of Lphmans  seems most probable,
viz., that " kiesteine is nothing else but the formation of
crystals of triple phosphate, and fungoid and ronfervoid
growths, which take place when the urine becomes alka-
N°e" (Phy*. Chemistrii.  Philad., 1856).  According to
Professor Pb \pee, kiesteine is composed of casein, butjirv
fat, and the phosphate of magnesia,  and is a normiil in-
gredient in the blood, especially of pregnancy, being gen-
erated from its albumen oid compounds at the rate orn bout
30 grs. per hour (Human Phys.  N. Y., 1856, p. 231).] 
URINE AND URINARY DEPOSITS—Gravel, and Urinary Concretions.    1339
abdominal parietes.  Whoever may be desirous
of perusing cases of this description will find a
number of them  related in the Ephemerides  of
Natural Curiosities,  and in the Memoirs of the
French Academies, and various "other works enu-
merated by Ploucquet and Reuss.
   120. IV. Gravel.— Urinary deposits, such as
are above described,  are formed on the cooling of
urine, and are, as described, either loose and pul-
verulent,  or more concrete, crystalline, or sand-
like.   These deposits, although associated with,
or  symptomatic  of,  various diseases, may occa-
sion, as respects their  effects upon the urinary
organs, but little disorder.  But when deposits
are formed in the warm urine within the urinary
apparatus, owing either to the quantity of these
matters contained in the urine, or to changes in
the states of their constituents, or of temperature,
vital  endowment, &c, and are discharged with
the urine  in the form of a fine powder, or of crys-
talline, sand-like particles, or of small masses,
then  the disease is termed gravel, and the symp-
toms are sometimes  very severe.
   121 The discharge  of such gritty matters as
these with the urine  is usually attended by symp-
toms of irritation, and pain in the region  of the
kidneys,  ureters, bladder, and in  the urethra,
thereby  constituting while  characterizing the
complaint commonly denominated gravel.  The
signs of irritation may be slight, or they may be
severe in one or other  of the situations just
named, or even in two or more of them.  But
the signs, as well as the causes which produce
this condition ofthe  urine, are the same as those
which attend the formation of calculi in the urin-
ary apparatus, although they are very frequently
much less severe  The chemical constitution of
the gravel discharged  is generally  the same as
that of urinary calculi;  the difference consisting
chiefly in the constituents precipitated from the
urine being detached or incoherent, or forming
numerous minute crystals, instead of large con-
cretions, of many concentric layers.  In the for-
mer case, the deposits within the urinary organs
are washed away by the urine before they have
been  sufficiently  long retained to concrete into a
nucleus, or to become a large calculus—or to as-
sume the  characters  now to be described.—Cal-
culi. The treatment of gravel is manifestly the
same as that recommended for urinary deposits
and urinary calculi.  (See y 179, et seq.)
   122. V. Urinary Concretions or Calculi.—
Correct views as to  the composition and forma-
tion of urinary concretions or calculi are of com-
paratively recent  date.   Previously to Van Hel-
mont these concretions were believed to be de-
rived  from  matters  contained in the food and
drink; but he contended that they are not form-
ed  from  these sources.   Hales  confirmed the
opinions of Van  Helmont as to the differences
between urinary concretions and common  stones,
and first directed  attention to the discovery of a
solvent for these  concretions.   Boyle, Whytt,
Alston, Slare, and others, subsequently spec-
ulated on the  subject  of solvents for calculi.
Whytt proposed lime-water for  this purpose;
and Alston contended that, although lime-water
is of some service in urinary affections, it is not
a solvent  of calculi.  At the commencement of
the last century the  Leyden School of Medicine
taught more correct doctrines  ofthe formation of
urinary concretions than had previously been en-
tertained,  and showed that these nuclei were de-
rived from the kidneys or from the bladder.   Van
Swieten contended that the elements of calculi
exist in the urine of men  the most healthy, and
that if the urine be evacuated before these ele-
ments  concur, in the formation of a concretion,
no such production takes place.  He considered
that the concurrence ofthe elements in the form-
ation of calculi is exerted more  or less slowly in
different persons; and that according to the ra-
pidity or slowness of such formation, the concre-
tions arc formed either in the kidneys or in the
bladder.  In  1776 Scheele discovered uric acid,
and  found it  in all  the  calculi  he examined, as
well as in all the urine.  Bergmann soon after-
ward discovered lime in certain concretions.   In
1797 Wollaston published his discovery of three
calculi in addition to those described by Scheele
—viz , the fusible, mulberry, and the bone-earth
—and demonstrated the chemical composition  of
these calculi.  A few years afterward, Fourcroy
and Vauquelin announced the presence of urate
of ammonia  and silica  in urinary concretions.
Dr. Wollaston, in 1810, discovered cystic oxide
as an urinary calculus.   Dr. Marcet published
an able work on urinary  concretions in 1817 ;
and  Dr Prout furnished, in  1821, more extend-
ed and exact views as to  their formation in his
treatise on this subject.   Since this period the
works of Mr. Wilson, of Sir B.C. Brodie, of Mr.
Crosse, of Norwich, of Dr.  T.  Thomson, of Dr.
Cumin, of Dr. Owen Rees, of Dr. Bence Jones,
of Mr. Coulson, and the more recent publications
of Dr.  Prout, have carried  the pathology and
treatment  of urinary concretions to their present
very high position in practical medicine and sur-
gery.
  123   A.  The form  of urinary  concretions is
generally  more or less  globular or  ovoid, espe-
cially after remaining long in the bladder.  Renal
calculi are, however, often of an irregular form,
owing  to their being moulded in the pelvis ofthe
kidney, &c, or  are  branched  like  a coralline.
Sometimes those found in the ureter are cylin-
drical.   W'hen two or  more calculi exist in the
bladder they  often present a polyhedral or an  ir-
regular shape, from one or more of their sides
being flattened, either by attrition or by diminish-
ed concentric deposition on these sides.   Wrhen
the calculi formed in the kidneys and passed into
the bladder are irregular or branched, the shape
of the  nuclei which they constitute is not alto-
gether removed by the successive deposits form-
ed around them in the bladder.  W7hen a portion
of a  calculus is embraced by a fold ofthe mucous
membrane, or sacculated between the muscular
fasciculi or coats ofthe bladder, the part exposed
to the urine increases by successive deposits,  so
that the sacculated portion ultimately appears to
form a pedicle to the entire calculus.  (Coulson.)
  124. B  The size and weight of urinary con-
cretions are most various—ranging from a few
grains  to  many ounces.   Earle mentions one
weighing forty-four ounces ; Lister, one of fif-
ty-one  ounces; and Morand, one weighing six
pounds three ounces !   The concretion described
by Earle  measured sixteen inches in circumfer-
ence.  The number of calculi coexisting in the
bladder or in the kidneys  is  often very various.
Most frequently vesical calculi are solitary ; but
two or even more are not uncommon.  They arc
often numerous in one or both kidneys, but gen-
erally not equally so in both.   From ten to twen-
ty or even thirty in both are not uncommon. An 
1340
URINE—Urinary  Calculi described.
equally great number are very rarely found in the
bladder, although it is stated that fifty-nine small
calculi were found in the bladder of Buffon.
   125.  C  The surface of calculi also varies in its
colour and characters.  The colour passes from
" white through pale  yellow to brown, brown-
ish-green, and even almost to black.  Phosphatic
calculi  are often white;  those  of uric acid vary
from yellow to brown;  those  of xanthic oxide
have a cinnamon  brown tint; while calculi of
oxalate of lime  vary  from yellow  to  yellowish-
brown, brownish-green, or even blackish-green."
The surface is either smooth, and even polished,
or covered with minute crystals, or more or less
rough, and even tuberculated, as in the mulberry
calculus.
   126.  D. The internal structure or section of a
calculus is either uniform, or formed  of concen-
tric  layers surrounding the nucleus; and, in ad-
dition to  the concentric lines indicating the sep-
aration of the layers, other lines, radiating from
the  nucleus  to  the periphery, are observed in
many of the concretions.  In  some the concen-
tric  "layers are easily separable,  in others  very
firmly  adherent, especially when the layers are
indicated only by very faint  lines, as in the oxa-
late of lime calculus.
   127. E. The  chemical composition  of the  nu-
cleus, and of the concentric layers or deposits
may be the same;  or that  of the  superimposed
strata may differ from the nucleus, or each ofthe
strata may be different. The constituents are,first,
those which  form entire calculi or layers  in  a
nearly pure state, and, secondly, those which con-
tain,  associated  with these constituents, small
quantities of other substances.
   128  First  Class.-I.  Uric  acid.   2.  Uric or
xanthic oxide.   3.  Urate of ammonia.  4. Cyst-
ic oxide,  or cystine.  5.  Ammoniaco-magnesian
phosphate.   6.  Oxalate  of lime.   7.  Phosphate
of lime.  8. Carbonate of lime.  9. Mixed phos-
phate of lime, and  phosphate  of  magnesia  and
ammonia.         •                  .     ,. ,
   129. Second Class.— Those concretions which,
with the foregoing, contain the following in small
quantities : 1. Urate of potass.  2. Urate of soda.
3. Urate  of lime.  4. Urate  of magnesia.   5. Car-
bonate of magnesia.  6. Silica.  7. Organic mat-
ter, fat, extractive, albumen, vesical mucus, blood.
In addition to these, oxide of  iron, benzoate of
ammonia, phosphate of iron, urea, oxalate of am-
monia, hydrochlorate of ammonia, in very minute
quantities, are said to have been formed.
   130. The  following Table,  drawn up by Dr.
 Bence Jones, shows  the readiest means of as-
 certaining the composition of urinary calculi:
1. By Heat     2. By Acids.
3. By Alkalies.
Destroyed
 by heat. 1
(Soluble in carbonate of potash,
  evolving ammonia.
Soluble in carbonate of potash,
  evolving no ammonia.
In ammonia, soluble, crystal-
  lizing when evaporated.
With nitric acid, -j In ammonia, soluble, not crys-
    not red.         tallizing when evaporated.
 Nature of
 Calculus.
Urate of am-
  monia.
 Uric add.
Cystic oxide.
Uric or xanthic
    acid.
fWith hydrochloric
   acid, soluble; be-
   fore heat  effer-
   vesces.
  Not
destroyed ■
 by heat,
With hydrochloric
  acid, soluble; aft-
  er heat efferves-
 With  hydrochlor-
   ic acid, soluble,
   without efferves-
   cence, or  before
1^  or after heat.
 In ammonia with  difficulty j
,   soluble, not crystallizing,   j
(Solution in  acid, when  neu-~
   tralized, gives a white pre
   cipitate with carbonated al
   kalies and oxalate of ammo-
   nia.
 Solution in  acid, when  neu-
   tralized, gives a white pre
   cipitate with carbonated al
   kalies and oxalate of ammo
(^  nia.
'Solution in  acid, with excess
   of  ammonia,  gives a white
   crystalline precipitate.
 Solution in  acid, with excess
   of ammonia, gives an amor-
   phous white precipitate.
 Solution in acid,  with excess"]
   of ammonia, gives a white, !
   partly  crystalline,  partly [
•!
                              amorphous precipitate.

   131.  i. Uric Acid Calculus.—Uric acid is the
most frequent constituent of urinary concretions,
either alone or in combination with bases, espe-
cially urate of ammonia, &c.  Calculi consisting
of uric acid only, or containing in addition a small
quantity of colouring matter, are more common
than those of any other single constituent.   Mr.
Coulson states the  relative  number of pure uric
acid calculi in the Museum of the College of Sur-
geons  to be  one third of the whole collection.
Dr. Prout estimated the general average of this
concretion in the several known collections to be
nearly 1: 6£.   The  relative  proportions  of those
Fibrin.
Carbonate of
   lime.
Oxalate of lime.
Phosphite of
ammonia and
 magnesia.
Phosphate of
    lime.

 Mixed phos-
   phates.
       Additional Tests.

I Soluble in water when boiled.
j Not  soluble in water when
j   boiled.
fSoluble in etrong caustic pot-
   ash ; the solution gives sul-
   phuret of lead when boiled
   with a solution of acetate of
   lead.
"Dissolves  without  efferves-
   cence in nitric acid, leaving
   a lemon-coloured residue,
   soluble in strong sulphuric
   acid, not precipitated by di-
   lution.
~With nitric acid becomes yel-
   low.
Soluble in dilute acetic acid,
  with effervescence.
 {Insoluble in acetic acid.  De-
   composed by strong sulphu-
   ric  acid, yielding carbonic
   acid and carbonic oxide.
( With phosphate of lime ia
\  very fusible before the blow-
(  pipe.
( With phosphate of magnesia
)  and ammonia is very fusible
(  before the blow-pipe.

( Easily fusible, without addi-
f  tion, before the blow-pipe.
composed chiefly of uric acid  mixed  with urate
of ammonia, and of urate of ammonia with minute
proportions of urate and oxalate of lime and phos-
phates, are estimated at 1 : 3£ ; and including the
calculi in which  the  nuclei are formed of uric
acid, the proportion is  about 1  : \\.   The  calculi
into which  uric acid enters in larger  or smaller
proportions, as one ofthe constituents, in the Col-
lection ofthe London College of Surgeons, are as
1 to 1 36 of the whole number.  Two chief varie-
ties of this calculus consist—1st, of that  in which
the uric acid is deposited in more or less distinct
concentric layers, the section of the calculus pre- 
URINE—Urinary Calculi described.                         1341
senting a series of concentric circles of a compact
and semi-crystalline structure;  2d,  of that  in
which the acid forms a mass of crystalline amor-
phous  grains.   These varieties, however, often
are mixed, or pass into each other.   The first of
these have a somewhat granular or finely tuber-
culated, but smooth or polished surface.  When
broken, the fragments are angular, whose surfaces
are fibrous, as if the concretion were composed
of crystalline fibres  radiating from  the centre  to
the circumference.   The fracture is always in the
direction of these radiating fibres and ofthe con-
centric layers.   The second variety, in which no
concentric lamellae  are seen, consists either  of a
firm aggregation of crystalline grains presenting
a radiated appearance, or of a porous and earthy
structure, often more  or less  loosely  cohering.
These  calculi are less regular than the  former,
"have a rough  surface, a granular and  unsym-
metrical  fracture, and are most  frequent in the
kidneys.   The  nucleus of the  laminated variety
frequently presents this character.  This form  of
calculus  is  more liable than the compact lami-
nated variety to spontaneous fracture in the blad-
der."   Calculi  sometimes present  cracks in the
direction of the radiating fibres,  probably owing '
to an unequal density in the deposits.*

   [* characteristics and tlsts of ubisaby deposits.
                   I. Coloured.
   (A.) Crystalline, which is uric acid, rhombic form, or
square tables, soluble  in nitric acid by heat in efferves-
cence; on evaporation, leaves a beautiful pink deposit
(mureid of Liebig), becoming pu-ple on  the addition of
ammonia; soluble in a boiling solution  of potash,  from
which hydrochloric acid precipitates it as a white, gelat-
inous substance, 6peed;ly becoming crystalline. Before
the blow-pipe blackens and dissipates with a peculiar
animal odour.
   (B.) Amorphous, which may be,
   I. Pink, red, or yellow Urate of Ammonia; is soluble in
hot water, and again deposited on cooling; soluble in
boiling solution of carbonate of potassa;  boiled with so-
lution of potassa, evolves ammonia: has all the charac-
ters of uric acid with nitric acid.  Before the blow-pipe
comports itself as uric  acid, except that  it gives out am-
monia and decrepitates strongly.
   II. Red  or brown Blood.—Urine  becomes opaque  by
heat or nitric acid; microscope detects the blood disks,
which often subside,  and form a distinct layer at the
bottom of the vessel. Chloride of sodium and other neu-
tral salts heighten the colour.
   III.  Gre, n or brown  Bile.—If from  the brown colour-
ing matter (biliphocin), on addition of nitric  acid, the
urine becomes blue, then green, afterward violet and red,
and lastly assumes a yellow or yellowish-brown colour;
if in small quantity, the intermediate colours are not ob-
served ; hydrochloric acid changes the urine to green.  If
from bilin, this may b.; detected by Pettinkofer's test, as
follows: (Add to the urine, by drops, two thirds of its
volume  of sulphuric acid, keeping the  mixture below
144°;  add a few drops of a solution  of cane-sugar (1 to 5
of water), and shake the mixture, when, if bilin be pres-
ent, a violet-red colour will be developed.)
                  II.  Colourless.
   (A.)  Crystalline, which may be,
   I. Oxala'e of Lime.—Octahedral or quadrilateral crys-
tals, insoluble in acetic acid soluble in nitric and hydro-
chloric acids; boiling with carbonate of potash forms sol-
uble oxalate of potash  and -'nsoluble carbonate of lime.
The former gives characteristic  rcaetions with chloride
of calcium, sulphate of copper, and nitrate of silver: be-
fore blow-pipe becomes carbonate of lime.  On continuing
the heat, lime only is left, giving out heat on the addi-
tion of water, and browning turmeric paper.
  II. Phosphate of Ammonia and Magnesia (triple phos-
phate).— Right rectangular, or trilateral crystals, soluble
in diluted  mineral and acetic acids, from which, by an
addition of ammonia, precipitated in a crystalline form ;
soluble in boiling solution of potassa, with  evolution of
ammonia.  Before the blow-pipe gives off ammonia, and
runs into a white enamel; addition of phosphate of lime
imparts ready fusibility.
  III.  Cystine, in  simple or compound tables, insoluble
in boiling  water,  soluble in ammonia (with odour of
sweet-briar) and alkalies, and precipitated by acetic acid;
  132.  A  third variety of uric acid calculus  is
known  as  the pisiform, and is very common.   It
is seldom  solitary ; many may exist at the same
time in the bladder, and some may be voided by
the urethra.  They are chiefly formed in  the kid-
neys, and are rarely larger than a common bean
or large pea. They have irregular angular shapes
caused by  attrition  against each other, are crys-
talline, laminated  near the surface, and often coat-
ed with a thin layer of urate of ammonia.
  133.  The  specific gravity of uric  acid calculus
varies with the density, and is usually from 15
to 1786 ;  but  it  has  been  observed in  rare in-
stances as low as 1276.  The colour of this cal-
culus varies from  pure white to a  deep brownish-
red, the colouring matter being of the same na-
ture as that ofthe urine, (y 18.)   Uric acid is in-
soluble in  alcohol and ether, but is soluble in so-
lutions  of potash  and soda  when  heated, and in
phosphate and  biborate of  soda,  and is  precipi-
tated  from these by acids.  Solutions of the alka-
line bicarbonates  do not dissolve it.  Nitric acid
dissolves and decomposes it, equal  volumes  of
carbonic acid and nitrogen being evolved.  " Sul-
phuric  and  hydrochloric  acids do not affect  it.
Uric acid is a feeble acid, but combines with bases,
and forms salts with them.   The  alkaline urates
are sparingly soluble, but very much more so than
the pure acid."
  134.  ii. Urate  of ammonia calculus, unmixed,
is rare.   In the collection ofthe College of Sur-
geons it exists  in the proportion  only of one in
500, although this substance forms the nucleus of
nearly one third ofthe whole collection.—(Coul-
son.) Dr. Prout, in 1823, first fully demonstrated
the nature of this concretion,  which seldom ex-
ceeds an inch in diameter, and is  almost  peculiar
to childhood.   It very  rarely  occurs in an  un-
mixed state after  puberty, and its  formation is  at-
tended  by much  constitutional irritation.   It is
flattened,  ovoid, smooth, of a brownish-grey or
clay colour,  often with a greenish  tinge,  It is
usually compact in structure, earthy and brittle,
consisting of thin concentric layers,  so closely ap-
plied  to each other as to  appear homogeneous.
The laminae are, however, easily separated.  Urate
of ammonia is a common deposit from urine, hav-
ing an alkaline  reaction, carrying  with it more or
less colouring matter, which gives it a yellow or
brown hue.   In  its pure state it is  white, and
much more soluble in water than  uric  acid.
  135.  This salt  is often associated with oxalate
of lime  in  calculi, the formation of this latter be-
ing preceded by a condition of the urine which
favours the deposit of urate of ammonia, ^o that
the nucleus  may  be formed of urate of ammonia,
while the  surrounding  layers  are a mixture  of
these salts.  These calculi sometimes also con-
insoluble in alcohol, tartaric and oxalic acids, and bicar-
bonate of ammonia.
  (B.) Amorphow, may be,
  I. Phosphate of Lime, readily soluble in dilute hydro-
chloric and nitric acids, sparingly in acetic;  precipitated
by ammonia in an amorphous condition, forming, when
collected rn a filter, a horny mass; oxalate of ammonia
in these solutions gives a white precipitate.   Before the
blow-pipe, first black, then white, leaving an ash wliich
is neut al.
  II.  Urate of Ammonia.—Characters as above.  (Col-
oured B.)
  Pus.—The microscope detects pus globules.  The urine
coagulates more or less by heat;  soluble in a solution of
potassa, forming a tenacious, glairy fluid.
  Mucus.—Insoluble in potassa; imparts little or no al-
bumen to the mine ; therefore slight or no coagulability
by heat, &c] 
1342
URINE—Urinary Calculi described.
 tain a small quantity of urate of lime.   Urate of
 ammonia is  also frequently  associated with the
 earthy phosphates, either as a nucleus or in alter-
 nate layers, or mixed in various proportions with
 the other constituents.
   136. iii. Xanthic or uric oxide calculus is so very
 rare as hardly to deserve notice, only four speci-
 mens of it having been found.  It may be distin-
 guished by the means stated in the Table given
 above (y 130).
   137.  iv. Cystic oxide calculus is also rare.  It
 is a product ofthe kidneys only, and hence should
 be differently named.  Dr. Prout found it  only
 in four out of seven museums.  That ofthe Col-
 lege of Surgeons contains one or two specimens.
 It is small, round, and yellowish, with a smooth
 semi-transparent and glistening  surface.   This
 substance is generally free from admixture  with
 others; " but uric acid sometimes forms the nu-
 cleus,  and a layer of uric acid has been found
 surrounding a nucleus of cystic oxide.   It is also
 occasionally  associated with  ammoniaco-magne-
 sian phosphate and carbonate of magnesia."
   138. v. Oxalate of lime calculus, in an unmixed
 state, exists in the Museum ofthe College of Sur-
 geons in the proportion of 1:20 ; in that of Saint
 Bartholomew, as 1:15; and in that of Guy's
 Hospital, as  1 : 14£.   When  oxalate of lime cal-
 culi  having nuclei of urate of ammonia are in-
 cluded, the proportion in the Museum ofthe Col-
 lege of Surgeons is 1 in 34.  If all the calculi be
 taken in which the oxalate of lime exists in any
 amount, then  the proportion  is, according to Dr.
 Prout, in St. Bartholomew's  Hospital, 1 : 44 ; in
 Guy's, 1:4;  in Norwich, 1 : 7J-; in Manchester,
 1 : 6^ ;  in Bristol, 1:3$-; in Swabia, 1: 27 ;  and
 in Copenhagen,  1 :2-r\j, the  average proportion
 being 1 : 4J-.   Oxalate of lime  calculus is rarely
 pure, being associated with  urate of  ammonia,
 uric  acid, urate and  carbonate of lime, colouring
 matter, and blood.  This calculus, long  known by
 the name of Mulberry Calculus from its tubercu-
 lated surface  and its  resemblance to that fruit, has
 usually a rounded shape, its  surface being dark-
 brown, or nearly black.  Its internal structure is
 compact and hard, imperfectly lamellated, the lay-
 ers forming waving lines, the colour of which is
 such as to give the surface of its section a resem-
 blance to a section of a piece of gnarled oak, varying
 from white or yellow to yellowish-brown, or dark
 brownish-green.   The tubercles ofthe surface ap-
 pear to consist of stellate crystals.  A second va-
 riety ofthe oxalate of lime  calculus is crystalline
 throughout, its surface being  studded with crys-
 tals of .the oxalate in acutely-angled octahedra,
 these being nearly pure oxalate of lime. A third
 variety consists of small rounded masses, with a
 smooth, polished  surface,  known as the hemp-
 seed calculi   It is occasionally crystalline at the
 centre and laminated toward the surface, but the
 laminae are so fine as to give the section almost a
 compact  appearance.  It is composed of mixed
 oxalate and phosphate of lime in variable propor-
tions.
   139. vi. Phosphate of lime calculus is rare, es-
pecially in a state of purity.  Two varieties have
been described, " one evidently of renal, the other
of vesical origin.   Although entire calculi of pure
phosphate of lime are uncommon, this substance
is often found nearly pure in the laminsa of altern-
ating calculi."  Dr. Prout  states that calculi of
phosphate of lime are in the ratio  of 1 :32^ in
St. Bartholomew's Hospital;  of 1:29 in Guy's;
 of 1 : 132 in Norwich; and of 1 : 155 in the Bris-
 tol hospital.   The  general proportion of  these
 calculi to others is 1 : 117.  No specimen exists
 in the Museum of the College  of Surgeons, and
 in some other collections.  The calculi considered
 renal are composed of the neutral phosphate of
 lime ;  those considered vesical are more common
 than the former.  Concretions  of neutral phos-
 phate  of lime are usually pale-brown, with a pol-
 ished  surface, regularly laminated, and the  lami-
 nae so slightly adherent as to  be easily separable
 into concentric crusts.   In some, radiating lines
 are  seen perpendicular to the laminae.  Those
 calculi contain animal matter which is precipi-
 tated from the alkaline urine with the phosphate
 of lime.
   140. vii.  Ammoniaco-magnesian phosphate cal-
 culus  is commonly  known as the " triple phos-
 phate."   This double salt rarely forms an entire
 calculus, but  is  a very common  constituent of
 other  calculi, either mixed with phosphate  of
 lime, as in the fusible calculus, or forming layers
 in alternating calculi.   The proportion of calculi
 consisting of pure phosphate of magnesia and
 ammonia, in the collection of St. Bartholomew, is
 as 1 : 129 ;  in Guy's,  as  1 : 43£ ;  in the  Bristol
 hospital, 1 : 218 ; in Copenhagen, 1 : 194 ; in the
 Museum ofthe College of Surgeons, 1:200; while
 the  other  collections  mentioned  by Dr.  Prout
 contain no specimen. The general ratio is 1:126$.
 Ammoniaco-magnesian phosphate is a frequent
 deposit from alkalescent urine, but usually mixed
 with more or  less phosphate of lime.   Calculi of
 this  double salt " are generally white, uneven,
 and roughened by the projecting summits ofthe
 crystals, which are transparent in the recent state,
 but opaque and without lustre  after being kept
 for some time.  These calculi  are either not lam-
 inated or imperfectly so, are friable and easily re-
 duced to powder. But occasionally they are hard,
 compact, and laminated ; exhibiting a semi-trans-
 parent crystalline fracture, which gives them the
 aspect of alabaster."  (Coulson, Op. at., p. 291.)
   141. viii.  Fusible Calculus.—Calculi known by
 this name consist of a mixture  of phosphate of
 magnesia and ammonia, with  phosphate of lime
 in very variable  proportions;  and they form a
 considerable portion of all collections.   In the
 College of Surgeons they are as 1:134;  in St.
 Bartholomew's as 1 : 12^ ; in Guy's, 1 :34; in
 Norwich, as 1:19 ; in Manchester, 1: 8i ; in Bris-
 tol, 1 :  12;  in  Swabia,  1:114-; and in Copenha-
 gen, as 1: 194, according  to Prout, the average
 proportion  being  1 : 12L   Fusible  calculi are
 white,  gray, or dull yellow, and more friable than
 any others," being sometimes so soft  as to whiten
 the fingers like  chalk when handled: these are
 not laminated.   Others  have  distinct lamellae,
 with sparkling crystals of triple phosphate be-
 tween them, which are so slightly adherent as to
 be readily separated ; others, again, are composed
 of crystals  aggregated into a  confused mass."
 These  calculi  are usually globular or  ovoid, but
 sometimes very irregular in shape,  being occa-
 sionally moulded by the cavity in which they are
 formed.  "They often attain  a larjre size, and
sometimes fill the whole cavity of The bladder;
in this  case  impressions of the folds  of the  mu-
cous membrane are  visible on the surface, and
when two or more in the bladder, they take a cu-
bic or  tetrahedral form."   Excrescences  com-
posed of triple phosphate  are  sometimes  found,
resembling pearls.  The ammoniaco-magnesian 
URINE—Urinary Calculi described.                       1343
phosphate is most abundant in those which have
a shining crystalline texture, the phosphate of
lime in the earthy and amorphous variety.   The
fusible calculus is found in all parts ofthe urina-
ry organs, and in large cysts, or in cavities in the
prostate  gland.   According to  Mr. Taylor, the
earthy phosphates are rarely succeeded  by any
other deposit; the only exceptions being one in
the College of Surgeons, in which layers of mixed
phosphates exist in  an oxalate  of lime calculus,
and one  in St. Bartholomew's Hospital, in which
a fusible calculus is surrounded by a layer of uric
acid.  The two ingredients of fusible calculi seem
to have a distinct origin, the ammoniaco-magne-
sian  phosphate  being derived  from the  urine,
while the phosphate, with a small proportion of
carbonate of lime, is secreted together with mu-
cus by the irritated mucous membrane.  This is
shown in calculi formed around a foreign body
introduced into  the  bladder.  This body is first
incrusted with phosphate  and carbonate of lime,
derived,  it is believed, chiefly from the mucous
surface of the bladder ; and  subsequently, the ir-
ritation being extended to the kidneys, the urine
becomes  alkaline,   and   ammoniaco-magnesian
phosphate is deposited, the layers  near the nu-
cleus containing more phosphate  of lime than
those near the surface ofthe calculus. Asa sec-
ondary deposit the  mixed phosphates are very
common, few calculi remaining for a long period
in the bladder without being incrusted by them.
The uric acid calculus is least subject to this
incrustation.   These calculi commonly contain
urate of ammonia and animal matter in consider-
able proportion, together with carbonate and urate
of lime and uric  acid.
  142. ix. Carbonate of lime calculus, associated
only with a  little animal  matter, is very  rare in
the human subject,  but common  in herbivorous
animals,  usually mixed in these with carbonate
of  magnesia.  Carbonate of lime  is,  however,
often found in variable proportion  in the oxalate
of lime and phosphatic calculi.  Brugnatelli,
Prout, and  Smith have described the carbonate
of  lime  calculi.  They are always small, the
largest not exceeding the  size of a large almond ;
are white or gray, but sometimes  yellow, brown,
or reddish, and the surface is dusted over with a
white powder. They show no concentric lamina;,
but irregular waved lines similar to those in the
mulberry calculus.  They are sometimes remark-
ably hard, and capable of receiving a high polish.
Others passed by the  urethra of  a rounded and
flattened  form are compact,  lamellar, and light
brown.   " No specimens of this calculus exist in
the  museums enumerated  by Dr.  Prout, nor in
that ofthe College of Surgeons."   "Mr.  Smith
describes eighteen removed from the bladder of a
young man ; and Brugnatelli forty-eight from
a similar source,  and sixteen, the  size of a nut,
from a woman."
  143. x. Alternating  calculi form a very large
proportion of those formed in the human urinary
apparatus.  This alternation of the constituents
in the layers of  the  same  calculus is manifestly
owing to successive changes in the urinary se-
cretion, depending upon varying states ofthe con-
stitution  and vital and assimilative power.  Al-
ternating calculi  consist of a series of alternating
layers, differing in chemical composition.   Some
are  composed  of two  layers, a nucleus  of uric
acid being covered by  a deposit of urate  of am-
monia, or of oxalate  of lime, or phosphate of lime,
or mixed phosphates.  The nucleus may be ox-
alate of lime, followed by uric acid, or urate of
ammonia, phosphate  of lime, or mixed  phos-
phates.   " Other  calculi  have three  differently-
constituted layers; thus, a nucleus of uric acid
may have deposits of oxalate of lime and mixed
phosphates, or oxalate of lime and uric acid; or
a nucleus of oxalate of lime, covered by uric acid
and urate of ammonia;  or  a nucleus of mixed
phosphates followed  by  phosphate of lime  and
mixed  phosphates.   Others, again,  consist  of
four or even more layers  : thus, a nucleus of uric
acid incrusted by urate  of  ammonia, uric  acid,
and urate of ammonia;  or  oxalate of lime, fol-
lowed by uric acid, oxalate of lime, phosphate of
lime," &c.   (Op.  at., 296.)
   144. The  proportion of alternating calculi, of
two layers differing in chemical constitution, ap-
pears from  several  sources to  average  1 : 2j[.
The proportion of calculi consisting of three al-
ternations are 1 : 8£ ;  and of those of four altern-
ations in the Norwich collection are 1 : 264-  The
order in which different deposits succeed  each
other in calculi has been examined by Dr. Prout,
with the view of elucidating the  changes in the
economy upon which this order depends.   He
found that the frequency of alternation of uric
acid and oxalate of  lime is nearly equal; that
oxalate  of lime follows urate of  ammonia more
frequently than uric  acid ; that the general ratio
in which phosphates  succeed other deposits in all
the collections is  1  :4-jAj ;  and   that  a decided
deposition of the  mixed phosphates in  calculi is
not followed by other deposits.
   145. xi. Fibrinous calculus was first described
by Dr. Marcet.   It is stated by Dr. Prout to be
usually of an amber colour and waxy consistence,
with more or less of a fibrous texture.   As to the
chemical tests for this and  the other calculi de-
scribed above, I must refer the reader to the Table
given above  from  Dr.  Blnce Jones (y 130); and
to the chapter on " The Chemistry of Urinary
Concretions," in Mr Coulson's able work already
referred to.
   [ Chemical Composition of Calculi in the United
States.—It is to be regretted that so little atten-
tion has been paid to the  chemical analysis of
our calculi.   So far as they have  yet been ascer-
tained, they are as follows :
   Ofthe 15 calculi,  removed from as many pa-
tients, by Dr. J. Mason  Warren, of Boston, 2
were of pure lithic acid ;  1 lithic  acid with layers
of phosphates ; 3 phosphate of lime ; 3 oxalate of
lime ; 2 oxalate of lime, with phosphates ; 1 cystic
oxide ; 2 triple phosphates.
   Of the 22  calculi, in the Museum ofthe Boston
Society  for  Medical  Improvement, from various
parts  of New England, 5 consist of uric  acid,
surrounded in one by thin layers of oxalate of
lime and the mixed  phosphates; 3 of uric acid
and the  urates ; 1 of urate of ammonia ; 2 of uric
acid and  mixed phosphates ; 1 of urate of ammo-
nia and  mixed phosphates ;  1 of uric acid and
urate of ammonia, inclosed by mixed phosphates ;
1 of uric acid and mixed  phosphates, with urates
of potash and ammonia; 1  of urate of ammonia
and oxalate  of lime;  2 of phosphate of lime ; 2
of mixed phosphates ; 2 of oxalate of lime ; and
1 of oxalate of lime and mixed phosphates.
   Of 5 operations for stone, performed by Pro-
fessor F. H. Hamilton, of Buffalo, 1 was a fusi-
ble calculus, with oxalate of lime as a nucleus ; 1
urate of ammonia; 1 fusible calculus with carbon- 
1344                        URINE—Urinary Calculi described.
ate of  lime;  1 fusible  calculus  with traces of
lit hates.
  Of 22 calculi removed by Professor Van Bu-
ren, of New  York, 2 were  pure  lithic acid ; the
rest were compound in their character, principal-
ly triple phosphates.
  Of 14 cases of lithotomy  performed by Dr.  J.
Dickson,  of Alleghany, Pennsylvania, in  13 the
stone was lithic acid; in 1 phosphate of lime.  Of
the cases of urinary disease occurring in Western
Pennsylvania  and Ohio, the  same surgeon states
that the great majority labour under the lithic
acid diathesis, about ten  per cent,  under the phos-
phatic, and about five per cent, under the oxalic.
  Dr. Charles Frick,  of Baltimore,  states  that
the great majority of urinary concretions  in  that
city are composed either of uric acid or oxalate of
lime, the phosphatic being very rare ; of 32 sep-
arate  specimens of calculi removed by Professor
N.  R. Smith, of Baltimore,  the same  chemist
found, on analysis, 4 of pure uric  acid ; 4 of pure
urate of ammonia ; 10 of pure oxalate  of lime ; 6
of phosphates ; 2  of urate  of lirne ;  1  of pure
cystine ; 15 contained uric acid,  either alone or
combined.   The  patients came  from different
parts ofthe Middle and Southern States.
  Of 4 cases of calculi removed by Dr. Ogier, of
Charleston, South Carolina, 2 were mulberry, and
1 principally phosphate of ammonia and magnesia.
  Of 71 separate specimens of calculi removed
by  Dr.  Dudley,  of Kentucky,  the results  of
analysis by Professor Peter, arranged with refer-
ence to the nuclei and bodies of  the calculi, are
as follows:
1. Predominance of the uric acid in the nucleus in 36  6
2.       "       of urate of ammonia       "     41 38
3.       "       of oxalate of lime        "       14
4.       "       of earthy phosphates     "        8
5.       "       of cystine               "      3  2
6.       "       of foreign substance       *'      4  3
                                             71
         Simple Calculi; whole number, 31.
1. Predominance of uric acid in the concretion......  5
2.       "       of urate of ammonia  "   ......  9
3.       "       of oxalate of lime     "   ......  0
4.       "       of earthy phosphates  "   ......  0
5.       "       of cystine            "   ......  2
                                             31
        Compound Calculi; whole number, 40.
  II. Number of specimens  in which uric acid predomi-
nated :
  Number of calculi having a nucleus  of uric acid, 1.
  A. Nucleus of urate of ammonia:
    1. Bodies principally oxalate of lime........ 10
    2.   "      "      urate of ammonia..... 7
    8.   "      "     uric acid.............. 3
    4.   "      "     fusible............... 9
                                          29
  III.  Number of specimens in which  oxalate of
lime predominated :
  A. Nucleus of oxalate of lime:
    1. Bodies principally phosphates........... 2
    2-   "      "      uric acid............. 2
    3.   "            urate of ammonia..... 1
                                          "5
  IV. Number in which earthy  phosphates pre-
dominated :
  A. Nucleus of earthy phosphates:
    1. Bodies principally phosphate of lime..... 1
    2.   "     "     fusible............... 1
                                          2
  V. Number in which fusible phosphates  pre-
dominated:
  A. Nucleus of foreign substances:
    1. Bodies, triple phosphates, phosphate of
       lime, and urate of ammonia............ 1
    2. Bodies fusible, trace of uric acid and' urate
       of ammonia........................... \
    3. Bodies fusible......................'..". 1
                                          ~l
                    Total..................40
   The conclusions arrived at by Dr.  Peter are,
 first, that calculous diseases are more frequent in
 the  limestone than  in  the freestone regions of
 Kentucky ; and. secondly, that there is a larger
 proportion of phosphatic and  oxalate  of lime de-
 posits, with a greater number of nuclei of urate of
 ammonia, and fewer of pure uric acid  in the lime-
 stone than in the freestone districts of the State,
 or where the water is free from calculous matter
   Dr. E. B. Haskins has analyzed 176 Tennessee
 calculi, of which 107 were duplicates, the weight
 ofthe concretions  ranging from 2 grains to 1027,
 the  average being 91  grains, and the aggregate
 16,038 ;  the  lowest specific  gravity  1198, the
 highest  1 812; average, 1509.   Of this number
 there were of
 Earthy phosphates, 9, with an average spec gr. of 1.33S
 Urates,           5,     "     "      "      1.601
 Oxalate of lime,   1,     "     "      "      1.C89
 Mixed,          30,     "     "      "      1.538
   Chemical Results.—The whole number of cal-
 culi analyzed  was,  as  already stated,  176, 107
 being duplicates, leaving  thus 69 separate speci-
 mens.   The results are arranged with reference
 to the nuclei and bodies of the concretions :
   1. Predominance of the urates in the nuclei, 48
       (3 duplicates)..........................45
   2. Predominance  of oxalate of lime in the nu-
       clei, 20 (6 duplicates).................... 14
   3. Predominance  of triple  phosphate in the nu-
       clei, 101 (95 duplicates)................. 6
   4. Predominance  of phosphate of lime  in the
       nuclei.................................. 9
   5. Predominance of uric acid in the nuclei, 4 (3
       duplicates)............................. 1
   6. Predominance of foreign matter........... 1
                                           t9
   The number of simple  calculi, or nuclei with-
 out  bodies, was 44.   The number-Of compound
 concretions, or those having a body upon a nu-
 cleus, was 132, of which 78 were duplicates, leav-
 ing  54 separate specimens.
   1. Predominance of urates in the bodies....... 8
   2.     "      of  triple phosphates in  the
       bodies, 93 (75 duplicates)................18
   3. Predominance of oxalate of lime in the bodies 15
   4.     "      of  phosphate  of lime in  the
       bodies, 15 (3 duplicates)................ 12
   5. Predominance of uric acid in the bodies___  1
                                           54
  The compound calculi,  or those having both a
body and nucleus,  may be arranged  as follows:
  I. Number of specimens in which urates predominated:
   1. Number of calculi having nuclei of urates 8
  II. Number of triple phosphate bodies, 93 (75
duplicates):
   1. Number having nuclei of triple phos-
       phate, 76 (75 duplicates)...............  1
   2. Number having nuclei of urates.........  12
   3.    "            "   of oxalate of lime..  5
                                           18
  III. Number of phosphate of lime bodies,  14 (2
duplicates):
   1. Number having nuclei of urates..........  7
   2-    "     "     "   of triple phosphate,
       4 (2 duplicates)........................  2
   3. Number having nuclei  of oxalate of liine.  3
                                           12
  IV. Number of oxalate of lime bodies:
   1. Number having nuclei of oxalate of lime.  2
   *•    \\            "   of urates*........12
   3-                 "  of foreign matter .  1
                                           IS
  V.  Number of uric  acid bodies :
   Number having nuclei of urates............  1
__________           Total..................54

u [*  ?« Raskins U1*es the term  "urates" instead of
  urate of ammonia, because be has never found this
substance  to exist in any other form than in combination
with  urate of lime, or of soda,  or both.] 
URINE—Urinary Calculi, Causes of.
1345
  These results are very similar to those of the
Kentucky calculi.  Excluding duplicates, we have
71 Kentucky specimens, and 69 Tennessee.  Of
the former, the nuclei in 6 were composed nearly
entirely  of uric  acid, and in 8 of earthy phos-
phates ;  in the  latter, of uric acid in 1, and of
earthy phosphates in 8.
  Bases of the Urates—Dr.  Haskins analyzed
84 specimens of the urates, with a view  to deter-
mine their bases, and the results arrived at were
as  follows :  Ammonia was found in all; lime
with ammonia  in 83; soda  with  ammonia and
lime in 55 ; and soda with ammonia alone in  1.
For magnesia and potash no search was  made.
The ammonia largely predominated over both of
the other constituents.  Urate of lime, which has
generally  been  regarded as a rare ingredient of
urinary calculi,  was present in  83 of the exami-
nations, and usually  existed in larger quantities
than the soda.*]
   146.  VI. Causes of Urinary Calculi.—The
causes  of urinary concretions may be inferred
from what I have stated above with reference  to
the pathological conditions occasioning  the sev-
eral forms of urinary deposit, the concretions tak-
ing  place  in different parts  of the urinary appa-
ratus being merely early deposits in  those situa-
tions of the same constituents as are precipitated
by the urine after being discharged from the body.
Whether the concretions  are formed within the
body, or the deposits take place after the urine is
evacuated  from  the body, many, indeed  most of
their causes, are the same ; the states ofthe urine
which produce them arising chiefly from, (a), age
and habits of life ; (b), from climate, locality, and
race ; (c),  from  diet and regimen ; (d), from mor-
bid digestion  and assimilation ; (e), from patho-
logical states of the kidneys, and from the meta-
morphosis of tissues and of blood-globules, in con-
nexion, (/), with constitutional and vital condi-
tions.  But it may be asked, W7herefore should
concretions form within  the urinary organs, con-
sisting of the  same or nearly the same constitu-
ents as are deposited  from the evacuated and cold
urine 1   To this question the chief answer must
be  that which I have stated above (see  y 80-4),
namely, that low states of vital power favour the
more rapid evolution of that portion'of vital em-
anation  which all secretions (the urine  as  well)
possess for a shorter  or longer period after  secre-
tion, according  to the amount of vitality endow-
ing the secreting organs, in  connexion with the
extent of change in the constitution ofthe  secre-
tions, with their accumulation and  retention, and
with the amount of vital influence  and animal
heat retained by them, or furnished to them dur-
ing their retention.   Although  these causes  of
urinary deposit  and concretion have  been  above
considered with  reference to the deposits  found
after the urine is evacuated, certain  topics con-
nected with them, more especially with the forma-
tion of calculi, require a  more particular notice
than they have yet received.
  147.  Deposits from the urine,  more or less
abundant,  after  evacuation may proceed  for  a
very long time without any deposit taking place
within any part of the urinary apparatus.   This
immunity from the formation of calculi may arise
either from the circumstance ofthe urine having
not been saturated with the substance  or  sub-

  [* For the above details we are indebted to the able
work of  Professor  Gross on " Diseases of Urinary Or-
gans."]
     III.                85
stances which usually pass into calculus, or from
the states of vital power being unfavourable to
the formation of renal or  vesical concretions, or
from  the absence of other causes  which favour
such  formation.
   148. i. Age and Sex.—The liability of children
to calculi has been  remarked from the  days of
Hippocrates ;  and  Mr.  Coulson quotes  the
" Methode of Physick," in  which the author,
Philip  Barrough, remarks that "stones in the
bladder do engender oftener in children than in
older folk."—(Lib. iii., c. 41, editio  quinta, 1617.)
Although the  liability  of strong  and  well-fed
children may not be greater than that of any oth-
er class of subjects, yet there is no doubt of weak-
ly, unhealthy, and ill-fed infants and children be-
ing more frequently affected with gravel and cal-
culi than older  persons.   Of 478 operations for
stone in the Norwich hospital during a period of
forty-four years, 227 were in children under four-
teen  years.  According to  Dr. Prout, the follow-
ing is the relative frequency  of urinary calculi at
different ages : Under 10 years of age, 500 ;  from
10 to 20,192 ;  from 20 to 30,104 ;  from 30 to 40,
94 ;  from 40 to 60, 112 ; from 60 to 70, 97 ; and
from  70 to 80,12. Taking into consideration the
numbers of those living at  the most  advanced
ages, urinary  concretions  are  more frequent at
these ages than  in the prime of life.*
   149.  Females, notwithstanding their more sed-
entary habits, and their liability to retain  their
urine for long periods, are  less frequently subject
to calculus than males.  This is partly owing to
their  temperate  and abstemious habits, and partly
to the facility  with which  a small  calculus may
escape from the female bladder soon after its de-
scent from the  kidneys, and before its  retention
in the bladder has enabled it to acquire a great
size  by  successive depositions around it.   The
female urethra,  admitting  of greater dilatation,
and being less complex than the  male  urethra,
and otherwise differently connected and circum-
stanced, allows  the spontaneous passage of cal-
culi which would  be retained in the male blad-
der, and could be removed  only by  an operation.
   150. ii. Habits of Living.—Sedentary habits
and luxurious feeding are more or less influen-
tial, according as  they may  be associated  with
other causes, in  occasioning urinary concretions.
The   former impairs very  remarkably the  func-
tions  of the skin, and prevents that  amount  of
blood-depuration which  these  functions effect;
the latter furnishes the pabulum or source from
which urinary concretions are in great  part de-
rived.  When these habits exist in, or are  con-
joined with, a gouty diathesis,  the occurrence of
gravel or calculi  is often  observed; and much
more  remarkably when a meat diet and malt liq-
uors are  very liberally indulged in ;  for this diet,
especially the  more nitrogenized  kinds, forms
urea and the urates in great abundance, and gen-
crates either gout, or gravel, or calculi, or both,
and  subjects  the kidneys to  a much greater
amount of depurating function  by increasing the
  * M. Civiai.e. in  his "Treatise on Calculous Affections,"
states  that of 5376 cases, 2416 were child-en, 2.67 a-lults,
and 793 old persons.  He says that 194G  occurred before
the age of ten, 943 from t n to twenty, 46') from twenty
to thirty, ."30 from  thirty to forty, 391 from forty to fifty,
513 from fifiy to 6ixty, 577 from sixty  to seventy, 199
from seventy to eighty, and 17 after eighty.  Instances
of calculus have been recorded  from birth, and very soon
after birth.  Mr. Coulson operated for stone on a child
of eighteen months, and upon a man of eighty years of
age. 
1346
URINE—Urinary Calculi, Causes of.
  The imputed infrequency of calculi in very cold
countries is accounted for with much difficulty,
especially as animal food is generally freely used.
The active employments followed by the natives
of these countries, a fish diet adopted by many,
and  other unascertained influences, may combine
to produce  this  partial immunity.   The greater
prevalence  of calculous diseases in Norfolk than
in any other  county in  England  is  fully  ad-
mitted.  Mr. Crosse, the  eminent surgeon of
Norwich, considered this prevalence to be owing
to a combination of causes—to the variableness
of the climate of Norfolk, to the prevalence of
northeast winds, and more especially to the fre-
quency of dyspepsia and acidity in the stomach,
and to the consequent superabundance of uric acid
in the urine.   Soemmering states that calculous
and  gouty affections are unknown, or most rare,
in some situations bordering  on the Rhine. Lie-
big imputes this immunity to the Rhenish  wines,
which contain a considerable quantity of the bi-
tartrate of potash. This salt, he contends, changes
in the progress  of  digestion  to the carbonate of
potash, and acts the part of an alkali.
   153.  It was formerly believed that the waters
of a locality had some influence in producing uri-
nary concretions.   This  opinion  has,  however,
been controverted by several modern writers, and
it is undetermined whether or  no  the waters
which  abound  in  calcareous or  other  mineral
substances  have any effect in occasioning urinary
quantity of morbid materials which  require  re-
moval from the blood.
   151.  When the skin  ceases to discharge  its
share of this  process  of blood-depuration, an  in-
creased demand  is made upon  the kidneys, and
an increased supply of the constituents of urina-
ry deposit is  furnished to  these organs.  It will
thus  appear  very manifest  that, as the same
causes as are more or  less concerned in the pro-
duction of gravel and calculi are  also produc-
tive  of gout, these  two diseases must be  fre-
quently associated in  the same person.   The  as-
sociation of calculi with rheumatism is much less
frequent than with gout;  but when  it occurs it
may be imputed in great  measure to  a  similar
combination of causes.
   152. iii. Climate, locality, and race very consid-
erably influence the occurrence of urinary con-
cretions.   It  is very difficult in many  instances
to explain the operation of these ;  but there is no
doubt  of  these  maladies being  more  frequent in
humid, temperate, and changeable climates, than
in very warm or very cold countries ;  in some lo-
calities than in others even of the same country ;
and in the white than  the dark races.  Holland,
France, England, Germany,  have been regarded
as furnishing the greatest number of  calculous
cases; but other countries are by  no means  ex-
empt from them.   Within  the tropics, urinary
concretions are more rarely observed than  in tem-
perate countries, and  chiefly or only  in the very
young and ill fed.   The marked infrequency of
these concretions in the dark races is chiefly to be
imputed to the  very  small proportion of  animal
food constituting the  diet of these  races, espe-
cially within the tropics, and to  the greater activ-
ity of their cutaneous functions.*

  * Dr. Gross (on the Diseases and  Injuries of the Uri-
nary Bladder, &c, Svo.  Philad., 1S51) confirms the  rare
occurrence of urinary calculi in the  coloured races.   In
ten years he never met with an instance of gravel or of
stone in a coloured person.  Dr. Dudley,  in Kentucky,
who has the largest practice there, never operated for
Btone on more than two or three persons, who are con-
stantly exposed to hard labour, and fare often upon the
coarsest food.  Dr. Gross states that urinary calculi are
rare in Canada, in Texas, Mexico, and California; that in
the United States a larger number of children are subject
to calculi in Kentucky, Ohio, Tennessee, and Alabama
than in any other part; and that the inhabitants of Mis-
souri, Iowa, Wisconsin, Michigan, Indiana, New York,
and New Jersey are comparatively exempt.
  [It is proper, in this connexion, to give a more detail-
ed account ofthe results of Professor Gr. Si's researches
in regard to the prevalence of  stone in  the bladder  and
calculous disorders in the United States.  From these it
appears that the great stone regions of this country  are,
as far as is at present known, Kentucky, Tennessee, Vir-
ginia, Ohio, North Alabama, and perhaps  Missouri, the
disease being comparatively infrequent in  all other  sec-
tions of the country.  The causes of th^se differences are
as yet not  satisfactorily known.   They cannot he satis-
factorily explained, on the  ground  of (inference of cli-
mate, geological formation, or habits of life, nor in  the
food, drinks, and  occupations of the inhabitants ; for in
these respects, for example, there is but little difference
between Kentucky and Indiana,  yet calculous affections
are very common in the former and very rare in the lat-
ter.  Corn-bread and pork constitute the staple articles
of food throughout the  Southern and  Western States,
with unleavened biscuit of wheat, potatoes, hominy, cab-
bage, turnips, and tomatoes, with coffee, tea, and milk
at breakfast and  supper.   Eggs, poultry, and milk  are
also freely used.  In the calculous districts lime-water
generally prevails, and is used freely by nearly all  the
inhabitants; but the same is true also of some parts of
New England and  Canada, Indiana, Illinois, &c., where
stone in the bladder is rarely met with.  The Germans
are remarkably exempt  from  calculous affections, and
they consume large quantities of malt liquors.  The cli-
mate is essentially the same in the calculous and  some
of the non-calculous  districts.  The prevalent diseases
in the calculous regions are intermitting and remitting
fevers, neuralgia, pneumonia, dysentery, rheumatism,
and dyspepsia; and urinary deposits of all kinds, espe-
cially the lithic  acid  and urates, are  common.  The
causes, then, which favour the formation of stone in the
bladder remain, for the most part, undetermined, though
there can be no doubt that such affections must be influ-
enced to  a greater or. less degree  by climate, food, and
drinks, occupation, &c.  We believe it will yet be made
to appear that the hygrometric state of the air (a high
dew-point) is one of the most efficient predisposing causes.
In all the New England States calculous affections are
very uncommon, although  much of the drinking-water is
strongly impregnated with lime.  The number of lithot-
omy cases that fell to the charge of Professor .1. ('. War-
hen, during a period of forty years, was only 'J5; and he
is said to have been the only surgeon in Boston who per-
formed that operation during that whole time. Only
three of these cases were  natives  of Boston: the others
came from different parts of New England.  Dr. Nathan
Smith was of*pinion that more cases of the disease orig-
inated in Vermont and Maine  than any of the other New
England  States, and these States  abound in limestone
more than any of the others.  Up to 1S55, Dr. J. M. Wap-
i:en, of Boston, had operated for stone 18 times;  Dr. V.
Mott, of New York,  103 times;  Dr. F. II. Hamilton, of
Buffalo, 5 times;  Dr. A. Trowbridge, of Watertown, N.
Y.. 18 times; A. March, of Albany, 16 times; W. Park-
er, of New York, 24 times; Professor Van Bu:-f.n. of New
York, 20  times (besides  several operations by Drs. Cae-
noch.vn.  Post, Buck, Wood,  Hoffman. Watson, &c).
During 17 years and a half (1837  to 1855) only 14 cases
of stone in the bladder were  treated in the New York
Hospital, which receives annually about 3500 patients.
In the Pennsylvania Hospital at Philadelphia, from the
time it was opened for the  admission of patients, in 1752,
till Slay,  1818, 100 years, only 83  patients were cut  for
this disease, of which few  originated in  Philadelphia or
vicinity.   Up to 1842, Profetsor Giisson, of Philadelphia,
had operated for  stone 50  times;  Dr. J. llnEA Barton,
36; George M'Cl:llan, 30 (and before his death. 5ft).
Dr. Panooast has had (1856) 41 cases; Dr. J. Dickson,
of Alleghany,  Pennsylvania, has operated on 14 cases in
the last seven years.
  Dr. Mkttauer, of Virginia,  has  performed the opera-
tion  for stone 91  times; Dr. P. C. Spenseb of Peters-
burg, Va., 24 times; Dr.  Dudley, of Kentucky, 207
times;  Dr. Gross, 40, &c.  These constitute the vast
majority  of operations of this kind performed  in the
United States during the last 30 years.
  With regard to age. American statistics are extremely
deficient.   Of Dr. Dri.i.nr's patients, three fourths were
under 15 years; and of 27 Kentucky cases of Dr. Gbosb,
14 were under this age.] 
URINE—Urinary Calculi, Causes  of.                       1347
 calculi.   The subject has not been investigated
 with precision,  and the  arguments  on both sides
 are loose, and indeterminate as to facts.
   154. It has been contended by  Mr. Copland
 Hutchison and Sir G.  Ballinoall that sailors
 and soldiers are almost exempt from urinary con-
 cretions.   But  when it is considered  that  both
 sailors and soldiers are of those ages in which
 these concretions arc seldom observed, the extent
 of this exemption cannot be great.   Whatever it
 may be, the activity ofthe digestive, assimilating,
 and depurating functions in these classes and at
 their periods of life evidently constitutes its chief
 cause.*
   155. iv.  Diet and regimen  has more influence
 on the frequency  of calculous diseases than is
 generally believed.   The evil  produced by animal
 food used in  excess—and  many use it in excess
 relatively to the amount of exercise taken—has
 been already adverted  to (y  150).  Highly ni-
 trogenized  animal diet  furnishes a rich and an
 abundant chyle, which,  during its  circulation in
 the  blood through  the  several viscera, becomes
 oxidized  and otherwise changed, and,  in various
 states of metamorphosis, under the influence of
 vitality, originates the most  important parts of
 those materials which require a continued elimi-
 nation from  the blood; and if this end be not
 attained  by the active  discharge of the  several
 depurating functions—by  the kidneys, skin, mu-
 cous surfaces, &c.;  and if it  be not promoted by
 exercise  sufficient for its fulfilment, an accumu-
 lation of  these materials in the blood takes place,
 and,  becoming more and more highly animalized
 and morbid, and irritating by  their  retention and
 accumulation, occasions serious  diseases, among
 which Gout  (as shown in that article, y  33-42)
 and urinary concretions are the most common.t
   156. v. Metamorphosis  and waste of tissues,
 &c.—It will be seen, from what has been stated
 above (y 41-5), that Baron Liebig and Dr. Gold-
 ing  Bird have attributed the  solid  materials dis-
 solved in the urine, with their deposits and con-
 cretions,  to the chemical combinations  of the
 elements  resulting fr6m the metamorphosis and
 waste of  the tissues in the course of the regener-
 ation and nutrition of these tissues.   But if we
 take  into consideration the great amount of these
 materials discharged into  the urine,  and refer
 them only to the sources from  which these writers
 derive them,  it must follow  that these tissues
 ought to be renewed several times every succes-
 sive year  of existence !   It must be  admitted that
 the metamorphosis and  waste ofthe tissues—to
 which I would  add similar changes in the  red
 globules of the blood also—furnish some  part of
 these materials ; but a much greater share is sup-
 plied by the food, by the  chyle conveyed into and
  [• There is good reason to believe that the use of sor-
 rel and the  footstalks ofthe rhubarb plant favour the pro-
 duction of oxalate of lime deposits, as they both contain
 oxalic acid, combined in excess with potash.  The free
 use of sugar may also act as a powerful predisposing or
 exciting cause.]
  [t Dr. W. P. C.  Barton, formerly at the head of the
 Medical and Surgical Bureau at Washington, expresses
 the opinion that sailors are  entirely exempt from calcu-
 lous diseases.   The same opinion substantially is ex-
 pressed by Surgeons Foltz, Ruschenberger,  Gref.n,
 Horner, Cornick, and others ofthe United States navy.
 Urinary deposits occur among landsmen and marines,
but rarely,  if ever, among those who have been brought
up at  sea.  The same singular immunity exists among
the seafaring people of all nations.  The  cause assigned
by our author, viz.. the activity of the digestive, assim-
ilating, and depurative functions, is doubtless the prin-
cipal one.]
 circulating with the blood, and by the successive
 changes therein produced, under  the influence
 of vitality ;  the regeneration and nutrition ofthe
 tissues requiring only a  small  but appropriate
 portion ofthe constituents thus supplied, the less
 appropriate materials being eliminated from  the
 circulation by the kidneys, skin,  and other depu-
 rating organs.
   157. vi. Indigestion, fermentation, and  mal-
 assimilation  are  causes of  urinary  deposit and
 concretion intimately connected with a too full,
 rich, or unwholesome diet.   Numerous articles
 of food are  indigestible in their nature, more es-
 pecially if not sparingly partaken of, and are lia-
 ble to become  rancid  in the stomach, and to ac-
 casion rancid eructations ; while others are more
 disposed to fermentation, and to  generate acidity
 in the stomach and bowels; both rancidity and
 acidity sometimes occurring simultaneously, ac-
 cording to the  nature of the  food, to the quantity
 taken, and to the powers of digestion and assim-
 ilation.  Owing  to  undue  and  superabundant
 quantity, or to improper quality, or to both, an
 imperfectly  digested  and assimilated chyle  is
 formed and  carried into the circulation, furnish-
 ing the  material elements of disease, and  more
 especially of urinary concretions.   But it is not
 only to  full diet, much animal  food, or to un-
 wholesome aliment, that these concretions may
 be remotely imputed, but also to insufficient food,
 especially in early  life   In this latter case the
 powers of life  are so  reduced by the insufficient
 nourishment as to imperfectly digest and assimi-
 late what is taken,  and the  blood  is thereby di-
 minished in quantity and impaired  in quality.
   158. vii.  Constitutional  and vital conditions
 manifestly combine  with the preceding causes in
 occasioning concretions in the urinary apparatus.
 These conditions I have viewed above (y 45, 157)
 as consisting of more or less manifest  impair-
 ment, not only of the digestive, and assimilating,
 and depurating functions, but also ofthe vital en-
 dowment throughout the  frame.  This general
 impairment of vital  power accounts for the prev-
 alence of urinary excretions in  delicate and in
 imperfectly or improperly fed children,  or pre-
 viously to puberty,  and in the aged, and for the
 comparative rarity of these concretions in persons
 during the prime of life, or during  the period of
 sexual activity, and in those who  are  neither
 over-fed or under-fed, and  who are not exposed
 to the remote causes above mentioned.
   159  viii.  Bodies  or substances  introduced or
passed into  any portion of the urinary apparatus
 are  liable to become the  nuclei around which
 urinary concretions may form and increase  by
 successive deposits.   Numerous  instances  of
 bodies having  passed into the bladder, and be-
 come  the nuclei of large calculi,  are recorded by
 medical writers.  To these it is  unnecessary to
 refer,  as they are sufficiently known; but  they
 satisfactorily prove that these bodies give rise to
the first act of deposition or crystalline formation
by the urine, when  more or  less  loaded  or satu-
rated with the constituents  of urinary deposit and
concretion.
   160. ix. Morbid states of some part of the uri-
nary passages may be attended by  an extravasa-
tion of a minute quantity of blood, or by a puru-
lent or mucous discharge, which,  either in  the
uriniferous tubes, or in the pelvis of the kidney,
or in the bladder, may become the cause of de-
posit, by attracting  the uric  acid, the urates, or 
1348                     URINE—Origin and  Growth  of Calculi.
other saline constituents of the urine, and form I
the nucleus of successive deposits.  It is not im-
probable that a change, such as I have just stated,
may take place in some portion ofthe kidney, or
even in some other part ofthe urinary apparatus,
owing either  to external  injury,  or to   other
causes, and, by favouring the concretion  of the
superabundant  saline constituents, or uric acid
in the urine, thus form  the  nucleus of a renal
calculus, which may  either remain  long  in the
kidney,, and  increase slowly, or pass  into the
bladder, and become, as in the  case of a foreign
body, the centre around which  successive and
large deposits  collect.  Most calculous concre-
tions are thus formed, their nuclei and earlier de-
posits being  formed in the  kidneys, their chief
increase taking place  in the bladder
   161.  Inferences.—The efficient causes  of uri-
nary calculi may doubtless operate differently in
different diatheses and constitutions, and in dif-
ferent circumstances, more especially in determ-
ining the nature of the deposit;  but there is some
reason for concluding, 1st. That a diet composed
chiefly, or of a large proportion  of animal food,
tends  to increase  the quantity of the  uric acid
and urates, and to favour their deposition, and to
lessen the generation and deposition of the phos-
phates;  2d. That  rancid and  acescent ingesta,
and rich sauces, exert nearly  similar influences
to  the  foregoing;  3d. That  whatever  promotes
the functions  of the skin tends to prevent  the
deposition of uric  acid, and to favour that ofthe
phosphates; and, 4th. That  indolence and indi-
gestion tend to increase the deposition of uric
acid and to lessen  that  of the phosphates, both
by producing  acidity of the prima  via, and  by
impairing the functions ofthe skin and liver.
   162. x.  The origin and growth of urinary cal-
culi was first  clearly stated by Van  Swieten
(Comm. in Aph.  Boerh.,  1414).  He  remarks,
that " stones proceed from elementary principles,
which, in a state of  solution, previously  existed
in  the humours, and when  these meet with  an
indissoluble  basis,  they fix  themselves thereto,
and form a calculus,  which continually increases
in  bulk from the  application of fresh  calculous
matter."   This statement is probably correct as
far as it goes,  but various topics connected with
the original nature and primary formation of uri-
nary concretions are not comprised in it.  Dr
Golding Bird and others contended for an oxa-
luric diathesis, which gives rise  to the  secretion
of oxalic acid and oxalates from the uric acid and
urates existing in  the blood.  Dr.  Owen Rees
 has opposed this doctrine, and  has  argued that
the oxalic acid and its  compounds are not pro-
 duced from uric acid or from urates already ex-
 isting in the blood, but that the change is effected
 in the urine, after its  secretion  by  the  kidney
 " In  this latter case the  uric and in combination
 will  be secreted as such into the urine, but by
 after  processes, occurring either in  the  urinary
 passages, bladder, or chamber vessels, it will pre-
 sent itself converted  into a compound ofthe ox-
 alic  acid."   If this be really  the case, then  we
 must admit that the state of system in which  we
 observe a tendency to the formation of oxalate
 of lime in the  urine must be considered identical
 with that accompanying the uric acid  diathesis,
 and  as requiring  the  same  treatment, and the
 same precautionary measures
    163 Dr. Aldridge, of Dublin, has shown the
 manner in which  uric acid and its compounds
become decomposed into an oxalic salt.  " He
has proved  that uric acid may be theoretically
considered as representing  the elements of ox-
alate and carbonate of ammonia, hydrocyanic and
formic acids, if we merely add to its atoms the
elements of water in varying  proportions.  He
has demonstrated that this really occurs ; for, by
heating urine, and in some cases by evaporating
it, he has succeeded in  causing a deposit of ox-
alate of lime, while  evidence of the presence  of
hydrocyanic and formic acids  could be obtained
from the fluid." (O. Rees, onCalc. Dis., &c, p. 5.)
   164.  a. The chemical reasoning, Dr. 0. Rees
remarks, which shows  how unlikely  it is that
oxalate of lime should exist in  the blood, is quite
borne out by pathological conditions.   He  there-
fore concludes, in opposition to Drs. Garrud and
G. Bird, that, whenever oxalate of lime  is found
in the urine, it should  be regarded as produced
after secretion, and that there  is no such thing
existing as an oxalic diathesis.  Lehmann, who
has also  opposed the  opinions  of the late  Dr.
Bird, has stated that morning  urine, left to stand
some  hours,  often  contains oxalate of lime in
quantity, when  the  fresh urine did not contain
any trace of it.  Wohler  and Frerichs found
that the urates when injected into the blood pro-
duced oxalate of lime in the urine.  Dr. O. Rees
thus " regards oxalate of lime merely as uric acid,
or urate  altered after  secretion," and that the
lists of calculi contained in museums will show
that the uric acid diathesis produces nearly the
whole  of the calculous diseases observed, espe-
cially by forming the nuclei  of most of those
which are formed of other constituents.
   165. The greatly increased  quantity, and the
insolubility of uric acid, are quite sufficient, causes
ofthe deposit of it in the kidneys, especially when
 in excess, and in the circumstances about to be
 noticed (y 167,169), without calling in the aid of
 any other agency   If the deposition ofthe uric
 acid in the calculous form in the kidneys, where
 it originally takes place in  the great majority of
 cases, if not in all, and if the calculus, having
 passed into the bladder. " fail  to produce any
 great irritation of the vesical mucous membrane,
 then it will be enlarged by  the continued deposi-
 tion of uric acid layers  ; but if, as is generally  the
 case, this calculus irritate the surfaces, then  the
 bladder becomes inflamed, and the mucous mem-
 brane  throws out an alkaline fluid, which now
 decomposes the ammoniacal  salts contained in
 the urine and liberates the  ammonia.  This may
 unite to a portion of uric acid, forming urate of
 ammonia, so that the  next layers ofthe calculus
 may consist either entirely of  urate of ammonia,
 or of that salt in admixture with uric acid.  The
 changes may cease here, and the calculus, though
 it  increase under these conditions, be thus com-
 pounded merely of two constituents   The next
 change may, however,  occur, and may determine
 the formation of a more compound form of con-
 cretion ;  and this will  consist  in the pouring out
 of an excessive quantity of alkaline secretion by
 the inflamed mucous surface   This will not only
 completely neutralize  the  acidity of the urine,
 but cause, like all alkaline solutions, a precipita-
 tion of the earthy phosphates  "  (Op  at., p. 28)
 These  will coat the calculus, intermixing or  not
 with the urate of ammonia, or uric acid, accord-
 ing to the amount of secretion and its alkaline
 character.
    166. b. In respect  of the phosphatic deposits 
URINE—Symptoms  of Calculi in the Kidneys.                  1349
and concretions, Dr. 0. Rees farther contends for
their production uniformly from irritation or dis-
ease of the urinary mucous surfaces, and for the
presence of uric acid or some other form of con-
cretion being a sufficient cause for the formation
of phosphatic layers on a calculus.  In answer
to the questions as to how phosphatic calculi are
formed when no other  calculous matter can be
detected as a nucleus, and what were the condi-
tions antecedent  to the phosphatic deposit in
such cases, he states that these calculi are rarely
met with, and when present are the consequen-
ces of disease of the mucous  membrane of the
bladder, and  where, of necessity, the alkaline se-
cretion consequent upon irritation of this mem-
brane  is poured out from it in quantity.  " This
state of things often follows upon enlargement
of the  prostate with stricture, so that the bladder
is not easily emptied."   The retained portions of
urine will have their earthy phosphates precipi-
tated by the alkaline secretion of the  diseased
mucous  membrane, and the formation of a calcu-
lus result.   Hence it follows, 1st, that the pres-
ence of other calculous  matters, by irritating the
bladder, causes a  deposition of the earthy  phos-
phates, these matters forming the nuclei around
which the phosphates are deposited ; 2d, that the
alkaline secretion from  the irritated urinary mu-
cous membrane occasions a concretion, independ-
ently of such nuclei, by precipitating the  phos-
phates.  It was long ago remarked by Dr. Prout,
that these salts, when present, were always found
covering other deposits, and  rarely alternating
with them ;  so that, if the  nucleus were  phos-
phatic, the crust would  be the  same, and no cov-
ering be found of any  other  form of calculous
matter.
   167.  Since uric acid is the nucleus ofthe great
majority of calculi, the conditions  under which
this deposit occurs should be considered.  In per-
sons subject to the continued excretion of uric
acid and the urates, the quantities discharged may
be very  great, without showing any tendency in
these  substances  to concrete  into the calculous
form.  These materials  may even give rise, from
their abundance, to attacks of "gravel," without
any considerable calculus being formed, and very
common means may give relief.  In other cases,
the deposits  in evacuated urine may be in far less
proportion, and yet the tendency to concrete into
calculi be very early shown.   These facts, as Dr
O Rees contends, seem to prove that, in  order
to  produce a calculus,  some condition  must be
present  besides that which we recognise in a
tendency to the deposit of solid matter  from the
urine.   It is  necessary to bear in mind what has
been said above (§ 166) respecting the  chemical
effect of the alkaline secretion from the  inflamed
urinary mucous membrane, upon which he places
more stress than the proofs may be supposed to
warrant  But besides  possessing the  imputed
chemical qualities, Dr. O. Rees infers  that the
secretion from the inflamed membrane evinces
mechanical conditions which must influence the
result  where a tendency exists  to  deposit solid
matters  from the urine, and that the  secretion
from the inflamed mucous surface, being of a te-
nacious  character, and containing fragments of
epithelium and mucous corpuscles, will cause the
particles constituting the deposit to unite and
form a nucleus or concretion of successive de-
posits.
   168   Instead, therefore, of viewing the earthy
' phosphates as secreted by the mucous membrane,
 Dr. 0. Rees believes that this  membrane acts
 merely through its alkaline secretion, which pre-
 cipitates the earthy phosphates from the urine;
 and he farther infers, that the same conditions no-
 ticed with regard to the bladder are present also
 in  the kidneys, and that it is to these conditions
 in  these latter organs, rather than to what exists
 in the bladder, that we ought to look for the chief
 cause of the formation of nuclei, and the very
I general origination  of calculi  in the kidneys.
, " At any rate, this would appear to apply so far
i as the production  of a nucleus is concerned."
 The mechanical conditions presented by the pel-
I vis and urinary tubules certainly are far more fa-
| vourable  to the agglutination of deposits than
i those  observed  in  the bladder; for  these  are
 smaller conduits and  cavities, and in the imme-
J diate  vicinity of the tubules the first  deposited
j matters are brought in intimate contact with the
 spheroidal epithelium, which under irritation rap-
i idly desquamates and is more especially liable to
 entangle floating particles  of deposit, and so to
! favour the formation of calculus.  "The reason-
 ing," Dr. O. Rees  adds, " I have used with re-
i spect to the bladder applies with full force to the
j formation and  growth of calculi in the kidney.
 From what I have now adduced, I would submit,
j that if we except cases in which are formed the
 four following rare substances, viz., cystine, car-
 bonate of lime, silicic acid, and  uric oxide, we
 may consider all calculous disease as originating
 in the gouty or uric  acid diathesis."   (Op. cit.,
ip. 38.)
I    169. A nucleus may form in  any part  ofthe
 urinary canals; but the tubules  are by far the
 most frequent seat ofthe original deposit.  Small
 particles are sometimes found  in the  secreting
 structure ;  and if  these do not  pass onward to
 the tubular structure, they may increase by de-
 posit of successive layers until a calculus of con-
 siderable size is produced   In this case a por-
 tion of the organ, corresponding to the develop-
 ment of the concretion, may be destroyed, and
 symptoms  varying with circumstances be pro-
 duced.  The first deposit may, however, pass low-
 er down into the tubular structure, or thence into
 the pelvis of the kidney, and either remain in ei-
 ther of these situations or pass  along the ureter
 into the bladder, causing more or less distress, in
 some cases extreme suffering, during its passage;
 and having reached the bladder, it may be ex-
 pelled through the urethra by the stream of wa-
 ter, or remain in the bladder and become the nu-
 cleus of a large concretion.
    170. VII. Symptoms  of Urinary Calculi.—
 i. In the Kidneys.—The symptoms produced by a
 calculus  or calculi in the kidney vary with the
 size, form, or smoothness ofthe stone, its situa-
 tion in the organ, and the constitution, tempera-
 ment, and diathesis ofthe patient.  The calculus
 may remain in the kidney, or even several may
 remain, or pass thence into the bladder.  If  it
 remain, cither relief of more or less severe symp-
 toms  may  take place after a time, owing to  a
 cystic  covering forming over it, or disorganiza-
 tion ofthe kidney sooner or later supervenes and
 destroys  the patient.   If the calculus remain in
 the kidney and  become encysted, more or less se-
 vere pains in the  loins or in one or both sides,
 often  extending down the thigh or  thighs, and
 sometimes upward under  the  shoulder blades,
! colicky pains in the abdomen, nausea,  vomiting, 
1350
URINE—Symptoms of Calculi in the Kidneys.
haematuria, and frequent calls to pass the urine, i
are complained of.  These symptoms may grad-1
ually subside, and they may recur oftener than
once, after indefinite periods and with various de-
grees of severity, especially after  sudden or se-
vere exertion, particularly when the trunk ofthe
body has experienced  a shock or concussion.
The pain often becomes dull or aching, or is seat-
ed chiefly on  one side ofthe abdomen, or extends
to the groin, or a sympathetic pain, resembling
neuralgia, is  experienced at a distance  from the
region of the kidney, and not unfrequently ex-
tends to the testicle ofthe affected side   After a
lengthened period, and after frequent recurrences
of the symptoms in slighter grades, the patient
either experiences an immunity from farther suf-
fering, or complains only of slight and wander-
ing or recurring pains, which often may be traced
to one or other kidney.
   171.  In less favourable cases of retention of
the calculus  or calculi in the kidney, the symp-
toms assume the features described when treat-
ing  of Inflammation of the Kidney (y 48, 49, 59,
et pluries), and of Pyelitis (art  Kidney, y  174-
183, 192-198, et pluries), and are fully described,
with the several relations of this subject, in the
article, and more especially at the places now re-
ferred to.  I  may, however, remark at this place
the difficulty of diagnosis between a calculus in
the right  kidney and the passage  of gall-stones.
At the commencement of the irritation produced
by a calculus in the right kidney,  and when the
symptoms are very severe, or when a calculus
has entered the ureter from the pelvis,  the com-
plaint may readily be mistaken for gall-stones,
especially when the vomitings, pain, and spasm
are very urgent, and if all  the symptoms  be not
carefully examined.  I have found it even recent-
ly very difficult to determine at first as to the
seat of disease ;  and this difficulty is increased if
there be, as there frequently is,  pre-existing dis-
order of the biliary  functions, more especially in-
terruptions of the biliary secretion, or some de-
gree of jaundice.   As the symptoms of renal cal-
culi proceed, and especially as  the calculi pass
into or  along the ureter, the nature of the com-
plaint becomes more manifest, and  indeed is most
frequently so from the commencement, especially
when the symptoms attending the secretion and
excretion of  urine  are  well  marked, and blood-
globules are  observed in the urine.  When the
haematuria is very  considerable, especially after
exertion or sudden movement of the trunk, in
connexion with the other symptoms of calculous
nephritis (see Kidney, y 48, el seq), the  nature
of the case  is evident;  and if the  draining of
blood continue for a considerable time, and the
local symptoms are very acute, the oxalate of
lime calculus is not unfrequently its cause.
   172. ii. The diagnosis of renal calculus is ren-
dered most difficult m the gouty and rheumatic
diathesis, and in cases of chronic disease of the
urinary bladder and prostate gland ;  for the pain
in one or  both sides ofthe lumbar region may be J
rheumatic or gouty, or may proceed from cachec-
tic nephritis,  or Bright's disease,  or from pyeli-
tis or abscess of the kidney, occurring either pri-
marily, or caused by calculi, or following chronic
uro-cystitis or stone in the bladder, or even from
inflammation or abscess of the lumbar muscles.
If any tumour or  swelling be detected in the re-
gion of the kidneys,  the antecedent symptoms
should be duly estimated, and  the examination
directed to the existence of collections of matter
in the pelvis and calices of the organ, or to their
distention by urine from obstruction of the ure-
ter, or to the  presence of malignant disease ofthe
kidney.  Of these several  states of disease, as
well as ofthe passage of a calculus along the ure-
ter, no correct diagnosis can be formed until the
urine be tested, and the results considered with
due reference to the quantity, specific gravity, ap-
pearances, deposits, and quality of this secretion ;
to the ability of retaining it, to the frequency of
the calls to void it, and to the particular altera-
tions of sensibility complained of in the regions
of the  kidneys, ureters, bladder, and urethra, as
well as in the testes, abdomen, and lower extrem-
ities, and to the states of constitution and of vital
power. In the course of renal disease associated
with calculi,  the  symptoms are so varied, and
manifest so numerous combinations, with the seat,
duration,  extension, and associations of morbid
action, that  descriptions applicable to all cases
would be hopeless; but, by recollecting that  ir-
ritation existing in one part of the urinary appa-
ratus will extend to, and more or less affect the
whole ; that although the symptoms will be pres-
ent chiefly in the situations just indicated, they
may  extend  still farther; and that a correct ex-
amination ofthe urine will indicate with more or
less accuracy the nature of the affection, espe-
cially when  viewed in  connexion with the local
and constitutional symptoms, the  difficulty  of
forming a diagnosis between the disorders which
result from renal calculi and those which most
nearly resemble them  will altogether disappear.
In this subject I must refer the reader to what 1
have stated respecting  the inflammatory and or-
ganic diseases of Kidneys and Urinary Blad-
der,  and the complications which they present
in practice.
   173. iii  The symptoms indicating the passage
of a calculus from the  kidney to the bladder may
be so slight,  especially when the calculus is small
and smooth, as to occasion but little inconven-
ience, and to excite no anxiety or- even the  atten-
tion ;  and it may remain long  afterward in the
bladder without the patient being aware  of  its
presence.  But if the renal calculus be large, or
rough, more  especially if it be an oxalate, its pas-
sage along the ureter is attended by the most ex-
cruciating  suffering.   The pain is  seated more
especially in the loins, generally  of one side, ex-
tends from the course ofthe ureter and down the
thigh, the cord to the testes ; and is attended by
retching, vomitings, and by intermitting colicky
or abdominal pains.   The patient is bent double,
or to one side, rolls about, and is in the greatest
agony  In  the less severe cases there are rigors,
nausea, restlessness, pain in the  back, stretching
in the course of the ureter to the bladder, thigh,
and testicle, often  with its retraction, coldness of
the extremities, and prostration.   The descent of
the calculus commonly  occupies from 12 to 24 or
36 hours.   " The calculus may become impacted
in the vesical orifice of the ureter ; the flow  of
urine from the corresponding kidney may then
be prevented ; dilatation of the ureter, and disten-
tion of the tubular structure of the kidney will
ensue, terminating in absorption of its secreting
surface; but  most ofthe usual symptoms of stone
in the bladder will be absent."*"

  [• M. Civiai.e classifies uric acid gravel under three  va-
rieties: 1. The passage of gravel spontaneously and with-
out pain; 2. Nephritic colics with emissions of gravel; 
URINE—Symptoms of  Calculi  in the  Bladder.                  1351
   174.  iv. The symptoms of a calculus in  the
bladder are well known, and require at this place
but few remarks.   But in tracing back the histo-
ry of these cases, and when inquiring into their
existing states, the facts should not be overlook-
ed, 1st, that  stone in the  bladder originates, in
the great majority of cases, in a calculus formed
in the kidney, which, having passed into the blad-
der, forms the nucleus of farther deposit and con-
cretion in this  organ ; 2d, that the formation of
the calculus  in the kidney, and its passage thence
along the ureter into the bladder, must have been
attended by  more or less  ailment referable to
these situations;  3d, that a  calculus very rarely
or never originates in the bladder without previ-
ous disease  cither of this viscus, or of the pros-
tate gland, or ofthe urethra.
   175. The symptoms chiefly characterizing  the
existence of a concretion in the bladder are fre-
quent calls to  micturate, pain at the  end of the
penis, hsematuria,  especially after exertion, and
pain with or without haematuria on a jolting mo-
tion or succussion of the trunk.  If these, how-
ever, be alone  recognised, they may  mislead  the
physician; for they may all be present, and  yet
a calculus may  not be present in the bladder
Hence the necessity of inquiring into the history
of the case, and of duly estimating the  early
symptoms   For some malignant growth may ex-
ist in the bladder and occasion all the symptoms
just mentioned.   A calculus in the vesical cavi-
ty generally falls behind the prostate, but it shifts
according to the posture of the patient.  In  the
earlier stages of vesical calculus, the viscus being
yet healthy, a  dull pain, with a sense of weight
about the neck of the bladder, or uneasiness, ex-
tends to the hypogastric region, perineum, groins,
or thighs.  If the stone be smooth, the symptoms
commence and advance so slightly and slowly as
to excite but little attention and no anxiety;  but
sooner or later, either from the size of the calcu-
lus or the irritation produced by it, the features
of the  affection  become manifest.  The bladder
is irritable and cannot contain its  contents;  the
calls  to micturate are more frequent;  and  the
expulsion of the  last drops is attended by pain,
shooting along the perineum and penis, and cen-
tring in the  glans.  Sometimes when the  urine
is flowing in a full stream, it is suddenly stopped,
as if by some  body falling  into and obstructing
the  orifice  of the urethra.   Exercise,  sudden
movements,  and the jolting of a carriage occa-
sion  great suffering,  and  even a discharge of
bloody urine, which in plethoric or other habits
of body may  be of considerable extent or contin-
uance ; as the  disease continues, and the bladder
becomes more affected, micturition becomes more
and more frequent and distressing.  Patients oft-
3. Nephritic colics without expulsion of gravel.   The dis-
ease in those, as well as phosphatic gravel, cystine,  and
oxalate of lime, may go on in spite of medical treatment,
when the difficulty may arise from  some morbid state,
which paralyzes  the efforts of nature and art.  For ex-
ample, the gravel may not be able to make its escape,
because it is retained in the kidneys or ureters, or in the
bladder, where it may be retained, 1st.  By a spasmodic
contraction of the urethra or neck of the bladder; or, 2d.
By one or more contractions in the deep-seated portion
of the urethra; or, 3d. By a tumefaction or other disease
of the i rostate; or, lastly, by a paralysis of the bladder.
M. Civiai.e rejects entirely the prevailing doctrines re-
specting the influence of nitrogenized food in the produc-
tion of gravel  and stone, and repudiates all attemps at
cure by chemical remedies, either internal or external,
and especially by alkaline remedies.  He,  however, at-
taches great importance to the influence of age, Gex, cli-
mate, and food, in the production of calculous affections.]
en  grind their teeth with agony;  and the last
drops  of urine are  expelled with spasm  of the
bladder, which endures for some time.  The urine
and contents of the vesicular seminales are some-
times  passed involuntarily,  and increase the dis-
tress  and exhaustion  of the patient.   There  is
occasionally priapism, with  or without sexual de-
sire.
   176. I need not farther describe the symptoms
of vesical calculus,  but  merely briefly advert  to
the importance of recognising some of the com-
plications of this malady, and which may either
precede it or follow  it, more especially the latter.
Of these the most important is disease ofthe kid-
ney or kidneys.   This  may have  preceded the
vesical calculus, and  been  associated  with,  or
caused by,  the formation of the renal calculus
which formed the nucleus for farther deposit and
concretion when it passed into the bladder.  But
in this state of complication the renal disorder is
generally slight, or  even hardly exists when the
calculus has reached the bladder.  If, however, it
be  arrested  in its course, more particularly at the
vesical extremity of the  ureter, the renal compli-
cation may be most severe and dangerous.   After
the calculus  has  been  long in the bladder and
superinduced much  disease in this viscus, the in-
terruptions  in the way of urinary excretion, the
extension of irritation along the ureters, and oth-
er  circumstances, often develop serious disease,
and even extensive disorganization of the kid-
neys.   In some cases, also, the irritation  of the
•bladder by a calculus may superinduce prolapsus
ani in children, or  even in older subjects, and
haemorrhoids  in the latter class.
   177. v. Diagnosis.—The symptoms described
above (y 174-6) generally lead to the important
measure of ascertaining beyond a doubt the ex-
istence of a stone in the bladder, viz., to sound-
ing.   The circumstance of  malignant disease of
the bladder being often attended by most of the
symptoms characterizing vesical calculus; and
the fact of this operation, which is so requisite in
the latter malady, being often most injurious  in
the former, should lead  us to pause before it  is
resorted to, and the  states and appearances ofthe
urine  very minutely examined.  In cases of ves-
ical calculus the urine generally contains more or
less of the ordinary sedimentary and organic mat-
ter, and the blood discharged with the urine  is
generally in smaller quantity than in malignant
growths in  the kidneys or bladder.
   178. In calculus,  haematuria generally follows
upon  some unwonted  exertion.   In malignant
growths in  the bladder or kidneys, the tendency
to nausea and vomitings is  greater, and there are
more marked appearances of cachexia and of an-
aemia  than  in calculus.  In some cases, also, a
careful examination of the  abdomen will lead  to
the detection of tumours, if there  be malignant
disease ofthe kidneys, especially after the bowels
have  been freely evacuated.  Malignant disease
of the kidneys or bladder, or fungoid growths  in
the latter, especially when far advanced, is char-
acterized by  discharges of urine  with  much
blood, intermixed with which  the cells constitu-
ting malignant disease may  be detected by the aid
of  the microscope.   Dr. Owen Rees reposes
much confidence  in the evidence  furnished  by
these  cells ofthe existence  of such disease.  He
describes them to be " of variable size, the small-
er being about four times the diameter of a blood-
corpuscle, the larger twice that size, or even  of 
1352                  URINE—Treatment  of Urinary Concretions.
greater diameter.  They are colourless and more
transparent than the white corpuscles ofthe blood,
and contain within them  nuclei of varying size
These nuclei differ in number in each cell. Some-
times only  one is present:  sometimes four or
five.  Though there would appear a general tend-
ency on the part of these bodies to assume the
circular form, they are for the most part of irreg-
ular outline.  Sometimes a mass of them may be
seen  agglutinated together, and then  they are
more or less square, or they may approach to the
hexagonal form."  Dr. O. Rees states that he
has never seen corpuscles like these in the urine,
except in cases of malignant  disease.   Where
these are found, he contends that the sound should
never be introduced into the bladder, as it may be
followed by excessive, or even fatal haemorrhage,
a case of this latter issue having fallen under his
observation.
   179.  VIII.  Treatment of Urinary  Concre-
tions.—i.  Of  Calculi in the Kidneys.—When
the symptoms indicating the existence of calculi
in the kidney are severe, and the patient  is strong
or plethoric, or not reduced by haemorrhages from
these organs, then cupping over the loins, follow-
ed by warm baths and fomentations, will afford
relief.   The preparations of soap and extract of
henbane, or of belladonna, may be prescribed in-
ternally, while mucilaginous or demulcent fluids,
containing the carbonates of the alkalies with
narcotics, should be  freely  administered   The
bowels ought  to be kept open by means of olive
oil in frequent doses, or by the citrate of potash
taken freely, in a state of effervescence, and with
the alkali in excess.   If haematuria be excessive,
the acetate of lead with opium, or the spirits of
turpentine, cautiously exhibited in small doses,
epithems of the same being applied to the loins,
will be found of service;  or the gallic or tannic
acids, &c, may be prescribed.  In cases  where it
might be injurious to abstract blood, dry-cupping
over the loins may be employed.
   180. Having removed the  more severe symp-
toms by these or similar means, a course of med-
icines calculated to prevent the formation of uric
acid and urates, and  to lessen their irritating ef-
fects, should be entered upon.   But such  a course
will prove ineffective if the diet and regimen of
the patient be neglected.  The citrate and bicar-
bonate of potash, the citrate or carbonate of mag-
nesia, and other antacids, conjoined with tonics,
will generally be of  service, both  in  preventing
acidity and promoting digestion, and  in depura-
ting the blood.  A vegetable and farinaceous diet
should be adopted, the  quantity of flesh-meats
much diminished, and the white  kinds of fish,
boiled  only, and with  no other  sauce than  a
squeeze of lemon, should replace a large portion
ofthe other articles of animal food usually taken
The beverage of the  patient may consist of any
of the mineral waters in which the alkalies  most
abound ; or distilled  water may be drunk, when
effervescing with the  bicarbonate of potash and
citric acid or lemon juice, or with the addition of
either the citrate of potash or citrate of magnesia,
according to the state ofthe bowels.   When the
bladder is irritable, the several kinds of soap, with
henbane or with  opium, may be taken at bed-
time.   In all these cases, I have seen  much ben-
efit result from the use of distilled* water, as the
  [* Pure rain-water will  answer equally well.   We
have often known great relief afforded by merely substi-
tuting this for the -water usually drunk.]
vehicle for depurants ofthe blood, and for the im-
portant domestic purposes of making tea, coffee,
&c.  The due promotion of the functions of the
skin, in this class of patients, and the use ofthe
warm  bath, of flannels next to the  skin, should
not be overlooked.
   181.  ii. The treatment of the passage of renal
calculi is  often of urgent importance, owing rath-
er to the  agony produced than  to the danger in-
curred.  The sufferings ofthe patient are gener-
ally increased in these cases by constant or fre-
quent  retchings, which also require to be as-
suaged.   A warm  bath should  be  immediately
ordered, and before it is ready, or while it is be-
ing prepared, from 40 to 50 minims of laudanum,
or a lesser dose of Battley's solution of opium,
may be given.   If the symptoms be still severe,
and the vomitings continue after the patient's re-
moval from the warm  bath, creasote may be pre-
scribed with demulcents, or other  substances;
or hydrocyanic acid, or  chloroform, may also be
added to  these.  The  warm bath may be repeat-
ed, or warm fomentations be employed, and emol-
lient and  mucilaginous fluids, containing alkaline
carbonates and anodynes, be  freely taken.  If
the patient's sufferings be not very  considerably
relieved by these, the extract or tincture of bella-
donna may be added to the pills or  mixtures al-
ready  advised, and to the fomentations, which
should be continued until complete relief is ob-
tained.
   182.  During the passage of calculi  from the
kidneys, the state ofthe urine should be careful-
ly ascertained, and the bowels satisfactorily evac-
uated, either by magnesia or the citrate  of mag-
nesia taken in demulcent vehicles,  or by oleag-
inous enemata, administered in large quantity,
and  repeated as they may be required.   After re-
lief is obtained, the medical treatment advised for
renal calculi should be  persisted  in for some time,
conformably with the  indications  furnished by
the appearances and deposits ofthe  urine.   The
diet and  regimen  recommended above (y 180)
should be continued throughout, or  modified ac-
cording as the state of the patient and the alter-
ations in  the urine may suggest, due care being
taken not to reduce the digestive and the assimi-
lative  functions,  not to  lower  vital  or  constitu-
tional power, and not to impair the secreting and
depurating actions.
   183 The treatment of vesical calculi differs but
little from that advised.  The avoidance of exer-
tion or of sudden movements, &c, as advised for
renal disease, strict attention to diet, and the adop-
tion of the medical treatment  recommended for
the several kinds of urinary deposit,  conformably
with the kind existing in the urine, and  for renal
concretions, are also required for vesical calculi.
In many  cases, however, the irritation produced
in the bladder, the consequent inflammation, hae-
maturia, &c , and the complication of disease of
the kidneys, of the prostate, &c, render the treat-
ment most difficult, and its benefits often doubt-
ful, however rationally conducted.  It is unneces-
sary to add at this place to what I have already
stated when describing the treatment of diseases
of the Urinary Bladder  and  of the Kidneys,
and when  noticing  the indications of cure  fur-
nished by Urinary Deposits.   WThen   a stone
exists in  the bladder  and produces irritation of
more or less manifest severity, the probability of
that irritation being followed by the consequences
just named, however judicious the medical treat- 
                                 URINE—Sun

ment may be, is very great; and hence the ne-
cessity of removing the stone by a surgical oper-
ation, unless the consecutive diseases or lesions
—the superinduced complications, forbid it£ per-
formance.   As to this and other topics connect-
ed with the  surgical treatment of vesical concre-
tions, I must refer the reader to the very able sur-
gical works  enumerated in the subjoined  Bibli-
ography and References.
  [We should, however,  in this  connexion, re-
member the remark  of Prout, that as healthy
urine contains no free uncombined alkaline  or acid
ingredient, lithic agents, or, more properly, hthon-
lithics,  are  to be sought  for among a  class of
harmless and unirritating compounds,  the  ele-
ments of which are so associated as to act at the
same time, with respect to calculous ingredients,
both as alkalies and acids.   The substances which
approach the nearest to such are the solutions of
the  supercarbonated alkalies, containing a great
excess of carbonic acid, and which may be used
in two forms—1st, as natural mineral waters, as
those of Saratoga, &c; or, 2d, artificial soda or
potash waters.  If the calculus is ofthe lithic acid
variety, from half a drachm to one drachm of bi-
carbonate of potash and as much tartarized soda
may be dissolved in a pint bottle and taken twice
a day with an equal quantity of soft or rain  water;
while, if the urine is alkaline and the concretions
are  ofthe phosphatic variety, the alkali may be
omitted altogether, and the compound consist ei-
ther of pure water  impregnated with  carbonic
acid gas, or  occasionally some acid, as the nitric,
may be substituted for the alkali. Lime-water has
been recommended for the urates by Chevallier,
on the ground of its forming a very soluble salt,
urate of lime, with uric acid ; and he also  thinks
it useful for phosphatic calculi, either by depriv-
ing  them of a portion ofthe uric acid they con-
tain, and thus rendering them less dense ; by de-
composing the ammoniacal salt which enters into
the composition of some ; or by acting on the ani-
mal  matter  which holds the molecules  of these
calculi together.  The phosphate of soda and bo-
rax  are also employed, on chemical grounds, as
good solvents for lithic acid.  On the whole, we
have no good reason  for believing that any ofthe
agents recommended as  true solvents for calculi
exert any such effect in any considerable degree,
but many of them, especially the alkalies,  relieve
the pain and irritation of the urinary organs, from
their sedative influence  upon the mucous  sur-
faces, or from their effect on the digestive organs.
Perhaps, also, the benefit which often results from
their use may be in  part  owing to the  fact that
they are accompanied generally with the copi-
ous  use of aqueous fluids.  With regard  to the
reputed influence of lithonlithics when injected
into  the bladder, we  must refer to the surgical
works of B iodie.Chelius.Velpeau, and Gross]
  184.  IX.  Diseased Excretion and Suppres-
sion of Urine.—The urine  may be voided not
only in the very different degrees of quantity, and
in the states of chemical constitution described
above as indications and important parts  of dis-
ordered vital function and of local disease, but it
also  may be discharged with more or less effort
and suffering on the part ofthe patient.  It may,
moreover, be retained in the bladder, owing either
to paralysis  and over-distention of the organ, or
to mechanical obstacles at the neck or outlet of
the viscus, or in some part of the urethra. The
urine is also often  either secreted in remarkably
pression of.                              1353

 small quantity, or  suppressed  altogether, owing
 to disease  of the kidneys, the blood and nervous
 masses becoming poisoned by the arrest of the
 important  depurating function of these organs,
 and by the resulting excrementitial plethora of
 the  vascular system, and accumulation of urea,
 &c, which these organs eliminate from the blood
 as long as these functions continue.  An altered
 or poisoned state of the blood may also  arrest the
 functions ofthe kidneys.
   185.  i. Difficult  excretion of urine, urina diffi-
 cilis excrctio, or Dysuria (from 6vc, difficult, and
 ovpov, urine), is entirely symptomatic of disease
 affecting some part of the urinary apparatus, or
 some organ or part in the vicinity.   It is gener-
 ally  characterized  by  heat and pain, as well as
 difficulty and delay, in procuring the discharge.
 Dysuria may depend upon the properties or chem-
 ical constitution ofthe urine, especially in irrita-
 ble  states ofthe urinary bladder and urethra; and
 in  such cases, as well as in others where  these
 properties are not present, it may be symptomat-
 ic of disease ofthe kidneys, especially  of inflam-
 matory and organic diseases.  Most frequently,
 however, it is a symptom of the diseases  of the
 urinary bladder and of the urethra, and of gravel
 and urinary concretions.  It is not unfrequently
 present in  diseases of the neck and body of the
 uterus, in the severe cases of dysrnenorrhcea and
 leucorrhoea;  in dysentery and inflammation of
 the rectum, and in cases of inflammatory haemor-
 rhoids.
   186. ii. Strangury, stranguria (from orpayyetv,
 to  squeeze, and ovpov, urine), is  a  more  severe
 degree of the preceding complaint, and is most
 frequently a symptom of diseases ofthe urinary
 organs, more  particularly of over-dist^ition of
 the bladder, of lesions of the neck of the  organ
 and prostate gland, and of the urethra, and of
 urinary calculi and gravel.  In dysuria the urine
 may flow in a full  stream ; but in strangury it is
 much interrupted,  or passes in small quantities,
 or in drops, after great effort.
   187. iii. Ischuria (from ttr^w, I arrest, and ovpov,
 the  urine) has usually  implied an  arrested dis-
 charge of urine ; the arrest taking place either in
 the kidneys—ischuria renalis; anuria  (Willis),
 renal ischuria ; or in the bladder, from paralysis
 ofthe organ, or from some obstruction  at its out-
 let—ischuria vcsicalis, I. vera,  I. retentwnis, vesi-
 cal  ischuria; or in the urethra—ischuria urethra-
 ls, from stricture, phymosis, &c.  Besides those
 symptomatic states of  ischuria, or of retention
 and suppression of urine, other forms of reten-
 tion arising from calculi, and from disease of, or
 tumours in, the uterus or vagina.  &c, may be
 enumerated.  This subject is more fully  discussed
 in the article Symptomatology (see y 210-218);
 but there is one part of it, and that of  the  high-
 est  importance, which requires a more  particular
 consideration,  namely. Ischuria Renalis, Anuria,
 of Dr. W'illis, or Suppression of Urine, the excre-
 tion not being eliminated by the  kidneys, urine
 not being secreted.
   188.  iv. Suppression of urine is always a symp-
 tom  of pre-existing disease, but of so many, and
 of so dangerous maladies, as to  require a short
 notice at this place.  It  is very doubtful whether
 or  no it ever is a primary or idiopathic malady,
 in the strict acceptation  of the  word ; although it
 occasionally deserves this rank as much as some
 others which have been so denominated.  It is
 often observed in the course of pestilential mala- 
1354
URINE—Suppression  of.
dies, more especially in the severer  grades  and
advanced stage of pestilential cholera.   It is  also
not infrequent in  the hamagaslric pestilence.  It
sometimes occurs as a fatal, or at least a most
dangerous  symptom of exanthematous  fevers,
more particularly  of scarlet fever.   In these, and
in other continued fevers, in which it is occasion-
ally  observed, suppression of urine has been ei-
ther too often overlooked, or not viewed with due
consideration.  In all these maladies it may be
either partial  or  complete.   In either case, the
consequences, as respects the blood, nervous  sys-
tem, and structures generally, may be readily in-
ferred.  It also frequently supervenes, either par-
tially or completely, in cases of  inflammation,
acute or chronic, of the kidneys, and of organic
lesions of those organs, most frequently of gran-
ular disease, or cachectic  inflammation  of the
Malpighian  bodies, but most generally in a  par-
tial or incomplete form.  Suppression of urine is
a  more  complete or rapidly dangerous or fatal
form; often follows injuries and diseases ofthe
spinal cord or its membranes, although retention
is a  more common result; and it is not an infre-
quent consequence of various modes of poison-
ing,  owing either to inflammatory action or con-
gestion  thereby induced in  the secreting struc-
ture ofthe kidneys, or to a paralysis of the gan-
glia  and nerves supplying these organs.
   189. A. The symptoms caused by suppression
of urine vary with the circumstances ofthe case,
and  more especially with the slowness or rapidi-
ty with which suppression takes place, and with
the  disease  of which it is  a  consequence.—A.
Wrhen this condition proceeds from  granular le-
sions, atrophy, or other organic change in the
kidneys^it is generally  slow in its progress, and
it is often not observed, or rather the diminished
excretion of urine has been of considerable con-
tinuance, before it has attracted notice ; the urine
being not only very  scanty, but also very much
altered from the  healthy state, as  shown in the
articles on Dropsy and diseases ofthe Kidneys,
and  in the preceding sections.  In these cases,
with the slow progress  of diminution of urine
and  of the  solid  constituents of this excretion,
the  cutaneous and  pulmonary exhalations are
sometimes increased, and their odour is most of-
fensive ;  effusion often  gradually supervenes in
the cellular tissue and in the shut cavities, some-
times with  evidence of a chronic inflammatory
irritation ofthe serous membranes investing these
cavities ; and ultimately the dangerous and com-
monly fatal phenomena rapidly supervening upon
the acute form of suppression, or  of that occur-
ring in  the advanced stage of malignant mala-
dies, make their appearance.
   190. B. When  suppression of urine takes place
more rapidly, the disease is then characterized by
many ofthe symptoms of continued fever.  There
arc pains in the back, but chiefly in the loins and
in the lower extremities, with nausea and vomit-
ing, and often  with a sense of weight or of un-
easiness  if actual pain  or severe aching in these
situations be not  felt.   In some cases vomitings
are  urgent,  and the fluid thrown up is generally
watery, and in a few instances has an urinous
odour.  The pulse is rapid, full, and distended;
perspiration, at first scanty, becomes more copi-
ous, in  some instances abundantly so, and  ulti-
mately it has often an offensive  urinous odour.
After a time varying from three to five days, or
occasionally longer, effusion takes place in  the
cellular tissue and shut cavities, with a tumid or
bloated state ofthe countenance, especially about
the eyes/  In cases of somewhat longer duration,
oedema of the face and extremities comes on and
advances more slowly ;  but as these changes ad-
vance, sopor supervenes and passes into profound
coma,  and sometimes into coma terminating in
convulsions, especially  in  children.   Generally
long before  these symptoms  appear, either  the
extreme diminution  of the quantity of urine, or
its entire suppression, has been recognised by the
physician, if he have been  consulted  so  early;
and when the catheter is introduced to determine
correctly the existence  of urine in the bladder—
the presence  or  absence of which, however, is
generally evinced by the state of the hypogastric
region—nothing beyond a very minute portion
of a thick, muddy, or mucous and offensive urine
is withdrawn.  This form of suppression of urine,
whether  occurring primarily, as I believe I have
seen  it in a very few  instances, or in the early
progress of other diseases, or in the gouty diathe-
sis, or as a consequence  of misplaced or sup-
pressed gout, may be ascribed to a state of con-
gestive inflammation of the secreting structure
of the kidneys, in which the organic nervous or
vital influence of these organs is rapidly exhaust-
ed or suppressed.
   191 C. When  suppression of urine, or anuria,
occurs in the  advanced progress of malignant or
pestilential maladies, the duration of the  symp-
toms more especially appertaining to it is much
shorter, and the course of the malady in which it
appears is very much  hastened  by it to  a fatal
issue.   The changes  usuahy consequent upon
the anuria often do not take place until shortly be-
fore death ; the earlier effects ofthe lost function
ofthe kidneys being chiefly an aggravation of all
the symptoms and diagnostic characters  of  the
malady in which it occurs.   It is very remarkable
in the case  of malignant scarlet fever and pesti-
lential cholera and yellow fever. Very soon, how-
ever, generally in a day or two, and often  after a
few hours, as in pestilential  cholera, sinking, so-
por, convulsions or coma, &c, occur and termi-
nate life ; cuCina ofthe face  and extremities, ef-
fusion v.i.hin the cranium, &c, also taking place
shortly before death in  scarlet fever, and some-
times  in  the haemagastric pestilence.   In pesti-
lential cholera, the watery discharges  from  the
stomach and  bowels prevent the  excrementitial
plethora ofthe vascular system from taking place,
that occasions the coma, effusion, &c, which are
usually the results of anuria, when it supervenes
in the course of other acute maladies.
   192. D. Drs. Willis and Schonlin described
a form of anuria which sometimes occurs in weak
and cachectic children, and which I have observed
also in the  children of the  poor  living in cold,
damp, or low situations.  In these the digestive
mucous surface is much disordered;  the secre-
tions and excretions are acid and offensive,  and
the cutaneous surface is affected by various erup-
tions, chiefly erythematous, vesicular, and pustu-
lar.   The urine is scanty, is sometimes more or
less albuminous, is voided in drops after short in-
tervals, with pain and difficulty, and is ultimately
quite suppressed.  The pulse is at first quick and
weak, but it gradually becomes slower, as sopor,
coma, or  convulsions  supervene.   These symp-
toms  are usually preceded by constipation, by
cedema of the face and extremities, by vomitings
and  retchings, and are ultimately followed by 
URINE—Bibliography and References.
1355
death.  In some cases, especially when perspira-
tions are abundant towards the close of the dis-
ease, this excretion has a urinous or  an acid
and  offensive odour.  The breath also often has
a similar odour.
   193.  E. In fatal cases of rapid or sudden sup-
pression  of urine,  and when this event occurs in
exanthematous and malignant diseases, the kid-
neys are found  of a very dark colour, from  the
congestion of dark blood, or they present a livid
or bluish-brown tint; or they are flabby, enlarged,
and  friable.  These changes are most remarkable
in the secreting structure, the  tubuli being often
filled with epithelian debris.   In malignant scar-
latina, suppression of urine presents appearances
in the kidneys described when treating of Scar-
let Fever  (see y 66).   In the  slower or more
chronic cases, the  appearances are altogether the
same as  those stated when treating of granular
or cachectic inflammation of the kidneys (y 99, et
seq.).   The  changes in the cases of suppression
of urine in children, which I have had an oppor-
tunity of observing, were similar to  those which
I have mentioned under the head of scarlet fever.
Indeed, in some of these cases I had viewed the
disease  as  an abortion or latent state of scarlet
fever, in which  the affection  of the throat  and
skin had not appeared, as I have described it  in
that article.   (See y 26, et seq.)
   194. It is manifest  that  the fatal result,  in
cases  of suppression of urine, arises frcm  two
pathological conditions : 1st, from the excremen-
titious plethora ofthe vascular system, the super-
abundance of the watery element causing effusion
on the brain, its membranes, cellular tissues, and
shut cavities; and, 2d, from the accumulation of
urea, uric acid, &c, in  the blood, which poisons
the  nervous masses and vital structures, thereby
aiding the destructive effects of effusion, or even
proving fatal independently of these  effects.
   195. F.  The treatment cf suppression of urine
is rarely  encouraging, owing to its want of suc-
cess, and the fatal results which surely follow the
very general failure of it.  Yet treatment should
not  be neglected,  as it  may succeed in a few or
rare  cases.   Besides,  hopes  of success may  be
reasonably  entertained, if the  suppression be in-
complete.  In cases occurring in acute, exanthe-
matous, malignant, or pestilential maladies, the
small  quantity  of urine passed  before  complete
suppression  takes place may  or  may not be al-
buminous, and of  diminished  specific gravity ; it
is sometimes thus altered in scarlet  fever, but it
is not, as far as  I  have seen, in  other malignant
diseases.   In these, if the state of the pulse  and
other circumstances allow, the patient should be
cupped on the loins, and the operation  repeated,
to an extent according to the features ofthe case
and  the effect produced.  If the loss of blood can-
not be hazarded, dry-cupping should  be adopted ;
and  the patient,  under all circumstances, should
be placed in a warm bath, rendered  more or  less
alkaline by the addition  of the carbonate of pot-
ass or soda.   After leaving the bath, a turpentine
epithem or embrocation  may  be placed over the
loins, or an embrocation consisting of equal parts
of the compound  turpentine  and  camphor lini-
ments should be applied in the same situation,
or over the abdomen.   The bowels must be kept
freely  open  by the  more diuretic  purgatives,
and  by terebinthinate or other enemata;  and di-
uretics  should be  taken, variously  combined,  or
conjoined with sedatives or anodynes, according
to circumstances, more especially the preparations
of taraxacum, of digitalis, of scoparium, &c.  ;
the carbonates, the nitrates, the acetates, the tar-
trates, the  bitartrates, and the biborates of the
fixed alkalies, in large doses, or in as large as the
stomach w ill tolerate.  If these fail, the following
may be tried as a dernier ressort:
  No. 364. R Olei Terebinthinffl, 3IJ.; Spirit. .lEtheris
Nitrici, Jss. ;  Spirit. Juniperi Comp., §ss. ; Olei Cajuputi,
tlj,xx.; Potassnj Nitratis, 3J.; Pulv. Tragacanth. Comp.,
3iij.; Pulv. Glycyrrh.,  36s.;  tere bene et  adde Syrupi
Ro-se, Syrupi Tolutani, aii, 3jss.;  Aquas destillatae ad
Jviij.  Misce bene.  Sit mist, cujus  capiat Cochl. ij.
larga, 3tiis, 4tis, vel 6tis horis, prius agitata phiala.

If the vomiting  preclude the retention of these
medicines,  a  very small quantity (£ or i minim)
of creasote may be  added, or from  three to six
drops of tinctura opii, to each dose, or both may
be given in addition, and the terebinthinated em-
brocation applied over the epigastrium.   When
suppression of urine follows chronic disease of
the  kidneys, complicated  with dropsy, and  more
especially when  it is associated  also with organic
disease of the heart, then  little  or no permanent
benefit will be derived from any means of treat-
ment ;  those just mentioned being the most ap-
propriate,   and  sometimes affording temporary
benefit.
  Biijliog. and Refer. —Hippocrates, Opera, p. 422.—
Celsus, lib. vii., n. i7. — Galen, De Loc. Affect., Ub. vi.,
c. 3.— Aretaus, Chronic, lib. i., c. 7.—Oribasius, Synop-
sis, lib. vi., c. 4.—Actuarius, De Urinis, &c, 8vo.  Basil.,
1529; et Methodus  Sled., lib. i., c. 10.—Avicenna, Canon.,
lib. i., fin. 2,  doct. 3; lib. iii., fin. 19,  tr. 2.—Gordon, Lib.
<le Urinis, fol.  Ferrara, 1489. —JEnidius, Carmina de
Urinis et Pulribus, 4to.  Vcnet., 1494. — J. de Ketam,
Fnsoic Medicinse de Judiciis  Urinamm, folio.  Vcnet..
1495.—Gentilis de Fuginio, De Urinis, 8vo.  Venet., 14rS.
— U. Binder, Speculum  Videndi Urinas Hominum, 4to,
15 6, in Hatter's Biblioth. Med. Pract., vol. 1., p. 492.—
Avon., The Judicyall of Uryns, &c, fol.  Lond.. 1512.—
J. Vasswus,  De Judicvs Urinarum, 12mo.  Lugd.. 1533.
—R. Ilecorde, The Urynal of Physic and the Judicial of
Urynes, 4to.  Lond., 1E.43.—E. Conhis, De Urinis, 8vo.
Franc, 1543; et de Abusu Urosropia\ Conclusiones ad-
vcrsus Medicastros, Svo.  Marop., 1546.—J. Vasse, his
Judgment of Urines, translated by H. Lhuyd, Svo.  Lond.,
1551. — Emerici, De Urinarum et Pulsorum Xotis, 4to.
Vien.,1552.—ir.C.,TheBookeof the Properties of Herbes,
&c, and with it a Booke of seeing of Vrynes, of all Col-
ours that Vrynes be of, with the Medecynes annexed to
every Vrync; and  every Urine his Urinal, 8vo.  Lond.,
152°, by W. Copland.  See Med. Bibliog., by J. Forbes.
— J. Colin, Miroir  des Urines, 8vo.   Poitiers, 1553. —L.
Thurneisen, Frfndung und Beschreibung des Hams, &c,
fol.  Berl., 1576.—Forestus, De Incerto et Fa laci Urina-
rum Judicio, lib.  ii., c. 3; lib. iii.—J. F. Ulmus, De
Certa Ratione Judicandi ex Urinis, 8vo.   Venet., 157S.
—F. Vallesius. De Urinibus, Pulsibus, ac Febribus. 8vo.
Aug. Taur., 15 8.—H. A. Lopes, El Origin y Nocimiento
de las Orinas.   Mexico, 15E5. — M.  de Oddis, De Urina-
rum Causis, Difforentiis, et Judiciis, fol.   I';>t:iv., 1591.
—F. Perrelli, Observ. de Urinis, 8vo.  Paris, 1597.—J.
Iiordingus, Uroscopia seu de Urinis, Svo.  Rost., 1605.—
J. Hart, The Anatomie of Urine*, containing the Convic-
tion ard Condemnation of thi m, 4to.  London, 16'. 5.—
Guerin, Datume certum graviditatis Indicium ex Urina ?
Paris, 16^6.—N. Bcrtrand, Nova philosophandi ratio de
Urinis, 8vo.  Rhed., 1630.—T. Brian, The Pissc-prophet,
or certaine Pisse-pot Lectures, discovering the Fallacies
and Juggling of the Pisse-pot Science, 4to.  Lond., 1637.
—J. Hart, Anatomy of Urines. Lond., 1652.—H.  Ham-
mond, Ourography, or Speculations on the Excrement
of the Urine, 12mo. Lond., 1656. — Willis, Opera, i., p.
f 23.—C. de Font, Collectio Operum de Urinis, 8vo.  Ul-
traj., 1670.—T. Alvey, De Urina? Materia, 4to.  London,
16S0. — Argentarius, De Urinis Liber, Svo.   Lips., 16S2.
—L. Bellinus, De  Urinis et Pulsibus, 4to.  Lips., 16S5.
—C. Merret.  Some Observations concerning the Ordering
of Urines, 8vo.  Lond., 1692.—Fernelius, Patbologia, lib.
iii.—T. H., Compleat Treatises of Urines, with the Right
Method of Urinal  Prognostication, 12mo.  Lond., 1703.
—T. Hicks, a Treatise of Urines, 8vo.  Lond.,  17(13 — &.
Steurling, Relationes Curiossp Medica? von den Signis
vom Urin, Svo.  Gotha, 17i'S. — haglivi, De Prax.  Med.,
lib. i., c. 9.—R. Flvdd,  Uromantia v. Ej. Medic. Cntho-
Iica, vol. i. — T. Guidotius, De Urinis Libellus,  12mo. 
1356
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Chinrgical  Society of London, vol. ii., p. 124.   (On the
Una and Saccharine Matter  in Urine.) —  [V. Pi out, in
Ibid., vol. viii., p. 520.   (Chemical Propartiis and Comp.
of U,ine )—Also in Ibid.,  vol. viii., p. 537.   (Treatment
of disordered.)—G. Wetzlar, Beytrage zur Kenntniss des
Menschlichen  Harnes, &c, Svo.  Fr., 18-1.—J. Berze-
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vol. iii., p. 257.—J. Bostock, in Ibid., vol. v., p. 8J.— W.
Prout  in Ibid.,  vol. ix., p.  472.—H. Bence Jones, in
Ibid., vol. xxvii., p. 102 and 143—B. C. Brodie, in Ibid.,
vol.  xx., p.  142.    (Changes  from Injuries of Spinal
Curd.) — Bostock, Cyclop,  of  Practical Med., vol. iv., p.
353.—A. Marcet  and W. Prout, in Trans, of Royal Med.
and Chiruvg. Society of London, vol. xii., p. 37.   (Anal.
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(Dischar e of Fat in Urine.)—G. Robinson, in Ibid., vol.
xxvi., p. 51. — A. B. Garrod,  in  Ibid., vol. xxxi.,  p. S4.
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xxxiii.,  p. 313.  (Albuminous and Fatty Urine.) — In
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the.)—T. B. Curling, in Ibid.,  vol. xx., p. 370.   (Pho ph.
of Lime in  Urine in Mollifies  Ossium.) — S. Solly, in
Ibid., vol. xxvii., p. 448.   (Pho<phate of Lime  Calc. in
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xxxiii., p. 211.  (Urine in Fragilitas and Mol.  Ossium.)
— Woehl r, in Journ. des Progros des Sciences Med., t. i.,
p. 41.— Doituck, in  Lond. Med. Gazette,  May 13th, 1837,
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Cann, in M.-m. de  l'Acad. Roy. de Med., t. viii., p. 6.6.
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to the Physiology and Pathology of Man, translat.  bv G.
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 la Pierre des Reins et de la Vessie, t. iii., 12mo.  Paris,
 1736. — P. Shaw,  Inquiries on the Nature  of Mrs.  Ste-
 phen 's Medicaments, &c.,8vo. Lond., 1739 ; and Exam-
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 with Animadversions on Lithontriptics, Svo.  London,
 1742.—J. Jurin, an Account  ofthe Effects  of Soap-lye
 taken for the Stone, 12mo.   Lond., 1745.—B. Langrish,
 Physical Experiments on Brutes to discover a Method of
 Dissolving the Stone by Injections, 8vo.   Lond., 1746.—
 J. Jurin, an Abstract of his Cases of Stone  and Gravel,
 Svo.   Lond., 1752.—R  Whytt, an  Iissay on the Virtues
 of Lime-water and Soap in the Cure ofthe Stone, 12mo.
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d'en operer la Destruction  sans 1'Operation de la Taille,
Svo.   Paris, 1S23.—M. Hollard, in Journ.  des Progres
des  Sciences Medicales, t. viii., p. 136.   (Pathologia  et
Cura.)—W. Prout, in Transact of Medical and Chiru  g.
Society of London, vol.  viii., p. 537.   (On the Treatment
of.) — A. Copland Hutchison, in Ibid., vol. ix., p. 443,
and  vol. xvi., p. 94.  (Infrequency of Calc.  among Sea-
men.)— W. Henry, in Ibid., vol. x., p. 1.5.  (Experimental
Examination  of 187 Specimens.) — A. Cooper, in Ibid.,
vol. viii., p. 4 5;  et vol. xi., p. 349;  vol. xii.,  p. 381.—
H. Bence Jones, in Ibid.,  vol. xxvi., p. 109.  (Exami-
nation of Calculi, &c.) — T. Paget, in Ibid., vol. xxxiii.,
p. 293.—M.  Ilobinet, Repert. Gener.  d'Anatom. et Phys.,
t. i., p. 535. — R. N. Barnard, Trans, of Med. and Phys.
Society of Calcutta, vol. v., p. 249.   (On Urinary Calculi
in the  Satives of Bengal.)—J. G. Crosse, a Treatise on
the Formation, Constituents, and Extraction of the Uri-
nary Calculus, &c, 4to.   Lond., 18C5.   (Cop ously illus-
trated  by Plates, with a most extensive Bibliography.)—J.
Yelloly, in Philosophical Transactions.  Lond., 1829.—A.
Campana, Richerche sulle Concrezioni Urinarie  Umane,
8vo.   Venet., 1830.—Jolly,  art. Calcul in Diet, de Med.
et Chir. Prat., t. iv.  Paris, 1831.—Thomson and Cumin,
in Cyclop, of Pract. Med., vol. i., p. 334.—Amussat, Con-
cretions Urinaires de l'Espece humaine, classees dans le
double Rapport de leur Volume et de leur Forme.  Par.,
1832.—B. C. Brodie, Lectures on Diseases ofthe Urinary
Organs, 8vo.  Lond., lS3i; and Lectures on Calculous
Diseases, in Lond. Med. Gazette, vol. viii.— W. England,
Observat. on the Functional Disorders  of the Kidneys,
which  give  rise  to the Formation of Urinary Calculi,
with Remarks  on thpir Frequency in the County of Nor-
folk, 8vo.  Lond., 1S30. — W. Lawrence, Lectures on Uri-
nary Calculi, &c, in London Med. Gazette, vol. vi.—R.
Willis,  Urinary Dis. and their Treatment,  8vo.   Lond.,
1838, p. 246-">49.  (Renal and Vesical Calculi.)—Von Watt-
mann,  Statistics of Calculus in Austria, and  Chemical
STD  REFERENCES.                         1357

 Constitution of Calculi in Vienna Collections, in British
 and Foreign Medical  Review, &c, vol. iii., p. 254.—M.
 Drantz, in Ibid., vol. v., p. 2C6.   (Line. Urine)—Rayer,
 in Ibid., vol. viii., p. 147. (Cn Milky Urine.)—L'Heritier,
 in Ibid., vol.  xvii.,  p. 437 —Graves, in Ibid., vol. xvi., p.
 243.   See also most  ot the volumes of thin able work,
 more especially vols, vii., ix., xii., xiv., xvi., xvii., &c.—
 G.  Owen Rees, on Calculous Disease ami its Consequen-
 ces, being the Croouian Lectures for 1S5.J, dtllvered be-
 fore the Royal Coll. of Phys., 8vo.  Lond., 1S5:.—Beibie,
 on Ailments connected with Oxaluria, in Edin. Monthly
 Journal of Medicine, August. 1849.—.<?. Cooper. Dirt, of
 Pract. Surgery, 8vo.  Lond., 7ih ed., 183-.— J. G. Crosse,
 Treatise on the Formation, Con-tituents, and Extraction
 of the Urinary Calculus, Plates, 4to.  Lond.,  1835.__J/.
 J. Chelius, System of Surgery, transl., with Note^ and
 Observat, by J. F. South, 2 vols., Svo.   Lond., 1845.—
 W. Coulson, on the Symptoms and Causes of,  und Oper-
 ations for. Stone in the Bladder, in Dis. of the Bladder
 and Prostate Gland, 4th ed., 8vo, 1852; and on  Lithotri^y
 and Lithotomy, 8>o.  Lond., 1S53.— R. Druitt The  Sur-
 geon's Vade  Mccum, 6th ed., 12nio.  Lond., 18 4.  —J.
 Miller, The Practice of Surgery, 2d ed., 8vo.  Edin., 1852.
 —J. Erichten, The Science and Art of Surgery, being  a
 Treatise on Surgical  Injur'es, Diseases, and Operations,
 Svo.  Lond., lSEP-. — W. Fergus on, System of Practical
 Surgery, 3d ed., 12mo.  Lonri., 1S5'.—B. C. Brodie, Notes
 on Litliot ity, with Account of Results of the  Operation
 in Author's Practice, in Trans, of Roval Medico-Chirurg.
 Society of London,  vol. xxxiii.. p. 170.
   The Buliogbaphy of Urine, I"einaey DrrosiTS, and
 Conceetions, est ecially ofthe  Cus<_s, Symptoms, and
 Treatment of Urinary Concretions, is the most extensive
 of any branch of Medical Literature.  I have mentioned
 only a few of the best works and memoirs on  the se sub-
 jects; but those who desire to be further informed will
 find numerous other references in rLOucQun's Litera-
 tura Medica Digesta,  articles Calculus  Uiinarius and
 Urina; in the Repertorium of J. D. Rf.iss. art*. CaUu-
 lus Urinarius, vol. xii., p. 17S-2i7, and Urina, vol. xv.,
 p. KJ4-174; and in the Appendix to Mr. Cbos^e's able
 and laborious work, referred to above.  M- st ot the Ref-
 erences I  have adduced are,  however, not  contained in
 these works.
   [Am. Biisliog. and Refer.—But very few monographs
 on the disorders of the urine and its deposits  have yet
 appeared from the pens of American practitioners.  The
 special works  of Prout, Bird, Marckwick,  Willis, Rees,
 Griffith, and other  British writers on these snbji cts, are
 familiar to American practitioners; and in no part of the
 world, it is believed, are these affections treated more ju-
 diciously and scientifically than by the physicians of the
 United St  tes, especially those more recently educated.
 All the recent improvements, both of a medical and sur-
 gical kind, have been here introduced;  and litl otrity
 has been practised more generally, it is believed, than in
 any other country, except France.  In no  other nation
 has the operation of lithotomy been generally more suc-
 cessful than in this, and in no  other can  any surgeon
 boast of a greater  number of successful* cases than our
 own Dudley.f  Without any disparagement to other au-
 thors, it will  be conceded that the work of Professor S. D.
 Gross, already referred to, on " The Diseases  Injuries,
 and Malforn.ations of the Urinary Bladder," &c, is not
 surpassed  by any other on the same subject in any lan-
 guage, as it embodies all that is positively  known on
 these affections up to the present time.  We take pride
 in referring American practitioners to this most enlight-
 ened work.—S. D.  Gro*s, Elements of Path. Anat., 8vo.
 Phil., 1815;  a Pract. Treatise on Diseases, Injuries, and
 Malformations ofthe Urin. Bladder, the Prostate Gland,
 and the Urethra. 8vo.   Phil., 1855.—J. S. Dorsey, on the
 I/thontriptic  Virtues  of the Gastric Liquor.   I hilad.,
 18f)2.—T. D. Mutter, Am. ed. of Liston's Surgery.— Wm.
 Gibson, a Sketch of Lithotripsy, Am. Journ. Med. Sci.—
 A. H.  Stevens, Notes to Cooper's First Lines of Surgery,
 8vo.  New York;  and  Lectures  on  Lithotomy.  N. Y.,
 1838. — Valentine Mott, Am. edit, of Velpeau's Surgery,
 transl. by Townsend, 3 vols., 8vo.  New York, V-5'x—A.
 S. Doane, Am. ed. of Good's Study of Medicine, 2 vols.,
 8vo.  N. Y.,  1848.— D. M. Reese,  Amer. edit, of Cooper's
 Surgical Dictionary.—G. Buck, Description of the Peri-
 neal Fascia, Trans. Amer. Med. Assoc, vol. i., p. £67.—
 Charles Frick, on  the Urine, 8vo.  Bait., 1850. — E. K.
 Kane, on Kyesteine, Amer. Journ. of Med.  Science, vol.
 iv., p. 13, N.  S.—On Crushing Stone in the  Bladder, see
 Randoljih, N. R. Smith, and  Gibson, in Am, Journal of
 Med. Science, vols,  xv., xviii., and rix, and Amer. edit.
 of Chelius's Surgery, edited by South. 3 vols., Svo.  Phil.,
 1847; also Gross on Urinary Organs.—B.  H Dudley, on
 Nature and Treatment of Calculous Diseases, Svo.  Lex-
  [* Out of '207 cases, 201 were cured; 1 in 34 fatal.]
  [t An analysis of 354 cases of lithotomy performed in
Great Britain gives one death in 4L] 
1358                             URTICARIA—Description  of.
ington, Kentucky, 1836; and in Boston Med. and Surg.
Journal, vol. xv.— J. H. Bush, Observations on the Op-
eration of Lithotomy, illustrated by cases from the prac-
tice of Professor Dudley, Trannsylvania Journ. of Med.,
1837.—Dickson, on Urethrotomy.  N. Y. Journ. of Med.
and Surg., No. 7.—P. Parker, Notes of Surgical Practice
among the Chinese, Cormach's Monthly Journal.  Ed.,
H4,.—John W. Draper, Human  Physiology, Statical
and Dynamical, or the Conditions and Course ofthe Life
of Man, 300 engravings, Svo.  New York, 1S56.— W. M.
Doling. Am. Journal of Med. Science, July, 1841.  (Case
<>f Incontinence of Urine.) — John Kelly, in Ibid., Jan.,
LS4f.   (Lithotomy, in which 228 Calculi were removed
from tlie Blxdder.)—Calvin Conant, Medical Repository,
new series, vol. iv., p. 184.  N. Y., 1818. (Removal of a
small Calculus by a silver Wire passed through a Cathe-
ter.)—Depeyre, on Lithotrity, N. Y. Journ. of Med., 1831.
— D.  D. Stable, on Incontinence of  Urine  in Children,
Am.  Journ. of Medical Science, vol.  lix., 1S55.—Charles
Ftfck, Report on Chemistry and Pathology of Urine,
Trans, of Med. and Chirurg. Faculty of Maryland, 1S55.
— H". G. Meacham, Case of Vesical Retention cured by
persistant  Catheterism, Buffalo Med. Journal, vol. xii.,
p. 619.—C.  M. Hewitt Case of Renal Calculus, in Ibid.,
vol. xii., 1857. — G. E. E. Weber, on the various Opera-
tions  for removing Calculi from the Bladder of the Fe-
male, New York Journ. of Med., July, 1S56.— J. M. Sims,
Two Cases of Vesico-vaginal Fistula cured, N. Y. Med.
Gazette, vol. v., 1S54; Am. Med. Monthly,  Feb., 1854.—
W. H. Van Buren, ( ases of Lithotomy, New York Med.
Times, 1S54, and New York Journ. of Med.—R. Coates,
Statistical  Account of the Ca-es of Urinary Calculi ad-
mitted into the Penn. Hospital from May, 1756, to May,
1835—total, 61 cases. — P. F. Eve, on  the Bilateral Op-
eration of Lithotomy, Am. Journ. of Med. Science, 1815,
and Southern Med. and Surg. Journal, 1S46.—A. Baker,
Jan., Lithotomy in the Female, with Remarks, Trans.
of New York State Med.  Soc, vol. vi., p. 133.— J. V. P.
Quackenbusli, on Prolapsus of the Bladder,  in Ibid., vol.
x., p. 57.—G. Hayvxtrd, Case of Vesico-vaginal Fistula
successfully treated,  Boston Med. and Surg. Journ., vol.
xxi., p. -.5.—T. Sewall, F^xtraordinary  Tendency to the
Fo.-mation of Urinary Calculi, in Ibid., vol. xx., p. 245.
  Am. Bidliou. op Ueine and Ueinaev Deposits.—G.
T. Elliot, Kiesteine  and  the  Urine of Pregnancy, New
York Journal of Mel., Sept., 1 ?5S.— W. A. Hammond,
Urological Contributions, Amer. Joum.  of Med. Science,
April, l->56. — Ckirles Frick, Report on the Chemistry
and Pathology of the Urine, Trans, of Med. and Chirur.
Faculty of Maryland, 1855; also Renal Affections, their
Diagnosis and Pathology, l2mo. Phil., 1S57.—John D.
Fisher, Essay on Paruria Eiratica, or Erratic Urine, N.
England Journal of Med. and Surg., July. 1825.—//. G.
Jameson. Case of Lithotomy, Amer. Medical Recorder,
1S25. .— S. A. Arnold, Case of Misplaced Secretion of
Urine, Ne. v England Journ. of Med. and Surg., October,
1S25. — I)r. Leuter, on Vicarious Urinary Discharge, in
Trans, of Coll. of Phys. of Philadelphia, 1828. — R. D.
J/uwcti. Remarkable Urinary  Calculus,  Am. Journal of
Med. Science, vol. iv., 182.).—J. Young, Incontinence of
Urine successfully treated by Nitrate of Potash, in Ibid.,
vol. v., N.  S., 1843.—M. Morison, Urinary Calculus, Am.
Journ. of Med. Science, vol. xxii.—Benjamin H. Dudley,
Observations on the Nature and Treatment  of Calculous
Diseases, Svo.  Kentucky, 1836.—J. Campbell, Case of
Worms in the Urinary Bladder, Am. Jouiu. of Medical
Science, vol. xxi., N. S.—T. D. Mutter, Urinary Calculus
in a Girl successfully treated, in Ibid., vol. xxi., p. 260.—
Berzelius, The Kidneys and Urine, translated from the
German by IF. H. Boye and F. Learning. Svo.   Philad.,
1813, p. 17J.—P. H. Hurd, Operation for the Stone on a
Female, in Ibid., vol. xviii., p. 110. — O. Partridge, on
the Pedate Violet, in Calculous and Nephritic Diseases,
in Ibid., vol. xix., p. 393.—L. V. Bell, on Urin. Calculi,
in Ibid., vol. xiii., p. 405.—J. P. Mettauir, a Case of Li-
thotomy, &c, in Ibid., vol. xii., p. 2S3. — L. P. Cowles,
Case of Calculus, in Ibid., vol. xiv., p. 120.— A. V. Leslie,
Case of Phosphatic Deposits terminating in Deposition
of Lithic Acid and Lithate of Ammonia, Amer. Journ.
of Medical Science, Jan.,  1848.   (Dr. L.  thinks that t:,e
shortest method of putting an end to the deposition of
the triple phosphates is to cut off at once the supply of
material in the food, and build up the system by tonics,
and especially animal food to the exclusion of vegeta-
bles.)—C. A. Lee, Albumen in Urine, Ohio  Medical and
Surgical Journal, Nov., 1853.—A.  Goldsmith, Case of
Lithotripsy, New York Journ. of Med. and CoL Science,
vol. xi., p. 53.—A. C. Post, New Mode of Operating for
Stone in the Bladder, in Ibid., vol. ii., p. 1S6.—J. L. Le
Conte, on a New Species of Urinary Concretion, in Ibid.,
vol. vii., p.  172.—J. Tliacher, Ca-e of Preternatural Re-
tention of Urine in consequence of Injury, Com. of Mass.
Med. Society, vol. i., p. 35—James Jackson, on a Vari-
ety of Paruria Retentionis peculiar to Females, Com. of
Mass.  Med.  Society, vol. v., p. 25. —Josiah BartleU, Case
 of Calculi,  in Com. of  Massachusetts Medical Society,
 vol. i., p. 53.]
 URTICARIA.—Synox—Urticaria (from Urlica,
   a Nettle, the eruption resembling that caused
   by it), Swediaur, Vogel, Willan.    Fcbrts Urtt-
   cata,  Vogel.   Exanthema Urticatum, Borsieri.
   Scalatina Urticata, Sauvages.   Purpura Urti-
   cata, Juncker.  Uredo, Linnaeus.   Esscra, Heb-
   erden.   Erysipelas Urticatum, Exanthesis  Ur-
   ticaria, Young.  Epinyctis prunginosa, Asprc-
   tudo,  Auct.  Exanthesis Urticaria, Good.  Nes-
   selfiebcr, Nesselsucht,  Nessetauschlag,  Germ.
   Fievre Orhee, Fr.  Orlicana, Ital.   Nettle-rash.
     Classif. — Order  Genus  (Willan),  III.
        Class, I. Order (Author).
    1. Definit.—A  febrile,  non-infectious  exan-
 theme, characterized by an  eruption  of prominent
 wheals or spots, paler or redder, or even both, than
 the surrounding surface, rarely of long continu-
 ance, often recurring or becoming aggravated in
 fits, and always attended by a burning and sting-
 ing sensation
   2. I.  Description — Dr. Willan  has enu-
 merated six  species of Urticaria:  1st. Urticaria
 febrihs;  2d. Urt.  evanida; 3d. Urt.  perstans;
 4th. Urt. Conferta,  5th. Urt. Subcutanea; and,
 6th. Urt.  tuberosa.   These  have been arranged
 by M. Rayer  under two heads, according as their
 course is  acute or chronic.
   3. i. Urticaria Acuta.—The first variety  un-
 der this head  is the  Urt. febrihs, which is gener-
 ally caused by the ingestion of various articles,
 and frequently by shell-fish (see $ 427, ct scq.),
 and is to  be imputed rather to a peculiar suscep-
 tibility or  idiosyncrasy  ofthe  individual than to
 any noxious or  poisonous  quality in the article
 occasioning the eruption.   Commonly in an hour
 or  two after the ingestion of the article causing
 this affection  the patient complains of a weight
 at the epigastrium, of nausea, sinking, or  giddi-
 ness.   These are followed  by febrile symptoms,
 by heat of skin, and  by the  appearance  of an
 eruption on the  shoulders, breast, the loins,  the
 inner  sides of the arms, thighs, &.C.,  generally
 consisting of reddish or whitish elevated  spots,
 surrounded by bright crimson areolae.  The spots
 are generally irregular, but sometimes circular,
 varying in size, and elevated above the surround-
 ing surface.   When numerous in any part they
 are often  confluent, the skin presenting a  red
 tint, and being stiff and swollen  (Urt. Conferta).
 The eruption  is  attended by distressing itching,
 pricking, or stinging,especially during the night;
 and sometimes the confluent variety  is associated
 with erythematous  blotches.  When this  form
 of the disease is caused by  shell-fish, or by  pois-
 onous ingesta (§ 427,434), the eruption is some-
 times preceded or attended  by vomiting or purg-
 ing, or by both ;  and spasms, sensations of chok-
 ing or  suffocation,  convulsions, sinkings, &c,
 have even supervened, and in rare instances term-
 inated fatally.   In the slighter cases of urticaria,
 caused  by  the ingesta,  the white itching eleva-
 tions of  the skin  are  not observed, a  simple efflo-
 rescence,  resembling scarlatina,  and belonging
 rather to  erythema than  to urticaria, being  the
characteristic symptom.  After twenty-four, thir-
ty-six, or  forty  hours  the eruption  usually  de-
clines, and soon  afterward leaves  only  slight
traces  on  the skin, which  are effaced in a few
days.
  4. Febrile urticaria sometimes appears without
any appreciable cause,  except teething in chil- 
URTICARIA—Description of.
1359
dren, and intense moral emotions in adults.  The
symptoms are nearly the same as those caused by
the ingesta, excepting that vomiting and purging
are not observed, that the febrile symptoms con-
tinue longer, usually a week or longer, and that
the eruption is less general, but appears and dis-
appears in  almost  all parts of the  surface, pre-
ceded by slight febrile  symptoms.   The patient
can often excite spots of urticaria by friction, but
these  generally disappear in  a few hours.   In
some instances the rash continues for two or three
weeks (Urticaria perslans, Willan), and is  at-
tended by anorexia,  functional disorders of the
digestive organs, febrile symptoms, general de-
pression, malaise, &c.  The eruption usually de-
clines  imperceptibly, but it  often  returns  with
itching in different parts, and at last disappears
When urticaria has been severe, or has continued
long, a slight desquamation generally follows.
   5.  Urticaria Chronica. — Chronic urticaria
often lasts  for months.   M. Rayer states that
he has known it to continue for several years.
This  form of the disease is most frequent in  fe-
males, and in persons with a delicate or sensitive
skin.  Although most common in those who com-
plain of disorder of the digestive functions, yet
it sometimes occurs in persons who are otherwise
in good health.  The eruption appears at irregu-
lar intervals, sometimes in one  place, at other
times in another (Urt. evanida, Willan), without
fever, and  often  for a few  hours only.  The
patches are generally irregular, and closely  re-
semble the wheals produced by flagellation.  They
have no  erythematous  areolae, and are attended
only by severe pruritus.   In some cases, instead
of itching, a stinging or pricking sensation un-
der the eruption is experienced (Urt. Subcutanea,
Willan).  In these the eruption is scanty, con-
sisting of a few red points, but  little elevated
above the surface, and a small number of spots,
that appear at very remote intervals.  M. Raver
considers this  form of urticaria to be very un-
common, and to be caused by violent moral emo-
tions.
   6.  A severer variety of nettle-rash sometimes
appears (Urt.  luberosa, Willan).   It consists
not merely  in  slightly prominent elevations, but
in true tuberosities of various sizes, which are
hard, deep-seated, extending to the subjacent cel-
lular tissue, attended by slight ecchymosis, and
by a  tense  and sore  state of the limbs.  These
tuberosities generally appear in the  evening or at
night, with  itching and  stinging, and disappear
before morning, leaving the  patient weak,  rest-
less, and  depressed.  They occur  more particu-
larly on the loins and extremities, but they may
come out over the  whole of the body, causing
swelling of the neck, limbs, and even the face;
and are attended by various symptoms, as dysp-
noea, irregular action of the heart, &c.   They are
usually developed with febrile action, and  sub-
side with the remission of the fever, reappearing
with its  accession (Febris intermittens  Urticata,
Frank).
  7.  The varieties  of chronic urticaria are very
irregular in their courses.  They sometimes dis-
appear  for several  days, and  reappear with  or
without an appreciable cause, after  uncertain in-
tervals.  They  often are not entirely removed for
many months,  in rare  instances, not for some
years ; and either spontaneously or by a method-
ical plan of cure.  Turner, Heberden, Rayer,
and others, mention cases which continued many
 years.  I have recently attended a case with Mr.
 Pettigrew, which resisted for  above a year the
 most active treatment.  When the eruption of
 these chronic forms of the disease is very severe,
 it is followed by a bran-like desquamation, con-
 stitutional  symptoms  of varied characters  and
 severity being present, or recurring irregularly.
   8. The  associations  of urticaria are  common,
 and often important.   With constitutional  dis-
 turbance  and disorder of the  digestive organs,
 often depending upon an improper regimen  and
 diet, urticaria is very generally associated.  J.
 Frank saw it complicated with quotidian and ter-
 tian agues, at Pavia, in May and June, 1794, and
 at Wilna, in March and  April,  1812, in so many
 cases as to appear epidemical.  In acute rheu-
 matism the wheals of urticaria may appear, al-
 though not so frequently as  the efflorescence of
 erythema or roseola.  Nettle-rash is uncommon
 in  connexion with  diseases of the  respiratory
 organs and passages.  It is  sometimes observed
 during various chronic visceral  diseases, or can-
 cerous  and organic maladies, and after miscar-
 riages occurring in nervous  females.   Urticaria
 may be complicated with other cutaneous erup-
 tions, especially with erythema, or with roseola,
 or  with lichen, and  occasionally with impetigo.
 Wichmann saw it associated with variola ; Hufe-
 land with measles ; Rayer with prurigo; and I
 have seen  it in a case of jaundice, and in another
 of senile prurigo.
   9. ii. The Causes of urticaria are most  fre-
 quently articles of diet, which, owing  to their
 unwholesome or indigestible natures, or to idio-
 syncrasy  or peculiarity  of susceptibility,  disor-
 der the digestive  and assimilating  organs,  and
 which,  by  passing into the circulation, excite
 more or less febrile  action, and affect the capil-
 lary vessels of the skin.  The  ingestion of nu-
 merous articles is liable  to induce urticaria,  one
 article being more certain to  occasion it than an-
 other, in those predisposed to it.   Mussels, cockles,
 lobsters, crabs, shrimps ;  the  roe of a fish ; dried,
 smoked, and  salt  fish;  dried, smoked, and pre-
 sevred meats ; mushrooms, nuts, and kernels of
 fruits (see art. Poisons, §  434, et seq.); cucumbers,
 and unripe or stale fruits ; some kinds of honey,
 preserves ;  oatmeal, especially when long kept;
 certain medicines, as the  balsams, resins, &c, and
 many other articles, according to particular idio-
 syncrasies, often occasion this eruption.   I have
 seen it caused by fresh pork.   Some persons are
 so  susceptible as  to become affected by it after
 slight friction.  J. Frank states that it is rare in
 Italy and frequent in Russia.  This is to be attrib-
 uted chiefly to the general use  of olive oil in the
 former, and of animal oils and rancid substances,
 and dried meats and fish in  the latter country.
 Nettle-rash is most common in summer, especially
 in women and persons  of a nervous and sanguin-
 eous temperament; and  is much more frequent
 in children, the young,  and  adults, than in  the
 aged.  Cold, or rather exposure to the air, appears
 to have considerable influence on the development
 of the wheals of urticaria, especially in respect of
 certain  parts  of the surface which  are usually
 covered.
  10. iii.  Diagnosis..—It should not be overlook-
 ed that the leaves ofthe  urtica urens, urtica dioi-
 ca, and rhus toxicodendron, the  bite  of the com-
 mon bug, of the gnat, of the flea, and the hairs of
certain caterpillars, may occasion an  eruption of
wheals, which, although evanescent, may at first, 
1360
URTICARIA—Treatment ok.
if the cause be not inquired after, be mistaken for
urticaria. The white and raised wheals surround-
ed by areola;, characterizing urticaria, differ from
patches  of  erythema  in these respects, and in
stino-ing, pricking, and itching.  Erythema nodo-
sum is distinguished  from urticaria tuberosa by
the persistent nature of the former, and the inter-
mitting course of the  latter.   Roseola  cannot be
confounded with the wheals of urticaria, as  it pre-
sents  red spots and  patches,  and not the dull
white  spots of urticaria, and  is not attended by
pruritus, and the pricking or stinging of this lat-
ter.   The history and  all  the  phenomena  of the
case will prevent the eruption  from being, at any
time during its course, mistaken for either measles
or scarlatina.  The  papula?  of Lichen Urticatus
are much more likely to be mistaken for urticaria,
but they are less extensive and less  prominent
than the spots of urticaria ;  their colour  is deep-
er,  they are  harder,  and  they  never  disappear
spontaneously.    The  bites of insects  already
mentioned,  although  causing  wheals  and  itch-
ings, cannot be mistaken for any form of urti-
caria.
  11.  iv. Prognosis.—This eruption has appear-
ed as a salutary crisis  in some instances of inter-
nal inflammatory disease, as remarked by  Koch,
Rayer,  and others.  While, on the other hand,
the sudden disappearance of urticaria has been
followed by the development  or the increased
activity of some internal disease.  This has very
probably been owing to the occurrence or progress
of the latter causing the subsidence of the urti-
caria,  rather than  to the  suppression  of  this
eruption.   No one  of the forms  of urticaria is
attended by any  danger,  although the  chronic
states  are often accompanied with much distress,
and frequently resist the most appropriate treat-
ment for a  long time.   The acute forms follow-
ing the ingestion of poisonous articles, however
severe, or even when  fatal, cannot have the un-
favourable results imputed to the eruption, inas-
much as these results proceed from other changes
produced by these causes,  the eruption being the
least important of their effects.
  12. v. Treatment.—When acute urticaria ispro-
duced  by the ingestion of poisonous substances,
or by articles which are injurious from the idio-
syncrasy of the patient, emetics and  the  other
means advised when treating of those  poisonous
articles which usually cause this eruption, are re-
quired (see  art. Poisons, §443, 450).   After the
stomach and bowels have been evacuated, liquor
ammonias acetatis and nitrate  of potash  may be
given in the camphor  mixture, or in any demul-
cent infusion or decoction;  or the hydrochlorate
of ammonia in similar  vehicles.  Subsequently a
warm bath may be resorted to  and repeated, and
the bowels  kept open  by means of cooling ape-
rients.   I have found olive oil, taken in frequent
doses on the surface of mint  water, and the  appli-
cation of this oil to  the surface, either before or
after a warm bath, of very  great service.  In full
and robust  habits of body, or  in the young and
strong, especially if visceral congestion be present,
vascular depletions, in form and amount according
to the  circumstances ofthe case, should be early
prescribed, a strict diet and regimen enforced, and
in all cases a free state of the bowels,  by means
of cooling aperients, and emollient and demulcent
decoctions, be preserved.  The insomnia and rest-
lessness so generally observed in the severer cases
of this eruption require opiates, but they should
be conjoined with cooling diaphoretics and al-
kalies.   1 have found James's powder, or the anti-
monial  powder, with the compound soap-pill, or
the compound ipecacuanha powder, or a full dose
of the carbonates of the fixed alkalies, or of mag-
nesia, in a demulcent infusion, very successful in
mitigating these symptoms, especially when ei-
ther of these means has been resorted to after due
evacuation of the bowels, and when taken early
in the night, or rather in the evening.   If febrile
action be present, saline aperients, the acetate or
citrate of potash or soda, with nitrate of potash,
and  spirits of nitric ether, in mint water, or in
camphor mixture ; or the citrate of magnesia, in
doses sufficient to act on the bowels, will be found
of great service
   13. The chronic states of urticaria are often
most difficult to  remove ;  and more especially as
they arc generally caused by errors in diet, and
perpetuated  by the use of articles which either
disorder the  digestive organs, or impair the depu-
rating functions, or  otherwise  affect the circu-
lating fluids, so as to irritate the capillary vessels
of the skin.   In these cases patients should adopt
a restricted  diet and regimen, and avoid spiritu-
ous, vinous,  and fermented liquors, all kinds of
shell-fish, and live entirely on farinaceous and veg-
etable food.  I have seen the most obstinate cases,
which had been  treated by the too generally pre-
scribed preparations  of arsenic, iodine, &c, in
large and improperly combined doses, yield to the
use, chiefly or entirely, of farinaceous and vege-
table diet, and distilled water; the secretions, ex-
cretions, and depurating functions generally be-
ing  duly promoted by gentle cooling aperients,
such as those mentioned above.
   14. When the chronic states of urticaria as-
sume a remittent  or intermittent  form, and if
they  do not  readily yield to the means already
advised, then the preparations  of cinchona may
be given with the carbonates ofthe fixed alkalies,
or with the solution ofthe acetate of ammonia, or
with the addition  of the nitrate of potash; and
warm alkaline baths, or vapour baths, be resorted
to.   External applications, especially those which
are oily  or greasy, should be avoided, excepting
the olive and almond  oils, to which  the hydrc-
cvanic acid may  be added when the stinging and
pricking are  distressing.  But even these should
be washed off in a few hours, before they are
made rancid  by the air and the  cutaneous exha-
lation.
  Biut.ioo. and Refer.—Celsus, De Re Medica, 1. i., cap.
28, tec. m.—Alberti, De Purpura Urticata.   Hala?, 1719.
—Chemniz, De Essera Arabum.  Hafn.,1707.—Clenlwrn,
on the Epidemic Diseases of Minorca.  Lond., 170S. —
Winterbottom,  in Med. Facts and Observat., vol.  v., Xo.
G.  (Caused by Almonds.)—Godart, Journ. de Med., t. x..
1759. — Planchon. in  Ibid., t. x., vii.. 1702. —Juncker,
Conspect. Med. Pract., fab. 64. —J. P.  Frank.  Intcrp.
Clinie, vol. i., p. 411.  (Intermittent, &c.)—Heberden, in
Med. Transact, of Royal Coll. of Phys., vol. ii., p. 133.—
Koch, Progr. de Febre Urticata.  Lips., 1792.—Zolbera.
Hufeland's Journ. der Pralct. Ileilkunde, b. xxvj., p. 12.
— Michcflis, in Hufeland u. Himly's Journ. der Prak.
Heilk., Jan.. H_0, p. 29, et Fabr.. 1812, p. 54.   (Shovx the
Injurious Consequences of the Suppression of Urticaria.)
—J. P. Frank,  De Cur. Hora. Morb., 1. iij., p. 112.  {States
that M tastasis to the Brain has followed the Suppression
of Urticaria by Cold.)—Saalmann, Descrip. febris urti-
cata?.  Lips., 1790 — Bateman, Synopsis of Cut. Pis., p.
132.  Ed., 18 9. — W.'chmann, Ideen  zur  Dagnostik, th.
iij., p. 12l>. —  Briche*cau, in Journ.  Compl. des Srieu.
Med.,  t. xxxvij., p. 2G6.  (Cases of Intermittent  Urtica-
ria.) — Schiedeman'ell, Frankische  Beytrjige, No.  35.
(Caused  by Fresh Pork.) — P. Rayer, Theoretical and
Practical Treatise on Diseases of the  Skin.   Lond., Svo,
!kk ' P' 201' ~ Macintosh,  Pra< tice of Physic, vol. i.. p.
155.  (States that dangerous Fever followed the Suppres- 
UTERUS—Morbid Sensibility or.                         1361
sion of Urticaria by Cold Application.)—J. Houghton, in
Cyclop, of Pract. Med., vol. iv., p. 371.—(See also Bibliog.
and Refer, to art. Skin, Diseases of, and art. Poisons,
&c.)
  UTERUS.—Some of the diseases of the ute-
rine organs have been considered in the articles
on the Ovaria and their diseases, on Menstru-
ation and its disorders, on Dropsies ofthe ova-
rium, uterus, and Fallopian tubes,  on  Leucor-
rhcea, and on the diseases of the  Vagina and
Vulva.   Certain uterine maladies have  also been
fully  described  with reference to the puerperal
states, when treating of  Puerperal Diseases.
It now remains for me to view those morbid con-
ditions of the uterus which are not noticed under
other heads, and which appear to be of such im-
portance as to require attention.
   I.  Morbid  Sensibility of the Uterus.—
Synon.—Hysteralgia  (from varepa, the  womb,
and uTijoc, pain);  Metralgia;  Uteralgia; Hys-
teradynia. 'YarepaTiyTJc,  Hippocrates.   Neural-
gie de I" Uterus, Metralgie, Fr.  Der Gebdrmuttcr-
schmerz, Ger.   Neuralgia of the uterus.  Irrita-
ble uterus.
   Classif.—I.  Class, V. Order.   (See Pref-
     ace )
   1.  Defin.—Pain of the uterus, generally very
severe, sometimes continued, at other times remit-
tent or intermittent, particularly of the neck of the
organ; occurring generally at a mature age,  but
seldom after the cessation of the  catamenia;  and
not necessarily depending  upon very manifest  or-
ganic disease, although more or less inflammation
and alteration of structure frequently exists.
   2.  Morbid sensibility of the uterus occurs,  ac-
cording to my observation, in two forms:  1st, in
that which has been denominated irritable uterus,
when indications  of a slow, chronic, and often
most protracted  state of irritation, amounting in
some cases to inflammation and its  usual conse-
quences, are present in the os and cervix uteri;
and, 2d, in that which is more neuralgic, where
these indications are not manifest, and where  the
nervous characters of intermission, &c, are most
evident.  An approximation ofthe characters of
the one affection to those of the other may, how-
ever, be remarked in some instances.
   3.  i.  Irritable  uterus, or irritability of the
uterus,  was first fully  described by Dr. Gooch
The notices taken of it in the works of Riedlin,
Pouteau, Riverius, Stoll, and some others,  are
extremely unsatisfactory, and even calculated to
mislead, it having generally been  referred  by
them to rheumatism or gout affecting the womb.*
Since the publication of Dr. Gooch's  observa-
tions on this affection, Prof. Dewees has directed
attention to it;  and the more  recent writers on
  [* Professor C. D. Mf.igs expresses the opinion ("Fe-
males and their Diseatts."  Phil., 1848, p. 418) that what
goes under the name of dysmenorrhoea is, for the most
part, " rheumatic disorder."  " The uterus becomes sensi-
ble on pressure with the finger; a pessary in contact with
it produces heat and pain, while the touch  reveals no
change in the form, dimensions, or resistance ofthe cer-
vix."  Dr. M. thinks it "identical with what has been
called irritable or neuralgic uterus;" states that it may
continue for a long time without inducing any cognizable
change in the parts. The volatile tinct. guaiac, so much ex-
tolled by Dewees in dysmenorrhoea, proves efficacious, ac-
cording to Professor M., "in virtue of its anti-rheumatic
therapeutical force."  The same able writer and teacher
states that the gravid uterus is also the frequent subject
of rheumatic attacks (Loc. cit). Dr. M. also admits that
" the womb, like any ofthe other tissues, may  be the seat
of a pure neuralgia or preternatural sensibility of the
nerves of the tissues" (p. 437), which would be likely to
be aggravated at the menstrual period.]
     III.              86
the complaints of females have farther illustrated
this subject,  and  shown  its  connexion  with
chronic inflammatory irritation.
  4. Irritable uterus is  seldom met with before
twenty-three years  of age, and as seldom  after
the  menstrual epoch has  ceased.   Dr. Gooch
says that it is not attended by change of struc-
ture, and that it does not tend to such change,
while  Dr. Dewees  states  that he  has usually
found some change about the neck of the uterus.
In  the  cases  of this affection for which I have
been consulted, some have been  unattended by
any manifest alteration of  structure, and others
have been accompanied by indications of chronic
inflammation ofthe cervix  and os uteri.  (§ 21,
et seq.)  In a case in my own family, no j^ itera-
tion could be detected for a very long time, but a
change of structure subsequently became mani-
fest, and assumed a malignant form.
  5. ii. Symptoms.—A.  The constitutional symp-
toms are  increased frequency  of pulse on the
slightest emotion or exertion; sometimes flush-
es, alternating with chilliness, previously to the
exacerbations ;  pain in the lowest part of the ab-
domen along the brim  of  the pelvis, and often
also in the loins, exacerbated by  exercise, while
it is diminished, although  not removed, by  per-
fect quietude in the horizontal posture ; the pain
sometimes recurs in paroxysms, even when the
patient reclines, or is quite still, and is generally
increased for  a  few days either before or imme-
diately after menstruation ; emaciation, paleness,
weakness, and increased sensibility and irritabili-
ty of the whole frame ; an  irregular state of the
bowels, with difficult or painful micturition, and
a pale, white tongue, particularly in the morning.
Sometimes the pulse is soft, at other times firm-
er than usual; and although generally somewhat
quickened, it is occasionally not above the usual
frequency  The skin is cemmonly dry, and its
temperature sometimes  augmented,  while the
hands,  legs, and feet, particularly the latter, are
cold.  The febrile  exacerbations  seldom termin-
ate in perspiration.  The patient occasionally com-
plains of headache, which is often increased to-
ward night.   The appetite  is usually impaired or
capricious ; and the bowels either  are  confined
or  much relaxed—most frequently the former,
the latter more particularly when acted on by pur-
gatives, which generally excite a paroxysm of
pain.  The urine is either  sparing, high-colour-
ed, and depositing a copious sediment; or it is
pale, copious, and limpid, particularly when the
affection is complicated with hysteria or neural-
gic pains in other parts ofthe body :  it is gener-
ally voided with difficulty  and  pain referred to
the urethra; sometimes it  is retained for a long
period, and passed with great suffering.
  6. B. The local Symptoms.—If the uterus be
examined, it will be found exquisitely tender,
particularly its orifice and neck, the former gen-
erally being neither misshapen nor indurated, al-
though frequently somewhat swollen—a state in
which the cervix often also participates.  When
the pain is excited by an  examination, or by coi-
tus, which is also very painful, it does not readi-
ly subside ; and it is often induced by the patient
seating herself  suddenly upon  a hard chair or
bench, and usually by the sexual  congress.   In
addition to these she frequently complains of a
throbbing  or fluttering  sensation in the pelvic
cavity and vagina.   Walking, riding, or any ex-
ercise increases the symptoms, and causes severe 
1362
UTERUS—Morbid  Sensibility of the.
lancinating pains through the pelvic cavity, par-
ticularly in the course of the urethra, and about
the centre of the sacrum:  as  these subside, a
dull, diffused pain is felt  in the same direction.
Leucorrhcea  frequently accompanies this affec-
tion, and often becomes abundant, the discharge
varying from a thin, transparent, and  inodorous
matter to a thick, muco-purulent, and offensive
fluid.  There is often increased heat ofthe vagi-
na.  The uterus is occasionally found lower in
the vagina than natural, and its neck is general-
ly shortened and enlarged, and sensible to the
touch.  Pain is felt immediately behind the mons
veneris and anterior part ofthe brim of the pel-
vis.   The catamenia are at first but little  affected
in this complaint, but  they ultimately  become
more and more scanty, while the sufferings ofthe
patient are generally increased  at their accession.
They often prematurely cease, the patient being
reduced by the protracted  disease and by the con-
finement.
   7. ii. Neuralgia Uteri, or  uterine neuralgia,
has been considered a distinct  disorder by some
writers, and a modification of irritable uterus by
others.  (See Neuralgic Disorders, § 43.) In
this form of altered sensibility  ofthe uterus, the
pain is most exquisite, is generally referred to the
body of the organ, does not continue  for a very
long  time, and  subsides  entirely,  or nearly en-
tirely.  It is altogether paroxysmal, and some-
times  almost periodic.  The general or constitu-
tional symptoms are less evident, or  altogether
absent in this affection ; but the debility and ex-
haustion may be greater.   Examination per va-
ginam does not excite the pain in  the intervals,
although  it may aggravate it in the paroxysm;
and neither  heat, nor leucorrhoeal discharge, is
usually present.  This  form of complaint is not
commonly—or it is rarely—induced  or  aggra-
vated  by the causes which occasion or increase
the sufferings in irritable uterus.   The chief fea-
tures of the neuralgic  disorder are the extreme
violence of pain during the paroxysm, and the
complete or nearly complete  subsidence  of it
during the intervals.  Cases, however, occur in
which the symptoms of the one form of disorder
appear to lapse into those of the other.
   8.  C. The diagnosis of morbid  sensibility of
the uterus is manifest in the severity ofthe pain,
and in the localization of it in  the  cervix and os
uteri, especially ofthe irritable form of disorder,
these parts evincing the utmost tenderness on ex-
amination, and the existence of great irritation,
and ultimately  of chronic inflammation and its
consequences ;  namely, excoriation, leucorrhoeal
discharge, &c.   The  neuralgic form of disorder,
as well as the  irritable form,  is unattended by
any manifest change of the body of the womb,
the symptoms  of metritis or inflammation of the
body of the uterus (§ 53, et seq.)  also being ab-
sent.  Although both affections are independent
of displacement  of the  uterus, yet they  may be
accompanied with displacements in one or other
form.   They cannot be mistaken  for dysmenor-
rhoea  or painful menstruation, for they  may be
present during  the  intervals between the men-
strual periods,  although they may  be aggravated
by the accession of these periods.   On vaginal
examination of  cases of these complaints, the
uterus is usually found in its natural position, ex-
cepting that it is sometimes situated lower down
in the pelvis, or otherwise more or less displaced.
In recent cases it is free from organic change, be-
yond slight tumefaction or fulness, and occasion-
ally softness of its mouth and neck;  but in pro-
tracted cases, the changes produced by continued
irritation and  consecutive chronic inflammation
usually supervene.
  9. D. The prognosis ofthe above states of mor-
bid sensibility of the uterus is favourable as re-
gards the life ofthe patient, although it is not so
favourable as respects a quick recovery.  It may,
if the  causes  continue to operate, be followed,
after some years, by organic change, or  even by
malignant  disease  of the os and  cervix uteri
While most of these  cases will  recover, if judi-
ciously treated, some can only be relieved,  and
others may continue  to suffer for many years,
especially if the  secret habits or vices in which
the malady has originated be persisted in.  The
issue of these cases will depend much on  the
causes inducing  them, on their  recurrence,  and
on the physical and moral  conditions of the pa-
tient.
   [Idiopathic uterine neuralgia is, no doubt, often
mistaken for what has been called by Valleix,
utero-lumbar  neuralgia.  Malgaigne has also
called attention to this affection, as well as Mitch-
ell, Beau, and others.   The former writer re-
gards it as a variety ofthe lumbo-abdominal neu-
ralgia, consisting essentially in an irritation of
the lumbar nerves, the irritation  usually concen-
trating itself on the cervix  uteri.  If the neural-
gia is confined to one side of the lumbar region,
the pain in the neck ofthe uterus is also confined
to one side, and when it  exists on both  sides of
the  vertebrae,  the  pain in  the  cervix  is more
strongly marked on the side in which the neural-
gia is most intense.  This affection has been
called  by some  hysteralgia,  rheumatism of the
womb, &c.; but it is simply utero-lumbar neural-
gia.  It  is generally  accompanied with leucor-
rhcea, or a discharge of mucus from  the vagina.
The prominent local symptoms of this  disease,
then, are pain in the uterus and over the lumbar
region, increased by pressure ; uterine sensibili-
ty, sensibly augmented by a digital examination,
sexual intercourse, or the introduction of a spec-
ulum ; also a discharge of mucus, &c.  The diag-
nostic signs are sufficiently clear, viz.,  pain on
pressing the lumbar vertebrae and the cervix ute-
ri.   The  prognosis' is favourable, provided  the
disease be recognised and the proper treatment
carried out.   The treatment  consists mainly in
powerful revulsives to the  spine and cauteriza-
tion of the cervix uteri.  Valleix recommends
a succession of blisters over the lumbar and sa-
cral  region, and  also the actual cautery to  the
cervix   Malgaigne prefers scarifications of the
neck of the uterus.  Mitchell, of Dublin, relies
on the red-hot iron to the spine.  A nitric acid
issue on the side ofthe lumbar vertebrae has been
found also very successful, and it is not  likely to
cause strangury, so often the result ofthe appli-
cation of blisters to this Tegion.   If this affection
is characterized by periodicity, quinine and other
anti-periodics  will be useful, and indeed  will oft-
en effect a cure without local remedies.]
   10.  E. Causes.—a. The predisposing causes
of these states of morbid sensibility of the uterus
are constitutional sensibility and irritability, the
nervous and irritable temperaments, the impuls-
ive and susceptible disposition, a spare  habit of
body, previous liability  to  painful, difficult, or
scanty menstruation, repeated abortions, and mas-
turbation.—b. The  exciting  causes are not accu- 
UTERUS—Morbid  Sensibility of the.                       1363
rately  ascertained; but they, appear  to  consist
chiefly of fatigue,  exertion, prolonged walks, or
dancing  or standing too  long, and falls on the
hips or back, or succussions of the body, partic-
ularly  when the uterus is susceptible, or during
the catamenia.  Riding on horseback or in a car-
riage, especially if the  road be rough, and during
the menstrual period, or without duly evacuating
the bladder ; the use of cold or astringent lotions
or injections to stop a profuse lochia or leucor-
rhcea; exposure to malaria, &e.; sitting on damp
or cold stones, earth or iron seats, venereal ex-
cesses, and self-pollutions; neglected or protract-
ed leucorrhoea.
   11.  F. The nature of irritable uterus was sup-
posed  by Dr Gooch to  be  similar to that of pain-
ful menstruation,  the  former being  permanent,
the latter recurring with  the periodic discharge.
He farther  inferred that it is  not inflammatory,
because  it does not terminate in change of struc-
ture ;  but it may,  and often does, terminate in
such change.   He states  that, after repeated ex-
aminations, nothing  is discovered  excepting ex-
quisite tenderness  and slight swelling, or rather
tension of  the  cervix  and os uteri.   He farther
supposes that the  fact of many cases, after hav-
ing lasted for years, terminating in entire recov-
ery, is a sufficient proof  that it is a  disease of
function only.  Dr. Dewees contends that it con-
sists of a chronic inflammation, which he con-
ceives may exist in some instances for an almost
indefinite period without  any very manifest de-
rangement  of structure;  and he  states besides
that he  has generally  detected in  this affection
increased heat, and tumefaction as well as pain,
which he views with justice as characteristic of
chronic inflammation.  M. Gbkest nearly adopts
the  views  of Dr.  Gooch, which,  however, are
much  more applicable  to the nature of neuralgia
of the  uterus than  to the  irritable form in which
morbid sensibility ofthe os and cervix uteri most
frequently  occurs  in practice.  (See Neuralgic
Affections, y  43, 44.)
   12.  My experience,  derived  from many cases
in which my opinion has  been requested in con-
sultation, leads  me to conclude that the two forms
of morbid sensibility of the uterus  are character-
ized by  very different  pathological conditions :
1st, that  neuralgia ofthe uterus is an  affection
of the nerves of this organ, induced by depress-
ing and  exhausting causes, and is altogether in-
dependent  of inflammatory action and organic
change, although it may be associated with one
or other of the several displacements and organic
lesions of the womb about to  be noticed; 2d,
that irritability  of  the  uterus is caused by irrita-
tion of the os and cervix uteri, this irritation be-
ing attended by exquisite morbid sensibility and
tenderness, and by some degree of inflammatory
action; that the irritation superinduces chronic
inflammation of these  parts, which may be pro-
tracted for a very long  period, before it is follow-
ed by excoriations,  by a morbid secretion and dis-
charge from the excoriated surfaces, and from
the irritated mucous glands in these  situations,
and  ultimately  by  granulations, ulcerations, and
even more  serious organic change.   According
to this view, the greatest number of the cases
formerly  termed irritable  uterus,  or which  had
this term appropriately applied to them at an  ear-
ly stage only, were actually instances of irritation
followed by chronic  inflammation  of the os and
cervix  uteri and its consequences.  The writings
of Dr. Henry Bennet  have fully demonstrated
the existence of these  lesions, which, although
denied  by Dr. Robebt Lee  and some  others,
have  been very often observed by Dr. Simpson,
Dr. Tyler Smith, Dr. West, Dr. Whitehead, of
Manchester,  M. Chomel, and numerous  conti-
nental writers, and by  myself.   The imperfect
manner in which  affections of the os and cervix
uteri were observed when Dr. Gooch wrote, pre-
vented the true state  of these parts from being
duly recognised and estimated; and yet his ad-
mission of the existence of tenderness, fulness,
tension, &c, in this situation, is a sufficient proof
of the presence of inflammatory irritation, or of
irritation usually passing into inflammation. (See
Inflammation of the Os and Cervix Uteri, <J 21, et
seq.)  When writing  upon this  subject in 1829,
I remarked that, if morbid sensibility  of the os and
cervix uteri exist for some time, it often induces,
or is attended by, an alteration of the circulation
in these parts, by swelling and tension, by great
tenderness, and by increased secretion from their
surfaces — the  augmented secretion  generally
tending to prevent the  disorganizing effects of
inflammatory irritation or  action   from   taking
place.*
  [* We are inclined to believe that the pure "irritable
uterus'' very seldom occurs in practice; for however un-
complicated it may be in the commencement, by the time
the physician is called in more or less engorgement or
inflammation has ensued from the irritation set up.  At
least such "has happened in nearly every case that has
come under our observation; so that the definition of the
disease by Dr. Gooch, who first  called attention to it,
will not hold true, viz., "a painful and tender state of
the uterus, neither attended by nor tending  to produce
change in its structure."   Dr. Dewees has given a very
accurate account of this affection {".4 Treatise on the Dis-
eases of Females," p. 306.   Phil., 1833), from which Dr.
Copland has very freely drawn in his description, both of
the general and local symptoms, as well as the diagnosis
and treatment. According to our countryman (Dr. D.), the
irritable uterus may be distinguished from a neuralgic
condition of this part by the following signs:  In  neural-
gia ofthe uterus there is an entire absence ofthe  general
or constitutional symptoms attending irritable  uterus,
especially the evening febrile movement; there is seldom
a vaginal or leucorrhoeal discharge; there is no preternat-
ural heat in the vagina, nor is the uterus so sensible to
the touch unless examined during  the painful continu-
ance of the paroxysm, and then, perhaps, it is more ex-
quisitely sensible than it is in the pure irritable uterus.
In neuralgia, moreover, the pain  is  less constant, but is
more violent during the paroxysms, which generally ob-
serve  periodicity.   In neuralgia, a paroxysm  may be
suddenly induced by passions or  emotions of the mind,
which is never the case  in the irritable uterus,  though
the latter is susceptible of great and occasional augmen-
tation of pain, through  the medium of the circulation,
by eiTors in diet or improper exposure.
  Dr.  Dewei s also calls attention to the fact  that irrita-
ble uterus is very apt to  be confounded with prolapsus
uteri, inasmuch " as the local symptoms of the latter are
a miniature representation of the former," and as, in the
former, the womb is certain to descend more or less, and
hence is supposed to be the cause of all the difficulty.
If a pessary be employed under such circumstances, the
symptoms will necessarily be aggravated, and the case
rendered still more difficult.
  By way of diagnosis, the mode of conducting an exam-
ination is all-important.    The patient is to be placed
upon her back, with the knees drawn up, the parts well
lubricated; then passing the finger gently into the vagi-
na, seek for the cervix uteri; and  when found, direct the
attention of the patient to the degree of sensation pro-
duced by touching it, as well as the body of the uterus
and the sides of the vagina.  Inquire if there be any ex-
traordinary sensibility in  either of these parts, and if so,
in which part it resides.   If there be tenderness,  the use
of a pessary or any mechanical means for supporting the
uterus is out of the question.
  The irritable uterus has also been confounded  with
dysmenorrhoea and carcinoma of this organ, but it. may
readily be distinguished from the former- by the circum-
stance that in dysmenorrhea pain is only felt during the
menstrual discharge, while the irritable uterus is not neo 
1364                    UTERUS—Treatment  of Painful States  of.
   13. iii. Treatment—Very different means are
requisite for these two forms of morbid sensibility
of the uterus.   It should not be overlooked that
the one is unconnected with inflammatory action,
is purely nervous, and is sudden in its accession
and in its subsidence, while the other is more or
less inflammatory either originally, or  consecu-
tively upon irritation, the morbid action, owing
to the organization and sympathies of the parts
affected, being more or less modified in character,
and prolonged in duration  The circumstance of
the os and cervix uteri being possessed of sensi-
bility only inferior to  that  of the clitoris,* their
erectile  organization, and their abundant supply
of mucous follicles, often render them exquisitely
tender and painful when inflamed, or even when
they are the seats of irritation, and enable them to
furnish  an abundant secretion tending to resolve
or to diminish  inflammatory action, and to pre-
vent the usual consequences of this  action. Not-
withstanding  the advantages these parts derive
from their  organization,  vital powers,  and free
discharge from their surfaces, when irritated,  in-
flamed,  or otherwise  affected, inflammatory ac-
tion, when once developed in them, is the more
disposed to be  protracted,  but it is,  from these
circumstances, much less liable to consecutive al-
terations of structure ; the chief organic lesions
which occur being superficial excoriations, gran-
ulations, and  ulcerations, with  a  more  or less
abundant leucorrhoeal discharge.   These altera-
tions are the  more likely to take place when the
uterus falls low in the pelvis, when  the morbid
secretion accumulates, or is retained, in  the vagi-
essarily attended by dysmenorrhoea, nor  is the latter us-
ually attended by this irritable condition of the uterus.
A digital examination will readily distinguish irritable
uterus from carcinoma uteri by attending to  the marks
laid down by our author.
  With regard to the pathology, we are disposed to coin-
cide with Dr. Dewees in the opinion that there is in this
disease more or less inflammation of a sub-acute kind of
all the tissues of the neck of the uterus, and perhaps  the
body also.  Heat,  swelling, and pain to a greater or less
degree, we have always  found present in this disease;
and in a case now  under treatment, of four years' stand-
ing, there is a  swollen, tender condition of the cervix
uteri, with slight  ulceration.  In another chronic case,
which came under my care recently, there was cdrisider-
able enlargement and ulceration ofthe neck of the'womb.
The pathology of Dr. Dewees  appears to us, therefore,
more accurate than that of Gooch, who denies the pres-
ence of inflammation in irritable uterus.   The most fre-
quent exciting cause of this affection,  according to our
experience, is repeated abo-tions occurring in females of
a highly nervous, susceptible temperament, and delicate
organization; although we have met with it, but less fre-
quently, in those of robust habit and of a sanguine tem-
perament.
  The treatment of this affection is necessarily protract-
ed, difficult, and uncertain, and the patience of both phy-
sician and patient is likely to be exhausted before a cure
is  effected.  Our water-cure  (?)  establishments abound
with such cases, where they are generally treated with
little discrimination and  less  success.  Most of these
cases are there treated for prolapsus; and in one institu-
tion, where such patients congregate in great number, we
found it a common practice to subject the uterus daily to
a pressure of some 20 lbs. of water to a square inch,  in-
troduced by a flexible tube attached to a  hydrant!  The
treatment laid down by our author comprises  all that is
known, and may  be summed up as follows:  Absolute
quiet in a recumbent posture, counter-irritants, anodyne
injections and suppositories, laxatives and enemata, and
tonics, with great attention to diet, &c]
  [* M. Jobert maintains that the projecting  portion of
the cervix uteri is entirely deprived of  nerves, and is,
under all circumstances, insensible.  Of course, he  de-
nies that it is ever the seat of pain.  Bouillatid goes
still farther,  and  denies  that the uterus receives any
nerves whatever from the cerebro-spinal axis;  this, how-
ever, is refuted  by the positive observations  of Tiei>e-
jiann, Robebt Lee, Mulleb, Hebschfeld, Boulan, and
others.]
na, when vital or constitutional power is depress-
ed or  exhausted, and when  the treatment pur-
sued, and other circumstances, permit the air to
have  access to the irritated or  inflamed parts.
This  form  of  altered sensibility of the  uterus,
however severe the pain characterizing it, being
either identical with, or nearly allied to, irritation
or chronic inflammation ofthe neck ofthe organ,
the treatment appropriate to it will be necessarily
the same as advised for that disease;  the more
painful symptoms being treated by such combi-
nations or modifications  of the remedies as have
been  found most  beneficial  in  neuralgic affec-
tions, and in irritable and exhausted states of the
system.
   14. The neuralgic affection, or the nervous form
of morbid sensibility ofthe womb, will, therefore,
be chiefly considered at this place;  the  means,
however, to be recommended for it will often be
also  required  in the inflammatory  states,  and
their  consequences hereafter to be noticed, either
conjointly  with  other  constitutional and  local
remedies, or after recourse has been had to them,
The indications of cure in this affection are, 1st,
to subdue the sufferings  ofthe patient; and, 2d,
to prevent their recurrence, by restoring the con-
stitutional powers, and  healthy state ofthe ute-
rus.   Certain of the means calculated to fulfil the
first will often aid the  accomplishment  of the
second intention.   The  means to be employed
with these views are the  same as have been fully
considered  when  discussing the Treatment  of
Neuralgic Affections  (see 6 80, et seq.); and
they may be used as there recommended and pre-
scribed.
   15.  In the more violent cases, the more ener-
getic  sedatives an<k narcotics may be applied lo?
cally, in the form either of suppositories, or of
injections thrown into the vagina, or of enemata,
the bulk of which should not  exceed three or
four ounces ;  sufficient care being taken not to
prescribe too large a dose of the more sedative
substances, especially in the injections, as the ef-
fects produced by them when thus exhibited may
be as violent as when taken by the mouth.  In a
case which I attended  with the late Dr Moore,
very marked relief was procured by carrying, by
means of a small  piece  of sponge, about half a
drachm ofthe  tincture of belladonna, in a female
syringe, and pressing it out when it reached the
os or cervix uteri.  The paroxysm generally sub-
sided  after a very few minutes, and the more re-
storative means recommended in the article now
referred  to were afterward taken.  These should
be adapted to  the  peculiarities  of the case, and
more  especially with due regard to the  states  of
the vascular system, and to the causes and asso-
ciations  ofthe complaint  These last it is most
important to recognise , for not  only  may  the
disorder be the result of depressing or exhausting
causes, but it  may be complicated with  one or
other of the several forms of displacement of the
uterus, and even with tumours or other organic
changes ofthe organ.
  16  Besides  the means now mentioned  for the
removal  of the paroxysm, others may be tried;
chloroform taken in doses of from twenty to thirty
drops, by the mouth, or injected into the vagina,
in the same or  somewhat  larger quantity;  or
suppositories, in  which the extract of belladonna
forms an ingredient, may be introduced ; or other
narcotics may be similarly employed  In the most
severe cases vomitings or retchings  may occur 
UTERUS—Inflammation of the Neck of.                      1365
and add  to the patient's distress;  for these the
oxalate of cerium has been prescribed by my friend
Dr. Panton, conformably with the opinion enter-
tained ofthe salts of cerium.   In a case which I
attended with Dr. Panton, the oxalate of cerium
was suggested by him, in doses of two grains,
thrice daily, and gave great relief.  Besides these,
various means have been recommended to be ap-
plied  either above the  pubis or over the sacrum
Embrocations of  turpentine containing opium, or
warm epithems  of turpentine, have often  suc-
ceeded in giving  relief in a short time when thus
employed.  Aconite or veratria applied over the
sacrum, has  been resorted to; a small quantity
of the extract or ofthe tincture of either of these
being mixed  in an ointment or liniment, but the
use of these powerful sedatives requires caution,
although externally applied.   In some  instances
warm narcotic injections, repeated and varied ac-
cording to circumstances, will be of service.
   17. If this complaint be dependent upon chron-
ic inflammatory irritation or action, or upon some
other lesion ofthe uterus (y 21, etscq), the means
required by such lesion should be adopted in ad-
dition to that which may appear most  appropri-
ate of the remedies now  advised; and the diet
and regimen ofthe patient ought to be  regulated
with  due reference to such  associations and to
other peculiarities of the case.  In the great ma-
jority the recumbent posture, varied as may be
required, rest, and ease of body and mind, are
necessary, and in all strict avoidance of the pre-
disposing and exciting causes, both ascertained
and inferred,  should be insisted upon.   A refer-
ence  to  these causes  will show (§ 10, 22) that
certain of them, when once indulged in, are not
readily relinquished, and that persistence in them
will render the most judicious treatment of no
avail.*
   18. The means which are most suitable for the
fulfilling ofthe second  intention, viz., the restora-
tion ofthe general health, and ofthe healthy state
ofthe sexual organs more especially, are the same
for this complaint as for accomplishing the second
indication of treatment advised for  the several
forms of inflammatory irritation or action of the
uterus (§ 108, et seq.).   In  some instances, in
which I viewed neuralgic or very painful affec-
tions of the uterus as  the result ofthe influence
of malaria, I  have  during  the intervals between
the paroxysms, and with tb& view of  restoring
the healthy functions, prescribed either the arsen-
ical solution  in the usual doses, or the prepara-
tions  of iron with quinine and camphor.
  II.  Inflammations  of  the Uterus  and Ap-
       pendages.
  [* If the uterine nniralqia be secondary or sympathet-
ic, our therapeutic measures should be directed to the re-
moval of the primary cause, be it engorgement, ulcer-
ation, or displacement.  If it be primary, we have gen-
erally found  cauterization, with  nitrate of silver, or
the  red-hot iron, successful in accomplishing a cure.  In
some cases it has been necessary, in addition, to insert
an issue on the sides of the lumbar vertebne or in the
hypogastric region.  If the pain be periodical, it should
be met, as in case of other forms of neuralgia, by qui-
nine, arsenic, &c.  Temporary relief is afforded by sup-
positories of belladonna, henbane, and opium.  In some
cases relief will be afforded by the introduction of the
uterine sound into the cavity of the uterus, as Malgaigne J
has  advised, on the principle that it modifies the nervous
sensibility of the mucous membrane.   In some cases,
where the pain has been very severe, we have found a
combination of tinct. aconite and chloroform act very
promptly in  relieving it.  They should also be used ex-
ternally over the hypogastric and lumbar regions by fric-
tion.]
     Classif.—III. Class, V. Order (Author in
       Preface).
   19.—Definit.—Pain and weight or uneasiness
in the  hypogastric region, and behind  the pubis,
often with pain in the lumbar and sacral regions
and  in the  regions of the ovaria,  extending to the
groins and tops of the thighs, with more  or less
symptomatic fever, increased towards evening.
   20. Inflammations of the uterus present very
different phenomena and occasion very different
results, according as the morbid  action is seated
chiefly or entirely in the neck of the organ, or in
the body, or in the internal surface, of the uterus,
or as it may implicate the peritoneal surface  of
the fundus.  The symptoms vary also with the
degree in which the adjoining viscera are affected
either  coetaneously or consecutively—with the
nature and extent of the complications, so often
presented by inflammation of this viscus; and
they vary with the grade of morbid action, and
with the manner in which  the  sensibility and
sympathies of the uterus are excited.
   21. i.  Inflammation ofthe Neck and Mouth
of the Uterus and its Consequences.—Inflam-
mation of the cervix  and os uteri  is generally
chronic and  often very protracted.  It is  rarely
acute unless it be caused by the gonorrhceal  vi-
rus, several instances of this form of disease hav-
ing  come before me, one  of them  at the com-
mencement of my practice, when the possibility
of the occurrence was generally denied  by the
physicians of this country.    But this  specific
form of the disease will  be noticed  hereafter.
When inflammation attacks this part of the ute-
rus  it is often slight and insidious in its acces-
sion, and, being frequently attended by more or
less discharge, is too commonly viewed as a form
of leucorrhoea, and considered of comparatively
slight importance. This circumstance often tends
to its neglect at a period when a judicious treat-
ment might  have removed the disorder without
any difficulty.  But, being overlooked or neglect-
ed, and perpetuated or aggravated by persistence
in the causes which occasioned it, the disease be-
comes most  obstinate and  protracted, and is fol-
lowed  by changes of structure which generally
render the treatment more  or less difficult.   In
all cases where the local and constitutional symp-
toms suggest even the idea of disorder or disease
ofthe uterus, the advice given by a most eminent
and  able physician, M. Chomel, should be  fol-
lowed : " La frequence et la diversite des affec-
tions de l'uterus,  la forme latente de beaucoup
d'entre elles, 1'eloignement qu'eprouvent la plu-
part des femmes a parler des sensations  et des
derangements dont cet organe est le siege, sont
autant de motifs pour le medecin de porter de lui-
meme  son attention de ce  cote, d'adresser aux
femmes les questions relatives a ce sujet, et enfin
de ne negliger aucun des moyens d'exploration,
toutes  les fois que quelque circonstance  en in-
dique la necessite.  L'oubli  de ce precepte de-
viendrait la cause d'erreurs de diagnostic aussi
graves que frequentes." Unfortunately the worst
features of our common nature—the most bitter
manifestations of the " odium medicum," which
is generally  the most bitter  and unjust against
those by whom success is achieved—have been
displayed respecting a recourse to those  means
which are requisite to " exploration," and the ex-
istence of those lesions which are to be  ascer-
tained  chiefly by  the exploration in question—
namely, by examinations per vaginam, by  means 
1366
UTERUS—Inflammation of the Neck of.
of the senses of touch and sight.   On this sub-
ject it is quite unnecessary to remark farther,
than that the abuse of any particular mode of in-
vestigation, or an improper recourse to and  em-
ployment of it, cannot invalidate the proofs ofthe
great advantages which are derived from its prop-
er and judicious use ;  and that the evidence and
practice of men of character, position, and expe-
rience, are not to be impugned or disparaged by
others who are not entitled in any point of view
to become the censors of their professional breth-
ren.
  22. A. The causes of chronic inflammation of
the  neck of the uterus and its consequences are
those which have been enumerated as producing
the  two chief forms of altered sensibility of the
organ (§ 10), more especially difficult or disor-
dered or arrested menstruation, excessive sexual
indulgences, and masturbation ;  falls on the back
or hips, or injuries in the vicinity of the pelvis or
peritoneum;  difficult and instrumental labours
and abortions; the extension of inflammatory ir-
ritation to the neck of the uterus from the vulva
and  vagina;  gonorrheal infection; the foul air
ascending open privies; the use of pessaries ;  dis-
placements  of the womb;  cachectic  habits of
body, and neglect of cleanliness.   In many cases
the  cause of disorder is either not manifest or can
only be inferred.  The disease seldom  occurs be-
fore puberty, or  long after the  cessation of the
menses.   It  is most frequently observed from
twenty to fifty years of age.
  23. B.  Symptoms.—The existence  of inflam-
mation of the neck and  mouth of the uterus is
evinced by the appearances of the part, by the lo-
cal  signs and symptoms, and by the sympathetic
or constitutional phenomena.  The appearances
of the cervix and os uteri, it might be supposed,
could not fail of evincing the existence of inflam-
mation of them, more especially since those ap-
pearances have been disclosed by the  use of the
speculum.  Even previously to the use of this in-
strument, this disease might have been detected
by the sense of touch  and the phenomena result-
ing from examinations by this sense, and by the
secretions and alterations of sensibility attending
it.  If the appearances constituting inflammation
of these parts admitted of doubt, and consequent-
ly of discussion—although discussion  has not in
this instance been always the  consequence of
either doubt or unbelief—surely the  several re-
sults of inflammation, more especially tumefac-
tion, excoriation, granulations, ulcerations, &c,
need not have been misunderstood  nor misrepre-
sented.   When treating of Leucorrhcea in 1841
(published in 1842), I referred the  two most im-
portant states of this complaint to " inflammatory
irritation of the mucous glands of the os and cer-
vix uteri," and to chronic inflammation ofthe in-
ternal surface of the uterus, and contended that
these forms of leucorrhcea, especially the latter,
are not unfrequentty of a  specific inflammatory
nature, or gonorrhoeal.   Of this specific form I
have seen several cases, the first  of which oc-
curred at the very commencement of my prac-
tice (in 1821); the last very recently, the inflam-
mation having extended  to the Fallopian tubes.
(See art. Leucorrhosa, § 19, et seq.)
  24. a. The appearances  of the cervix and os
uteri vary with the severity and character of the
inflammation—with the amount of irritation and
congestion preceding and attending it; with the
intensity of the morbid action ; with its duration
and the amount of exudation and secretions ac-
companying it; with its extension to the internal
surface of the cervix;  and with alterations of
structure  which may have already taken place
The earliest appearances are not always observed,
for  congestion or irritation, of  a more  or less
inflammatory character, may have existed  for a
longer or  shorter time before the complaint had
advanced  so far as to induce the patient to have
medical advice.  When the mucous surface of
the cervix is simply congested or  inflamed, it
usually presents a red or livid hue, instead ofthe
pink  or pale  rose colour of health; it is  often
dotted with florid papulae, or with whitish pustu-
lae, according as its mucous glands are inflamed
or distended with a muco-puriform matter.  Fre-
quently the surface of the cervix is covered with
this matter so as to prevent its exact state  to be
observed until this secretion is removed.  At first
the cervix is somewhat swollen  or enlarged, but
still soft;  but with the persistence of the inflam-
matory action, and with the exudation into the
structure  ofthe cervix, more or less induration is
superadded.  At this early period the os and cer-
vix uteri are hotter and more tender or even pain-
ful to the touch than in the healthy state; but
the amount of tenderness and of pain appears to
depend more upon the temperament and suscep-
tibility of the patient than upon the severity of
the inflammatory action—or rather upon the irri-
table  character of this action ; the pain being in
some cases, both in this stage and throughout the
disease, such as to constitute the irritable uterus
of several writers, as noticed above (y 3, et seq.).
  25.  b. As  the disease becomes more chronic
or protracted, the cervix becomes somewhat elon-
gated, and approaches nearer or almost lies upon
the posterior part  of the vagina.  At the same
time the os uteri is more open than natural, ow-
ing, in some cases, to the congestion, inflamma-
tion or enlargement of the muciparous glands at
the orifice and internal canal of the  neck, exter-
nally  to the  os internum of the uterus, and in
others to  congestion of its internal mucous sur-
face  and subjacent tissues.  This inflammatory
state  of the mouth and canal of the cervix was
shown, when treating of Leucorrhcea (in 1841),
to be a frequent cause  and  form of that  com-
plaint, as it is an associated condition of chronic
inflammation  of the cervix ;  and it  usually pre-
sents a dark redcfTsh or livid hue.  The muco-
puriform matter secreted by the inflamed mucous
surfaces of the cervix varies much in appearance
and quantity in different cases; but the chief part
of this secretion, as  I have stated in the article
just referred to (cj 19, et seq.), manifestly proceeds
from the cervical canal.   The state and character
of this secretion, especially upon its discharge,
depend much upon the time of its retention in the
vagina and upon the exclusion or access of air.
  26. c. Inflammation in the neck of the uterus
may continue a long time without giving rise to
its usual results.  This may be owing to the par-
tial resolution it may experience from the exuda-
tion or secretion from its surface and from the
mucous glands, or from the menstrual flux.   But
after an indefinite time, the mucous membrane
of the cervix and os uteri, more especially  that
portion immediately surrounding the mouth of
the cervical canal, undergoes farther change, gen-
erally commencing with excoriations or abrasions
ofthe surface and passing on to ulcerations,but
very rarely with loss of substance.  These may 
UTERUS—Inflammation of the  Neck of.                     1367
present minute  red  granulations, or vegetations
of a livid hue.   When an abrasion or excoriation
is alone present, the  surface is generally of a
vivid red, and the granulations on its surface  are
very minute ; this state of the lesion occurs chief-
ly within the mouth and canal ofthe cervix, and
most  frequently in  single females.  In  a more
decided form of ulceration, the  granulations of
the ulcerated surface may be firm, of a vivid  red
hue, scarcely bleeding on pressure, or they may
be large, fungous, livid, and bleeding readily on
a slight touch.  Sometimes the granulations or
vegetations on the inflammatory sore rise above
the level of the surrounding parts, bleed profuse-
ly when they are touched, or even separate par-
tially.   Inflammatory ulceration of the cervix is
rarely or never excavated ;  it is always on a level
with or above the non-ulcerated tissues, and its
margin never presents any abrupt induration.
Hence the  difficulty  of determining its existence
and limits by the touch, and the source  of differ-
ences of opinion as to the existence of ulceration
of this part.  The  cervix  very  seldom  presents
more than  one ulceration  situated around  the
mouth, dipping into its  cavity, and extending
more or less on the  outer surface.  If the ulcer-
ated state  consist of several patches, it may be
referred to aphthous or ulcerated mucous follicles.
   27.  The  form of the  os uteri  is  generally
changed, owing to the existence of the ulcerated
6tate now described  both within and around  this
part.   The lips of the  os swell,  enlarge, expand,
and open the cervical canal.  This opening  va-
ries with the amount of inflammation and ofthe
changes above  described,  but  it  is  generally
greatest in females  who  have  had several chil-
dren.   When with  these changes the lips ofthe
os uteri are much hypertrophied and indurated,
the opening may admit the first phalanx of  one
or even of two fingers, and it may then assume
the form of two segments of a  sphere, separated
by  a  deep fissure,  within which the ulcerated
surface is situated.
   28.  Ulceration, or the changes now described
as constituting the  ulcerative state of the cervix
and os uteri, gives to  the surface of these parts
a soft, velvety character, when examined by  the
touch.  This sensation and the open state of the
os uteri are the chief indications which this sense
can furnish of the existence of this lesion ; but,
as inflammation alone will open  the cervical ca-
nal, and as the velvety sensation cannot be  de-
pended upon, the existence of ulceration can only
be determined  by an instrumental  examination.
The state of the parts detected by touch, and  the
symptoms about to be noticed, warrant a resource
to this examination.  " In nearly all the  cases
in which ulceration  occupies the exterior of the '■
cervix,  it will also be found, on examination, to;
penetrate more  or  less  deeply  into  its cavity.
The entire canal of  the cervix, as far as the os ■.
internum,  may  be  ulcerated.   Even when  the
cervical canal is free from ulceration, if ulcera-
tion exists externally, it is generally inflamed to
a greater or less depth."  The natural coarctation
of the os internum appears generally to consti-1
tute a  barrier to the extension of ulceration into
the cavity  of the uterus.  But to this rule there
are exceptions, as respects the inflammatory state,
which obviously extends in many instances.
  29.  d. The discharges from the vagina caused
by chronic inflammation of the  cervix uteri  are J
identical with those which are  described under i
the head of Leucorrhcea.  For, as I described
these in that article as resulting from inflamma-
tory action, as evinced by the local and general
symptoms (see  c)  19,  et seq.), their  connexion
with the changes above described and disclosed
by the speculum is obvious.  The discharge gen-
erally consists of various proportions  of mucus
and  pus, it is rarely  the latter  only  or chiefly,
unless the inflammation be specific or gonorrhceal.
It is not unfrequently tinged with blood, especial-
ly  after violent  exertion or sexual intercourse
In these circumstances, the blood is exuded from
the ulcerated or granular surface, and is seldom
in  considerable  quantity—when in quantity  it
may be unmixed  with the  muco-puriform  dis-
charge.
  30. e. Hypertrophy ofthe neck ofthe uterus is
generally a consequence of chronic inflammatory
action, congestion and swelling of this part being
an  early result.  It may, however, remain long
without farther  change, its structure retaining
its softness and  elasticity.  After a time, the ex-
udation of plastic lymph in  the  interstices of its
structure either  is  considerable, or becomes par-
tially organized, and renders it both hypertrophied
and indurated.   At first the inflammatory action
is  often  acute,  as indicated  by increased heat,
vivid redness, and tenderness on pressure; but
these signs subside, the hypertrophy advancing
with more chronic indications ; and sometimes so
far as to very greatly increase  the size  of the
cervix.  In virgins and women who have not had
children, the cervix seldom enlarges to any great
extent.   It may be  indurated and yet not  in-
creased in size; but when  it is  enlarged in this
class of patients it seldom  is more than two or
three times the natural size.   In women who
have borne children the hypertrophy of the cervix
with induration  may,  according to Dr. J Henry
Bennet, in extreme cases reach the size  of the
fist.   Some French  writers ascribe the ulcera-
tions existing in these cases to the hypertrophy ;
but  he justly  contends that the ulceration may
commence as  early as the hypertrophy and ad-
vance with it;  and he has seen ulceration con-
fined to one lip, accompanied with induration and
hypertrophy of that lip only.  When the chronic
inflammation causing these changes in the cervix
has followed a miscarriage or delivery, the  hyper-
trophy is  generally the more  remarkable.   Hy-
pertrophy and induration are commonly confined
to  the cervix, but sometimes they extend  to the
body of the uterus, indicating that it  is also the
seat of chronic inflammation.
  31. As  the indurated cervix enlarges, the ex-
ternal opening expands and assumes a transverse
form ;  so that instead of a nearly circular orifice,
there is  a deep fissure  with well-defined lips.
This occurs more especially when the induration
is  attended  by  ulceration.   Sometimes one of
these lips may  be many times  larger than the
other.   When the superior lip is much enlarged
it covers the os uteri, which  is underneath  it;
when the inferior one is thus  changed the os  is
above it.   Dr.  H. Bennet says that he has seen
both the superior and the inferior lips separately
enlarged to such an extent  as to form  a kind of
tumour projecting a couple of inches beyond the
non-hypertrophied lip.  He states  that the hy-
pertrophied cervix is sometimes divided into sep-
arate lobes, owing to antecedent laceration of the
cervix during an abortion or instrumental labour
The laceration not healing,  the ulceration  in tlie 
1368
UTERUS—Inflammation  of the  Neck  of.
course of time is followed by hypertrophy of the
segments into which the cervix is divided.  These
segments sometimes  assume a stony hardness;
and they may be mistaken  for scirrhus, but may
be distinguished from that malady as  follows:
" When  the  lobular,  knotty irregular  condition
of the cervix is the result of laceration, and  is
simply inflammatory, the fissures which separate
the lobes radiate round the cavity ofthe os as a
centre—which is not the case in a cancerous tu-
mour—each separate lobe being perfectly smooth
in itself, and free from tubercles,  or  superficial
irregularities.  Not only is this  lobular form of
induration erroneously considered cancerous, but
even the hard inflammatory hypertrophy is  still
more erroneously considered  to be  frequently
malignant."
  32. /. Displacement is  often consequent upon
inflammatory hypertrophy of the cervix ; the en-
tire organ generally descends, and the cervix  is
thus brought nearer the  vulva, and at  the same
time  directed backward.   The  retroversion of
the neck ofthe uterus is commonly met with in
married females  suffering from inflammatory in-
duration.  With them it is chiefly owing to in-
tercourse, and  generally becomes permanent.
Enlargement and induration, when very consid-
erable, often occasion more or less  prolapsus,
unless the vagina be very contractile.   In women
who have had many children, and in  whom the
vagina is lax, and offers  an insufficient support
to the uterus, the prolapse may be so great, es-
pecially when standing, as to reach the vulva, or
even  to  appear  externally.  When  the cervix
thus lies low in the vagina, a sensation of weight,
dragging, and bearing down is experienced, es-
pecially when erect.  This sensation is caused
by the traction of the organ on its ligaments and
organs with  which it is connected, and by the
pressure of the cervix on the vagina and  vulva.
The  hypertrophied cervix may be directed ante-
riorly, or behind the pubis, and be more or  less
high.  This position is generally owing to some
enlargement  of  the body of the uterus, causing
the organ to fall back into the cavity of the sa-
crum,  thus  throwing' up the  cervix.   The  en-
larged cervix occasionally lies diagonally, or to
either  side, but this position seldom amounts to
a diseased condition
  33  g. Pain  is  not  always  experienced in
chronic inflammation of  the neck of the uterus,
and when it is felt, the situation  of it is very oft-
en such as not to designate the seat of disease.
In some cases pain is almost or entirely absent,
although there  may be  leucorrhoeal  discharge,
and considerable constitutional disturbance, even
with slight feverish symptoms towards  evening
My experience enables me to vouch for the accu-
racy of Dr  J. H. Bennet's remarks  respecting
the seat of pain; for in  several cases  to which  I
have been called, an examination has confirmed
the connexion of the pain  with the local affec-
tion.   The  pain is  dull, aching,  constant,  and
generally circumscribed, usually felt  in one tor
both  the ovarian  regions,  but much  more  fre-
quently in the left than in  the right; pain of a
similar character is also often experienced in the
back, and even  still more  frequently, according
to my experience, in the  lower  region of the
sacrum, just above the os cocygis.  When it  is
felt in this situation the  neck of the uterus  will
be found low in, and pressing upon the posterior
walls of, the vagina.  Sometimes the pain in the
back is scarcely perceptible, or is described only
as a " weakness," excepting after fatigue, when
it is usually more severe.   The patient says that
her back  is  broken,  and that  she can  neither
stand, sit, nor walk with comfort.   " When there
is pain in the region of the uterine neck, it is ex-
perienced  behind  and above  the pubis.   It  is
seldom circumscribed, like the ovarian pain, but
radiates all  over  the  lower hypogastric  region.
These three pains—the lumbo-sacral, the ovarian,
and the lower hypogastric (I name them in the
order of their relative frequency)—may exist con-
jointly or separately.   They are  produced  alike
by inflammation without  ulceration, and by in-
flammation with ulceration.  They are, however,
much more marked when  there is  ulceration,
more frequently severe, and much more constant."
  34. These pains are not to be mistaken for
neuralgia  of the  uterus,  which  is much  more
acute,  comes  on  suddenly after  intervals, and
ceases as  suddenly, and  is  seated in  the uterus
itself (<) 14, et seq.).  The  neuralgic pain is some-
times present only for an hour or two, and rarely
longer than ten or twelve hours, the intervals be-
ing characterized  by  freedom  from pain.   It is
sometimes symptomatic of organic disease ofthe
womb, as fibrous tumours in the structure of the
organ.  But it is often felt independently of any
evident lesion, the os  and cervix uteri  being
healthy and free from any morbid sensibility.
  35. In addition to the pains described, the pa-
tient sometimes complains of pain in the hip, round
the crista of the ilium, in the  groin, and down
the thigh; posteriorly along the course of the
sciatic nerve and its divisions, and anteriorly and
internally  along the course of the anterior crural
and obturator nerves.  These pains  I have re-
ferred rather to chronic inflammation of the inner
surface ofthe uterus and  enlargement ofthe or-
gan than to chronic inflammation of the cervix.
In the former case they may be  caused by defi-
cient support of the vagina, partial prolapse and
pressure ;  in the latter case they  may be sympa-
thetic.  The pains caused by diseases  of the
uterus are always increased by standing, sitting,
walking, and exertion, but relieved by reclining
and the horizontal posture.
  36. h. The functions of the uterus are often
interfered  with during the continuance of chronic
inflammation of the cervix. As respects  men-
struation, it may be stated, that it may for a time
go on without any marked change.  But it usual-
ly becomes more painful, very scanty, or excess-
ively abundant, and irregular as  to the interval,
the duration, and  the quantity.   The pains, es-
pecially on its accession of this period, are great-
ly increased in the situations above described, and
are often attended by  retchings and vomiting, by
recurring  uterine  tormina,  and by marked  ten-
derness of the hypogastric region.   The irrita-
tion, congestion, enlargement, and other lesions
of the cervix become aggravated  during this pe-
riod.
  37. This disease must  necessarily be a cause
of sterility in many instances, the morbid states
of the cervix and os,  and the  discharges  from
them, interfering more or less with impregnation,
not only in recently-married females, but also in
women who have borne children.  Some females,
however, become  pregnant,  notwithstanding the
existence  of extensive disease of these parts;
but when it takes place  under  these  circum-
stances it  is generally painful, and apt to termi- 
UTERUS—Inflammation  of the  Neck  of.                     1369
 nate in abortion.  Sterility proceeding from this
 disease may be removed by curing its cause. Dr.
 Bennet states that he is continually seeing pa-
 tients  who  have ceased child-bearing for years,
 owing to inflammatory disease ofthe cervix, re-
 cover the power of conception when the local af-
 fection is cured.  Sometimes they become preg-
 nant even  before they are quite well, in which
 case they seldom miscarry, even if the treatment
 is suspended, although the  pregnancy is  often
 laborious.
   38.  i. Uterine inactivity, or exhaustion, is often
 a symptom of chronic inflammation ofthe os and
 cervix uteri, especially when attended by profuse
 leucorrhcea and ulceration  or granulations,  or
 when  the disease is severe.  Dr. J. H. Bennet
 remarks that this  absence  of natural sensations,
 or sexual desire, sometimes exists independently
 of any physical pain, and occasions great unhap-
 piness in married life.   He attributes this change
 to the  modified vitality of the diseased uterine or-
 gans and impaired general health.   The cases of
 this description which I have met with have been
 chiefly those in which there was reason to believe
 that the complaint had been caused by self-pollu-
 tions,  and where the tenderness  of the os uteri
 and adjoining parts rendered sexual congress
 more  or less painful;  for instances  are not rare
 of masturbation being persisted in, although mar-
 ital congress is resisted or evaded.   When the
 cervix is so tender from this  disease as to render
 congress painful, the sensation is experienced at
 the time and for some  hours afterward, or even
 longer.  It may be felt either behind the pubis  or
 in its usual situations.   But although the disease
 may be severe, the  cervix being ulcerated and
 enlarged, congress may not be painful.  Wheth-
 er painful or not painful—the former especially
 —this act may be followed  by a discharge of a
 little blood, or even by considerable haemorrhage.
 That the evasion of marital congress is owing
 rather to the circumstance just adverted to than
 to the  disease of the cervix, is evinced by the fact
 that such evasion is not manifested in other dis-
 eases of the uterus,  or very rarely.
   39.  k. Constitutional and general symptoms are
 always present when the cervix uteri is diseased.
 It should not be overlooked that  this part ofthe
 uterus possesses marked sensibility and intimate
 relations with all parts ofthe economy, through
 the medium chiefly  of the ganglial and  sympa-
 thetic  system   Hence the digestive functions are
 more or less disordered according to the duration
 and severity ofthe local complaint; and there are
 frequently both  nausea and vomiting on  the ac-
 cession of the  catamenia.   The  disorder of the
 stomach and digestive organs is often somewhat
 similar to that consequent on  early pregnancy,
 and is the consequence ofthe inflammation.  The
 leucorrhcea  so  generally present  has  been too
 often imputed to this disorder of the digestive or-
 gans, instead of these complaints  being regarded
 as results ofthe inflammation ofthe cervix.   The
 urinary function is often more or less disturbed,
 in respect both ofthe saline  constituents of the
 urine, and of the frequency  of the calls to dis-
 charge this secretion, and the sensations  attend-
 ing the act.  Dysuria is sometimes  complained
 of, and  a  portion of the secretion from  the in-
 flamed  cervix often passes from the vagina at the
time of micturition.
  40. The pulse is sometimes very materially af-
fected,  and becomes  more or less  accelerated to-
 wards evening; and, as debility increases, it is
 generally weak, or small and irregular, and read-
 ily accelerated on any mental or physical excite-
 ment.  A protracted state of the disease, espe-
 cially when characterized by granulation, ulcera-
 tion, and abundant  leucorrhoeal  discharge, ulti-
 mately occasions aneemia, pallor, a sickly or sal-
 low appearance ofthe countenance, loss of flesh,
 and a flabby state ofthe muscular structure. Con-
 tingent upon  the course of the disease, various
 sympathetic affections often appear,  especially
 nervous headache,  depression  of mind, a sense
 of weight or pressure  at the summit ofthe head
 or on the forehead, pain and tenderness in the
 course  of the  spine,  and  numerous  hysterical
 symptoms.   These phenomena are generally ex-
 acerbated during the catamenial period, especial-
 ly  when  this period is  disordered in any way.
 Most of the symptoms described in the articles
 Hysteria and  Spinal Irritation originate  in
 this disease ofthe cervix and os uteri.
   41. Dr. J. Henry Bennet was the first who
 gave full accounts ofthe diseases ofthe cervix  of
 the uterus ; and he  was followed by Dr. White-
 head of Manchester, Professor Simpson of Edin-
 burgh, and Professor Miller of Louisville, U. S.
 Various other writers on uterine diseases have
 coquetted with the subject,  and, after having en-
 deavoured to  controvert the statements of these
 physicians, have at last fallen in with their views.
 From these and other sources of information, fur-
 nished not only in this country, but even  much
 more abundantly on  the continent, as will be seen
 in the Bibliography, the great importance of in-
 flammatory disease  of the cervix uteri is made
 apparent.   Dr. Whitehead has given an enu-
 meration ofthe lesions of this part of the uterus;
 and, although I do not profess this or  any other
 specialty, but endeavour to practise as a physi-
 cian in  all medical cases, yet I am  sometimes
 consulted respecting uterine diseases, and I am
 thus enabled, from  some experience, to say that
 the statements and  descriptions furnished by the
 physicians whom I  have mentioned are  unassail-
 able.
   42. " 1st. Inflammation and superficial erosion,
 implicating one or both lips of the os uteri, and
 more or less ofthe  external and internal cervix ;
 2d. Varicose ulceration, commonly occupying the
 back part of the anterior lip, sometimes confined
 to the posterior, and occasionally implicating both.
 It gives rise to haemorrhages obeying, more  or
 less perfectly, the menstrual periods, and to puru-
 lent discharges in the  intervals ;  3d. Ct'dema of
 the  cervix ; 4th. Fissured  ulceration of one  or
 both commissures,  of the  anterior or posterior
 lip,  or implicating all these parts  at the  same
 time ;  5th. Induration ofthe cervix, with or with-
 out  abrasion  of surface; 6th.  Endo-uteritis,  or
 inflammation ofthe  lining membrane ofthe ute-
 rus, affecting the body as well  as the neck, and
 sometimes accompanied with induration of the
 cervix, or erosion of one or both lips of the os
 uteri; 7th. Follicular ulceration; 8th. Gonorrhoe-
 al inflammation, affecting the lips and  adjacent
 cervix, and especially liable  to  spread to the lin-
 ing membrane ofthe entire organ ; 9th Syphilitic
 disease in its primary, secondary,  and  tertiary
 stages ; 10th.  Prolapsus uteri, which owes most
 commonly its existence to disease  of the lower
 part of the  uterus, as the primary exciting con-
dition."
  43. To  this enumeration  of lesions, given by 
1370
UTERUS—Inflammation  of the  Neck of.
Dr. Whitehead, maybe added hypertrophy, with
or without ulceration, or granulation, or dilatation
of the cervical canal.   This, in one or other of
these states, is a frequent consequence of chronic
inflammation of the cervix.  Gonorrhozal inflam-
mation of the cervix and its canal is  of greater
importance than is usually considered.   I have
seen several instances of this form of disease, and
in nearly all it extended to the lining  membrane
of the uterus, and was accompanied with great
suffering.   In three cases of married  ladies, not
only did this extension occur, but the ovaria also
became  remarkably  enlarged.   Recovery ulti-
mately took place, but the ovaria remained more
or less enlarged in all.
   44. C. In the virgin and unmarried female, in-
flammation and its consequences noticed above
are by no  means infrequent; and, although par-
tially described by me in the article Leucorrhcea
in the section on "Leucorrhaa from inflammatory
irritation ofthe mucous glands ofthe os and cervix
uteri" (y 19, et seq )  before the appearance of
Dr. Henry Bennet'b work, yet to him the  dis-
tinction is justly due of having first fully described
and elucidated this subject in respect of this class
of patients ; and I can fully corroborate his state-
ment that  inflammation  and  ulceration of the
cervix uteri in  the virgin is not  an uncommon
disease, and that to it may be referred most ofthe
severe  forms of dysmenorrhoea and  leucorrhcea
which  resist the  ordinary modes of  treatment.
Even within these few months I have been call-
ed to several cases, under the care of other prac-
titioners, where this disease existed,  from ages
varying from  nineteen to thirty   Scanty, ex-
cessive, and irregular  menstruation, as well as
the complaints just mentioned, not unfrequently
proceed from inflammatory states of the cervix,
and internal surface of the uterus, as shown in
the article on Menstruation.   (See more espe-
cially y 85-129.)
   45. The causes of inflammation of  the cervix
uteri in unmarried  females have been already no-
ticed.  (y 10, 22.)   The  symptoms in them are
not materially different from  those already de-
scribed :  the  permanency of a leucorrhoeal  dis-
charge ; the local pains ; dysmenorrhoea, and oth-
erwise disordered  menstruation;  spinal  irrita-
tion ; sympathetic  pains in  the hips, thighs,
spine, and under the left mamma; bearing down,
weight in  the  pelvis, debility, pallor, anaemia,
emaciation, &c.  In addition to these, partial pro-
lapse of the uterus, and  other deviations  of its
position, are  not infrequent in this  class  of pa-
tients.
   46. D. During pregnancy inflammation and ul-
ceration of the  os and cervix uteri may be pres-
ent, having existed  previously, or supervened sub-
sequently to impregnation.  MM. Boys de Lou-
ry and Costilhes  first noticed this state  of the
disease;  and soon afterward  Dr. Henry Ben-
net, in 1846, and Dr. Whitehead, in  1847, fully
illustrated this association of inflammation ofthe
cervix uteri.  Dr. Bennet remarks  that he  for-
merly believed that the disease mostly originated
subsequently to conception.  This opinion, how-
ever, his later experience on  a wider field has
shown to be erroneous.  Although it sometimes
thus originates, the cervix is diseased in the ma-
jority of cases previous to conception.  He adds
that the disease generally produces sterility when
it attacks young married females at the onset of
their married life,  but not so  generally arrests ]
 conception when they have had children before
 they are attacked.   The indications furnished by
 tactile and ocular examinations in this state of
 the disease are  the  same as already described.
 The disease  is  attended by pains  in  the  back,
 sacrum, above and behind the  pubes,  and by a
 sense of weight and bearing  down, and muco-
 purulent discharge.  As pregnancy advances the
 pains increase;  the sickness and vomitings at-
 tending this state become severe ; and the muco-
 puriform discharge  is often accompanied with
 more or less haemorrhage.  Dr. H. Bennet has
 very satisfactorily shown that this disease in the
 pregnant state is often a cause of the various
 disorders complained of in this state, or haemor-
 rhage, obstinate sickness, death  of the foetus,
 abortion, moles, &c.; and Dr. Whitehead has
 fully corroborated this statement.  These are
 most important  practical facts;  and,  however
 sneered at by some, doubted by others, and dis-
 believed by a few, I have had occasions, since the
 date  above  mentioned, to be  convinced of the
 truth of the. statements made by these physicians.
 I may here  adduce a summary of Dr. White-
 head's researches on the influence ofthe lesions
 under consideration  in producing abortions; and
 in this he confirms what had been previously ad-
 duced by Dr. H. Bennet.   Inflammatory ulcera-
 tion was the cause of abortion in 26 in  every 100
 cases ; and this  event occurred between the mid-
 dle ofthe sixth and the middle ofthe ninth month
 of pregnancy.   Varicose  ulceration induced ab-
 ortion in 6  or 8 out of every  100, and it oper-
 ated  during the  latter two or three  months.
 C3dema ofthe cervix, acting l.'.iewise in advanced
 pregnancy, was  observed  in about 1 in 25 or 30
 cases.  Fissured ulceration was found to exist in
 20 to 24 out of  every 100 cases, and may cause
 abortion from the fourth to the middle ofthe sev-
 enth month.
   47. E. During and after abortion and parturi-
 tion, inflammation, ulceration, and induration of
 the neck of the uterus are  often productive of
 much and serious disorder.  Induration, enlarge-
 ment, and rigidity of the os and cervix uteri, in
 abortion or in labour at the natural period, render
 these ar'.b both  difficult, painful, and prolonged;
 and these lesions of this portion ofthe  uterus, as
 well as ulceration,  often occasion haemorrhage
 after abortions and parturition, and this  haemor-
 rhage is frequently followed by profuse, puru-
 lent, or muco-purulent discharge.  " When the
 patient first attempts to rise and walk, she feels
 a sensation of weight and bearing  down, which
 gradually increases,  instead  of  diminishing.  If
 the haemorrhage and purulent discharge are con-
 tinued and abundant, and the  uterine  pains are
 very  severe,  several weeks  often elapse before
 she is able to leave her bed ; and when she does,
 she remains weak, languid, and  is unable to make
 the  slightest exertion."   Inflammatory ulcera-
 tion, during the first stage of the puerperal pe-
 riod, powerfully predisposes to puerperal fevers,
 and  to abscess of the ligaments.  It is so com-
 monly developed after abortion, Dr. Bennet re-
 marks, that  he always looks for it when the pa-
 tient does not rally, but presents the symptoms
 already described.
   48 F In advanced life, and after the cessation
 of the menses, inflammation and ulceration ofthe
 neck ofthe uterus are sometimes met with   At
 this period, especially when  the menstrual epoch
I has long ceased, ulceration is the form which in- 
                  UTERUS—Inflammation of

flammation of this portion ofthe uterus generally
assumes.  The most prominent symptoms at this
epoch are severe and constant pain in the sacrum
and lower part of the back, less severe and less
constant pains in the ovarian regions,  and in the
hypogastrium,  leucorrhoeal discharge in  some
cases only, and bearing down and prolapse of the
uterus much less frequent  and more slight than
in younger females.  Ulceration of the neck of
the uterus, in advanced age, seems to be oftener
the remains  of inflammatory disease  present at
the time when the menses  ceased, than an  affec-
tion which had commenced subsequently to that
period.
   49. ii. Inflammation  of the  Body of the
Uterus in the Non-puerperal State.—Synon.
—Metritis ; Hysteritis ; Inflammatio Uteri.—In-
flammation  of the womb  may  assume various
forms or states.  It may be  acute, sub-acute, or
chronic; it may be sthenic,  or asthenic, or septic ;
it may  be common or specific; and it  may  affect
either the internal surface, or the whole body of
the organ.  In the  article on Puerperal Dis-
eases I discussed Inflammations of the Uterus, its
Appendages, and Vans (see  y 176, et seq.) with
reference to the several puerperal conditions; and
I now proceed to consider those forms of inflam-
mation of this organ which I have now mention-
ed, and as they commonly occur in the non-puer-
peral state.
   50. A. Internal Metritis. — Endo-Metritis.
—Non-puerperal  Inflammation  of the  internal
surface of the womb, in its most  frequent forms,
has been partially considered  under the  head
Leucorrhcea (y  25, el seq.) and  Menstruation
(c; 78-129).   I have there  shown that inflamma-
tory states of the internal  surface of the uterus
may occasion certain forms either of leucorrhcea,
or of menstruation, varying with  the modified
states of vascular action, not only in the uterus,
but also in .the cervical canal; the morbid action
being rarely limited to the  former, but generally
extending to the latter, and often  also  to the sub-
stance of the uterus.  Dr.  H Bennet considers
that a sero-sanguinolent discharge is  as charac-
teristic  of endo-metritis as  the rust-coloured' ex-
pectoration is of pneumonia  The internal cavity
of the uterus in  health is not much larger than
that of the neck; but it is not improbable that,
during  the period of menstruation, or  when con-
gestion or inflammatory action exists in this part,
this cavity may be  somewhat enlarged, as, in-
deed, the whole organ frequently is in these cir-
cumstances.  If in addition to the discharge just
noticed, there be a dull, deep-seated pain behind
and slightly above  the pubis, and more or less
general febrile reaction, endo-metritis may be
confidently inferred.  Since,  in the introduction
of the  uterine  sound, and its  improvement by
Professor Simpson,  a recourse  to it has  been
considered as a means of diagnosis in endo-me-
tritis ; for, if the os internum of the cervix  be so
completely open as to allow the uterine sound to
pass freely  into  the  uterine cavity, and if this
cavity be increased in size, and be more sensitive,
the above symptoms being also present, this com-
plaint is certainly  present.  But endo-metritis
may exist and  not be attended by the sero-san-
guinolent discharge alluded to.   It is  only  when
the inflammation is most severe that it is present.
In the  less severe and congestive states, it is
characterized by the discharges and the symptoms
described in the sections on Leucorrhcea above
its Body—Acute Metritis.              1371

referred to, and, during the menstrual periods, by
the painful, difficult, inflammatory,  or haemor-
rhagic symptoms described in the article Men-
struation.  (See v 78-129.)
  51. As endo-metritis is  commonly attended
by  chronic  inflammation  of the  cervix and os
uteri, the symptoms of the latter are  generally
present.   Nevertheless, the former gives rise to
nearly the same symptoms; yet the deep-seated
and  constant pain behind  and  partly above the
pubis, the sensation of weight and bearing down,
the swollen, sensitive, and enlarged conditions of
the organ evinced on examination, the states of
the  discharge and of menstruation already no-
ticed, and the accompanying febrile  action, al-
though often slight, but always increased towards
night, sufficiently indicate the nature of the dis-
ease.
   52.  The progress and termination of endo-me-
tritis depend much upon  its causes and the cir-
cumstances in  which it originated.  It is often
attended by more or less  inflammatory action in
the  cervical canal,  and in the  substance  of the
organ ; and, according to the extent of this asso-
ciation, to the occurrence  of the disease after dif-
ficult or instrumental labours or  after  abortions,
and to the domestic, moral, and hygienic  condi-
tions of the patient, the  course, duration, and
termination ofthe complaint should be imputed.
A chronic form of the disease is apt to supervene,
especially in the circumstances now alluded to;
and even  in  favourable  cases  the  acute form
generally passes into the chronic, the constant
discharges from the internal surface and neck of
the uterus, whether  sanguinolent, serous, muco-
puriform, or purulent, and the catamenial dis-
charges, whether difficult, scanty, or  excessive,
or attended by coagula, or by plastic exudations,
ultimately tend to reduce the acute into a chronic
state of the disease.   Ulceration of the internal
surface of the uterus has been rarely noticed as a
consequence of endo-metritis. When this occurs,
the cavity of the uterus is considerably enlarged,
and contains pus, mucus, and  a bloody matter,
which are discharged more  or less freely, and
often at intervals.   Dr. Hall  Davis  examined
the uterus of a woman which exhibited these ap-
pearances, with several large ulcerations  in the
internal  surface.
   53.  B. Acute Metritis, in the non-puerperal
state, is  a rare  disease.   At  the commencement
of  my practice  (in  1822), having described an
undoubted instance of it, at a meeting of a medi-
cal society in this city,  the case was  considered
apocryphal.  Since then,  I have been  requested
to see other cases, both simple, specific, and com-
plicated, but( in most of them the inflammation
had commenced in the neck and internal surface
of the uterus, or had extended to these  parts, and
thence to the body of the  organ, and in some
instances to the uterine appendages. On referring
to the notes which I took of the more remarkable
cases—since the one in 1822—which I have seen,
I find that the disease occurred in seven married
females  who had never  been pregnant,  and in
three unmarried  females.  In four cases  it was
referred  to  gonorrhoea  communicated by their
husbands, and in three of those the disease ex-
tended to the uterine appendages, the ovaria be-
coming acutely inflamed and ultimately remark-
ably enlarged.   These four  females had  never
been pregnant.   I have notes ofthe disease as I
observed it in six married females who had had 
 1372             UTERUS—Inflammation of

 children,  but  who had not been pregnant for a
 very considerable time previously to their attacks.
 In two of these last, the cause and course of the
 disease were  so singular  as to  require a more
 particular notice in  the sequel.  Within these
 few years other cases have beep seen by me ; and
 I  am  at this  time seeing in consultation a very
 acute  case ofthe disease in a single woman.   In
 none  of these instances could any doubt be en-
 tertained  as to the seat of the malady.
   54.  a.  The seat of metritis is  the whole body
 of the uterus ; but the disease may commence in
 different  ways.  It may attack the whole organ
 primarily, or  extend to it from the internal sur-
 face of the neck.  These  parts may themselves
 be affected consecutively upon inflammation  of
 the vulva  and  vagina, especially when they are in-
 flamed by specific, or asthenic, or contaminating
 causes.   Inflammation ofthe body ofthe uterus,
 in the non-puerperal state, seldom extends to the
 peritoneal surface so as to  give occasion to either
 partial or general peritonitis, as so generally ob-
 served in  puerperal metritis.  An instance, how-
 ever, occurred, to which I was called towards  its
 close,  of  a lady who  had  been  treated  by very
 astringent injections  for the removal of profuse
 discharge from the internal uterine  and cervical
 surfaces.   With the suppression of the discharge,
 acute  metritis supervened, and was very rapidly
 followed by inflammation of the peritoneum cov-
 ering the  pelvic viscera, and ultimately by death ;
 the progress of the disease being manifested  by
 examination  after death.  Metritis, in very rare
 cases, may occur in the non-puerperal state from
 the extension  of inflammation from the rectum or
 bladder.  Many years ago  I attended, with Dr
 Robert Lee,  a married lady, who was attacked
 at first with dysenteric tenesmus, manifestly ow-
 ing to inflammatory action which had commenced
 in the  rectum and sigmoid flexure of the colon.
 Soon  afterward unmistakable evidence of acute
 metritis appeared.  This lady had not  conceived
 for several years.  Soon after the full develop-
 ment of the metritis,  which was  attended by in-
 tense  suffering, phlegmasia alba  dolens of the
 left thigh began to appear,  and when the subsi-
 dence  of  it commenced, the right thigh  became
 similarly  affected.   She  ultimately  recovered
 But disease may commence almost simultane-
 ously in the rectum and vulva from certain septic
 emanations, especially in females who  have had
 children  I was called to two  families living  in
 the opposite outskirts of London, during a very
 warm autumn, after a hot summer.   The privies
 of both houses were open, very full, and  offensive.
 Several younger members of these families were
 attacked by dysentery, with distressing tenesmus,
 and their mothers became the subjects of both the
 dysenteric affection and asthenic inflammation of
 the vulva,  rapidly extending to the vagina, and to
 the neck and body of the uterus.   In both these
 cases the  symptoms of acute metritis  were un-
 mistakable and most violent, and  were, with the
 dysenteric  affection,  manifestly  caused  by the
 state ofthe privies, to  which, indeed, the patients
 themselves referred them.   I have, both  in this
and in foreign countries, had frequent  reason to
 impute the occurrence of Dysentery (see y 24)
to  open privies, &c.; but these two are the only
instances I recollect of both dysentery and acute
metritis having appeared  coetaneously  in  the
same female.
  55. b. Symptoms.—The patient complains of
 its  Body—Acute Metritis.

 severe  and constant pain deeply seated in the
 hypogastric region, chiefly behind and above the
 pubis, darting into the  ovarian regions, around
 the  hips, and  sometimes down the thighs, with a
 sensation of weight and  uneasiness in the pelvis,
 and of severe pain of the lower lumbar, lumbo-
 dorsal, and sacral regions.  Pain, on firm pressure,
 is felt just above the pubis, in the median line,
 and equally to the right and left of that line.  On
 examination, the vagina  is generally hot and dry;
 the  cervix and os uteri are swollen and sensitive
 to the  touch  or to pressure.   The body of the
 uterus  is enlarged, and  attempts to ascertain its
 size are attended by extreme pain, and often by
 nausea or  retchings.  The symptoms  are always
 aggravated by sitting down on a hard seat, or by
 an examination per vaginam,  and the patient is
 unable to walk or stand, or to sit up in bed.   She
 generally lies on her back with her knees drawn
 partially upward.   Calls  to pass urine are  fre-
 quent, and attended by dysuria.  The  bowels are
 usually constipated, and costive motions are pass-
 ed with extreme pain and difficulty, the harden-
 ed faeces being surrounded by much mucus.  In
 many cases violent paroxysms of pain  occur after
 intervals of comparative  ease.
   56. This acute state of the disease is not often
 preceded by chills or rigors, and it is at first  not
 attended by any vaginal discharge, unless it have
 supervened upon vaginitis, or endo-metritis, as
 in some cases of asthenic or diffusive inflamma-
 tion of the vagina and vulva.   However, when
 the  inflammation has commenced in, or extended
 to, the  inner surface of the uterus ($ 50), a sero-
 sanguinolent, or purulent discharge takes place.
 As  the disease subsides, a copious discharge, of
 various appearances, occurs.   In addition to  the
 usual febrile  or constitutional symptoms, espe-
 cially thirst,  restlessness, scanty, high-coloured
 urine, constipation, headache, want of sleep, &c,
 there are  constant nausea;  a white  or furred
 tongue ; pain and swelling of the mammae, and
 sometimes hysterical  symptoms,  but  chiefly in
 nervous and  hysterical females.  In less severe
 cases the  symptoms are milder, and the nature
 of the complaint  is evinced chiefly by a  careful
 digital examination.
   57. c. Terminations —In from  seven to four-
 teen days the  disease subsides, generally without
 either suppuration or inflammation of the  uterine
 veins, in the non-puerperal state;  but  this latter
 result may occur  in this state, as shown in  the
 case attended  by Dr. R  Lee and  myself (v 54),
 and  in two other cases for which I was consult-
 ed,  and which terminated fatally, the  uterine
 phlebitis having been followed  by  secondary pu-
 rulent formations, as shown by examination aft-
 er death.   It  is chiefly in the cachectic habit of
 body in females addicted to intoxicating liquors,
 as in one of the two cases just now alluded  to;
 and  when  the causes are  of a septic  or  infect-
 ing nature, and the  disease assumes an asthenic
 character, that either the veins become implicated
 on the one  hand, or the peritoneum on the other.
  58. Acute metritis may degenerate into  the
 chronic state,  and  occasion  the  inflammatory
 forms of leucorrhcea  and of disordered  menstrua-
 tion  (see those articles), or various consecutive
 lesions ;  and it may give rise to purulent collec-
tions, either near to, or even in the cavity of the
 uterus.   In either case the collection,  as it  be-
comes increased, is evacuated sometimes more or
less suddenly,  and after a greater or less increase 
UTERUS—Inflammation of its Body—Chronic Metritis.             1373
of suffering, per  vaginam.   WThen  matter is
formed near the outer surface, it most frequent-
ly extends to the cellular tissue between the lat-
eral ligaments, and finds its way, as in cases of
suppuration occurring in those ligaments.
   59. d. The  prognosis of acute non-puerperal
metritis is generally favourable when the consti-
tution of the patient is sound ; when the disease
is treated  promptly and  judiciously,  and the
causes are not of a contaminating or specific na-
ture,  as in the cases above  alluded to (y 54).  In
drunken females, in the cachectic, and when the
disease  has  been produced  by infectious or con-
taminating  agents, the  extension  of inflamma-
tion to  the  ovaria, to the veins,  or to the perito-
neum, should be dreaded ;  and in either case the
patient's life may be placed in the  utmost jeop-
ardy.  Even if the acute  should lapse into the
chronic state, or give rise to chronic inflammation
of the lateral ligaments, much and prolonged suf-
fering will result.
   60. e. Diagnosis—Acute metritis may be mis-
taken for acute cystitis, or the latter for the for-
mer  But a careful examination  of the  hypo-
gastric region, ofthe state  of parts  per vaginam,
and  of the condition of the urine and the phe-
nomena attending the discharge of it, will readi-
ly disclose the organ affected.  When the  lateral
ligaments are inflamed, the pain and tenderness
on pressure are experienced on  one side  of the
median line, or in  one side of the pelvis ;  " and
the finger passed up towards the uterus, detects
the inflammatory tumour lying on one side ofthe
uterus."
   61  /. Examinations  after  death from   acute
metritis in the non-puerperal  state  are rare, un-
less  death  has been caused by uterine phlebitis
or by peritonitis, as in the cases  alluded to above
which occurred  in my practice.  In these cases
the uterus was  considerably enlarged, and very
much softened, especially  towards its internal
surface.  The substance of the  organ was infil-
trated with a dark ichorous fluid  in one case, and
with a greenish brown fluid in the other. The
cavity of the uterus was much enlarged in both,
but much more so in one than in the other, and
its surface was covered with a chocolate-coloured
or rusty exudation in the one,  and by a rusty
purulent exudation in the other; this latter con-
taining  a little of a softer matter of the same ap-
pearance and  of an offensive  odour.   The sper-
matic veins  were inflamed,  and contained coagu-
lated  blood, phlebitis extending throughout the
uterine  and spermatic veins to  the vena  cava,
with  coagula  mixed with an ichorous  or sa-
nious purulent  matter.  In one case  purulent
collections, more or less of a sanious appearance,
and offensive odour, existed in the  liver; and in
another, matter was formed in one of the eyes,
which had burst shortly before death.   In a third
case  above  alluded to (Y 57)  peritonitis  super-
vened, the uterus presenting but slight alterations
of structure,  but  the peritoneum exhibited the
lesions described in the article on  this membrane.
(See y 80, et seq )
  62. C. Sub-acute and Chronic  Metritis.—
Sub-acute metritis is merely  a less severe form
of the acute, most of the  symptoms  described
above (v 53, et  seq ) being present, but in a slight-
er degree    The chronic form ofthe  disease may,
like the acute, vary much  in severity ; but, un-
like it as respects  frequency, is a common form
in its simple and complicated  states.   It gener-
ally is seated in a part ofthe body ofthe uterus ;
and, in  the opinion of Dr. H. Bennet, in nine
cases out often  in the posterior wall of the  or-
gan, in its  inferior region, adjoining to the base
of the cervix.  It is commonly the result  of ex-
tension of chronic inflammation ofthe cervix, and
in some instances of the acute or sub-acute state
of the disease.  In these instances it may exist
either in the anterior wall, or in one ofthe  lateral
walls, of the uterus.
  63. a. The symptoms vary much with the ex-
act seat of  the disease, and  with the periods dur-
ing or near menstruation.   In the intervals be-
tween these periods  the patients are  compara-
tively easy ;  the local symptoms are either much
mitigated,  or but little complained of;  and fever
is either slight, or experienced  chiefly in the
evening or night.   In many cases, however, the
functions of digestion, assimilation, and nutrition
are impaired, and various nervous symptoms are
experienced.  When the vascular determination
preceding  menstruation supervenes, then  all the
symptoms  characterizing the  disease are  devel-
oped.  A constant, dull, aching pain is felt in the
lower hypogastric  region,  behind and a little
above the  pubis, and in the left or right ovarian
regions, most frequently the left.   A dull aching
pain is  also present under  the left mamma or in
the left  hypochondrium.in  the lumbar-sacral  re-
gion, extending  around the hips, and  down the
insides  of  the thighs, and  is often more  com-
plained  of  than the deep-seated pain in the pel-
vis.  Walking, descending a stair, or riding in a
carriage, and every kind of motion, are extremely
painful, more especially before, during, and after
menstruation; and in some cases are then ago-
nizing.   On the accession of this period, the pa-
tient's  sufferings are sometimes aggravated  by
sickness and vomiting.
  64. On  examination  per vaginam, in addition
to co-existing disease of the cervix, the seat  of
disease  is  easily  detected.   The  finger, when
passed to the base of the cervix, and around it,
meets with an exceedingly  sensitive elevation, in
some cases regular, in others irregular, but  spher-
ical.  Pressure on the tumefied part is very pain-
ful.  Occasionally there  is hardly any perceptible
swelling, but exquisite tenderness, pressure giv-
ing  rise to sickness.   The womb is  generally
movable, but the attempt to move it is attended
by pain and nausea.  Owing to  its mobility,  in-
flammation and  enlargement of a portion  of the
uterus is generally attended by more or less dis-
placement  ofthe organ,which falls more or less
in the direction  of its enlargement.  If the pos-
terior wall  be the seat of enlargement, as is most
commonly  the case, the  organ falls backward  to-
wards the cavity ofthe  sacrum, and the cervix is
turned upward and towards the pubis, producing
retroversion; but never  in  such  a manner as to
press upon the urethra, as  sometimes  occurs in
retroversion  during  pregnancy.    The  cervix,
however, may remain in its usual position, and
not be anteverted, it forming an angle with the
body of the uterus, which is said to be retroflect-
ed.   If it be the anterior wall which is tumefied,
the uterus  may  fall forward, especially in mar-
ried  females, and occasion  anteversion.  W7hen
retroversion is connected with much enlargement,
the uterus  presses upon the rectum, and becomes
a mechanical obstruction to the process of defae-
cation.  In both forms also  of displacement, es-
pecially when very marked, considerable disorder
• 
1374            UTERUS—Inflammation of its Body—Chronic Metritis.
of the  functions of the urinary bladder results,
the calls to urinate being often, difficult, or oth-
erwise affected. Chronic metritis affecting chiefly
one ofthe sides ofthe uterus, or associated with
disease of the appendages of that side, may like-
wise occasion more or less  displacement in that
direction ; but this is comparatively rare.  Chron-
ic metritis may  not be necessarily attended by
any vaginal discharge;  but  such discharge is
most frequent, owing to the co-existence of  in-
flammation ofthe cervix and vagina, and is either
muco-purulent, or purulent with a more  or less
sanguineous tinge.
  65  b. The constitutional symptoms of this dis-
ease, especially when protracted, are well marked,
and are, according to my observation, well de-
scribed by Professor Simpson and Dr. H. Bennet.
The countenance  is generally  pale and sallow,
and offers  an expression of languor  and pain;
the "faaes uterina" being more especially mani-
fested by this malady, and particularly during or
near the period of menstruation.  Emaciation is a
frequent sign, although not always recognised or
recognisable at first.  Nausea is generally  pres-
ent ; in the most severe cases it is almost con-
stant ;  in the less severe, only at the accession or
during menstruation.   Nausea, or  sickness with
loathing of food, but without vomiting, is so char-
acteristic a symptom of metritis that, when it is
present in chronic inflammation of the  cervix,
the extension of the disease to the body of the
uterus  may be inferred.  Besides the intimate
sympathy existing between the stomach and ute-
rus, numerous other sympathetic  derangements
occur in the course of the  disease, more espe-
cially palpitations, heartburn, headache, feverish-
ness, want of sleep, restlessness, morbid states of
the urine, constipation, dysuria, painful defalca-
tion, &c.
  66. c. The progress and terminations of chron-
ic metritis are very variable.  It is generally  pres-
ent for some time before the symptoms mentioned
above are developed.   It is at first attended by
slight or obscure symptoms, which become more
severe  about  the  period of menstruation, and
more and more  constant with the advance  of
time, until the patient  is prostrated by their  se-
verity and continuance.  While recurring men-
struation, by the vascular determination and con-
gestion characterizing it, tends to exacerbate the
disease, the vascular discharge, especially when
considerable, reduces the severity of it, favouring
a partial resolution, and perpetuating the chronic
condition, when unaided by judicious treatment.
When, with the periodical exacerbations, other
causes of developing uterine  inflammation are
conjoined, the chronic may pass on to the acute
form, and, in  either form,  may be extended to
the uterine appendages, or even to the peritoneal
surface.   Cancerous degeneration  of this  state
can rarely or never occur, unless in the cancer-
ous diathesis.  The most common  consequences
of chronic metritis are those  already noticed,
namely, displacements, enlargements, and the
extension of the disease to adjoining organs or
parts.
  67. d.  Diagnosis. — Patients  affected  with
chronic metritis, existing either simply or  with
chronic inflammation and ulceration ofthe cervix,
but a few years ago, were generally considered
as subject only to functional dysmenorrhoea, or
to displacements  of the  uterus.   Dr. Henry
Bennet referred these latter to chronic metritis,
and viewed them when present as consequences
of metritis, which, however, might exist without
having  as yet  been followed by these  conse-
quences.  Whether or no displacements of the
womb ever occur without previous inflammation
and its consequences, enlargement, &c, becomes
a question, and one which requires solution ; but
there appears no reason  to doubt the fact of the
latter often producing and frequently being asso-
ciated with the former.   However, it should not
be overlooked that, when an enlargement of the
uterus  is  great, when it  is not attended by any
considerable  pain or tenderness  on pressure, it
very probably  arises from  the formation of a
fibrous  tumour  in  the uterine walls.   In these
cases, there is generally  displacement in the di-
rection ofthe uterine tumour.  When the tumour
is large, it is often  attended by more or less in-
flammatory action ;  and when this obtains, then
both pain and tenderness may be expected.  " An
inflammatory tumour also of the broad ligaments
may be mistaken for chronic metritis, occupying
the lateral region of the  womb, especially if the
tumour be lying on the  uterus, as is often the
case."   The  symptoms characterizing the latter
affection will be noticed in the sequel;  but both
affections are sometimes  associated.
   68. It may be difficult to distinguish  cancer
ofthe womb  from chronic metritis.  If the  ute-
rine swelling presents nodosities or irregularities
of surface ; if the pains  are lancinating; if the
general health is very much impaired ; if the pa-
tient is  sallow,  cachectic, emaciated, anasraied,
and weak, well-founded suspicions of cancer may
be entertained.  It is chiefly from the history of
the case, and from the consideration of a variety
of circumstances, that a correct diagnosis can be
formed.  Cancer most frequently commences in
the cervix, and  extends  to the body of the or-
gan.  But in both situations it is either latent,
or it does not come before the physician until it
has made considerable progress.   It is then, or
it soon becomes, immovable, owing to adhesions
between the  uterus and  surrounding tissues.
" In chronic metritis there may be adhesions, but
they are not  of the  perfectly  immovable nature
of those observed in the malignant affection.  In
cancer, the nodosities and inequalities are sharp,
knife-backed, irregular; in chronic metritis, they
are spherical and regular in  their irregularity.
Cancerous tissues are seldom  very  sensitive to
the touch, whereas it is  the reverse with the in-
flamed  uterus.   Cancer  has a tendency to pro-
gress and to pass  through its periods in the
course  of a limited  space of time, say one, two,
or three years.   The symptoms indicating the
existence  of  chronic metritis, on the  contrary,
may generally be traced  back for several years,
and when recognised, the disease appears to re-
main nearly  stationary,  if left  to  itself   The
consideration of these differences will also pre-
vent cancer being mistaken for chronic metritis.
If cancer  of  the uterus  has become ulcerated,
the distinction is still plainer."   (Op. at,p 44.)
  69  D.  Enlargement  of  the Body of  the
Uterus —Hypertrophy,  or overgrowth of the
uterus, more  especially of its body, may  in many
cases be traced back for weeks or months to an
abortion, or a severe labour, or to disease after
delivery.  It  may, however, originate independ-
ently of any ofthe puerperal states   But in most
circumstances it commences without marked se-
verity,  generally with slight ailment only,  and
• 
                     UTERUS—Inflammation

even when supervening upon abortion or deliv-
ery, it manifests merely a state of incomplete con-
valescence.   When  inflammation in any form
follows either abortion or delivery, the process by
which the womb is restored in a few weeks to its
condition previously  to  conception—the process
of Involution, as termed by Rokitansky and West
—is checked.   This  process takes place in the
structure of the uterus, which, having performed
its grand function, undergoes a  state of degen-
eration, and a partial  conversion into a fatty mat-
ter, rendering it more susceptible of being either
absorbed or eliminated in the lochia.   During the
second week after parturition this process is most
active ; but it proceeds also during the third and
even fourth week.   The process of reconstruction
soon  follows, and, according to the German mi-
croscopists, cells,  nuclei, caudate cells,  and the
elements of new fibres are formed, and the organ
is built up anew.  The manner of this reconstruc-
tion has  not been  satisfactorily explained by his-
tologists; but it appears most probable that this
renewal  goes on pari passu with the removal of
the old materials.  ' The interior ofthe uterus un-
dergoes similar changes to those which take place
in its substance.  " It is not until its lining mem-
brane, with the exception of that of the cervix,
has been several times  reproduced and then cast
off in  a  state of  fatty  degeneration, that it  re-
sumes the same condition as before impregnation.
The occurrence of inflammation appears to inter-
rupt these processes, for, though fatty degenera-
tion of the tissues takes place, yet the  removal
of the useless material is but imperfectly accom-
plished,  while  the elements of the new uterus
are themselves, as soon as produced, subjected to
the same alteration ; and the organ remains, long
after the mischief  has passed away, increased in
size, and, at the same time, composed of a tissue
inapt for all the physiological processes of con-
ception, pregnancy, and  child-bearing."  (West,
Lect., p.  92.)   This result will follow not only
the mild, or  chronic, or sub-acute states  of in-
flammatory action developed in the organ during
the process of  involution, but even  any excite-
ment ofthe sexual organs occasioning determina-
tion of blood to the organ, more especially sexual
intercourse too soon after delivery or abortion.
   70.  Symptoms,  Sec.—Enlargement  of the ute-
rus consequent upon  deficient involution may con-
tinue a considerable time without causing more
at first than protracted convalescence, and a feel-
ing of local and general ailment; but generally
farther disorder ensues,  often with increased or-
ganic lesion.   A  sense  of weight and  bearing
down; pains deep  in the pelvis, back, and sacrum,
often extending to the hips and thighs, numbness
or pains  in the limbs ; difficult and painful defae-
cation, frequent micturition, &c., are usually com-
plained of   After a  time  various complications
of this lesion occur,  more especially prolapsus,
retroversion, congestion or chronic inflammation,
frequent, or difficult,  or  excessive menstruation,
&c
  71  True hypertrophy, or enlargement ofthe
uterus independently of defective involution, oc-
curs in both married and unmarried females.  Dr.
West cc-Visidcrs that  it is met with in the former
chiefly, and remarks  that  "excessive or  intem-
perate  sexual intercourse does not produce  it,
though that leads  to its  own train of evils ; but
there has in many instances seemed good reason
for associating the condition with the imperfect
of Fallopian  Tubes, etc.                 1375

 performance of that function, and sometimes the
 evidences of that being the case have been con-
 clusive."  There can be no doubt  of this being
 a not infrequent cause, although it is not the only
 organic lesion consequent upon this cause, ova-
 rian disease being perhaps an equally frequent
 result.  Although true  or primary hypertrophy
 of the uterus  may be most frequent in  married
 females, it is by no means rare in the unmarried,
 especially after twenty-six or twenty-eight years
 of age, where  there  is  reason to infer that the
 vice of masturbation has been long practised.  It
 is in this class, as well as in widows, and in  mar-
 ried women who have either impotent or nearly
 impotent husbands, a consequence of frequently-
 excited and imperfectly-gratified desire.  Sexual
 intercourse is imperfectly performed, and although
 frequently attempted, never duly consummated;
 and thus congestion of, or active  vascular de-
 termination to, the uterus is maintained, without
 conception and its  successive changes taking
 place, whereby the mischief resulting from reit-
 erated and inefficient sexual  efforts is prevent-
 ed.   Hypertrophy of the  neck of the uterus has
 already been noticed (y 30, 31).  Enlargements
 which result from the development of tumours in
 the  organ are more  appropriately considered in
 the sequel.*
   72.  iii. Inflammation  and  Abscess  of the
 Fallopian Tubes and  Cellular  Tissue.—In-
 flammation and abscess of the uterine appendages
 were,  until recently,  described only as a disease
 of the puerperal state.  Under the head Ovaria,
 I have considered inflammation and  other dis-
 eases  of these  organs, independently of the puer-
 peral  state; and in  the  article on Puerperal
 Diseases, " Puerperal Inflammations of  the Ute-
 rine Appendages" have  received due attention
 (y 187, et seq.).  It now only  remains for me to
 describe inflammation and abscess of the Fallopian
 Tubes and  Cellular Tissues, independently of the
 puerperal conditions.   This disease  has been no-
 ticed by MM. Gendrin, Velpeau, Marechal de
 Calvi, and by Dr.  Doherty, Churchill, and
 Lever ; but it was not  fully discussed until Dr.

  [*  Inasmuch as both  hypertrophy and atrophy of the
 uterus  are, in part, normal at the periods of puberty and
 involution, there is some danger of confounding morbid
 with the healthy conditions of the organ.  Like  other
 organs, the weight and dimensions of the adult, healthy
 uterus  fluctuate  considerably.  The following  measure-
 ments will be found sufficiently accurate: Entire length,
 from 24 to 26 lines; greatest breadth, 18 lines; thickness,
 9 lines; cervix,  from 10 to 12 lines long; its  breadth,
 from 6 to 8; its  thickness, from 5 to 6 lines; length of
 uterine cavity, 12 lines; its breadth, 9  lines; greatest
 thickness of the fundus, 5 lines; of the sides, 4  lines; of
 the cervix, 3 lines.  After one or more births,  all these
 measurements increase  from one fifth to one quarter.
 The  weight of the uterus varies from 8 to 12 drachms,
 and may, after  several pregnancies, amount to  two
 ounces. Hypertrophy or atrophy may involve the whole
 or only a part of the organ.  An  atrophic condition is
 probably a frequent source of sterility; the organ, and es-
 pecially the cervix, is small and ana?mic, its tissue dense,
 and the ovaries  in an  equally undeveloped condition.
 After the climacteric period the cervix often disappears
 entirely, and nothing but an indurated ring remains at
 the summit of the vagina.  We meet with hypertrophy
 of the  uterus as  a morbid state more frequently than
 atrophy, partly the result of irritation set up  by other
 morbid processes, and partly as an exaggerated expres-
 sion of the normal condition.  The former may consist
 in fibrous or other tumours, involving the substance or
 cavity of the uterus, which may give rise eventually to
 expulsive efforts, or blenorrhagic affections ofthe mucous
 surfaces.   Disease of the ovaries may also give rise to it
 by the consensual irritation thus set up.  Where hyper-
 trophy  is confined to the cervix, the anterior lip is  more
 frequently enlarged than the posterior.] 
1376
UTERUS—Inflammation  of Fallopian Tubes, etc
Henry Bennet directed due attention to it in
his work on Inflammation of the Uterus and Ap-
pendages.   This malady in the puerperal states
is always severe  and generally dangerous; but
in the non-puerperal conditions  it is commonly
much more  mild,  and is often either not  recog-
nised or confounded  with  other diseases.  In-
deed, inflammation of the uterine appendages oc-
curring after parturition presents as  great differ-
ence from the same disease in the ordinary state
ofthe system as puerperal metritis offers to non-
puerperal metritis.  In  the puerperal states of
these maladies, as I have shown, inflammations
of the womb,  ovaries, Fallopian tubes, cellular
tissues, &.c, have a tendency to extend  to the
peritoneum, or to diffuse themselves, and  pro-
duce most important and often fatal  consecutive
changes.  But  in the non-puerperal  form, there
is a tendency to assume the sthenic instead of
the asthenic diathesis, and to limit itself  to the
tissues primarily attacked ; peritonitis and other
consecutive  or fatal alterations rarely occurring.
   73. a. The causes of non-puerperal inflamma-
tion of the Fallopian tubes are the same as those
which  more commonly  produce metritis  (Y 10,
22) and ovaritis (v  6, et seq.); especially arrested
menstruation, disordered states of this function,
and abortive impregnation.
   74. The inflammation may originate either in
the cellular tissue,  in the ovaries, in the tubes, or
in the uterus, the disease  of the  one structure
often extending more or less to the others.  This
extension of inflammatory  action from the one
part to the rest  and to the peritoneum is most re-
markable in  the puerperal states (see Ovaria, y 6,
et seq., art. Puerperal Disease, y 181, et seq.),
but it is much less so in the non-puerperal con-
dition, the disease being generally limited to the
cellular tissue,  and to  the  organs contained be-
tween  the folds of the peritoneum,  this surface
seldom  being implicated in this condition.  Dr.
H. Bennet states that he has repeatedly seen
inflammation of the Fallopian tubes supervene
in females labouring under  chronic inflammation
or ulceration of the cervix uteri, this  latter being
the point of departure of the inflammatory action.
   75. b. The symptoms of non-puerperal inflam-
mation of the uterine appendages are nearly the
same  as those of acute metritis (y 53).   These
are the usual febrile phenomena : severe pains in
the lower hypogastric region, increased on stretch-
ing the body to  the erect posture, or on walking;
a sense of weight and tenderness deep in the pel-
vis ; difficult or painful micturition and defalca-
tion, &c.  These  symptoms are also present in
metritis ; but the pain is greatest in  the ovarian
region,  to the right or left of the median line,
where, if the ovarium be much affected, some de-
gree of swelling may be perceived.   So nearly,
as may be  expected, does the one  disease ap-
proach  to the other in characters and course,
that, unless  there be from the first  a  deep-seated
tumour of an inflammatory  nature perceptible in
one or both ovarian regions on external pressure,
it is most difficult to distinguish the  one malady
from  the other by  any other means than by  a
careful digital examination.   The bladder having
been emptied, the patient placed on her back, and
the knees flexed, the finger  should be passed into
the vagina, and carried underneath and round the
cervix, the leftjband being firmly applied over the
hypogastric region, above the pubis.   By pushing
the vaginal culde sac by the finger in the several
directions around the cervix, especially while ex-
ternal pressure is being made, the presence of
inflammation of the cellular tissue, ovaries, and
Fallopian tubes, or of its consequences, is evinced
by an unusual resistance on the side or sides of
the uterus.  " The vaginal cul de  sac has disap-
peared, and resting on the side of the cervix and
body ofthe uterus, there is an indurated swelling,
very different from  the normal  condition, and
from what obtains on the other or healthy side,
supposing disease to exist on one side only, as is
most frequently the case.   Pressure on the in-
durated parts is attended by very great pain, and
there is a marked increase ofthe  natural heat"
By directing the  finger around the inflammatory
tumour, while the left hand is pressed downward,
the tumour is found to be movable and  distinct
from the parietes  ofthe pelvis. This tumour be-
ing generally situated close to the side  of  the
uterus, seems to  form one mass with this organ.
Hence inflammation of the lateral ligaments may
be confounded with metritis even when a vaginal
examination is  resorted to, and an  inflammatory
swelling recognised.  If this examination should
not be satisfactory,  the  uterus and appendages
may be  farther  examined per  anum.   Dr.  H.
Bennet believes  that a tumour formed by an  in-
flamed lateral ligament is  more intimately con-
nected with the uterus when  it is purely phleg-
monous, or the result of inflammation of the cel-
lular tissue, than when it is formed by the inflamed
ovary.   It is, however, very difficult to distinguish
between these and acute or chronic metritis.
  76  c.  Progress  and  Terminations—In the
acute stage, inflammation of the lateral  ligaments
is attended by the usual train of febrile symptoms.
As it passes into  a chronic state, it occasions nu-
merous  morbid phenomena,  which have  been
noticed  as characterizing other chronic  uterine
diseases, especially  dyspepsia, cephalalgia, con-
stipation, palpitation, insomnia, debility, emacia-
tion, evening exacerbations of fever, &c.  It may
terminate in resolution in the first stage, when
promptly  and judiciously  treated ;  but, unlike
metritis, which very rarely, in the  non-puerperal
state, terminates in suppuration, inflammation of
the Fallopian tubes, especially when seated chiefly
in the cellular tissue, generally ends in suppura-
tion—it being purely phlegmonous inflammation.
  77. d.  Suppuration  may  be expected in the
course of a few days from the  commencement of
the inflammation, unless checked by early and en-
ergetic treatment.   The occurrence of rigors, fol-
lowed by sweats, and a temporary abatement of
the more acute  symptoms, and sometimes a deep-
seated fluctuation perceptible to the touch through
the vagina, or even through the abdominal pari-
etes, indicate the presence of  suppuration. The
purulent collection in this  part is  rarely absorb-
ed ; but it generally finds an exit, before the acute
inflammatory symptoms  have subsided.   Adhe-
sive inflammation connects the abscess with ei-
ther the  vagina,  rectum, abdominal parietes, or
bladder, the contained  pus making its way after
a variable period  in  one  or other of these direc-
tions, most  frequently in the  upper part of  the
yagina, or in the rectum.  It  very rarely opens
into the bladder or abdominal parietes.   It some-
times opens in more  than one  situation suc-
cessively.   The abscess  may,  however, ulcerate
through the peritoneal  folds of the lateral liga-
ment, and be evacuated into the peritoneum,
causing acute peritonitis ; or " the  purulent mat- 
UTERUS—Complications of Uterine Inflammations.
1377
ter may pass along the round ligament and ap-
pear in the labia  externa, or, escaping from the
pelvis along with the large femoral vessels, follow
their  course, and point in the thigh.  These,
however,  are  quite  exceptional cases,  and are
very rarely met with, especially in the non-puer-
peral  form of the disease.''
  78  e.  The  abscess  generally opens into the
vagina or rectum, or into both.   The perforation
commonly occurs during exertion, or when cough-
ing, or in the act of defalcation ; and the purulent
discharge is very frequently either mistaken for
an  increased flow of the  whites, or overlooked
when it is passed  from the rectum with the stools.
This  usually obtains when the disease is either
not recognised, or viewed as metritis.  In some
cases, the perforation is attended by a sense of
bursting.   The discharge  may take place a few
days after the development of the inflammation,
or not until after several  weeks.  The quantity
of pus discharged varies from a few drachms to
half a pint.  The opening of the abscess into the
vagina is the most favourable issue that can oc-
cur   The pus occasions  some  irritation of the
vagina, but this  is seldom  considerable.  The
opening  of the abscess  into the rectum is the
next most favourable termination, but it gener-
ally causes considerable irritation of this bowel,
with dysenteric stools  or tenesmus.  The perfo-
ration ofthe bladder or ofthe abdominal parietes
by the abscess is  so rare,  and the occurrence so
manifest, that the phenomena attending it require
no  remark, farther  than that, as in the case of
the rectum, the urine does not pass through the
opening, owing to the pressure of the abdominal
organs keeping the  opening closed.
  79. When the pus is discharged, a decided lull
is observed in all the symptoms.  The deep-seat-
ed pains, the tenderness and swelling, and the fe-
brile disturbance rapidly subside.  When the ab-
scess has opened into the vagina, the improve-
ment is often rapid, and the patient is believed to
be convalescent.  But, as Dr. H. Bennet justly
observes,  this improvement  is  often deceptive,
with reference to  the future.  On making a care-
ful  examination, the tumour on the side of the
uterus is diminished in size,  and  is much  less
sensitive to the touch; but, although less in size
and less inflamed, it is nearly always still percep-
tible ; and the symptoms indicating chronic  uter-
ine inflammation generally exist; pain, heaviness,
bearing down, tenderness, often swelling in one
or both ovarian regions;  pain in  the back, in-
ability to stand erect, or to walk for any time, or
to go up and  down stairs, being complained of.
The orifice by which the pus was discharged may
remain open,  or  it may  close.  In  the former
case the pus  escapes  as it  is formed,  and  after
some  time it becomes closed, and the tumour is
resolved, the disease being brought to a close in
the course of a few weeks, or of a month or two.
This,  however, occurs only in some cases; for in
others the closing of the orifice is followed  by a
re-formation of the  abscess; and before it again
escapes, by the former or another opening, the
acute inflammatory symptoms previously experi-
enced are reproduced,  generally in a mitigated
form.   The  vascular  determination attending
menstruation favours the  reappearance of acute
symptoms, and thereby perpetuates the disease.
These returns  of the malady become less and less
frequent  as the  inflammatory  swelling  of the
uterine appendages  diminishes, and as the struc-
    III.              87
tures return to their natural condition.  " A fe-
male who has suffered inflammation and suppu-
ration of the lateral ligaments, even in its mildest
form, may be from several months to one or more
years  before all  trace of local inflammation has
disappeared,  and  before  she  can be said  to  be
radically well."  During this period she is never
quite free  from symptoms of uterine irritation, or
of slight exacerbations of her former malady, es-
pecially at the menstrual periods, which are often
delayed or irregular; the quantity of discharge
being  generally  scanty, seldom  excessive.   A
leucorrhoeal discharge is always present, in vari-
ous quantity.  (See Puerperal Diseases, y 181,
et seq.)
  80.  /. The  Prognosis of this disease in the
non-puerperal state is not serious as regards the
life of the patient:  in  the puerperal state it is
much more serious (see Puerperal Diseases, y
183, and 256, et  seq.), and often most unfavour-
able.   Apart from this state, this disease seldom
terminates fatally, although  it entails  suffering
for  months or even for years.  Acute metritis
generally  terminates by  resolution, under judi-
cious  treatment (y 111, et seq.), without suppu-
ration, and without consecutive lesion; but in-
flammation of the lateral ligaments, although ap-
parently not a more  severe disease at  its com-
mencement, and period  of full development, oc-
casions lesions which time only can remove, or
which  are never completely removed.
  81.  iv. Associations  or Complications  of In-
flammations of the Uter'us, &c.—Inflammation
of the vagina and vulva may  be associated with
inflammation of the neck of the uterus, or even
with internal or endo-metritis also; and the in-
flammation may commence either in the vulva or
vagina, and extend to the neck of the womb, or
in this latter, and extend to the former.   In cases
of gonorrheal inflammation of the  neck of the
womb, it may be  inferred that the inflammation
commences most  frequently in the vulva and
vagina ; but  such may not always be the  case;
for  it is not improbable that the neck of the ute-
rus is sometimes primarily affected. In the  cases,
fortunately rare, in which septic or contaminating
causes produce an asthenic or diffusive form  of
vaginitis, as well as in gonorrhoeal inflammation,
the disease is always prone to extend from the
neck to the  internal surface  of the womb, and
even also to the uterine  appendages.
  82.  Various derangements  of the uterus, for-
merly considered as functional, are in most cases
merely symptoms or associations of inflammation
of the  cervix and internal surface of the uterus,
as Dr.  H.  Bennet has fully succeeded in demon-
strating, and as I have  stated  to be the case in
several forms of Leucorrhcea, and of disordered
Menstruation.   The leucorrhoeal discharge va-
ries with the tissue affected and the nature  of the
affection.   It may consist of natural mucus from
the mucous follicles ofthe vulva, vagina, and cer-
vix uteri; of a white creamy mucus secreted  by
the mucous membrane of the cervix and vagina,
from congestion of this membrane, such conges-
tion not always amounting to  disease; and of a
puriform mucus, or a white or ropy transparent
mucus mixed with  pus, which  is always  the
product of inflammatory  action and of its conse-
quences.  These three forms of vaginal discharge
may be combined  in chronic inflammation of the
cervix.  But this disease may exist without any
leucorrhoeal discharge whatever, the morbid se- 
1378
UTERUS—Complications of  Uterine Inflammations.
cretions being absorbed in the vagina.  (See art.
Leucorrhcea, y 19, et scq.)
  83. Amenorrhoea and  other  menstrual disor-
ders are often consequences or complications of
uterine  inflammations.  Dysmenorrhoea  is very
frequently a result of inflammation of the cervix
uteri; and when thus associated, other disorders
are often superinduced,  more especially the sev-
eral states  of hysteria,  convulsive  affections,
spinal irritation, &c.  The changes  which take
place in the cervix and its canal, in consequence
of inflammation or ulceration of them, are often
such as  occasion difficult menstruation  as the
consequence of contraction ofthe os internum, or
ofthe canal which forms the cavity ofthe cervix.
The swelling and hypertrophy of the cervix are
frequently associated with this contraction, when
the cervical canal itself is not  the chief seat of
inflammation.   Dr. Simpson believes that, unless
the uterine  sound pass, without effort, into the
uterine  cavity, there is  contraction of the os in-
ternum ; while Dr. Henry Bennet contends that
there exists, at the os internum, a kind of mus-
cular sphincter, formed  by a strong band of the
circular muscular fibres ofthe cervix, and destined
to close the uterus during pregnancy; and that
this sphincter in  the  healthy state prevents the
uterine sound from passing into the uterus with-
out considerable pressure be made ; and he adds,
that when the inflammation ofthe cervix ascends
as far as the os internum, or when endo-metritis
exists,  or the organ is enlarged by the formation
of tumours  in its body, then the sound passes
readily into the uterine cavity, thereby furnishing
a sign ofthe presence of these diseases.
  84. It has been considered that menorrhagia
and uterine hamorrhage generally are results of
active or passive  congestion, or of tumours or
polypi, or  of malignant disease, of the  womb.
Dr. Henry Bennet, however, contends, and with
apparently  much truth  as well as talent, that,
in the absence of malignant disease and of uter-
ine tumours, the quantity of blood  lost  during
menstruation is seldom  increased,  for a continu-
ance, so  as to  constitute  menorrhagia, and that
the menstrual periods are seldom morbidly ap-
proximated, unless there  exist some degree of
chronic inflammatory disease ofthe cervix, or un-
less menstruation be finally disappearing   Con-
gestion of the uterus  he admits to exist in men-
orrhagia, but it is generally the result of inflam-
mation of the cervix ; and it assumes an active or
passive  character, according to the constitution
of the patient, and to  the amount of reaction pro-
duced by the disease  on the system.  If the in-
flammation is  active  and has not debilitated the
patient, the haemorrhage is also  active or sthenic.
If the disease ofthe cervix has  existed long, and
has produced anaemia or debility, the haemorrhage
is passive or asthenic.  It is difficult to  explain
the reason  why inflammation, granulation, or ul-
ceration of the cervix  should, in some cases, ren-
der menstruation scanty, too rare, or difficult, and
in others profuse or too frequent.  But the fact is
proved by observation, and it may be  referred to
the states of innervation of the  uterine organs in
different persons, and to the sympathies exerted
between this very sensitive part of the uterine
organs, in connexion with the vascular conditions
of  these organs, and of  the system generally.
Dr.  Bennet, however, believes that,  where the
inflammation extends to the body of the  womb,
menstruation  is  generally scanty or  retarded;
whereas, when it  is limited  to  the  cervix, it is
often profuse or more frequent than usual.   Al-
though this association of inflammation ofthe cer-
vix uteri with disordered  menstruation is so com-
mon, as now stated,  still cases occur in which
this latter must be referred to other pathological
sources.   Indeed profuse menstruation  is occa-
sionally produced by mere congestion or determ-
ination of blood to the uterus, independently of
the existence of inflammation of the cervix, es-
pecially when the catamenia are finally disappear-
ing.  The association of inflammatory ulceration
of the cervix uteri with haemorrhage during preg-
nancy, in the opinion of Dr. H.  Bennet,  very
frequently exists ; the former being the source of
the latter, and  thus  furnishing a  natural expla-
nation ofthe presumed menstruation of pregnant
females.
   85. That  chronic inflammation of the neck and
of the body of the uterus should occasion, and
be  associated with, sterility,  with abortion,  with
hysteria, in  its  several forms ; with spinal irrita-
tion, with chlorosis, and  with various anomalous
neuralgic and  other affections, in different case's,
according to the circumstances peculiar to the
individual, cannot be  doubted, although the rela-
tion between it and these ailments was overlook-
ed  until Dr. H. Bennet  and  some contemporary
physicians, British and continental, insisted upon
the fact of  its  frequent  existence.   Besides the
complications  of this disease with  these com-
plaints, the  former is often associated with other
lesions ofthe uterus itself and its appendages, as
with enlargements, polypi, and fibrous tumours of
the womb ;  with the various forms of displace-
ment ofthe  organ, with lesions ofthe ovaria, and
with uterine phlebitis.
   86. Besides the above associations,  others af-
fecting the adjoining  organs  or  parts are not in-
frequent, and  are to  be  viewed as  being much
more frequently consequent upon chronic inflam-
mation ofthe cervix and  body ofthe uterus, than
existing as the primary affections.  Inflammation
of the urinary bladder, or of the rectum  and sig-
moid flexure ofthe colon, more especially of their
mucous surfaces ; haemorrhoids,  and  prolapsus or
fissures of the anus,  and syphilitic disease of the
cervix uteri, severally   occur  as  complications
of  one  or other  of  the  forms of metritis.   Of
these  the diseases of the rectum and  urinary
bladder are chiefly consequences of the extension
of severe or  protracted inflammation of the cervix
and body ofthe womb, sometimes  extending also
to the uterine appendages, these latter, in a few
instances, being the medium of morbid connexion
between the different maladies.   It is compara-
tively more  rare for disease of the large bowels,
or of the bladder, to occasion  any of the forms of
metritis, than for this last to cause, by the exten-
sion of inflammatory action,  one or  other of the
former.   Yet I have seen instances, in the non-
puerperal  states, of metritis  which had super-
vened on dysentery, and  even of asthenic inflam-
mation, that had  extended to most of the pelvic
viscera, consequent  upon a  dysenteric  attack.
Such complications as these  are, however, much
more frequent and fatal in the puerperal states;
and in these the veins are also very commonly
implicated.  This  complication  of metritis  with
uterine phlebitis may occur even in the non-puer-
peral  state,  as  I  have seen in a  few  instances.
In  a very remarkable case of this  kind, which
was seen in consultation with me by Dr. R. Lee, 
UTERUS—Treatment of Inflammations of the.                 1379
metritis supervened upon dysentery in a married
lady, aged about 35 years, and who had not been
pregnant  for several years.   Uterine  phlebitis
also took place, and was followed by phlegmasia
dolens.  Inflammation ofthe caecum and pericae-
cal tissues may extend to the  uterus%nd uterine
appendages ; but this is a very rare occurrence.
   87. III. Treatment of Inflammations of the
Uterus and Appendages.—Much of what I have
stated above respecting the treatment ofthe nerv-
ous and irritable states of the  womb (see y 13, et
seq.) is applicable  to inflammatory action  in  ei-
ther the  cervix or body of the  organ.  It is man-
ifest that, as the several inflammatory states  of
the uterus, whatever may be their precise  seats,
occur in the nervous, the debilitated, the anaemied,
as well as  in  the  plethoric and the robust, the
treatment, especially the general or constitution-
al, must depend in  great measure on the knowl-
edge, acumen,  and experience of the physician,
by which he is enabled to  ascertain the precise
peculiarities of each  case.  A most important
part, however, of the treatment is entirely local or
surgical; but, in the management of female dis-
eases, no division  should be made into medical
and surgical means, for here,  as in all other de-
partments of practice, surgery, although ancillary
to, is also a part of, medicine.
   83. i.  Of Inflammation of  the Neck of the
Womb, and its Consequencf.s.—There are few
complaints  more prone to relapse, and in its  se-
verer states more difficult to remove, than the one
now under consideration.   But these are not the
only evils ;  the difficulty often of conducting the
treatment conformably with the requirements  of
the case and the prepossessions of the patient, is
also a positive obstacle to success, particularly in
females whose circumstances of life require exer-
tion, or prevent them from enjoying the requisite
comfort and ease, and in unmarried females. The
treatment must necessarily depend upon the pe-
culiarities of the case, with what is known or  in-
ferred as to its  causes, upon the duration of the
disease, and upon the alterations which have taken
place in the part.   But in this, as well as  in  all
other inflammations ofthe uterus, the indications
of cure consist, first, in subduing inflammatory ac-
tion  and  painful symptoms;  and, second,  in  re-
storing the constitutional energies, and thereby
the healthy state ofthe uterus.   It often becomes
a  great difficulty to know when to discontinue
the first indication, and when  to aim at the sec-
ond ; for a too early adoption of means calculated
to restore the health may occasion a relapse  of
inflammatory action and its attendants.
   89 A. The treatment before any organic lesions
have taken place, and while inflammatory action
is unassociated, comprises the  two intentions  of
cure just  stated (Y 83).  The  means which are
found most successful in fulfilling theirs* inten-
tion are the horizontal posture, and quietude  of
mind and body; injections  of an emollient, re-
frigerant, or anodyne kind; cooling diaphoretics,
with  or without narcotics,  warm or tepid hip-
baths, local depletions, alterants, and sometimes
derivatives.   This state of the disease, especially
at its commencement, is so often  unattended  by
severe symptoms, unless  when it is associated
with  the  neuralgic and irritable  conditions de-
scribed above (see  y 5, et seq), that it  seldom
comes under medical  care; and it is not, com-
monly, until either  excoriations, granulations,  or
superficial ulcerations, very frequently associated I
 with  leucorrhcea, disordered  menstruations, and
 deviations from the natural position of the womb,
 that medical aid is resorted to.  In all cases, due
 care  should be taken to ascertain the admitted
 and probable causes of the complaint.   It will be
 seen, on referring to these causes (see v 10), that
 certain of them can hardly be fully ascertained,
I although they may  be inferred with a near ap-
 proach to  certainty; and in some  cases they
 will be admitted by  the patient,  if inquiries be
 made  with due address.  The  state of  general
 health should also receive attention, and the treat-
 ment  be regulated  accordingly, and with strict  *
 reference to the condition and periods of the uter-
 ine functions.
   In the mild cases, if they have not been of long
 duration, and  if the  cause have been only tem-
 porary in  its operation, and not a persistent or
 habitual vice, means directed to the improvement
 of the general health, to the regulation and  pro-
 motion of the secretions and  excretions, more
 particularly to the prevention of faecal and urin-
 ous accumulations,  aided  by  rest, the avoidance
 of sexual  excitement, and  by emollient  and as-
 tringent or refrigerant  injections, according to
 the peculiarities of the case, will be sufficient to
 restore the health, even without strict reference
 to the succession of indications  of cure mention-
 ed above (Y 88).
   90.  In severe cases, especially in those of long
 duration, and  in those  where the above means
 fail of affording satisfactory relief, the indications
 of cure stated above  should be adopted, more par-
 ticularly if thickening or enlargement of the cer-
 vix or any other of the  lesions described  as con-
 sequences of chronic inflammation be  present.
 For these the means enumerated for fulfilling the
 first indication should be prescribed.  For  this
 purpose,  constant  repose on a couch or sofa,
 avoiding very warm  beds, and the upright or even
 the sitting posture, vaginal injections, hip-baths,
 local vascular depletions, and a recourse to caus-
 tics, are the means  of cure now in general  use.
 But, although the chief remedies, they are not
 the only ones; and in  all cases they should be
 aided by constitutional and moral treatment, by a
 proper diet and regimen, if, indeed, the local rem-
 edies be not considered  as being aids only to the
 constitutional means.  These latter require to be
 so diversified, according  to the temperament, hab-
 it of body, strength, and  other peculiarities of the
 case, that  a selection of them  appropriately to
 these peculiarities must depend upon the judg-
 ment of the physician.
   91.  a. Vaginal injections  are often of great
 service, whether simple or medicated   They wash
 away the secretion from the inflamed cervix, and
 prevent  the stagnation  of it  in  the vagina  and
 around the cervix; an occurrence tending to in-
 crease  irritation and morbid sensibility of the
 parts.   The frequent injection of cold water only
 has not only a cleansing, but also a tonic and
 healing effect.  In some cases  the temperature
 of the water may be heightened somewhat above
 fifty degrees of Fahrenheit.   But in most cases
 the temperature of spring water is best, the quan-
 tity injected, or the duration of the injection, be-
 ing regulated by the physician.
   92.  Medicated injections are either  emollient.
 astringent,  or  anodyne.   Various emollient in-
 jections are of service in slighter cases, and when
 pain or irritation is  experienced;  and they may
 be made vehicles  for anodynes.   Milk and  wa- 
1380
UTERUS—Treatment of Inflammations of the.
  ter, decoction of marsh-mallows, linseed tea, &c,
  may be used, cold or tepid.   When irritation is
  considerable, a small quantity of the bi-borate of
  soda, or of any of the anodynes, especially vinum
  opii, tincture of henbane, or tincture of belladon-
  na, may then be  added to the above.   Injections
  also of the decoction of poppy-heads, either alone
  or with chamomile  flowers,  may  be  prescribed.
  Astringent injections are very commonly resorted
  to in  this complaint, especially  when the  dis-
  charge is  abundant.   In this and the above cases,
  the means advised for the treatment of Leucor-
• rhcea (see cj 16,  17),  and of that state of the dis-
  ease especially which I have  ascribed to " inflam-
  matory action of the mucous  glands of the cervix
  and os uteri"  (y 23,  24), are quite appropriate.
  Of the several astringent injections in common
  use, viz.,  sulphate of alumina, sulphate of  zinc,
  acetate of lead, solution of nitrate of silver, decoc-
  tion of oak bark, and solution of tannin, Dr. H,
  Bennet states that he prefers the first and the
  solution  of nitrate of silver.   The first three he
  uses in the proportion of a drachm to a pint of
  water, increasing or diminishing the strength ac-
  cording to circumstances. He, however, consid-
  ers  that  injections  are  serviceable  chiefly for
  cleansing the vagina, for diminishing uterine irri-
  tation, and  for removing vaginal and  vulvar in-
  flammation ; but that they are generally power-
  less to subdue confirmed inflammation ofthe sub-
  stance of the cervix, or  even of  the membrane
  lining its cavity ; for he believes that their ineffi-
  cacy  in inflammation of the cervical canal is
  partly owing to the fluid not reaching the region
  affected ;  and that in inflammation of the cervix,
  a remedy which is only applied to the surface can
  scarcely be expected to  subdue the deep-seated
  disease.   When injections  are  prescribed, due
  care  should be taken that they are properly ad-
  ministered.  The patient should be on  her back,
  with the pelvis raised, and means be used for their
  retention for a time in the upper part of the va-
  gina.
     93. When marked irritability and acute sensi-
  bility characterize inflammatory action ofthe cer-
  vix, Dr. Dewees recommends lukewarm flaxseed
  tea, to be thrown up by a female syringe of suffi-
  cient size three or four times a day, and to be re-
  tained there for some time by applying a cloth to
  the vulva.  I have more frequently prescribed, es-
  pecially for unmarried females, in order to remove
  the  more painful symptoms, injections  into the
  rectum, containing either the extract or the  sirup
  of poppies, or  compound tincture  of camphor, or
  vinum opii, or tincture of henbane.  In a case of
  remarkable severity which I attended with the late
   Dr. Moore, a small  quantity of tincture of bella-
   donna was pressed  from a piece  of sponge con-
  tained in a syringe, when introduced as far as
   the cervix  uteri, and always afforded immediate
   relief.
     94  b.  Baths.—Warm hip-baths at the tempera-
   ture of 90° are occasionally of service.   Dr. J. H.
   Bennet advises them at a temperature of 63° to
   85°  Fahrenheit, according to the season  of the
   year and feelings of the patient.   At this temper-
   ature they  have  a sedative effect, while at higher
   degrees he believes that they determine the circu-
    ation to  the pelvis   In painful or difficult  men-
   struation, a temperature  of 94° to 98° is often de-
   cidedly beneficial.   Dr Gooch states that he has
   found a partial steam-bath, used by drawing the
   flannel sack up to the praecordia, so as to enclose
the abdomen  and extremities, these being  ex-
posed to the action of the steam for half an hour
every day, preferable to the warm hip-bath. En-
tire warm baths are useful in winter, when only
occasionally resorted  to, and when they can  be
had in the ^tient's house or apartment.  During
summer a tepid bath  at 65° or 70° is of service
every second,  or third, or fourth day.  Cold and
shower  baths  should be  reserved for advanced
convalescence, and are  important means for ful-
filling the second intention of cure.
  95. c. Vascular Depletions.—These should  be
chiefly local;  and, with all respect for those who
cultivate this specialty, I cannot agree with them
in the choice  of situation from which the blood
should be abstracted.  The situation preferred  by
the more recent writers on diseases of the uterus
is the inflamed cervix itself; but the  several dif-
ficulties in the way of the general physician, if he
be averse to the manipulation which this practice
involves, and if he have due regard to the feelings
of the patient, and even in some cases to  senti-
ments of virgin purity, will induce him to choose
other situations than this one from which blood
may, in  this disease, be abstracted with advantage,
and to have recourse to other  and various means
by which the  end in view may be accomplished.
I know that in  all cases  where this and other
appliances  to the neck of the womb are resorted
to by physicians who  practise  in this especial de-
partment the utmost attentions are paid by them
to the modest feelings  of the patient, and to  all
decent,  and  even delicate observances;  but I
should prefer  having  recourse, in the first  place,
to such means as cannot be  objected to by the
sensitive mind,  or even  by  the captious; and
leave such measures  as may become matters  of
reproach to both the patient and physician,  al-
though  most unjustly,  to  the necessities of  the
case—as a  dernier ressort in practice.   I may
write under prejudice in favour  of older modes
of practice,  for I have employed  these and seen
the benefits they afford, when judiciously employ-
ed and  combined ; but I nevertheless admit that
the measures  more recently had recourse to  are
often more quickly successful, and sometimes suc-
ceed after the others have failed.
   96. Local abstractions of blood should  be  di-
rected as  near as possible to the seat  of pain.
Cupping is more serviceable than leeches, par-
ticularly when the pulse is full  or firm, and the
patient  not reduced.   In these cases,  or when the
patient  is young and plethoric, or when the men-
strual discharge has been scanty for some time
previously,  a  general depletion  will be advanta-
geously premised, and more  especially when the
blood is taken from the  feet when immersed in
warm water.  When pain is referred to the  sa-
crum, cupping  may  be  directed on this part.
Leeches are generally  most beneficial when  ap-
plied to the vicinity of the anus, or the labia pu-
dendae, or  to  the inner parts of the  tops  of  the
thighs just below the vulva or groins.   The quan-
tity of  blood that may be taken away should  de-
pend upon  the  habit  of body, the state  of  the
circulation, and on the severity and  duration of
the complaint.  My objections to the application
of leeches  to  the cervix  uteri are, 1st, those al-
ready hinted at above, and particularly in respect
of  unmarried females;  and, 2d,  the  risk  of  the
application  of them to this pan being followed by
an excessive determination of blood to the organ,
or by ulceration  of their  bites, and consequently 
UTERUS—Treatment of Inflammations of the.
1381
increased irritation.  It will, however, be admit-
ted that these are contingencies which may sel-
dom occur;  nevertheless, they should not be haz-
arded.
  97. The  repetition of local depletion should
necessarily depend upon the effect of the previ-
ous  operation, and upon the circumstances just
mentioned.   In cases of long continuance,  when
the constitution is much enfeebled, even local de-
pletion is but ill borne, and should seldom exceed
from four to six ounces.  In these  its repetition
is rarely attended  with much advantage.   But
when the repetition seems required and gives re-
lief, it should generally be to a smaller amount
than the first, and be performed at a time  when
the return or increase of pain is anticipated.   In
this way it may be repeated thrice, or even more
frequently,  to the  small amount  now  named.
There  are,  however, instances where  even  a
small local depletion  aggravates the symptoms.
These occur chiefly in  weak, nervous,  or anae-
mied females, and in cases of long standing, or
where the leucorrhoeal  discharge has  been long
profuse.   In this class  of patients the second in-
dication  of  cure  (y 88) should be  immediately
adopted.
   98.  Dr. Henry Bennet remarks  that the ap-
plication of leeches to the cervix uteri, when oft-
en repeated, is  more frequently injurious  than
beneficial, and that the  consequences mentioned
above then frequently result from them.  I  must,
however, refer the  reader to his work for  many
judicious observations  respecting the local em-
ployment of leeches in this disease.   Dr. West
states that, "so long as acute symptoms are pres-
ent, or whenever they  reappear in the  chronic
stage of the  disorder, local leeching generally af-
fords more speedy and more  decided relief than
other remedial means.   The  leeches  should be
applied to  the uterus itself;  not  above four in
number at a time ;  nor  is it in general expedient
to repeat their application above once in a week
or  ten  days.  Another precaution consists in
never  leeching  the womb  within four or  five
days of a  menstrual period;  lest  the  regular-
ity of that  function be disturbed, either by  being
brought  on prematurely or (which is  much less
frequent) by its occurrence being postponed for
several days. The pain which is left behind aft-
er menstruation in some of these cases—in those
especially in which the discharge  is scanty—is,
however, often very greatly relieved by the ap-
plication of  a few  leeches as the period passes
off." (Led., p. 140.)
   99. d.  Cooling aperients are generally required
both at the commencement and during the course
of treatment, owing to the state  of the bowels
and to the effects of narcotics  taken from time to
time.  Those aperients which will operate copi-
ously once, or twice at  most, and without  irrita-
ting the lower bowels, are the most eligible.   Cas-
tor oil, the electuary or confection of senna, ei-
ther alone or with sulphur and bi-tartrate of pot-
ash, will prove the most certain.  In very chronic
case's, or when the digestive organs  and  the sys-
tem generally are much weakened, rhubarb and
magnesia; or the compound infusions of gentian
and senna, in equal parts, with tartrate of potash,
tincture of henbane, and tincture of cardamoms,
will be found of service.
   100. e. Narcotics or sedatives are often required,
not  only in  the injections, as  advised  above, but
also in the medicines taken by the mouth, or ad-
ministered in enemata.   They are most service-
able after a gentle action on the bowels has been
produced.  Camphor, in the dose  of one or two
grains, with the nitrate of potash and the extract
either of henbane, or of hemlock, or of poppy,
given in the form  of pill twice or thrice daily, or
about ten grains  of either of these extracts, dis-
solved in water gruel and injected up the rectum,
immediately after the bowels have  acted, will fre-
quently afford relief when much pain is experi-
enced.  Subsequently the bitter infusions may be
prescribed with tincture of henbane, and  small
doses of nitrate of potash and bicarbonate of pot-
ash or of soda.   These means also  serve to di-
minish irritability  of the bladder by  which uter-
ine inflammation is often attended.  If deposits
ofthe phosphates exist in the urine, small  doses
of hydrochloric acid, with  tincture  of henbane
and extract  of pareira, prescribed in the infusion
of calumba, or of orange peel, generally are of
service.
   101. /. External applications of various  kinds
have  been recommended, as the croton-oil lini-
ment (one part of the oil to ten of simple cam-
phor liniment), by Dr. West, to be applied over
the sacrum  by means  of a sponge twice a day;
in order to relieve the  back-ache, plasters of opi-
um or of belladonna, to the same situation, and
with the same intention ; and a small blister, or
an anodyne  liniment, applied over the part, when
pain is  urgent in either iliac region.   Dr. Old-
ham advises the following in this latter situation:
  No. 3C5.  R Extracti Belhidonnae, 3SS.; Tinct. Aconiti
(Fleming's), 3iv.; Linimenti Saponis Comp., fjss.  Misce.
I-'iat Linimentum.
In cases where pain either in the back, sacrum,
or iliac regions is  most severe, I have found more
relief procured from an embrocation, frequently
recommended in this  work, consisting of  equal
parts of the compound camphor liniment, of the
turpentine liniment, with variable proportions of
sweet oil and cajuput oil, applied over the part
on folds of flannel  or spongiopiline, than from
any other application.   Warm turpentine stupes
are also very beneficial.
   102. B. When inflammation ofthe uterus is at-
tended by  granulations, excoriations, ulceration,
and hypertrophy of the  cervix, additional  means to
those already mentioned are recommended, espe-
cially by recent writers on uterine diseases.   Dr.
HenryBennet states, that the solid nitrate of
silver, or a strong solution, should be applied ev-
ery three or four days to the  inflamed mucous
membrane covering the cervix, where there is
neither ulceration nor hypertrophy of this  part;
and this treatment should be the first resorted to
when the cavity of the cervix is inflamed, " car-
rying the caustic into the cervical cavity as  far as
it will pass."  When ulceration and hypertrophy
of the neck  of the uterus are present, he  adds
that the means already advised seldom succeed in
effecting a cure, unless the ulceration be recent,
although they mitigate the severer symptoms ; a
relapse occurring  in a short time.   Repeated re-
lapses, and a perpetuation of ulceration ofthe cer-
vix and cervical canal, are the  consequences of
palliation merely,  owing to the repeated determ-
ination of blood  to the uterus during the men-
strual periods.  Should the disease not yield (and
it seldom does) to the antiphlogistic means dU
rected as above, the most efficacious treatment,
he remarks," indeed the only one that can be de-
pended upon, is by direct stimulation of the dis- 
1382                  UTERUS—Treatment of Inflammations of the.
 eased and ulcerated surface, and to modify its vi-
 tality in such a manner as to induce a healthy
 action, and, finally, cicatrization.  This end is ob-
 tained by the use of caustics  of varied strength,
 according to the nature and  extent  of the  dis-
 ease, its chronicity, and the  effects  produced."
 " We must first  subdue sub-acute inflammatory
 action by emollients, depletion, and astringents;
 and then modify, by direct stimulation, the  dis-
 eased surface, so as to substitute healthy repara-
 tive inflammation for morbid ulcerative inflamma-
 tion."
   103. The last part to heal in an ulceration of
 the neck of the uterus is that which dips into the
 cervical  cavity.   Dr. Bennet therefore  insists
 upon the necessity of separating  the lips  of the
 os with a bivalve speculum, in a good light,  and
 of thus carefully exploring the state of the cervi-
 cal canal before the disease is pronounced to be
 cured.  Unless this precaution be used, the  ul-
 ceration  may be only partially cured, and the  dis-
 ease will return and extend over the  cervix in a
 few months.  The agents recommended  for the
 cure of disease of the cervix—for chronic inflam-
 mation,  excoriations,  granulations, ulcerations,
 with  or without enlargement,  induration and de-
 viations—are chiefly the more  energetic caustics,
 which he enumerates in the order of their powers
 of cauterization: The  solution of, and the solid
 nitrate of silver,  the mineral  acids, the acid ni-
 trate of mercury, potassa fusa,  potassa cum calce,
 and the actual cautery.   It is obvious that a re-
 course to either  of these requires both address
 and careful appliances. The nitrate of silver, acid
 nitrate of mercury, and  potassa  cum calce,  are
 chiefly recommended by British writers on uter-
 ine diseases;  these and  the actual cautery also
 being much employed by French physicians. For
 very full directions for the  use of these caustics,
 I must recommend the reader to the works  of Dr.
 J. Henry Bennet, Dr. Simpson, and of the other
 writers mentioned  above;  but as  the directions
 given for the use of these means by Dr. West are
 more succinct, I  shall give them  nearly  in  his
 words; premising, however, that the able and  ex-
 perienced physicians now named  generally have
recourse to the more energetic of these caustics in
the most severe and protracted cases, and  when
more  or less hypertrophy ofthe cervix is associa-
ted with  other lesions.
  104. When the  granulations  on the os and
cervix uteri become large, soft, very vascular, and
bleed easily, the surface furnishing  a copious
 glairy discharge, sexual intercourse being painful
 and often followed by bleeding, Dr. West then
recommends "extensive scarifications, which may
be followed by the daily application of powdered
 alum  on  a piece of cotton-wool, or by the  intro-
duction  of a piece of cotton-wool soaked in a
 strong solution of alum.   By means of a piece of
thread tied to the cotton-wool, it can be removed
by the patient herself in the course of a few hours,
though it must always be introduced through the
speculum.   In the  greater number of instances
the state of the os uteri becomes  so much im-
proved in four or five days, that  this mode of treat-
ment may then be dispensed with, and the  sedu-
lous employment of strong astringent injections
 will usually suffice to complete the  patient's cure.
 When this is not the case, but the  morbid condi-
tion still continues, more powerful applications
may be needed.   The nitrate  of silver is not  in
 general suitable in these cases, for  its application I
 is often followed by pain and also by bleeding.
 The acid nitrate of mercury, both in this instance
 and also whenever a strong caustic is required,
 has seemed the most useful application ;  and with
 moderate care its employment is unattended by
 risk.   When it is used, however, the patient must
 lie on her  back, and  one of Coxeter's bivalve
 speculums being introduced so as thoroughly to
 expose the  os uteri and include the  cervix, a little
 cotton-wool must be carefully disposed all round
 the edge ofthe speculum, so as to absorb any of
 the superfluous acid, and to prevent it from run-
 ning down outside the speculum, and thus injuring
 the vagina.  A brush can easily be  extemporized
 by trimming a little piece of cotton-wool after it
 is placed in the  holder, and the whole  diseased
 surface  may then be painted over with the caus-
 tic, which immediately forms upon it a white es-
 char.  A piece of dry cotton-wool  now pressed
 against the part will absorb any superfluous caus-
 tic ; the little  strips placed around  the edges of
 the speculum may then be removed, and the spec-
 ulum withdrawn."  As an additional precaution,
 a piece  of  moistened  cotton-wool may be intro-
 duced up to the os uteri, before the withdrawal
 of the speculum, whence it may  be removed in
 the course of a few hours, by the patient.  " It is
 seldom that either pain or bleeding follows this
 application  ; and at the end of a week the eschar
 will usually be separated;  the  surface will be
 found to have lost its fungous character, and cic-
 atrization to  be  commencing  at  its edges.  A
 zinc lotion  of about five grains to the ounce, or
 the black wash employed as. a vaginal injection
 twice a day, will now generally be  sufficient; but
 sometimes the surface puts on an indolent char-
 acter again, and  it may  then  be  expedient to
 touch it once or twice with the nitrate of silver,
 and I have occasionally found it necessary to re-
 peat the application of the acid nitrate  of mer-
 cury."  (Lect, p. 146.) Dr. Henry  Bennet em-
 ploys, as escharotics, either  the acid nitrate of
 mercury, or the potassa cum calce, fused in sticks
 of three different sizes, according to  the peculiar-
 ities of the  local lesion;  and gives  ample  direc-
 tions for the use of these and other caustics, ap-
 propriately  to the circumstances of the  disease.
 He, however, admits that cauterization ofthe cer-
 vix is an operation not without danger, and must
 not, therefore, be  either injudiciously resorted to,
 or carelessly  carried  out.   Although his  own
 " practice has been hitherto free, or all but free,
 from serious accidents, the same immunity can-
 not always be expected. Indeed, I recently learn-
 ed from M. Gendrin that within the last few years
 he has had several cases of acute metritis and of
 abscess in the lateral ligaments, the evident and
 immediate result  of deep  cauterization.  But he
also  tells me that he has seen tie  same results
 follow the use  of the nitrate of silver and  of in-
 jections ; and I may mention that the two most
 severe instances of acute metritis that I have my-
 self witnessed  for some time in the unimpreg-
 nated womb occurred after the use of weak astrin-
 gent vaginal injections."  (Op. cit., p. 426 )  I
 believe, however, when vaginal injections are fol-
lowed by those severe results, that the inflamma-
tion  of the cervix, or the  leucorrhcea. for which
 these means were used, was only a part ofthe ex-
isting lesion ; and that endometritis, or a chronic
metritis, had also existed  at the same time, and
was developed  into the acute state by the  iniec-
tions.                                     a 
UTERUS—Treatment of Inflammations  of the.                 1383
   105.  C. Treatment of Hypertrophy and Indura-
tion of the Cervix Uteri.—These changes are the
results of repeated congestion, or of inflammatory
congestion and of nutritive hypertrophy.   The
continued existence, or repeated  recurrence  of
inflammatory congestion, gives rise to increased
development of the vessels, to the exudation  of
plastic lymph,  and to the partial organization of
this lymph, and to greatly increased  size and
density of this part of the uterus, often extend-
ing partially to the substance of the uterus itself,
and associated with chronic metritis (y 62, ct seq.).
This lesion is commonly attended by more or less
prolapsi, and often with deviations.  The enlarged
cervix  may,  moreover, be excoriated, ulcerated,
or covered by granular formations, owing  to the
alterations of its follicles.  The local means  of
cure are those already  recommended, aided  by
the constitutional treatment hereafter  to be no-
ticed (y 106, et seq).  Dr. H. Bennet states that,
" if hypertrophy resists the ordinary antiphlogistic
means of treatment, it never withstands the melt-
ing influence of deep cauterization with potassa,
or the  actual cautery."  Of the  two he prefers
the potassa, or potassa cum calce  ; Dr. West the
acid nitrate of mercury.   The actual cautery may
therefore be dismissed.  It  should be clearly un-
derstood that  these means are not intended to
destroy the hypertrophied cervix, " but merely to
set up  an  artificial eliminatory inflammation, by
means  of an  eschar or issue, of limited extent,
established  in  the centre of the hypertrophied
region.  I do  not calculate in the remotest de-
gree on the  destruction  of tissue to which the
caustic or cautery gives  rise, for diminishing the
size of the hypertrophied cervix,  but solely and
entirely on the inflammation subsequently set up."
An eschar of the size of a shilling will answer
the purpose of reducing the hypertrophy.  It may
be necessary to apply the caustic several  times.
" The ulcerations occasioned by the  deep appli-
cation of potassa heal very rapidly, even when left
to  themselves.  It is  better, however, to touch
them at intervals  with the nitrate of silver, to
prevent the granulations from becoming too lux-
uriant, and to favour the cicatrization, which usu-
ally takes place in  from four to six weeks."
   106. D. Constitutional and general Treatment.—
The constitutional treatment of chronic inflamma-
tion ofthe cervix and os uteri, and its usual con-
sequences, should not be overlooked, even while
local means are being applied.  Indeed, in many
cases, this  treatment should precede a recourse
to local measures, these  latter only following the
failure ofthe former.   In some ofthe more recent
works upon this and other diseases of the uterus,
too little importance is attached to the recognition
ofthe causes ofthe existing malady, and upon the
prevention and removal  of these causes, which,
when removed, the salutary efforts of nature would
then of themselves often effect a  cure.  In this
disease  especially, as well as in the displacements
and deviations  of the  uterus, sexual  excitement
and self-pollution  are the most frequent causes,
and these are usually allowed to continue, owing
to the difficulty and delicacy of the subject, to
ignorance of medical men of the great frequency
of this vice, and to an equal ignorance of the im-
morality and  injurious consequences of it on the
part of those  who indulge irt it.
   107. The constitutional treatment which I have
adopted for many years,  when uterine irritation,
as it was then termed, or when chronic inflamma-
tory irritation, as more recently shown, was pres-
ent, always was much modified, according to the
features ofthe case.   If leucorrhcea was its promi-
nent character, the means advised when treating
of this  complaint were prescribed.  If the men-
strual function was disordered, the treatment rec-
ommended for the various forms of such disorder
was had recourse to ; and, whenever inflammatory
irritation of the uterus was inferred, then means
more or less  antiphlogistic were  advised, often
conjoined with tonics, and with  other  remedies
adapted to the peculiarities  of the case.  In a
very large  proportion of the cases of this com-
plaint,  the causes which have produced  it, and
the  discharges which characterize it, as well as
its exhausting nature and duration, have produced
so much debility and irritability, and so extensive
a range of sympathetic disorders—nervous, neu-
ralgic, hysterical, cerebro-spinal, vascular, and an-
aemic—as to imperatively require constitutional
treatment, however  much the local means above
described may be required or confided in.   What
this treatment should be, or how conjoined with
regimen and  local measures, must depend upon
the acumen of the physician, and upon the appro-
priate use of each or of all in  particular cases and
circumstances.   But in most  cases the  patient
should  recline on a cool  hair couch, should sleep,
if married, apart from her husband, on a hair mat-
tress, and avoid very warm feather or down beds,
all  sources of sexual excitement, and  whatever
appears to aggravate her complaints.  She should
preserve an open stale of the bowels by  means of
cooling aperients, or of these conjoined with tonics.
The bicarbonates ofthe fixed alkalies may be taken
with the nitrate of potash in bitter infusions, or
the liquor ammoniae acetatis with nitrate of potash,
in similar vehicles   The terebinthinate  embroca-
tion already advised (§ 101) may be employed ex-
ternally, and a cooling, and yet tonic or restorative,
regimen and diet adopted, avoiding much animal
food, and  all heating and stimulating beverages,
as well as coffee and strong tea.  In a severe and
tedious case,  for which  I was consulted  by Mr.
Barnwell, the  following pills proved of very
great service :
  No 366. R Camphorse rassp, 3j.; Pota6saj NMtratis, 3J.;
Sodae Sub-carb. ex6ic, jss. ; Extr. Hyoscyami, 3ij.; Sy-
rupi papaveris, q. s.  Slisce.  Fiat massa a>qualis, quam
divide in Pilulas xxx.,  quarum binas, ter in die capiat.
After these were taken for some time, they were
replaced by the infusion  of calumba, bicarbonate
of soda, tincture of calumba, and tincture of hy-
oscyamus.
  108.  In the above manner, the second indication
of cure  may be initiated, and may thus advance to
a more  tonic and restorative or nutritious treat-
ment, so as to restore the constitutional  energies,
and thereby the healthy state and functions ofthe
uterus.  This end can be attained only by medic-
inal  and regiminal means, both of which, how-
ever, should be commenced  with caution.  In  a
few  instances  I  have prescribed, with  marked
benefit,  the cod-liver  oil, on the surface of a tonic
infusion, with one of the mineral acids,  as the
compound infusion of orange peel with sulphuric
acid ; or the compound infusion of roses, or the
infusion of cinchona with hydrochloric  ether or
hydrochloric acid, or with both.  In other cases,
the  tonic or bitter infusions or decoctions maybe
ordered  with the  alkaline carbonates, nitrate of
potash, and tincture either of henbane or of some
other anodyne.  In cases which have been of long 
1384
UTERUS—Treatment of Inflammations of the.
duration, or have been caused by self-pollutions,
or which are characterized by shattered health,
by pallor of the countenance, cold extremities,
and more or less anaemia, the milder preparations
of iron, as  the tincture of the muriate or of the
acetate of iron, may be prescribed with the prep-
arations of calumba  or  quassia.   Dr.  Davies
states that he has given, in these cases, the phos-
phate of iron with much benefit.   In some cases,
especially where there is hypertrophy ofthe cervix
uteri, the iodide of iron may be tried in the sirup
of sarzae ;  or  the iodide of potash may be taken
with either the bicarbonate of potash or the solu-
tion of potash in a tonic infusion, &c.
   109. The mineral waters, natural or artificial,
may likewise  be resorted to, according to the pe-
culiarities of the case.  The Bath and  Tunbridge
waters, the Harrowgate waters, the  waters of
Seltzer, Geilnau, of Ems, of Vichy, of Pyrmont,
&c.,have been severally recommended, and found
of some service.  The regimen  and diet of the
patient are  of much importance.   If married, she
should sleep apart from her husband; and whether
married or unmarried, she ought to avoid all causes
of excitement and irritation.   She  should enjoy
the advantages of a cool and pure air.   The diet
ought, while febrile and inflammatory symptoms
are present, to be light, cooling,  and chiefly  fari-
naceous ; and animal food should be  given in  very
small quantity, until convalescence is advanced,
when it may be taken more liberally.   The  bev-
erages may consist of toast-water, barley-water,
or of lemonade, or ofthe imperial drink.   After-
ward, when recovery is far advancing, the Rhen-
ish wines, or claret, or claret and  water, &c,  may
be allowed.  In most cases, coffee and  tea are
inappropriate.  Cocoa, or cocoa-nibs, prepared in
a simple manner, and dry-toast with little butter,
should be preferred.   Patients who have caused
this  complaint by  self-pollutions  have generally
great appetites;  and their indulgences  in  food
and  in  their  unnatural vice  tend to  perpetuate
the disease, and to frustrate the treatment.  For
them, the  diet should  chiefly  consist  in  a large
proportion  of vegetable  and farinaceous  sub-
stances, whereby the stomach  may be  filled,  with
as little excitement ofthe circulation as possible.
The mind  should  always be occupied by useful
pursuits, and, as much as may be,  by agreeable
employments.
   110. E. Treatment of Inflammation ofthe Cervix
Uteri in the unmarried, during and after Preg-
nancy, and in advanced  Life.—A well-informed
practitioner may apply what has been  already
adduced to these circumstances  of life, but  with
due care and  precaution.  In unmarried females,
the great difficulty of treatment is in the  local or
instrumental part; but a recourse to it will depend
much upon the severity and other peculiarities of
the case, and upon the results of constitutional
treatment, which should be previously employed,
the causes ofthe disease having been ascertained,
and removed  as  far as possible.  "The existence
of pregnancy," Dr. H. Bennet states, " so far  from
being an obstacle to the local treatment of inflam-
matory and ulcerative disease of the  uterine neck,
is a strong reason why it should  be adopted and
carried out without delay, unless  the patient  have
reached the latter period of her pregnancy. If so,
as the child is viable, and it is rather difficult to
bring the cervix fully into view,  it is as well, un-
less the symptoms be urgent,  merely to resort to
astringent  injections, and to  reserve  all  instru-
mental treatment until  after the confinement."
In the early or first  six months, the local  treat-
ment, Dr. B. states, must consist in astringent
injections, and cauterization with the nitrate of
silver or thcacid nitrate of mercury, the potassa
cum calce being much too powerful in these cases.
If ulcerative disease of the cervix exist after an
abortion or confinement, he never interferes until
four or five weeks  have elapsed, and  he then
cauterizes the diseased surface with the nitrate
of silver.  If blood be poured out from the ulcer-
ated surface, the cauterization invariably stops it;
and the case then falls into the general category.
But it should be recollected that, during lactation,
the mucous surface ofthe cervix and vagina pre-
sents  a vivid red or congested hue, from sympathy
with the mammae and nipples;  hence this condi-
tion should not be mistaken for inflammation, and
ought not to be interfered with by treatment.  The
disease of the cervix in females past the menstru-
ating age is generally intractable, and  requires the
most powerful caustics, but having been removed,
the cure  is permanent.
  111. ii. Treatment of Acute Inflammation
of  the Internal Surface and Body  of the
Uterus.—Although the treatment  of endo-me-
tritis, by local means, is supposed, especially by
some  French writers, to  be appropriate to this
state  and seat of the  disease, yet such means,
however cautiously  resorted to, cannot fail  of
being more or less dangerous.   As this form  of
metritis frequently commences in the cervix or its
cavity, extending to  the cavity,  and to some ex-
tent, in most instances, to the substance or body
ofthe organ, and in some cases also to the broad
ligaments, these circumstances  should always be
considered, and the treatment should be prompt
and decided.   If the patient be  young, or strong,
or plethoric, especially if the disease has followed
the suppression ofthe catamenia, or of other evac-
uation or excretion,  blood should be taken from
the arm,  or from a vein in the  feet immersed in
warm water, and cooling diaphoretics and aperi-
ents exhibited.  The warm or tepid bath, or hip-
bath,  may follow the depletion ; and, if  the pain
be severe, camphor, nitrate of potash, and extract
of henbane, or extract of belladonna,  or a minute
dose of aconite, may De prescribed every four or
five hours, or after longer intervals,  if the bella-
donna or aconite be given.  In the cases just de-
scribed, local depletions—by leeches applied over
the ovarian  regions, or below the groins, or by
cupping on the loins or sacrum—may be directed
after the blood-letting, especially if this latter has
not produced the  desired amount of  benefit;  in-
deed,  in most cases the local depletions  will also
be required.  In milder cases, and in less robust
or plethoric females, the  local  depletions, when
resorted to with decision, will generally be suffi-
cient, especially when  the internal or  general
treatment is judicious.   Their repetition may, in
some  cases, be required, but this, as well as the
quantity of ilood  which should be taken, should
depend upon the severity and other features of
the case.  After the local depletions a tepid bath,
and subsequently  the  terebinthinated  epithems
and embrocations already advised, may be placed
over the hypogastric region, the flannel on which
the embrocation is sprinkled having been either
warmed or wrung  out of hot water.
  112 These  measures having been employed,
time should be allowed for their operation, and
for the subsidence  of the disease. This latter ob- 
UTERUS—Treatment of Chronic Inflammations of the.
1385
 ject will, however, be promoted by rest in the
 horizontal posture;  by the avoidance of sexual
 excitement; by recourse  to  cooling  diaphoretic
 medicines, especially the liquor ammoniae aceta-
 tis, with small doses of the vinum or liquor anti-
 monii tartarizati, and some anodyne or narcotic.
 The only aperients allowed should be cooling, and
 such as may not irritate the rectum :  as the citrate
 or carbonate of magnesia; the phosphate of soda;
 the  acetate  or tartrate of potash, prescribed  in
 emollient vehicles, or with either of the prepara-
 tions of senna or rhubarb.  Calomel, or calomel
 with opium, should not be given in  metritis, as it
 is apt to aggravate the complaint by irritating the
 rectum; and medicines containing  aloes should
 also be avoided.
    113.  The regimen and diet of the patient should
 be strictly antiphlogistic, and the beverages allow-
 ed ought to be demulcent, emollient, and slightly
 alkaline.  As  convalescence  advances, the  alka-
 line mineral waters of Vichy or Ems  may be al-
 lowed.   When the disease is neglected, or im-
 properly treated, it may extend to the broad liga-
 ments and ovaria, as shown above (y 72, et scq.),
 or it may lapse into a chronic state ; which state,
 however, may be primary, although it  is much
 more frequently a consequence of chronic inflam-
 mation of the cervix, or of the cavity of this part,
 or  of the body of the organ, and  is most fre-
 quently partial or limited in its seat, as shown
 above (y 64).
    114. iii. The Treatment of Chronic Metri-
 tis.—Chronic  metritis, often  commencing in the
 cervix, is also  frequently kept up by the inflam-
 mation  of this part and its  consequences.   In
 most cases, therefore, the disease of  the cervix
 should be first  and chiefly attacked, by the means
 already  advised for the several morbid conditions
 of this part (y 102, et seq).  The chief local means
 are, rest in the horizontal  posture,  emollient or
 astringent vaginal injections, the  occasional ap-
 plication of leeches to the cervix, before or  after
 menstruation, according to the  period at which
 they appear  most serviceable, and a recourse to
 anodynes when the sufferings of the patient are
 severe.   These latter, or  the narcotics  already
 mentioned (y 93); a recourse  to belladonna, both
 locally and internally, or to chloroform, or to the
 hydrochloric ether, or hydrocyanic acid, &c. ;
 the introduction of opiate or other anodyne injec-
 tions or suppositories into the rectum or vagina ;
 and the external  embrocations and  epithems al-
 ready advised  (y  101), are  the chief  means by
 which we may hope to remedy this  state of dis-
 ease.  In obstinate and protracted cases, M. Gen-
 drin and Dr. H. Bennet have had recourse to an
 issue formed above the pubes, keeping it open for
 some months.   In a severe and prolonged case,
 which I attended with Mr. Flockton, many years
 before the appearance  of this  recommendation, I
 directed an issue to  be made  below  both  groins,
 with the most complete success.
   115.  The enlargement, partial  or  general, of
 the cervix and body of the  uterus, in protracted
 chronic  metritis, suggests  not merely the local
 measures noticed above for reducing this enlarge-
 ment, and the other evils which usually attend it,
 but  also  such   other  general or  constitutional
 means as are sometimes found of service in re-
moving other states of enlargement,  morbid dep-
osition or growth.  These  means may not be of
much avail in the disease now under considera-
tion ; but the most important of them may be so I
[ employed and combined  as to very considerably
 improve the general health, which is usually in-
j jured by the local  malady, and to  alleviate the
 sufferings of the patient.  These means are, the
 bichloride of mercury, the preparations of iodine,
 the iodide of arsenic and  mercury, the fixed alka-
 lies and their salts, and the preparations of sarza,
 severally but separately  conjoined  with tonics,
 anodynes, or narcotics, &c.   On these principal
 medicines I proceed to offer a few remarks, in re-
 spect to the treatment of chronic metritis and its
 complications, especially  when characterized by
 enlargement of any part  of the uterus.
    116. The bichloride of  mercury is beneficial or
 injurious, according to the manner of prescribing
 it.  It may be of service even when the constitu-
 tion has been very remarkably injured by this pro-
 tracted malady.  But it should in most instances,
 and in these especially,  be prescribed either in
 the fluid extract  of sarza, or in the compound
 tincture of cinchona, or  in the  decoction or in
 mixtures, consisting chiefly of all these, with or
 without some narcotic, as the tincture of conium,
 or of henbane, &c, or with  a few  drops of the
 tincture of opium, or with the compound tincture
 of camphor, if the medicine  should have too  re-
 laxing an effect on  the bowels.  This substance,
 thus taken, in doses varying  from the sixteenth
 to the eighth of a grain, has a very salutary tonic
 and alterative effect, even although the hypertro-
 phy of the uterus may not be much, or even at all,
 reduced by it.
   117.  The  preparations  of iodine are of service
 only when given  in small doses, and continued
 for a considerable time   The iodide of potassium
 I  have, in these cases, prescribed in  doses of one
 to two  grains, thrice daily, with the bicarbonate
 of potash, or liquor  potassae, or Brandish's  alka-
 line solution, in a tonic infusion  or decoction, or
 as I have prescribed the  bichloride of mercury
 (<J 116).  The iodide of mercury and arsenic is
 sometimes of service when extemporaneously pre-
 scribed in the compound fluid of sarsaparilla, or in
 any better infusion.   The iodide of iron may also
 be given  in  the form of pill (see Form. 535), or
 in the sirup of sarsaparilla, but in  moderate doses,
 and in cases evincing more or less anaemia, and
 when there is reason to suspect that the disease
 has been caused or  prolonged by self-pollutions.
 In these  cases, also, the  carbonates of the fixed
 alkalies, the tartrates, the nitrates, &c, are of serv-
 ice, when taken in tonic  or bitter infusions, and
 conjoined with anodynes or narcotics.  I have had
 reason to believe that the combination  ofthe bi-
 borate of soda  with  these, in  doses  sufficient to
 preserve the bowels  in an open state, without of-
 fending the stomach, has been of more service in
 reducing hypertrophy ofthe uterus, whether par-
 tial or general, than  any other means.
   118  Dr. H Bennet states that, when all ordi-
 nary therapeutic agents fail to  remove chronic in-
 flammation  and induration of the uterus, he has
 established, as a counter-irritant,  an  artificial ul-
 ceration or issue in the neck ofthe uterus itself,
 with potassa fusa, or potassa cum  calce, inde-
 pendently of any disease of that region,  and with
 very great benefit to the patient.
   119. As the chronically inflamed and enlarged
 uterus often falls back upon the rectum, thereby
causing constipation and  painful defaecation, es-
pecially when the  faeces are more or less solid,
care should be taken  to preserve the bowels in an
open state.   The means  which  I have usually 
1386
UTERUS—Treatment of Inflammations of the.
 preferred arc electuaries, composed of the bi-tar-
 trate of potash, the bi-borate of soda, and the con-
 fection of senna, sometimes  with sulphur, and
 with any suitable sirup ;  which may be taken ev-
 ery  night.   They have a deobstruent effect upon
 the  uterus, while they preserve a lax state ofthe
 bowels.   In cases  where emaciation or anaemia
 are  prominent, in addition to  nutrients, restora-
 tives, or tonics, as circumstances have suggested,
 I have prescribed the  cod-liver oil, and  more re-
 cently this oil containing some one of the prep-
 arations of iron, of iodine, or of mercury, &c.
   120. iv. The treatment of enlarged uterus
 hardly differs from  that recommended for chronic
 metritis  (y 114, et seq.).   Rest, attention  to the
 secretions and excretions;  cooling saline aperi-
 ents and diaphoretics,  local depletions, in moder-
 ate quantity, at intervals of about a fortnight; the
 preparations of iodine in small doses, with alka-
 line solutions or the bicarbonates ;  the bichloride
 of mercury in minute quantity, either alone or with
 the  preparations of cinchona ;  the liquor potassae
 with sarsaparilla ; and more especially the avoid-
 ance of sexual excitement, and of all heating or
 stimulating  beverages, and  the recumbent  pos-
 ture, on  a cool sofa, and on a hair mattress at
 night, are the means which will alone be of any
 service, if they be perseveringly adopted.
   121.  v.  Treatment of  Inflammation  and
 Abscess of the  Uterine Appendages.—At an
 early stage the treatment of inflammation of the
 uterine appendages is the same as that advised
 for acute metritis (y 111)   But in order to pre-
 vent suppuration, which is very much more liable
 to occur in the former than in the latter, more
 prompt and more decidedly antiphlogistic meas-
 ures are required,  especially  general and local
 blood-letting.   If, however, these means fail  in
 preventing the formation of pus, or in procuring
 the  absorption of  whatever may have already
 formed, the purulent collection will find its  way
 to the exterior by the  vagina,  rectum, abdominal
 parietes, or bladder.  In these  circumstances we
 can  only endeavour to control the symptoms, by
 means suitable for this purpose, to assist nature
 in throwing off the morbid formation, in the di-
 rection to which she points, to support  the con-
 stitutional powers  of the patient, in order  that
 this  end may be attained, and to palliate the more
 distressing symptoms which present themselves.
 The  treatment advised for chronic metritis is suit-
 able  for this stage of the disease.   If the abscess
 open into the urinary bladder, the means  required
 will  be suggested by the state  of the urine.  If
 this excretion continue acid, the carbonates ofthe
 alkalies, with demulcents, opiates, or  other ano-
 dynes, will be  most serviceable;  and tonics, re-
 storatives, the  preparations of buchu, or pereira,
 &c, be also required.  If the urine become  am-
moniacal, or even neutral, the mineral acids, with
 cinchona, quinine, or other  tonics, opiates, &c ,
 should be exhibited.  If the abscess open in the
rectum, or flexure of the  colon, the consequent
tenesmus, and  other dysenteric symptoms,  will
 subside after a short time, if, with restorative and
anodyne  medicines, amylaceous or mucilaginous
injections, with opiates,  be  administered.    The
bursting ofthe abscess into the vagina terminates
 favourably if the  constitutional powers  be sup-
ported, and the unpleasant symptoms palliated,
the vagina being occasionally washed by a lotion
of tepid or of  cold  water.  If the  abscess point
externally, tonics, with alkalies, and attention to
 the excretions, are necessary; and as soon as fluc-
 tuation and redness ofthe tumid surface  appear,
 an opening, made  by the lancet, should not be
 delayed.  Afterward, the powers of life should be
 duly  supported; and the ingress  of  air into the
 cavity of the abscess carefully prevented, while
 the rcaccumulations of matter should be prevent-
 ed or moderated by gentle pressure;  and when-
 ever  any collects, it should be discharged.
   122.  IV. Inflammations of the Uteris and
 Appendages  of a  Specific Nature.—Inflam-
 mation ofthe uterus may be caused by gonorrhoea
 or by syphilis—by gonorrhoea more  frequently
 than  is generally supposed, by syphilis very rare-
 ly.—i.  I have seen several cases of gonorrhceal
 inflammation of  the womb and appendages,
 and in  every case the disease was most severe;
 and whether extending to the os and  cervix uteri
 from  the vagina, or by possibility commencing in
 the  former, owing to the direct  contact of the
 morbid matter with  that part, the inflammation
 had advanced along the canal ofthe cervix to the
 internal cavity of the uterus, and in  three cases
 to the broad ligaments and ovaria—in one to both
 ovaria,  and in another to the  ovarium of the left
 side  and pelvic peritoneum.  Mr. Acton, in his
 excellent work on " Diseases  of Ike Urinary and
 Generative Organs in both Sexes," has treated this
 subject in  a chapter on " Blennorrhagia of the
 vulva, urethra, vagina, uterus, and  ovary," but he
 views the disease as in all respects the same as
 inflammation of those parts, occurring independ-
 ently of a specific  contagion.   That it is the
 same as respects the inflammatory condition—
 that it is an acute form of inflammation, there can
 be no doubt;  but  that it is  more severe, more
 disposed to extend to the uterine  cavity and ap-
 pendages, than  common  inflammation, whether
 acute or chronic, commencing in the cervix uteri
 and produced by other causes, would appear from
 the cases I have treated.  All these  cases were
 of married  women, the gonorrhceal infection hav-
 ing been  communicated by their  husbands, and
 in all the  infection was most manifest, the pa-
 tients not being previously subject to  any leucor-
 rhoeal discharge, and was followed  by most severe
 symptoms  of inflammation  of The  womb, and by
 the extension ofthe inflammation  still farther, as
 stated above. On this subject Mr. Acton remarks
 that, " a female  suffering  under uterine blennor-
 rhagia may be seized with shivering and a fever-
 ish state of the system ;  vomiting may come on,
 together with  pain  referred  to the  iliac fossa,
 where more or less tension may be present (in no
 way resembling the superficial pain produced by
 peritonitis); but if the finger be  carried up the
 cul de sac of the vagina, and the patient desired
 to turn  upon  the opposite  side, pain  of a most
 acute  kind  will be felt.   The blennorrhagia may
 cease  for the moment, one ovary may be attacked
 only,  or both simultaneously, as in epididymitis;
 revulsion will explain the partial cessation of the
 discharge.   Lastly, we believe that a great num-
 ber of ovarian  dropsies may result from a chron-
 ic inflammation of  that organ, the consequence
 of such  complications."  (Op. cit.,  p. 308.)  I can
 fully confirm the correctness of this last remark
 by a recent case of ovarian dropsy, which occur-
red in the wife of a very eminent man, and was
the ultimate  lesion  which  followed  gonorrhoea
communicated by her husband.   She  was from
the commencement, and is still, under my profes-
sional care. 
UTERUS—Pr
OLAPSE  OF THE.
1387
  123. i.  Syphilitic Ulceration of the Cer-
vix Uteri.—Both Dr. Henry Bennet  and Mr.
Acton agree in considering syphilitic ulceration
ofthe cervix as a rare occurrence.  The latter re-
marks  that, in  the vagina and os uteri, the cir-
cumstances favouring contagion do not often oc-
cur, for if the contagious pus of chancre reaches
as far, it is generally deposited on a layer of mu-
cus, which protects the membrane beneath.   He
concludes that " ulcerations of the neck  of the
uterus are, in ninety-nine times out of a hundred,
merely  simple  affections, the result  of acute  or
chronic inflammation, very intractable in ordinary
treatment, and will persist an almost  indefinite
time, unless we employ local applications."  True
syphilitic ulcers ofthe cervix uteri are described by
Mr. Acton as differing from all other ulcers of this
part.   " They are small, covered with a chamois
leather  secretion, which it is difficult to remove ;
their edges are distinct;  they look as if a portion
of mucous membrane had been punched out of
the os uteri, and inoculation has shown that they
were true chancres, situated on this unusual posi-
tion."   (Op. at., p. 292 )
   124.  ii.  The treatment of these specific dis-
eases ofthe  uterus is not different from that ad-
vised for the affections above  described.—A. As
respects gonorrhoea!  inflammation of the womb
and its appendages, the means are the same  as
those advised for the more acute  inflammations
of these parts; the chief modifications consisting
in a more prompt and decided use of these means,
especially when the  symptoms are very severe
In many cases, the inflammation ofthe vagina is
so severe, and the swelling of both it  and the vul-
va so great, as  to prevent a recourse  to  many of
the means already advised,  especially at an early
stage, injections of an emollient and anodyne kind
being first prescribed, and sedatives,  demulcents,
refrigerants,  and narcotics  internally.   In other
respects, and as the disease continues  or is pro-
longed, the remedies already recommended for
inflammation of the  uterus and its appendages,
should be administered  appropriately to the pe-
culiarities and complications of individual cases.
   125. *B. The treatment of syphilitic ulceration
ofthe cervix consists in the  use ofthe acid nitrate
of mercury locally, as directed above  (y 104), and
in the employment  of the  constitutional  means
indicated by the existing state ofthe  case, and by
the appearance of any  signs of venereal  ca-
chexia  (see that article).
  126.  V. Displacements  of the Uterus —
The womb being suspended in a cavity more  or
less capacious,  but liable to  alterations in the ex-
tent of its capacity ;  its  supports being not only
yielding, but also  admitting of considerable mo-
bility ;  its manifest changes in size and position
during pregnancy; and its movements during coi-
tion, and the venereal orgasm, are circumstances
requiring consideration while endeavouring to de-
scribe and explain displacements of the uterus,
as well  as to remedy  these evils.  The causes of
these disorders are  often manifest, but in some
cases they can  only be inferred from insufficiently
conclusive evidence*  It is not  to  be  disputed

  [* Dr.  J. II.  Bennet, of London, was the first writer
who attributed descent of the womb to an increase in it?
weight.   " The uterus," he remarks, " is so slightly poised
or suspended in the cavity of the pelvis, that the slight-
est modification in  its volume gives rise, to a change in
its position.  The inflammatory hypertrophy of the cer-
vix increasing considerably the specific gravity ofthe in-
ferior portion of the uterus, the entire organ descends,
that an enlargement of the organ will favour its
descent; that muscular efforts, especially lifting
heavy  weights, will have  the  same  effect, even
independently  of enlargement, and  particularly
when the vagina and ligaments are relaxed by
child-bearing, leucorrhcea,  etc.; and  that partial
or general enlargement, the pressure of loaded
adjoining viscera, too  severe or prolonged exer-
tion, especially during the  menstrual period, falls
on the back, hips, concussions ofthe trunk ofthe
body, &c, will  occasion either that or other forms
of displacement.
   127.  It should not  be overlooked  that, in the
great majority of instances of displacement ofthe
womb, other lesions of the organ, either inflam-
matory or structural, are associated with  the dis-
placement.  This circumstance is of no mean im-
portance both  in recognising  the cause, condi-
tions, and relations of displacement, and in regu-
lating the treatment and regimen of the patient.
   128.  i. Descent or prolapse ofthe womb is
the most common form of  displacement, and pro-
ceeds from increased weight ofthe organ, or from
impaired tone of its supports.—A. Dr. West has
considered this lesion with reference to its grades,
and divided it into the first, second, and third de-
grees of prolapse.  " In the first degree the organ
is merely lower than  natural,  but still preserves
its  proper direction, its axis corresponding with
that of the pelvic brim, and this, even though it
should  be so low that its  cervix rests upon the
floor of the vagina.   In prolapsus of the second
degree, the uterus is situated with its fundus di-
rected backward, its  orifice forward, so  that its
long axis corresponds with the axis of the pelvic
outlet.   In prolapse of the third degree,  or, as it
is often termed, procidentia ofthe uterus, the or-
gan lies more or less completely externally, hang-
ing down beyond the vulva, though  it generally
admits  of being replaced within the vagina, if not
of being altogether  restored to its natural posi-
tion."   It is obvious that a due recognition ofthe
circumstances, both physical and pathological, fa-
vouring and  causing this displacement, is of the
greatest importance in preventing and removing
the different grades and complications of it ob-
served in practice.  The womb is not merely sus-
pended by the duplicatures of the  peritoneum
within  which it is contained, but it is also poised
upon the vagina, which,  in the  healthy virgin
state especially, furnishes it  very  considerable
support  The  curved direction ofthe vagina, the
connexion of the organ, appendages, and vagina
with the adjoining viscera, with the pelvic and
perineal fasciae, &c , also  aid  in supporting the
uterus in its situation.
   129.  These  combined supports, however, may
prolapses."  (" A Practical Treatise  on Inflammatory Ul-
ceration  and Induration  of the Seek of the  Uterus."
Lond., 8vo, p. 212, 1845.)  When we consider, however,
that the weight  of a non-gravid womb seldom exceeds
two ounces, and of that the vaginal cervix constitutes not
more than one fifth part; and,  moreover, that the gravid
uterus at three or four months of gestation rarely de-
scends, we may well doubt whether much  can be justly
attributed to this cause.  Ninety per cent., at  least, of
the?e cases occur in females who have had children, and
probably a still larger proportion, so that we must look
to gestation and labour,  and  accidents connected with
them, as the principal causes.   Professor Bedford has
very properly called attention  to the fact, that both pro-
lapsus and procidentia of the  womb are often owing to
mismanagement of the placenta, as pulling upon  the cord
before it is detached (" Clinical Lectures on the  Diseases
of Women and Children."  N.  Y., 8vo, 1855, p.  46, &c),
and some of the worst cases we have ever treated could
be traced to this cause.] 
1388
UTERUS—Prolapse of  the.
severally be  relaxed  or overcome during  the
epochs of life  following puberty.   In  the virgin
and unmarried state, leucorrhcea, menorrhagia,
anaemia, exhausting discharges, and frequent ex-
citement of the venereal orgasm by masturbation,
severally tend to relax the tone ofthe parts which
support the womb in its natural position.  During
the sexual orgasm its mobility is manifested to
the greatest natural extent, its descent often oc-
curring in various degrees, without becoming
greater than is consistent with the healthy func-
tion ;  but it is obvious that, when unnaturally
produced, the healthy  condition is at last exceed-
ed, and that more or  less displacement is apt to
occur,  especially as the same cause practised to
excess tends remarkably to relax  the tone of the
parts upon which the healthy position of the or-
gan depends.   In the married  state, as well as
sometimes  in  the unmarried, although more re-
markably and  much more frequently in the  for-
mer, enlargement and greater weight  of the
womb, and the stretching, relaxation, and other
changes ofthe supporting parts consequent upon
abortions, child-bearing, difficult labours, and pu-
erperal diseases, very materially predispose to the
descent and other displacements of this organ.
If, in these circumstances, the erect posture be too
early resumed after delivery or abortion, if falls
or concussions of the trunk of the body be expe-
rienced, or if violent muscular efforts be made, as
in lifting or carrying heavy weights, a greater or
less descent, or hernia ofthe uterus is apt to take
place.   Aged  and emaciated females, married or
unmarried, are most frequently  liable to this dis-
placement, sometimes to its utmost extent, owing
to the  absorption ofthe adipose tissue  adjoining
the vagina and vulva, especially when the excit-
ing causes just mentioned have occurred.
   130.  Descent of the uterus, even in its  first
and second degrees, is very commonly attended
by some degree of retroversion ; and this state  is
often, as well as the descent, increased by consti-
pation of the bowels ; the hardened faeces, in the
efforts at defaecation, augmenting the extent of
both states of  displacement, by pressing upon the
fundus of the  uterus.  Dr. West justly remarks
that " the close connexion  between the cervix
uteri and the neck of the bladder is a temporary
obstacle to the complete descent of the womb,
while  at the same time it favours the retrover-
sion of the  organ; but if at length this yields,
the urine accumulating in the bladder distends its
fundus and the vaginal anterior wall into a pouch
which drags down the uterus in front just as the
prolapse ofthe rectum drags it down behind;  and
the organ now soon comes to lie beyond the ex-
ternal  parts;  the case being thus converted into
one of procidentia uteri, or of prolapse in the third
degree."  (Led., p. 156.)
   131. This displacement ofthe uterus is, in the
course of time, followed by still farther changes.
The neck of the  womb, being the first part pro-
truded, and the most exposed to irritation, be-
comes more and more hypertrophied,  and  often
excoriated ; the enlargement being both in length
and thickness.  The protrusion  of this part of
the organ is partly due to inordinate growth, its
thickness being sometimes equal to, or even great-
er than that ofthe wrist. The lips ofthe os uteri
become enlarged with the rest of the organ, and
the  transverse opening formed  in women  who
have had children is converted into a wide open-
ing situated deeply between projecting lips, whose
surface is irritated, excoriated, vividly red or gran-
ulated, and covered by an albuminous  secretion.
The prolapse beyond the vulva may continue only
in a partial state for years, the fundus and a por-
tion  of the  organ remaining within the  pelvis,
while the neck and the lower part are external.
In this state, the organ may still be replaced with-
out difficulty,  especially  when  the prolapse has
followed soon  after delivery at the full period, the
pelvic floor being sufficiently yielding in most in-
stances.   In the course of a variable duration of
time, a partial  descent is often followed  by a com-
plete protrusion  of the  organ, " the vagina be-
coming inverted, and forming the outer walls of
a tumour, at the lower part of which the womb is
situated.  So  long as the procidentia  is incom-
plete, this tumour is somewhat pyriform in shape,
its base being directed upward; but afterward,
as it increases in  size, it assumes an oval form,
owing to more or less of the bladder being drawn
down into it in front, and of the rectum  also, in
many  cases, behind.   Its bulk is also  farther
swelled, in numerous instances, by the small in-
testines sinking down into the sac, and thus add-
ing to its size until it equals or exceeds that of
the adult head."
   132.  In these cases, the uterus itself forms only
a comparatively small portion ofthe large extern-
al tumour.  The susceptibility of the organ, and
the disposition to hypertrophy, are much  dimin-
ished by constant and complete prolapsus from
the pelvic cavity.  " The bulk ofthe tumour, and
the difficulty  of its replacement, depend chiefly
upon two causes.   Of these, the one consists in
the  enormous hypertrophy  which the  vaginal
walls undergo. Not only does their mucous mem-
brane lose its  ordinary character and become cov-
ered by a layer of cuticle like that of the  skin, to
protect it from the various sources of irritation to
which it now becomes  exposed,  but  the walls
themselves attain a thickness of as much as half
an inch, and present a dense muscular structure.
The other cause ofthe bulk ofthe tumour, and
of the difficulty of replacing it, arises from the
presence  of the intestines in the sac, which sel-
dom reside  there  long without inflammation of
their peritoneal covering being set up ; not of so
acute a character, indeed, as to produce formida-
ble symptoms, nor even as always to call for treat-
ment, but matting their  different coils to each
other, and tying them firmly to the interior ofthe
sac."  This latter cause pf  difficulty in attempt-
ing to return  a long procident uterus should not
be overlooked, for, even though no intestines have
descended into the external tumour itself, chronic
peritoneal inflammation may agglutinate them  to
each other,  or to the walls  of the  pelvic  cavity,
and thus oppose the replacement of the womb.
   133. B. The Symptoms ofProlapse oftheUterus.
—The symptoms may be severe in some cases,
and  hardly  experienced  in  others.  In the un-
married, and when occurring suddenly or rapid-
ly, prolapse of the uterus is  attended by much
more severe or acute symptoms than when it oc-
curs in married females  after miscarriage or de-
livery, or when it takes  place slowly.  When it
is caused  in  single  females  after   prolonged
dancing or  riding  on  horseback,  the  symptoms
are generally  rapid and severe ; and even in mar-
ried females who  have borne children, and have
subjected themselves to these causes, the descent
is usually rapid, and  the symptoms are also se-
vere, but the  prolapse is generally greater than 
UTERUS—Treatment of Prolapse of the.                     1389
in the single.   The  sensation  most frequently
experienced is that  termed "bearing down," or
of falling down of the pelvic viscera.   This feel-
ing is augmented by lifting weights, or by bodily
exertion, and then it is often attended by a sharp
pain.  Defalcation is difficult and painful, and is
followed by some degree of tenesmus.   Pain in
the direction of the vagina,  when  sitting down,
especially on  a hard seat, pain  in  the back and
low in the sacrum, and a very frequent desire to
pass water, are always experienced.   Leucorrhcea
is  often complained of, and the catamenia are
either profuse, prolonged, or too frequent.   The
digestive organs are soon after  more or  less dis-
ordered, the bowels are constipated, and  the gen-
eral health suffers ; and as the prolapse  becomes
chronic or prolonged, the cervix and even the
body ofthe uterus become hypertrophied.
    134. External prolapse, or  procidentia uteri,
generally follows the internal prolapse, or that in
which the uterus and cervix still remain within
the external parts, and usually takes place gradu-
ally.  It is favoured by emaciation or the absorp-
tion of the adipose substance in the vicinity of
the vulva; and it occurs  most frequently after  a
too early change of position after  parturition or
 miscarriage, or too  early exertion,  or walking
 about, after these occurrences.   In these circum-
 stances especially, sudden, unusual,  or great ex-
 ertion, or straining at stool, or lifting  weights,
 may  occasion  procidentia  suddenly;  and the
 symptoms may then be severe.  As the cervix,
 the lower part, and the body of the organ, suc-
 cessively protrude—the former parts only  occa-
 sionally at first—the pains, inconvenience, and
 distress increase, and ultimately the whole organ
 lies nearly always or constantly without the ex-
 ternal parts.   After the protrusion, the sensibil-
 ities of the uterus become blunted by the expos-
 ure, and the vaginal leucorrhcea subsides.   But,
 as the procidentia increases, the relations of the
 uterus with the adjoining organs and  parts are
 changed.  The urinary bladder and urethra are
 more particularly implicated, occasioning dysuria,
 a frequent desire to empty the bladder,  or incon-
 tinence of urine.   The rectum  is also affected so
 as to render defaecation difficult or painful; while
 the descent ofthe small intestines into the  pelvic
 cavity, and the excoriations, thickening, irritation
 and ulcerations of  the exposed parts,  owing to
 exposure to the air, and to the dribbling of urine,
 and to other contingent occurrences, increase the
 sufferings of the patient.  With the  complete
 prolapsus, hypertrophy of the  organ  increases,
 more especially its  cervix and  the lips  of the os
 tincae,  which, moreover, become  ulcerated to  a
 considerable extent, the cavity ofthe cervix being
 drawn apart, so as to become open or gaping, the
 ulcerations extending into it.   In many cases of
 internal prolapse, pregnancy takes  place ; but this
 period is often one of considerable suffering.  If
 the prolapse be slight, pregnancy generally cures
 it, as the uterus rises in the pelvis  with the ad-
 vance  of gestation,  especially  if care  be taken,
 and the patient remains in  a recumbent position
 long after delivery.   When the uterus is  either
 partly or altogether external, impregnation  rarely
 takes place.   In the  former case, the  sufferings
 ofthe patient are greatly increased by impregna-
 tion ; and  miscarriage  usually takes place, the
 organ being unable to rise into the pelvic and ab-
 dominal cavities.   "In some few instances, how-
 ever, pregnancy runs its course undisturbed, in
spite of a great degree of prolapsus;  and cases
are on record in which the uterus has descended
farther and farther, until  a  great portion of it
hung down between the thighs ; but the develop-
ment of the foetus has, nevertheless, gone on in
this unnatural position ; and others still stranger,
in which coitus has been practised immediately
through the os uteri, and impregnation and  un-
disturbed gestation have followed in spite of the
existence  of irreducible  procidentia." (West,
Led., p. 172.)
   135. C.  Treatment.—The causes which  tend to
oppose the return of any long-existing procidentia
ofthe uterus have been explained above (v 132);
and the same causes, although operating in a  less
degree in  simple or internal prolapsus, often pre-
vent the complete restoration of the womb to its
normal position.  The first object, in respect of
treatment is, to ascertain the causes of prolapse,
and the circumstances connected with its occur-
rence and progress ; for the means of cure or of
palliation  must be directed  accordingly.   Care-
fully avoiding  the causes  of prolapse  (<$  126, et
seq.), the  patient should strictly observe rest  and
the recumbent posture ; preserve a gently open
state of the bowels, and have recourse to astrin-
gent injections, and the cold hip-bath.   When
the womb is much enlarged, as well as  prolapsed,
the measures advised above  for the enlargement
(cj  115-120) should be adapted to the peculiarities
of the case.   It should be recollected  that there
is always a tendency to a return of the descent,
even when the womb has regained its  proper po-
sition, upon the recurrence of the menstrual pe-
riod.  If, therefore, due care and proper  precau-
tions be not taken on the accession and during
the course of this period, the descent may return,
and each  return will be attended by an aggrava-
tion not only of the extent of the prolapse, but
also of the enlargement ofthe organ, and of the
profuse menstruation which generally attends it,
 especially if the patient be allowed to remain in
 an erect or sitting posture.
    136. As respects a recourse to mechanical sup-
 ports in order to preserve the uterus  in  situ, as
 well as regards a selection  of those supports, I
 must refer the reader to directions contained in
 Dr. West's very able and instructive lectures,
 and be contented with a  reference  to the more
 general principles and directions he has there ad-
 duced: 1st. In cases of slight descent  of the  ute-
 rus, resulting  from a  general loss of tone in the
 parts, or from some temporary or accidental cause,
 as excessive fatigue, over-exertion ;  2d. In cases
 where the descent ofthe womb is still compara-
 tively recent, and is due to the persistence of pu-
 erperal hypertrophy, owing to imperfect  involu-
 tion of the organ (y 69) after abortion  or  labour;
 3d. In cases where uterine  disease, of whatever
 kind, was the occasion of displacement ofthe or-
 gan, such disease being still in a stage requiring
 treatment.   In these several circumstances,  me-
 chanical support ofthe uterus is not necessary or
 suitable.   On  the other hand, mechanical means
 of some  kind or other are  required,  1st. In all
 cases of external prolapse or procidentia; 2d. In
 cases of long-standing prolapse ofthe  second de-
 gree, associated with much relaxation of the va-
 gina, and consequent weakening of the  uterine
 supports; 3d. In all cases of extensive laceration
 of the perineum, and for a similar reason in cases
 of prolapsus in the aged; 4th. In cases of less
 degrees of prolapse attended by extreme suffer- 
1390
UTERUS—Versions  and Deviations of  the.
ing;  5th. In all cases of considerable prolapse of
the vagina, with or without descent of the  rec-
tum or bladder, and in all cases in which the uter-
ine prolapse is  secondary to any  of those other
forms of displacement.   It is  unnecessary here
to describe the several kinds of support or con-
trivances which  have  been  advised.   They are
either external or internal, according to the man-
ner of their employment.  They are well described
in Dr. West's work just  referred  to, where very
judicious directions are also given for their use
   [There is every  shade  of opinion in our pro-
fession in regard to the  use of pessaries, from
Heberden, who says," A prolapsus ofthe vagina
or the womb is only to be relieved by a pessary"
(Commentaries, chap  102), to those  who pro-
scribe them altogether   Professor Meigs is very
decided in favour of pessaries,  and says, " A man
might as well treat fractures without  the  splint
as these affections without some mechanical stay
and  support."  (Loc.  at., p  144 )   After con-
siderable experience in the treatment of this af-
fection, we are satisfied that the time has not yet
come for the abandonment of this instrument.  If
an evil, it is a necessary  one, and the objections
to its use are  chiefly founded on its  abuse or in-
judicious use ; from its too large  size, improper
shape, or wearing too long without  removal, &c
Certain  are we that the operations  proposed for
its relief by Dieffenbach  and Marshal  Hall,
viz., removing portions ofthe vaginal  wall,  and
thus  causing  contraction ofthe  canal, arc alto-
gether  unjustifiable, and  such as very few  fe-
males will or  ought to submit  to.   The severity
of the remedy is  disproportionate to  the disease ;
besides, permanent relief may generally  be  af-
forded by safer  and less painful means.   More-
over, the contractedness of the vagina thus pro-
duced would, in child-bearing females, render la-
bour difficult and dangerous.   The glass or ivory
pessary is regarded by many as the  cleanest and
best in common use in  this country,  and they
maintain that it will accomplish whatever can be
reasonably expected from such an instrument.
   The medicated pessaries, recommended by Hip-
pocrates, are not to be lost sight of in the treat-
ment of prolapsions ofthe womb.  The sachet or
small  bag,  made of soft  linen, and filled with
finely-powdered galls, to which a  few  grains of
sulphate of quinine and alum  are added, and to
which a small bit of tape  is attached at the low-
er end, and soaked  for an hour or more in  claret
or astringent port-wine, often answers  an  excel-
lent purpose in constringing and  giving tone to
the parts.   It should be  pressed  and dried in a
napkin,  and dipped in sweet  oil, when  it  can
readily be introduced within the vagina as a med-
icated elytroid pessary.   If carefully introduced,
and this may be  done  by the patient, it may re-
main, with the aid  of a napkin  well  adjusted, for
several hours, and this may be practised daily for
an indeterminate period.    Such  medicated  sa-
chets will be found  very useful  in all cases  of re-
laxation and fall of the vagina,  and also in  many
cases of leucorrhcea.   The contents may be va-
ried to suit the circumstances ofthe case, as vary-
ing proportions of oak  bark, tannin, kino, opium,
henbane, cubebs, Peruvian bark, &c.  The spono-e,
which is sometimes employed, is  objectionable,
from its irritating nature and its uncleanness;  the
caoutchouc bottles  are in every respect prefera-
ble.  One should be  selected with the  neck entire ;
after stuffing it with finely-carded wool, the neck
is to be securely tied ; it should then, after being
well lubricated, be  properly adjusted, with the
cylindrical neck towards the vulva, which serves
to keep it in place, and it may be worn for a long
time without changing.   Where there is much
sensibility or irritability of the parts, such a pes-
sary would be far preferable generally to one of
wood,  ivory, silver,  or glass, were it as cleanly.
A few years since, Dr. Clay, of Manchester, En-
gland, presented us a pessary which, in some
cases,  wc have found preferable to any other.   It
is gilt, and pear or globe-shaped, attached to a
cylinder of elastic silver wire, covered with gum-
elastic, which projects  from the vulva, to which
an elastic bandage is attached and fastened to a
girdle  of suspender-web around the body.  This
retains the uterus securely in place, and is worn
without  pain or inconvenience.]
   137. These contrivances for the relief of pro-
lapsus of the uterus or vagina are merely pallia-
tive , they bring about, however, a cure, in some
cases by preventing any increase ofthe displace-
ments, and by giving time for nature  gradually
to remove them, more especially in  slight or re-
cent cases.  But in cases of long standing, and
in those in which the descent is considerable or
complete, there is much  uncertainty in their re-
sults.  Therefore  operations have been devised
for contracting the orifice of the vulva, and the
prevention by such means of external prolapse.
In cases of lacerated perineum, the restoration of
this part by an operation is obviously the most
successful mode of curing a prolapse, and it has
been often successfully attempted.  But in cases
where the orifice of the  vulva is relaxed, or is
widened by the uterine descent, means have been
taken  by Dr. Fricke, Mr. Brown, M. Gerardiv,
M. Langin, and Dr Kennedy, for its contraction,
with various degrees of success.  These means
will readily suggest themselves to most medical
men.  A  farther  notice  of them does not fall
within the scope of this work*
   138 ii.  Ascent of the Uterus.—This state
of displacement deserves  notice only in as far as
it is of some importance as a symptom • 1st. Of
advanced pregnancy, from the fourth to the eighth
month;  2d Of some cases of inflammation of the
pelvic  cellular  tissue, or  of the tissues between
the folds of the broad ligaments; 3d. Of an ad-
vanced stage of inflammation or of dropsy ofthe
ovaria; 4th. Of fibrous or other tumours of the
uterus when they increase in size and draw the
uterus upward ; and, 5th  A great degree of con-
traction ofthe pelvis.
   139  iii. Of other Displacements and De-
viations of the Uterus —The displacements of

  [* B.  F. Barker, in a paper on " Uterine Displace-
ment"  (.\V;« York Medical Gazette,  Mnv, 1S53), recom-
mends for prolapsus a pessary made by cutting out a
double thickness of patent lint of a triangular form, so
that when rolled up it will form a cone of "a proper size.
A piece of tape is tied to it, half an inch from the apex,
for the purpose of facilitating withdrawal.  The pessary
is to be soaked in a saturated solution of tannin.  The
patient placed on her back, the uterus is replaced, so that
its axis  corresponds with that  of the superior strait; the
cone is then introduced, apex first; but after it is in the
vagina, it  is turned so as to bring the base under the os
tincae.   Dr. B. recommends to introduce a new one twice
in the twenty-four hours.  Where there is tenderness, he
adds 5ij. laudanum to the solution of tannin.  The size
of the pessary may be gradually lessened.  The patient
is advised  to take exercise, and not keep the  recumbent
position.  The tannin is supposed to relieve congestion
of the cervix when present, while at the same time  it
gives tone to the vagina.  General  remedies, as iron,
quinine, &c, may also be necessary.] 
UTERUS—Versions and Deviations  of the.                   1391
 the uterus which consist of versions and flexions,
 or, strictly speaking, of deviations of the body and
 neck of the organ from their normal position, have
 only  recently  received due attention; and. al-
 though descent of the womb, in its several de-
 grees, has been  duly considered, owing to the
 prominent manner in which it is brought before
 those who have professed the study of the exten-
 sive class of female diseases, yet other deviations
 of the womb from its natural position have been,
 until lately, but imperfectly investigated by them,
 in the married and child-bearing states, and en-
 tirely neglected in unmarried females.  This neg-
 lect has in great measure originated in imperfect
 knowledge or entire ignorance, 1st. Ofthe prob-
 ability ofthe displacement being congenital; and,
 2d. Of certain  ofthe causes of these deviations,
 especially  those causes which more frequently
 occur in unmarried than in  married females, and
 to which I have sufficiently adverted already (see
 y 10, 22).
   140.  A  Dr. W. Hunter first directed attention
 to retroversion ofthe uterus as sometimes taking
 place in the  early months  of pregnancy; but it
 was not recognised as occurring in the unim-
 pregnated  womb  until cases  of  it  in this  state
 were published by Professor Osiander in 1808,
 and Professors Schweighauser, in  1817, and
 Schmitt, in  1820, farther illustrated the history
 and symptoms of this displacement.  More re-
 cently, Professor Simpson, of Edinburgh, and M.
 Velpeau, have fully investigated the nature and
 signs ofthe  several  deviations ofthe unimpreg-
 nated  uterus from the normal state.  Not  only
 may the fundus of the womb fall backward into
 the hollow of the  sacrum  or forward against the
 symphisis pubis, but it may also incline towards
 either side.  Its  body may, moreover, be  bent
 upon the cervix, forming a new  class of devia-
 tions, called  flexions;  and Dr. West states that
 there is reason for believing that  retroflexion and
 anteflexion  are of more frequent occurrence  than
 the corresponding alterations in  position  of the
 whole of the organ,  which are known as retro-
 version and  anteversion.  The tendency  of the
 womb when  at all enlarged, either in the early
 period of pregnancy, or by disease, is not  only
 to sink below its natural position,  but at the same
 time to fall back with its fundus towards the hol-
 low of the sacrum ;  besides, enlargement of the
 organ, either from imperfect involution, or from
 disease, is generally most considerable at its  pos-
 terior parietes, thereby causing a tendency to fall
 towards the heavier  side.  The distention ofthe
 bladder also,  so frequently continued for  a  pro-
 longed period, and a  loaded and constipated state
 ofthe bowels, aid in producing this form  of de-
 viation, whether in the gravid or in the non-grav-
 id uterus ;  while  sudden efforts or violent exer-
 tions, falls, concussions of the trunk, will concur
 with these  and  other causes  or circumstances, as
 with the catamenial period in the non-gravid, in
 producing this  form  of deviation, namely, retro-
 version    Previous delivery, miscarriages, diffi-
 cult menstruation, congestion  of  the uterus, in-
 temperate sexual  indulgence, and increased de-
 termination of blood to the organ, will also  pre-
 dispose to, or even  cause, this occurrence, as  well
 as some other conditions hereafter to be noticed
 (v 142, et scq ).
   141. B. Anteversion of the non-impregnated
uterus was, only a few years ago, considered to
be a rare occurrence.  I find  in the notes of a
 case which I saw, with Mr. Hoyland, in 1843,
 that I remarked that one to  have been only the
 fourth that I  had seen, and  that  this case was
 most probably owing to adhesions of the fundus
 of the uterus, as the lady had been some consid-
 erable time previously the subject of pelvic peri-
 tonitis.   Madame  Bovin had, however,  many
 years previously pointed  out attacks of circum-
 scribed peritonitis as a not infrequent cause of
 abortion.   Without such adhesions it is difficult
 to account for  the occurrence of  anteversion,
 owing to the relative position of parts; and there
 is much reason for inferring,  with Dr. West, that
 many  of the  cases believed to be those of ante-
 version were  actually cases of  anteflexion,  the
 fundus of the organ having been  bent forward
 on its cervix.   But even  in this case the  expla-
 nation of its occurrence is not easy.  In married
 females, however, some allowance should be made
 for the mechanical effects of sexual intercourse
 in connexion with the venereal orgasm  in  the
 female.
   142.  C.  As respects  the  deviations usually
 termed version  and flexion,  Dr. West remarks
 " that in the greater number of cases  of alleged
 version of the womb, either forward or backward,
 the organ is really flexed or bent upon itself; and
 farther, that not unfrequently the two conditions
 coexist, the whole  womb being thrown  more
 forward or more backward than natural, while in
 addition the body  of the organ is bent upon its
 cervix."  As  far as the symptoms are concerned
 to which they give rise, these varieties of devia-
 tion present but little difference.
   143.  As to the point of flexion of the uterus,
 whether backward or forward,  Dr. West agrees
 with Professor Virchow, of Berlin, in considering
 it to be the junction between the body and neck
 of the womb,  or, in other words, the spot  corre-
 sponding to the internal os uteri; and that the flex-
 ion is owing to the anatomical fact that, while the
 neck ofthe womb is firmly connected with the pos-
 terior and lower part of the bladder, its body is per-
 fectly moveable.  As to the comparative frequency
 of the two forms of deviation,  Dr. West  states
 that his notes furnish the particulars of twenty-
 six cases of retroversion and retroflexion, and of
 nine of anteversion and anteflexion.  M.Valleix,
 however, gives thirty-five deviations of the ute-
 rus forward, and thirty-three backward ; and Dr.
 Mayer, of Berlin, sixty-three  cases ofthe former,
 and  sixty-four of the latter.  The frequency of
 adhesions,  and of other  indications of previous
 inflammation,  as a cause of deviations of the
 uterus, is  shown by the statement of Dr. West,
 that he met with these lesions of the womb, its
 appendages, and the vicinity, in twenty-two out
 of sixty-six cases, in which he examined the uteri
 of women who had died of some other than uter-
 ine disease.
   144  Protracted flexion of  the uterus may be
 expected to be followed by farther lesions.  These
 are narrowing of its cavity, at the point of flexion
 especially, and atrophy ofthe parietes ofthe womb
 on the side towards which the flexion occurs, there-
 by rendering it permanent.
   145. The cervix is very  generally more or less
diseased in all the forms of deviation ofthe uterus,
presenting the several states  of lesion  described
above as being seated in the cervix externally and
internally—these being chiefly  indicative of  in-
flammatory irritation or action, granulations, ex-
coriations, ulcerations, enlargement of the cervix, 
of Deviations of the
1392                    UTERUS—Symptoms

and an open or gaping state ofthe os and cervical
cavity, enlargement ofthe posterior lip of the cer-
vix, &c (see y 27, ct scq.); these severally, or two
or more of them jointly, being very frequent com-
plications of deviations ofthe uterus from the nor-
mal state. That these lesions ofthe cervix are not
always consequences ofthe deviations, my expe-
rience induces me to believe, and to infer that Dr.
H. Bennet more correctly attributes the deviations
to pre-existing disease of the cervix.   It appears
to me that those alterations of sensibility of the
cervix associated with more or less irritation  or
chronic inflammatory action, and with the several
consequences of sexual excitement, leucorrhoeal
discharges,  disordered  menstruation, and their
numerous and  ever-varying  sympathetic  affec-
tions, are more  likely to give rise to deviations
of the position of the uterus, and not only to the
deviations already noticed, but also to others, con-
sisting of obliquity of position, or to lateral devia-
tions (which 1 believe to be the most frequent of
any, and to be generally of temporary duration),
when unconnected with disease ofthe ovaria and
the broad ligaments, than that these deviations of
the womb from its natural position should occasion
disease of the cervix.  It may be readily allowed
that any pre-existing disease in this part may be
aggravated by lesions of position ; but that the
former is a consequence of the  latter, requires
farther proof, and the positive evidence furnished
of a different succession of lesions would require
to be  previously disproved.
   146. D. The symptoms of deviations of the uterus
have been subjects of contention even with those
who have taken female diseases under their spe-
cial protection.   How, therefore, shall those who
get only occasional glimpses of uterine diseases
decide, when so very opposite  views  are  enter-
tained by the professors of this specialty ]  The
former are,  however, the judges in  the cause ;
the latter are the partisans or advocates of their
respective doctrines. Thus it is stated, by a very
recent and able writer on these diseases, that "the
symptoms are by some  described as being both
numerous and characteristic, and the appropriate
treatment is by  them alleged to be both simple,
safe, and successful, while others deny that the
mal-positions, taken by  themselves, produce any
symptoms, and assert that the proposed treatment,
while attended by very considerable risk, is wholly
inadequate to the removal of the  evil which it is
intended to  cure.   Each of these opinions, too,
is maintained by men equal in the eminence of
their  position, in their practical experience, and
in their good faith."   (Op. at., p. 206.)   This
statement is borne out by the discussion on this
subject reported in the "Bulletin de VAcademic
de Medecme" for 1853-4 (vol. xix., p. 778-976),
and is there fully and remarkably illustrated.
   147.  It is very obvious to the student of human
nature, that, however well-informed individuals
may be in their especial department, and however
eminent in popular estimation, as long as occur-
rences, morbid  actions,  and their consequences,
vary so  as to give rise to modified  or different
signs, phenomena, or symptoms, and  to develop
modified or altered features  or aspects, so long
will the observers of these see and believe certain
of them in preference to, or to the neglect of, the
rest, and thus form one-sided views,  which the
very majesty of their position, in either profes-
sional or popular opinion, or both, will not admit
of being impugned, and for which they  will con-
tend with biased judgments, even in opposition
to the most obvious truths   Now, as one of the
professed judges in such matters, and having no
preconceived opinions as regards them, I venture
to state that  the symptoms vary, in severity  and
number, with the  causes—predisposing  and  ex-
citing—with the sensibility and irritability ofthe
sexual organs themselves, and ofthe constitution,
with the existing deviation  and its extent, with its
several associations with disease ofthe cervix  and
its consequences, with the states of the natural
and morbid uterine discharges, and with the sev-
eral complications which deviations ofthe uterus
present with the adjoining viscera.  Hence it may
be inferred that the slighter deviations which have
taken place slowly or gradually in females evincing
but little susceptibility  or  irritability, and which
are not associated with marked disease of any part
of the  uterus, or of structures connected with it,
may not occasion any disorder calculated to excite
anxiety in the patient, or to require medical advice,
and yet  may exist for a long period, or may dis-
appear altogether, from the efforts  of nature or
from changes in the female economy or in  the
constitution.   But deviations  of the uterus to a
considerable  extent, especially when occurring
suddenly from well-recognised causes, and when
associated with other uterine lesions, or with
diseases of adjoining parts—and even when  ex-
isting simply in susceptible, sensitive, or irritable
females, married or unmarried, more especially in
the latter when  masturbation is suspected—then
will very generally occasion symptoms which, if
they do not prove, should at least induce the phy-
sician to ascertain its existence or non-existence
by an examination.  That the symptoms are often,
however, more or less equivocal, or that they may
frequently accompany other lesions of the womb,
must  be admitted, but a  vaginal  examination
readily solves the difficulty, and evinces the true
nature of the complaint.  The symptoms usually
present in uterine displacements or deviations arc,
excessive, painful, or difficult menstruation, leu-
corrhoeal discharge, pain in the pelvis generally,
and most severe  in that part of the pelvis towards
which the fundus  uteri  is turned or  flexed, pain
and difficulty in defaecation and micturition, con-
stipation, frequent calls to pass urine, or some-
times retention of it, and sterility.  According to
the temperament and habit of body ofthe patient,
various  sympathetic disorders may be induced by
uterine deviations, chiefly affections ofthe digest-
ive organs, as nausea or retchings on the accession
ofthe catamenia, hysterical symptoms, pain under
or in the mammae or in the spine, neuralgic pains
in the limbs,  &c.
   [The  above remarks of our author explain very
satisfactorily the differences  of opinion  on this
question between Dr.  Bennet on the one hand,
and Drs..Tyler Smith, West, and R. Lee on
the other.  Because we  meet with some cases in
which  inflammatory lesions of the neck of  the
uterus, including ulceration, exist, without creat-
ing constitutional  disturbance or any particular
suffering, it by no  means follows that it is so in
all cases.  In some women, as Dr. Bennet  has
remarked, the organic  sensibility of the womb
and its  sympathetic connexion with the rest of
the economy are  so slight, that severe uterine
disease,  inflammatory  or  other, may  exist  for
months or years, as in other organs, without pro-
ducing much local discomfort  or much  general
disturbance ;  but then these must be regarded as 
UTERUS—Treatment  of Deviations of the.                   1393
 exceptional cases.  It would  be wrong to  infer
 from  these that  inflammatory lesions are of no
 pathological importance.  The same remark will
 apply to uterine displacements, and  indeed  all
 affections of the  uterine organs, and it is in ac-
 cordance with what we observe in all other parts
 of the body.   On one point we must, however,
 express a doubt, and that is, whether the slight
 increase of weight attending hypertrophy ofthe
 neck, or even body of the womb, is the principal
 cause of prolapsus, or any other displacement
 It may co-operate with other causes, possibly,
 but in itself  alone it  can have no important in-
 fluence.]
    148.  As respects this disputed question, Dr
 West justly  remarks  that, although cases prove,
 on the one hand, that flexions of the womb  do
 not of necessity give rise to any distress, and, on
 the other,  that the removal of a flexion of the
 organ may not be followed by relief of the pa-
 tient's sufferings, the fact still remains that dis-
 placement  ofthe  womb is in very many instances
 attended by various uterine ailments  not expe-
 rienced  before  its occurrence    Here, however,
 the question  suggests itself, Are the  sufferings
 of the patient due simply to the displacement, or
 to the morbid condition with which the displace-
 ment is associated, or to the two causes conjoined'
 Dr. West  answers this question by stating that
 " there are circumstances which appear to favour
 the opinion that, in the majority of instances, the
 symptoms are due not to displacement alone, but
 to displacement accompanied by some other mor-
 bid state ofthe womb."  This opinion  is confirm-
 atory of that previously given by Dr. H. Bennet,
 that the deviation is nearly always a consequence
 of chronic inflammation ofthe cervix, is associa-
 ted with the cervical disease to which the  suffer-
 ings ofthe  patient are  mainly due, unless in ex-
 treme cases of displacement.  For some remarks
 on the diagnosis of versions and flexions of the
 uterus, and on the use of Dr.  Simpson's uterine
 sound for this purpose, I must refer the reader to
 Dr. West's lectures, and to the other recent works
 on uterine disease.  There  can, however,  be but
 little difficulty in the diagnosis between such de-
 viations and tumours in the uterus, for which they
 can hardly be mistaken.
   149. E. The treatment of deviations ofthe uterus
 has been a matter of dispute among modern au-
 thorities on uterine diseases.  Certain  of these
 contend  that the  lesions of the uterus to  which
 the deviations are due, and to which the  symp-
 toms are chiefly owing, should be made the objects
 of treatment, while others attempt to restore the
 uterus to its right position, and to maintain it there
 by  mechanical contrivances.   Schweighauser,
 Schmitt, Oldham, and others, have  supported
 the former  treatment, while Dr.  Simpson, Vel-
 peau, Kiwisch, and Valleix have resorted to
 the latter.   These contrivances have undergone
 various alterations in  the  hands  of the several
 authorities who have had recourse to them.  From
 what  I have seen of cases  in  which they were
 employed,* and from the opinions of M. Dubois

  * In two of unmarried females who had previously con-
 sulted me for hysteria with leucorrhcea, the mechanical
contrivance in question was resorted to by the physicians
 to whom they had subsequently confided their treatment
I was requested by the parents of these two young fe-
males to see  them in consultation with the physicians
then attending them, their parents having been dissatis-
fied with this treatment.   The contrivances in use for
them were shown mo; their appliance and object were
    III.               88
 and Professor Scanzoni, as stated by Dr. West,
 I believe  that, although they may be  successful
 in some cases, under the care of able and careful
 practitioners, they are attended by no small risk,
 as respects the uterus, its appendages, and peri-
 toneum, and that the return  of the displacement
 is very frequent after the mechanical contrivance
 is removed  At a recent discussion  in the Acad-
 emy of Medicine at Paris, " M. Dubois stated that
 he had himself treated upward  of twenty cases
 by means  ofthe uterine supporter, which in some
 instances  was worn  for several months, but that
 the displacement reproduced itself within a very
 short time after the removal of the  instrument;
 and  that he had  made a similar observation in
 the case of many patients who, having been thus
 treated by M. Valleix and Dr. Simpson, had been
 dismissed by those gentlemen as cured."*   Pro-
 fessor Scanzoni remarks that "theobservation of
 fifty-six cases of flexion of the uterus during the
 past four years compels me to express my decided
 conviction that the mechanical treatment of this
 affection is either useless or  positively mischiev-
 ous."  He concludes  that, having quite discon-
 tinued the use of these mechanical contrivances,
 and  contented himself with  a recourse to cold
 vaginal injections, with the  antiphlogistic  treat-
 ment of any chronic uterine inflammation, and
 the application of caustic to any  ulceration ofthe
 os uteri, and with the  endeavour to  remove  the
 chlorotic symptoms which are seldom absent, he
 has been much better satisfied with the results of
 treatment  than he was when he was seduced into
 the  application of a variety  of mechanical con-
 trivances.   (Led., &c, p. 225.)
   150. It  is obvious from the foregoing, as well
 as from my own limited experience, that attention
 to the improvement of the general health, to  the
 removal of the local lesions  of the  uterus with
 which displacement is  often  associated, as they
 admit of removal by local and constitutional treat-
 ment, to alleviation of the  more painful or dis-
 tressing symptoms, and to the improvement of the
 secretions  and  excretions, are the true principles
 which should guide the physician in the manage-
 ment of these complaints.  The means which are
 chiefly required are  such  as have already been
 recommended.  If the catamenia be excessive, the
 sulphuric acid  and sulphate of magnesia, or the
 supertartrate of potash, if the bowels be consti-
 pated ; the sulphate  of alum  if this state do not
 exist, or the gallic acid, tannin,  or the infusion
 of matico, may be  prescribed internally, and con-
 joined with henbane, or with conium, or with the
 extract or tincture of belladonna, or ofthe Indian
 hemp, if pain be  urgent.  After the second or
 third day, if the discharge be excessive, cold ene-
 manifest.  The patients themselves were in favour ofthe
 treatment, but their  general health appeared much im-
 paired since they were my patients. I stated to the par-
 ents that I could not approve ofthe means  employed for
 single females, that the contrivances could not be always
 applied, and that the complaint would return whrn they
 were relinquished.   I therefore refused any farther in-
 terference in the>e cases.
  [* In 1849  I had an opportunity, through the polite-
 ness of Professor Simpson,  of observing, for some time,
 his treatment of uterine affections, especially of devia-
 tions of the uterus, by means of his stem-pessary; and it
 is due to him to state that, although I examined several
 cases in which this instrument had been worn, some for
 a period of a year or longer, there was no instance in
 which the wearer complained of its causing  irritation,
 pain, or serious inconvenience.  These results, so differ-
 ent from what I bad been led to expect, satisfied me that
 the dangers  from the use of this instrument  have been
greatly exaggerated.] 
1394                          UTERUS—Inversion  of the.
mata  may be  administered  twice  daily; and in I
order to remove the anaemia and debility generally
characterizing  these  cases, chalybeate  prepara-
tions, variously combined, according to the  cir-
cumstances of the case, should be  given, and the
diet and regimen  strictly enforced.
  [When we consider that the uterus has no fixed
position in the pelvis, but is liable to be altered, both
in its position and axis, by a variety of extrane-
ous agencies—the state of the urinary bladder in
front, the rectum  behind, the intestine above, and
the colon on either side, and consequently from a
variety of morbid  states incidental to these organs,
it is liable to be deposed from its natural position,
and to have its axis altered from its normal state
—we shall be  led to  doubt the pathological im-
portance and significance which are assigned by
some to its displacement.  Doubtless the  same
causes which give rise to abnormal states of the
chylopoietic or abdominal viscera,  simultaneous-
ly disturb the functions of the uterine and pelvic.
We  often discover uterine displacement where
no uterine or constitutional disturbance is pres-
ent ;  and we treat cases of retroversion, for ex-
ample, and even  prolapsus, successfully, by  con-
stitutional remedies, when there is  considerable
uterine and constitutional derangement.  We are,
therefore, disposed to believe that the uterine or-
gans, in these cases, suffer in a secondary, rather
than in a primary manner ; and that, retroversion
being a consequence of the more general derange-
ment referred  to.  any treatment, to be successful,
must be founded  on  the various antecedent con-
ditions which  gave rise  to  the  uterine malady
If these remarks  are founded in truth, then  such
mechanical  remedies as  the stem-pessary will
be likely  to do more harm  than  good; for the
idea  that the  uterus  is to maintain a fixed  and
undeviating position is  opposed, as  we  have
seen, to all correct physiological principles.  We
agree, then, with  Dr. Bennet, that displacements
of the uterus are constantly  met with, but, ex-
cept  in  extreme  cases, they are  in reality of sec-
ondary  importance.  They  often  exist in  the
healthy without being recognised  or complained
of; and they often  remain after the removal of
disease, without  distress or inconvenience being
experienced ;  while in  those  who suffer  from
uterine  ailment, they generally coexist with de-
cidedly inflammatory lesions.  Their presence may
generally be explained by these lesions ;  and they
generally disappear by degrees, as the inflamma-
tory lesions are cured and removed.
   Prof. Hodge, of the University  of Pennsylva-
nia, has introduced a pessary for uterine displace-
ments, which is regarded by some as superior to
all others, on  the  ground  that it  restores  and
maintains the  vagina in  its  normal proportions.
This  instrument consists  of two  lateral  bars,
curved to correspond with the walls of the vagi-
na, united at  the top by a triangular bar.   This
instrument  is  said  to maintain the vagina in its
original shape, and thus keeps the uterus in situ,
pressing  away  from  rather than  against the
womb.   It has the  advantage of not being liable
to derangement, and  readily permits  the natu-
ral functions  of  all the pelvic organs to be per-
 formed without obstruction, while it is worn with-
out  annoyance, and  can be introduced and re-
moved with great facility.  It is also believed to
 be well calculated to replace the womb when dis-
 placed  in any  way, although  it seems more  par-
 ticularly adapted to cases of retroversion.   Here
the posterior wall of the vagina is kept  so dis-
tended by the  back part of the pessary, that, in-
stead of yielding, as before, it bears  the  fundus
uteri  upward  and forward, throwing the cervix
downward in  the vagina,  and keeping it there.
Its advocates allege that its mere introduction al-
ters the position of the uterus from retroversion
to that of simple prolapsus in the first degree,
and that it is by the distention of the  posterior
roof of the vagina to its normal dimensions that
the organ  is kept in situ, and not by any force
exerted against it; thus avoiding the danger of
local  injury, while it  corrects the displacement.
When well adapted to the dimensions ofthe pel-
vis and vagina, it is said, it may be worn without
annoyance for months,  or even years.  There is
one inconvenience, however, attending its use in
some cases, which may, nevertheless, probably be
guarded  against, viz., the  fundus so pressing on
the posterior bar of the pessary as to  bear up the
two  lateral bars, and thus their anterior ends ex-
cite irritation  under the pubic arch.  If the fun-
dus uteri be well thrown  forward, this  objection
may be obviated.  Perfect rest in bed for a few
days, after the reposition of the organ by means
of the uterine sound, is all that will generally be
necessary  to secure this  result.  The  same in-
strument will  serve  also for prolapsus, flexions,
and  anteversions  of the uterus—for the latter,
made with the addition of a front bar, uniting the
anterior  ends  of  the lateral bars, thus forming a
parallelogram — although  it  would  seem  best
adapted  to cases of retroversion.  Proper peri-
neal support will  be necessary in addition, in bad
cases.  One great advantage this instrument un-
doubtedly possesses, viz., it allows the free appli-
cation of injections, &c, to impart  strength to
the relaxed vaginal walls.   This instrument is
generally made of silver, and afterward  gilded.
   Dr. West, who has  had great experience in
the treatment of uterine diseases, remarks (" Lec-
tures on  the Diseases  of  Women," 8vo, p. 413.
Lond., 1856.   Part I.), in regard to displacements
and flexions of the womb,  as follows : " Though
I have tried the  uterine supporter" (Simpson's)
"in   a  few cases, I  have  now  for  some time
quite given up its employment, and content my-
self with a mode of treatment which, though it
seems to promise  less, yet almost always affords
great relief—which, in  a large number of cases,
quite removes the patient's sufferings, and is not
unfrequently followed  by the complete rectifica-
tion of the position of the womb.  The principle,
indeed, on which I act in  the  management of
these cases amounts pretty much to this:  that, to
the best of my power, I take care of the general
symptoms, and  leave  the  misplacement  to take
care of itself"  We are satisfied that, as a gen-
eral rule, this is the proper course to take; at the
same time, it must be conceded that there are ex-
ceptional cases in which a suitable pessary may be
used with advantage, especially in retroversion,
on the principle of supporting or distending the
vagina upward behind the uterine neck.]
   151. VI. Inversion of the uterus—the turn-
ing of the organ inside  out—is clearly impossible
in the untmpregnated healthy womb.  It is one
of the most  grievous  and fatal  accidents which
can befall a female.  My late friend, Dr. Crossb,
of Norwich, in his elaborate  essay on  Inversion
of the Uterus, states  that  of 400 cases of inver-
sion  of  which he had  found mention,  350 were
consequences of parturition.   Of the remaining 
UTERUS—Inversion of the.
1395
 50 cases, 40 were said to have occurred from the
 presence of a polypus in the interior of the womb,
 the accident  taking  place  either spontaneously
 or from tractation in attempting to remove the
 growth.  Enlargement ofthe  uterine  cavity, as-
 sociated with some cause exciting contraction of
 its fibres, are the conditions essential to inversion
 ofthe organ.
   152. A. The symptoms of inversion ofthe ute-
 rus are  sudden collapse  or sinking, with abun-
 dant haemorrhage, with disappearance  of the tu-
 mour formed  by the uterus in the abdomen, and
 the presence of ajarge spherical body  either just
 within the vagina, or projecting beyond the ex-
 ternal parts.  My friend Dr. Radford has, how-
 ever, shown that,  except in cases where the pla-
 centa still partially adheres to the uterus, the haem-
 orrhage is not  so formidable as might be antici-
 pated ; and that the shock to  the system is in
 great degree independent of the loss of blood.
   153  B. Inversion ofthe uterus is caused chief-
 ly by the detachment of the placenta after deliv-
 ery, owing to undue force or want of care ; and,
 in rarer cases, by  a spontaneous and unequal or
 irregular contraction of the uterus, either while
 throwing off the placenta, or even soon after, or
 upon the detachment of it, while the cervix and
 os uteri are at  the same time comparatively re-
 laxed.   This  explanation of spontaneous  inver-
 sion of the womb was ably given by Dr. Rad-
 ford, and confirmed by Dr. Simpson.  The press-
 ure of the bowels on the fundus caused by the
 action of the abdominal muscles during the de-
 tachment of the placenta may also favour this
 occurrence.  A polypus or tumour firmly attach-
 ed to the interior of the fundus uteri, having de-
 scended through the os uteri, may likewise excite
 irregular action and drag the fundus with it, there-
 by producing, with varying degrees of rapidity,
 inversion of the organ.
   154.  In most instances the inverted  uterus be-
 comes speedily  firmly contracted ; but in a few
 cases the uterus remains soft and flaccid, and even
 capable of replacement.   The haemorrhage often
 continues at short and uncertain intervals, and in
 very variable quantity from  the period  of the ac-
 cident, but to this there are occasional exceptions.
 The consequences of inverted uterus  tend with
 varying degrees of rapidity  to the destruction of
 life—at  least in the  great majority of instances.
 Dr. Crosse states "that  in  72 out of 109  fatal
 cases, death took place in  a  few hours,  in 8 with-
 in  a week,  and in 6 more within four weeks
 The immediate danger, however, being surmount-
 ed, there follows during lactation an interval of
 comparative safety and  of  cessation  of serious
 symptoms, which reappear when suckling is over.
 It appears that ofthe remaining twenty-three pa-
 tients only one died at the fifth month, and then
 as the result of an  operation which had an unsuc-
 cessful issue ;  one died at eight months, three at
 nine months, and the others  at various periods of
 from one to twenty years."
   155. C. The  diagnosis of inversion may be
 overlooked or mistaken.   The inverted uterus has
 even  been torn  away by  ignorant pesons who
 had  believed it to be the  placenta.  Tr. Crosse
 considered that  the womb  may be prrtiilly in-
verted spontaneously  a short time  afer the de-
tachment ofthe  placenta, or depressed at its fun-
dus.  This may  increase to introversion; but the
partial inversion, although attended by much vital
depression and  haemorrhage, will not occasion
 any tumour in the vagina, nor a complete disap-
 pearance of that formed by the uterus in the ab-
 domen.   Introversion of the uterus may, howev-
 er, soon pass into complete inversion.  An invert-
 ed uterus njay be mistaken  for polypus, and a
 fatal issue result, as indeed it has resulted, from
 this error. The history ofthe case generally will
 assist the diagnosis, but polypus may complicate
 pregnancy, and may occasion both a tumour after
 delivery and haemorrhage.  The firm constriction
 of the  os uteri upon  the cervix of an inverted
 womb causes the part to assume the form  of a
 pedicle, thereby rendering the diagnosis more dif-
 ficult, unless an examination be made per rectum,
 when the uterus, if inverted, will not be found in
 its place, while, if the vaginal tumour be a poly-
 pus, it will be found in  its proper place, and prob-
 ably also somewhat enlarged.   The uterine sound,
 as improved by  Dr. Simpson, will  also aid the
 diagnosis, if properly used.
   156.  D. The treatment of inverted uterus is at-
 tended by great difficulty.  If the accident occur
 before the detachment of the placenta, the re-
 moval of this body should be effected before the
 replacement  of the uterus be attempted.   Dr.
 Simpson's accurate views as to the source of haem-
 orrhage  in parturition  show that fears of serious
 bleeding  in consequence of  the removal of the
 placenta in these cases need  not be  entertained.
 Two modes of returning the uterus when inverted
 after labour have been recommended.  The one
 by pushing back or  indenting the inverted fun-
 dus with the  finger; the other by grasping the
 womb between the fingers, compressing it, and
 by pushing it upward into its proper situation.
 Either of these modes may succeed in recent cases
 occurring after delivery, w hile the organ is soft or
 flaccid, or as long after as it  may remain in this
 lax state.  In these cases, as well as in others, in
 which the replacement is attempted either when
 the organ is more firmly contracted, or when some
 time has elapsed from the occurrence ofthe acci-
 dent, chloroform may be found of use in facilita-
 ting the operation, although in some cases where
 this substance has been employed no advantage
 was procured from it.
   If the inverted womb  cannot be replaced, im-
 mediately after the recurrence ofthe inversion, it
 will remain irreducible, and entail on the patient
 all the miseries and perils incidental to this state.
 The only means of averting these are by opera-
 tions, which are attended by very serious hazards.
 The chief reasons which can  be urged for such
 operations—the removal ofthe inverted organ by
 ihe knife or  by ligature—are profuse  haemor-
 rhages or  discharges endangering the patient's
 life.   Dr. West4 has given the following table of
 the results in 50 cases  of inversion ofthe uterus
after delivery, in which extirpation of the organ
was performed.
Uterus removed by	Cases.	Recovered.	Died.	Operation Abandoned.
	33 4 8	28 3 5	8 1 3	2
Uterus removed by				
Ute' us removed by knife and ligature				
	50	36	12	2
  157. It is of importance to know the results of
extirpation at different periods from the time at
which the inversion occurred.   If the operation
be performed soon after the  occurrence ofthe ac-
cident, it cannot be expected to be as successful 
1396
UTERUS—Fibrous Polypi of  the.
as at a remote period from the occurrence, as the
organ will diminish in size, vascularity, and sen-
sibility by the lapse of time.   Accordingly we
find that, of 21 cases thus operated upon within
twelve months from the occurrence, of the  acci-
dent, 9 died, and 12 recovered ; while of 25 cases
in which the  operation was not performed  until
one year, or much longer periods, had elapsed, 23
recovered, and only 2 died.  Of the occurrence of
inversion from a polypus, and ofthe various modes
and appliances for extirpating the uterus, I  must
refer the reader to works on surgery, and to those
enumerated in  the Bibliography  and Refer-
ences to this  article.
   158. VII. Of Polypi of the Uterus.—Polypi
and tumours ofthe womb generally occur during
the period of  sexual activity, or, if they be devel-
oped at a somewhat later period,  or soon  after
the climacteric period, they have generally origi-
nated some time previous  to it.  It is often very
difficult to ascertain the causes which either pre-
dispose to or  excite their formation ; but there is
reason to infer that inordinate excitement or de-
termination of blood to the uterus, with a dispo-
sition to  hypertrophy of one or more of the tis-
sues of the organ, are the chief causes of these
lesions.
   159. i.  Mucous polypi, or excrescences from the
folds of the arbor vita, are often met with, varying
from a third of an inch to nearly an inch in length
to about three  or four lines in thickness:  they
are connected with the mucous or villous  mem-
brane of the  canal of the  cervix by a very  slen-
der and  short pedicle.  They  are  usually  of a
bright rose tint, are supplied with a delicate net-
work of  vessels, and consist of mucous  mem-
brane,  with a small admixture of cellular tissue
internally.  They may  spring from any part  of
the cervical canal;  but they more frequently arise
nearer to the  external than to the internal os ute-
ri. Although  generally pediculated.they  are some-
times sessile,  and in rare  cases they seem as hy-
pertrophied folds of the arbor vitae.  These pro-
ductions are either single or multiple, two or three
existing  in the same patient; and having  been
removed, they may be reproduced in a few months
afterward.  They may  even coexist with fibrous
tumours ofthe uterus. Dr. Montgomery, of Dub-
lin, believes them to be sometimes precursors of
maHgnant disease ; and this was observed in one
case which was  under my care.   In  rarer in-
stances these polypi are  much larger than  now
stated, and consist of a cellular or fibro-cellular
tissue  invested  by  mucous membrane ; some-
times they reach the size of a fig, are  flattened,
and hang down beyond the os uteri into the va-
gina.
   160. ii. Follicular polypi, or polypi  from en-
largement of the follicles  of the cervix, are not
unfrequently  observed.  They appear as cysts, of
the size of a  pea, imbedded between the folds of
the arbor vitae, and hardly projecting beyond the
level of the canal.  They are, however, sometimes
much larger,  are more or less numerous, and are
distended by albuminous  matter.   When  large
and numerous, they cause the absorption of the
cervical structure,  and even occasion the bulging
outward  ofthe structure ofthe cervix.
   161. iii.  Complex polypi, consisting of mucous
follicles, the mucous or villous surface, and fibro-
cellular tissue of the cervical canal, are  more fre-
quently seen  than either ofthe foregoing.  These
polypi are  cither pediculated, the pedicles being
sometimes  of considerable length, more  rarely
very short, or appear as  continuous tumours or
growths from the inner surface of one or other of
the lips ofthe os.  When divided they are found
to contain  a tenacious, transparent, albuminous
matter, identical with that secreted by  the .\'a-
bothian glands.  When small they  consist chiefly
of cysts filled with this matter.  When  they are
much larger, and reach the size of the first joint
of the thumb, these cysts or vesicles are not so
distinct, but exist in the form of canals, arranged
longitudinally, between which  a fibro-cellular tis-
sue enters more or less abundantly.   Their surface
often presents an uneven or tubulated appearance,
is generally not very vascular, and is composed.
according to Virchow, of a dense cellular tissue,
covered by a thick layer of tasselated epithelium.
   162. iv. The symptoms indicating the existence
of polypi generally  appear gradually,  and may
with increasing severity continue months or even
years before medical aid  is required.  There are
usually at first leucorrhoeal discharge, haerior-
rhage, or both, followed  by bearing down pains
in most cases.   When the polypi are very small,
they may produce either very slight symptoms or
no symptoms  at all.  Haemorrhage is, however,
very generally experienced, especially when the
polypi occasion enlargement of the neck of the
womb.  The size ofthe polypus may not influence
the haemorrhage, a small one often causing more
than a large one.  Dr. West  considers  that the
structure of the polypus influences the symptoms,
and that those polypi which present the compound
structure due to the enlargement ofthe Nabothian
glands are always productive of profuse leucor-
rhcea ; and their vascularity of surface being less,
they are less frequently  the occasion of haemor-
rhage.  The much rarer occurrence of follicular
polypi is attended by a profuse  albuminous dis-
charge, and is not associated with profuse menor-
rhagia, unless in rare instances.  The symptoms
now mentioned should always  suggest digital ex-
aminations, and  if no polypus can be felt, examin-
ation by  the speculum becomes requisite.
   163. v. The treatment of poly pi is  thus described
by Dr. West: "The smallest may be removed by
laying hold of them with a pair of long forceps
and  twisting  them off, while those which are
somewhat  larger,  after being twisted  to  check
the risk of bleeding, may be cut off by a pair of
scissors.   The bi-valve speculum  should always
be employed in doing this, and both forceps and
scissors are made for the purpose,  so constructed
as to be readily worked within  the speculum."
For the sessile growths or tumours, noticed above
(§ 159), he  applies the acid  nitrate of mercury,
which destroys  them, and  arrests  the  bleeding.
As respects the  removal of larger polypi and the
several means of accomplishing it, I must refer the
reader to the work just quoted, or to the surgical
works where this operation is  fully described.
   164. VIII. Fibrous polypi or tumours within
the  uterus are  among the most serious organic
diseases ofthe uterus, and the least amenable to
treatment.   They are uncertain in their rates of
progress, being in some cases rapid and in others
slow, and in rarer instances  almost altogether
cured by the efforts of nature, which either throws
off the morbid structure from the organ in which
it is seated, or stops its growth.  These  tumours
vary much in structure and in  their seat. When
they arise from the internal surface  ofthe uterus,
or underneath the internal membrane, they are 
UTERUS—Fibrous Polypi of the.                        1397
generally considered as a form of polypus, and de-
scribed as such—as fibrous polypus of the uterus.
Dr. West considers them to be fibrous tumours,
growing from the inner surface of the womb, or
less frequently from either lip of the os uteri.
   165. A. Fibrous polypus of the uterus is nearly
identical with other fibrous tumours ofthe organ,
and differs chiefly either in being developed imme-
diately underneath the internal  membrane, or in
having more or less ofthe fibrous structure of the
womb interwoven with or covering it.  Fibrous
polypus ofthe uterus is pediculated, and, growing
from  the  interior of the womb, is more vascular
than other tumours of the organ   The pedicle is
composed of uterine fibres mingled with more or
less dense cellular tissue.   A  layer of uterine
substance is continued a short distance from the
pedicle along the tumour, in some cases, or invests
it in part or altogether in others.  In addition, the
polypus is always covered by the internal mem-
brane of  the uterus, which  becomes firmer and
denser than natural, both it and the  fibres of the
womb being developed with the growth of the
tumour.   These tumours are  generally  single,
but they are sometimes double, very rarely more
numerous.  They are of very different sizes, and
occasionally  remarkably large.   They may, in
some instances, be enucleated from  their  cover-
ings ; in  others their substance is intimately
connected with their envelopes.  The vascular
supply of these tumours through their pedicles
is generally small in proportion to their size and
to the quantity of blood in their substance.   This
comparatively small supply of blood, the profuse
haemorrhages they occasion, and the arrest ofthe
haemorrhage by ligatures around their pedicles,
have  rendered it very difficult to determine the
actual source of haemorrhage.   Dr. West seems
to believe that it is rather from the irritated mu-
cous  membrane of the uterus than from the sur-
face of the tumour itself that the bleeding flows ;
and a variety of considerations confirm this opin-
ion.
   166.  These  polypi  being generally  formed
within the uterus, influence the organ in  some
respects, according to the situation whence they
spring.   If they arise low  down, or in the cer-
vical canal, the tumour soon grows beyond these
limits, and, passing down into  the  vagina, may
acquire a considerable size without disturbing the
uterine functions.  If they arise from some part
high  up,  or near the fundus of the  uterus, they
often remain until they have acquired a great size,
occasioning enlargement of the organ and thick-
ening of its walls, as in pregnancy.  But in many
cases, before or soon after the tumour has reached
the size of an orange, the os uteri gradually dilates,
allows its passage through it, and embraces its
pedicle.   In some  cases this result takes  place
without   much suffering; but  in others violent
uterine action is excited by the tumour, which
recurs at intervals, and  resembles the pains of
labour.   The  tumour, or polypus, is thereby  ex-
truded from the uterus into  the vagina; and the
irregular contractions of the uterus, especially
when the polypus  is firmly  attached near the
fundus, may drag down  or invert the organs, as
stated above ($ 151).  Generally the polypus is
detected soon after it has passed into the vagina ;
but if not detected, and when allowed to remain
in this situation, it acquires a large size.   I be-
lieve, however, that the  largest tumours of this
kind reach their full size within the uterus.  In
a case which came before me, and in which Dr.
Lee was consulted, two tumours were thrown off
of the size of between two and three pounds each,
immediately after passing the os uteri.
  167.  Fibrous  polypi may present oedema of
their substance, extravasation of blood into their
structure; and having passed into the vagina, they
may undergo ulceration, especially if air come in
contact with them,  or even sloughing.  When
they are detached spontaneously, or  by means
which produce firm contractions  of the uterus,
as in  two  cases  where this was effected by the
treatment  which I adopted, their pedicles give
way, and the whole mass (fibrous structure and
envelopes) is thrown off.
   168.  B.  The  symptoms  of fibrous polypi are
nearly the same  as mentioned above (§ 162)—
leucorrhcea, haemorrhage, and bearing down, [to
which may be added enlargement of the  uterus,
and sympathetic irritations in  bladder, rectum,
and distant organs.]   The haemorrhage is at first
experienced chiefly at the menstrual periods,which
are prolonged, or return at shorter  intervals, or are
more  abundant, approaching to flooding, leucor-
rhcea  being present in the intervals.   Bearing
down is almost constant in some cases, or recur-
rent in others, with expulsive pains  or  efforts,
when  the  tumour  has  far  advanced.   When
these symptoms are present, a vaginal examina-
tion should not be delayed.  If the polypus have
not passed  the  os uteri, the diagnosis becomes
very difficult.  In these circumstances the uterine
sound, as  advised by Professor Simpson,  or dila-
tation ofthe  os uteri by the sponge tent, as rec-
ommended by the same eminent authority, be-
comes necessary.
   169.  C.  The treatment  of fibrous polypi has
always hitherto been considered  as entirely in-
strumental or surgical.  In  two  cases which I
treated, the means employed were strictly medi-
cal,  and proved in  both,  within a few hours,
successful,  the  tumours having  been extruded
through the os uteri by the action of the uterus,
and entirely thrown off.   In one of these cases
the haemorrhage was excessive.   I  prescribed
immediately the bi-borate of soda in solution,
and directed the dose, about six grains, to be re-
peated every hour or two.  A tumour, about the
size of a child's head, was  soon after thrown off,
six or seven doses ofthe borax having been taken,
when vomiting was occasioned ; but the haemor-
rhage had very much abated  a*short time before
the tumour came away.   A day or two afterward
haemorrhage returned, a vaginal examination was
made, the os uteri was found somewhat  dilated,
and another tumour was  felt pressing upon the
opening.   I  then requested Dr. Lee  to see the
patient with me, when the same medicine was
given as before, and the second tumour was ex-
pelled in a few hours by the contractions of the
uterus.  The only other case of fibrous polypus
ofthe womb which I have had an  opportunity of
treating was one of a single tumour of large size ;
much haemorrhage  had taken place, and I pre-
scribed the infusion of secale cornutum, with as
much ofthe bi-borate of soda as it  would dissolve,
to be given every hour or two, until eight ounces
were  taken.   Soon after the whole was given the
tumour was expelled.*

  [* Galvmism may often te employed with success  to
stimulate the uterus to expel the polypus, or moderate
the attendant haemorrhage, as suggested by Dr. Radford.
Experiments made upon the gravid uteri of Bome of the 
1398                            UTERUS—Tumours  of the.
   170.  The  operations  advised  for  removing
fibrous  polypi are by ligature  and by incision.
Dr.  R.  Lee  records  27 cases  of the removal
of fibrous polypi of the  uterus ; nine terminated
fatally  (West).   Excision  of  the polypus  has
been dreaded in  these cases, the risk of danger-
ous  haemorrhage  from the operation having been
considered  great.  Velpeau, Lisfranc, Dupuy-
tren, West, [Simpson,] and Arnott, however,
greatly  prefer excision to the ligature.  Velpeau
found the haemorrhage troublesome only in two of
twenty  cases on  which he thus  operated.  " Lis-
franc states that he met with but two out of 165
cases, and Dupuytren also but two out of nearly
200; while they all refer to instances of phlebitis,
or of peritoneal  inflammation leading to  a  fatal
issue after  the operation by ligature."  Torsion
and  strangulation of the pedicle by compression
have likewise been advised for  removing fibrous
polypi; but they  are liable to the same objections
as have been urged against the use ofthe ligature.
It is unnecessary to refer farther to the mode of
operating by excision, inasmuch as whoever is
capable of undertaking the operation requires no
directions respecting it, or, if he should, he will
find  them in Dr. West's work now quoted, or in
any  systematic work on surgery.
  [If phlebitis and puerperal fever are  liable to
result from the use ofthe ligature in these cases,
from consequent  sloughing and  suppuration,  the
same results are  likely to happen from an empty
or exsanguine state  of the  blood-vessels.   We
have not the necessary data for  an exact calcula-
tion  ofthe comparative dangers of each, but such
as we have  lead  us  to coincide  in opinion with
Professor Simpson, and  prefer excision.  It has
been suggested  that  some  modification of  the
electric cautery might be substituted for the knife,
and  thus  avoid the  risk  of consecutive haemor-
rhage ;  but  whether it be practicable or not, we
have no means of judging.]
  171.  I may here  mention that fibrous polypi
may  coexist  with pregnancy, and that, although
remarkably small previously to impregnation, they
may  participate in the'development ofthe uterus
during this period.  They do not, however, gener-
ally produce marked symptoms during pregnancy,
nor interfere with its natural course.   After the
commencement of labour their injurious influence
becomes manifest, either presenting a mechanical
obstacle to the passage of the child, or giving rise
to very serious consequences subsequently, by oc-
casioning dangerous  haemorrhage, or other diffi-
culties.   They may also  at this time lead to very
serious  mistakes as respects their diagnosis. The
question as  to their treatment at this time is of no
small importance ; for excision,  however great
the haemorrhage, may be followed by  phlebitis,
or metritis,  or pelvic  peritonitis.  Therefore, if
the haemorrhage  cannot be controlled  by opiates
and astringents, the ergot or borax may be exhib-
ited, at  first  singly, and, if they  fail, afterward in
combination.
  172. IX. Tumours in the Walls and Exter-
nal Surface of the Uterus.—{.Description.—a.
These morbid growths are more or less intimately
connected with the parietes of the womb, and are
in many instances identified with the structure of
lower animals prove very conclusively the power of this
agent in  producing  uterine contraction. These experi-
ments also prove that the inflnence is greater when  one
pole  is applied to the upper part of the spine, and  the
other to the uterus,  than when both poles are applied to
the uterus itself.]
 the organ.  Several tumours are more frequently
 formed in the same case  than one merely; but
 when thus multiple, " one or  two generally out-
 strip the others in the rapidity of their develop-
 ment, the rate of which, as well as the nature of
 the symptoms, is greatly influenced by the situa-
 tion  that  they occupy."   However  situated, or
 however large, uterine tumours are commonly
 firm, spherical in form, with nodulated surfaces,
 and their  structure is  sometimes interrupted by
 cavities containing fluid,  and varies  in density,
 elasticity, and succulency.  They are thus well
 described  by  Dr. West :  " On  a section  being
 made of any of these tumours, they present great
 similarity to each other, being composed of a dense
 grayish structure,  intersected  by numerous dead
 white bands and lines, which  are almost invaria-
 bly arranged according to  a definite type or plan.
 In some instances these fibres have a concentric
 arrangement, while in others they have a wavy
 distribution, or are disposed around  several dif-
 ferent  centres.  Tumours of the first  kind  are
 usually remarkable for their hardness, and their
 small degree of vascularity;  they are also con-
 tained within a remarkably distinct fibro-cellular
 investment, are imbedded in the uterine substance,
 and seldom attain a size exceeding that of a shelled
 walnut.  The other varieties are more vascular,
 less firm, have a less complete capsule, may occupy
 all parts of the exterior or interior of the womb,
 and may grow to a very large size, so  as to weigh
 twenty, forty, or even seventy pounds.  Moreover,
 it happens sometimes that, in  the course of their
 development,  two or more tumours coalesce, at
 least  apparently, so as to form  a large growth,
 though on a section it will be seen that the dif-
 ferent growths remain distinct from  each other,
 separated by fibro-cellular septa, the  remains of
 the more complete investment by which,  when
 smaller, each  was  surrounded."  (West's Lec-
 tures, &c, p.  267.)  When these tumours are
 seated near to the internal surface of  the uterus,
 or under the internal membrane, the fibres ofthe
 womb either passing over the surface of the tu-
 mour in some parts, or actually passing into it,
 they form the fibrous polypi, or internal tumours
 of the uterus already described (§ 164, et  seq).
 The vascularity of these tumours varies in differ-
 ent cases,  and, like the tissues with which they
 are connected, they are resolved  into gelatin by
 boiling.*

  [* The microscopic characters of fibrous  tumours are
 somewhat various.  In all we find a large portion of the
 mass consisting of tissue resembling  the tendinous  or
 fibrous, being composed of exceedingly slender, uniform,
 pellucid filaments, undulating or crooked,  more or less
 perfectly  developed, and  variously arranged; and this
 occurs in all parts of the tumour, both in the more ho-
 mogenous basis-sub6tance, as well as in the intersecting
 bands, the microscopic difference consisting only  in the
 less or more regular arrangement of the fibrous structure
 or appearance of the tissue.  But in different specimens,
 or even in different parts of the same, the tissue appears
 more or less perfectly formed; so that, while in some
 distinct filaments or undulating fasciculi may be dissect-
ed out, in others there is rather a fibrous appearance than
a fibrous structure.   Nuclei or cytoblasts are also com-
monly strewn through the substance of the  tumour, the
less abundantly  in proportion to the fibrous  character of
 the tissue.  There are also other elementary  tissues min-
gled in fibrous tumours, as smooth or organic muscular
fibres,  and these are sometimes so abundant as to justify
 the name of muscular tumours, as described by Vogel;
 and the mingling of the muscular fibres in  imitation of
 the uterus is usual, if not constant.   In some specimens
elastic  fibrps may be found intermingled with the more
abundant fibrous tissue, thus imitating the structure of
fascia.  As a general  rule, the characters of fibrous tu-
mours are modified towards an imitation of tissues in ct 
                          UTERUS—Tumours

   173. These growths may be developed in any
part of the walls of the uterus.  Sometimes they
are formed " immediately beneath the peritoneum
covering the  uterus, or the first half inch or inch
of the ovarian ligament or Fallopian tubes," and
are limited to the  fundus, or upper part of the
body ofthe uterus, more frequently on its poste-
rior than on its anterior surface.  They there gen-
erally remain of a small size, and hardly exceed
that of a pea or bean ; seldom projecting farther
than one half of their bulk.   In other cases they
either grow outward or  inward, from the thick-
ness of  the  uterine  parieties, being  apparently
only attached to them  by a  thick pedicle, into
which some  uterine fibres enter.   The tumours
which grow outward from the uterine walls some-
times attain the size of a large orange, or even a
greater bulk;  they, unlike the tumours which
grow into the cavity of the womb, receive no in-
vestment of fibres from the substance  of the or-
gan,  and are often present in  considerable num-
ber.  Dr. West mentions as many as twelve pro-
jecting from the external surface, the interior  of
the  organ being free from disease.  Wherever
may be their origins, these growths tend as they
increase  in size, with few exceptions, to become
pediculated;  these exceptions being  the firm,
slightly vascular tumour, with concentric arrange-
ment of fibres,  which remains imbedded in the
uterine walls, without projecting either externally
or internally'.  In rare cases, also, the  more vas-
cular, elastic, and succulent fibrous tumour is^de-
veloped in the uterine walls, attaining the size  of
the foetal head, producing very great enlargement
of the organ, and retaining a spherical form.   It
may be  imbedded in the  substance of the womb,
without projecting  more in one direction than  in
another.
   [There is good reason to believe, from the in-
vestigations  of  Dr. Bristowe (" Report  of  the
London Path. Soc." for  1853), that all so-called
fibrous tumours of the uterus, at least in their ear-
lier stages, before degeneration has taken place
in them, are  essentially  muscular tumours—not
simply fibrous tumours  with a  greater or less
quantity of muscular fibre mixed up with them,
but developments of true and undoubted muscu-
lar tissue.  Their most usual position,  according
to Dr. R. Lee's  analysis of 74 cases, is the sub-
mucous, viz., those  projecting into the  cavity  of
the womb ; and the pedicles  of these  are  gener-
ally situated just below the openings of the Fallo-
pian tubes.   The next position in which they are
most abundant is  the posterior wall and fundus
of the uterus ; they are rarely situated in the an-
terior wall, and  still more rarely in the  cervix
uteri.
  If we examine fibroid tumours of the  uterus
under the microscope, we discover elongated nu-
clei imbedded in an amorphous stroma, while the
fibrous appearance is scarcely perceptible;  in
fact, from the analogy they present to the genu-
ine uterine tissue,  in the unimpregnated state,
they would seem to be homologous rather than
heterologous productions. We have already stat-
ed that Dr. Bristowe regards them as true mus-
cular tissue.   They are generally but scantily
supplied with blood-vessels, and the haemorrhage
to which they give  rise is not owing to  a lacera-
tion of their vessels, but to the irritation and con-
gestion they  induce in the superincumbent mu-
near which they are placed, and their chemical qualities
are also probably similar.]
of the, described.                       1399

cous  membrane, which, from the  same  cause,
may ulcerate  and slough.   In pregnancy, they
cause haemorrhage by preventing  the normal de-
velopment of  the organ; hence they are  apt to
cause miscarriages.  As a general rule, however,
they produce sterility.  Fibrous tumours have not
been observed before puberty.  Dr. R. Lee states
that they are  most  frequent in virgins, and  that
they exist in 20 out of 100 middle-aged women.]
   174. The influence exerted by  these tumours
on the womb depends  more upon their situation
than upon their bulk.   When they are seated ex-
ternally to the womb, and grow into the peritoneal
cavity, they often acquire an enormous size, and
the womb is  much elongated, and even  drawn
upward into the pelvis, but seldom increased in
bulk.  If, however, a small tumour be developed
in the walls,  or within the organ, more or less
increase of size will be  observed.  These tumours
reach the greatest size when they are single and
attached to the external surface of the  uterus.
Walter  has  described one which weighed  sev-
enty-four pounds.
   175. b. The ultimate  changes  which  uterine
tumours undergo are interesting,  and often tend,
under the influence of  vital resistance, to a more
or less salutary issue.  1st.  When the tumour is
externally attached to the uterus,  its pedicle  may
become ultimately so attenuated as to be  detach-
ed nearly or altogether from the womb, especially
if it had formed previously adhesions to  the ad-
joining peritoneum ;  such  cases are, however,
very rare.   2d. When the tumour is developed
internally, or passes into  the cavity  of the organ,
it undergoes the changes and their results  already
described (§ 166, et seq.).   3d. The tumour is
sometimes softened, the more liquid  parts are
absorbed, and  either a calcareous  substance is
deposited, or  remains  after the  other elements
are removed ;  that the former or actual  deposit
of calcareous  matter takes  place is evinced by
the quantity of the calcareous matter or deposit.
This change takes place both in small and in large
tumours, and most frequently in those attached to
the outer surface of the uterus ; but it may also,
but rarely, occur in those which are developed
internally.   Fibrous  tumours of the womb were
formerly believed to sometimes degenerate  into
cancer.   This  change  is now considered never
to occur.  That a tumour, developed in the walls,
or attached to  either surface of the uterus, may
coexist with cancer of the cervix,  is possible, and
the coincidence has been observed in rare cases.
  [Fibrous tumours not unfrequently contain cysts,
especially those whose  texture is not dense ;  and
this may be owing to softening and liquefaction of
part of the tumour, with effusion of fluid in the af-
fected part, or to an accumulation of fluid in the
interspaces  of the intersecting bands.  In other
cases, where the cysts are of smaller size, and have
smooth and polished internal surfaces, it is more
probable that their production depends,  as Paget
states, on a process  of cyst-formation, as in the
breast and other organs.  Some fibrous tumours
are thickly beset with numerous well-defined and
lined cysts ; in others there is only one large cyst,
or one vastly predominating in size over all the
others, when it may and has been  mistaken for
ovarian cyst, and the contents discharged  by tap-
ping (Lond. Med. Gaz., vol. 37, p.  1022).  Some-
times fibrous tumours  undergo a calcareous de-
generation, consisting in  an amorphous and dis-
orderly deposit of salts of lime and other bases, 
1400             UTERUS—Symptoms and Diagnosis of Tumours of the.
in combination with, or in the place of the fibrous
tissue, denoting a loss of formative power in the
tumour.   Fibrous  tumours also undergo  some-
times a softening  process, with increased  vascu-
larity and  congestion, and become  oedematous;
and  then, as their tissue loosens, become very
soft, or even dilfluent, or else break  up, and ap-
pear shreddy and  flocculent.  In this state the
outer and less softened  part of the  tumour may
burst, or they may separate or slough.  Bayle
states that fibrous tumours exist in 20 per cent, of
women who die after 35 years of age]
   176  c. The frequency of tumours  ofthe ute-
rus has been very differently stated  by writers;
but they seem to be, with the probable exception
of cancer, the most common of organic diseases
of this organ.  Mr Pollock states that  of 583
cases in which the uterus was examined  at St.
George's Hospital, 265 were diseased, and in 39
of them fibrous tumours  existed, and in 38 cancer
was  found.  The statistics ofthe malady are very
unsatisfactory.  In 70 cases, in which Dr.  West
examined  the uterus of women who died after
puberty of other than uterine diseases, 7 present-
ed fibrous tumours of the organ. From these and
other observations made by Malgaigne, Braun,
Chiari, and others, tumours ofthe uterus are ob-
served chiefly between the ages of twenty-four
and  sixty; and most frequently from thirty to
fifty.
   177. ii.  The Symptoms.—Tumours of the ute-
rus are very often not manifested until they reach
a large size ;  and  they  exist  even  many years
without producing any  inconvenience, or being
suspected  until they are  detected after   death.
The  growths from the  exterior surface  of the
womb frequently occasion no symptoms but those
produced by them when  they reach a great bulk,
or when they disorder the sensibility or functions
of adjoining parts.    But those which are  imbed-
ded in  the walls of the organ, disturb either the
functions  or the  sympathetic relations  of the
womb, although their size may be small.   It has
been already shown that the growths or polypi
which  occupy the cavity of the uterus, occasion
abundant  haemorrhage  and other  phenomena.
(ij 162. 168.)  When these tumours  are formed
after the cessation  of the catamenia, the severity
of the symptoms they occasion is much less than
at an earlier epoch;  and when they are develop-
ed in single women,-the  symptoms generally be-
come much more severe  after marriage, and they
often either occasion sterility, or, if impregnation
takes place, abortion.  If pregnancy take place in
these cases, the puerperal states, as well as abor-
tions, are attended by much greater danger than in
the healthy state of the  uterus.  The symptoms
of uterine tumours  are most commonly slight at
their commencement, and slowly increase  in se-
verity.   They sometimes, however, are sudden,
more especially the uterine haemorrhages,  which
recur after intervals, and are more  and more se-
vere ; but, unless when caused by internal growths,
are not followed by leucorrhcea or any offensive
discharge.   Dysuria, or retention of urine, some-
times suddenly occurs.   As the tumour enlarges,
pain in the region of the uterus, bearing down, and
sense of discomfort in  the pelvis, are felt, with
frequent calls to pass urine.   The character of
the pain is somewhat peculiar ;  it is rather  a dull,
aching, or  gnawing, but constant pain, seldom
preventing sexual intercourse ;  yet sometimes at-
tended by throbbings, or a sense of heat or burn-
ing, or with intense neuralgic pains such as have
been already described (y 7, ct scq.). When these
symptoms  are present, the abdomen,  especially
towards  the pelvis, should be  carefully exam-
ined ;  and  if any tumour be detected, the diag-
nosis between a uterine and an ovarian tumour
should be made
   178. iii.  This diagnosis is extremely difficult,
and cannot be attempted without a careful ex-
amination,  first of the abdomen, and next per va-
ginam, and in both  situations.  Tumour of the
uterus, when so large as to be felt on examining
the abdomen, is always firm, frequently nodula-
ted or uneven, seldom mesial, and  generally in-
clining to either  side.   On examining per vagi-
nam,  the tumour, if uterine, rarely draws  the
uterus upward, unless  it be attached near  the
fundus.  It is most frequently seated in the pos-
terior parietes, and is, more especially in these
cases, accessible to examination. It is then found
to be firm, sometimes uneven, carrying the cervix
towards the symphysis  pubis, and  often more or
less retroverting the organ, and often displacing
it somewhat from the mesial line.   The os uteri
is generally small, circular, and healthy ;  or some-
what hard, or enlarged, or turgid.   If the tumour
be intra-uterine, or be imbedded in the walls, the
uterus will be found larger, heavier, and less move-
able than natural, and if it be seated low in the
womb, the  cervix uteri will not be unlike  the
form assumed in pregnancy, not unfrequently dis-
appearing, and its lips being thinned  Dr. West
remarks that an enlarged,  heavy, and somewhat
hard uterus, coupled  with causeless recurrence
and frequent return of uterine haemorrhage, while
the os and cervix uteri  arc healthy, and I might
add absence of pain, or but slight pain during co-
ition, are almost always pathognomonic of fibrous
deposit in the uterine substance.
   179. Tumour ofthe uterus must be large to be
mistaken for tumour of the ovarium.   The for-
mer is always slowly developed, and rarely rises
out of the pelvic cavity; the latter much more
rapidly increases  in  bulk, and when large rises
out ofthe pelvis.  The one is hard, and non-fluc-
tuating ;  the other is softer, and obscurely, if not
more  manifestly, fluctuating.   The ovarian  tu-
mour generally attains a much greater bulk than
the uterine, is at first more inclined to either side,
and is seldom attended by haemorrhage during its
growth ;  or by retention of urine  when largely
developed.   The cervix uteri is sometimes drawn
upward, but is seldom altered ;  while large uter-
ine tumours are uneven, nodulated, solid, are at-
tended by alteration of the lower segment of the
uterus, and by the absence of, or difficulty of find-
ing, the cervix and os uteri, and not unfrequently
by retention of urine.
  180. The haemorrhage attending tumours of
the uterus  may be mistaken for abortion.  The
patient not unfrequently encourages the opinion
of pregnancy from a desire of being in this state,
and care should be had not to be thus misled ;  but
to  question the patient as to the history of the
case, and to examine locally with care and with
reference to contingent diseases ofthe uterus and
of its appendages.  The frequent recurrence of
haemorrhage, the  absence or character  of pain,
and the state of the cervix and os uteri, will gen-
erally guide the diagnosis in these cases.
  181. Fibrous tumour  of the  posterior uterine
wall may be mistaken for retroverted uterus, with
which, however, it is often associated.  It is, nev- 
UTERUS—Treatment of Tumours of  the.
1401
ertheless, of importance  to ascertain  the nature
of the lesion, although but little may be done  as
regards its treatment.  In these cases, a recourse
to the uterine sound, when it can be  introduced,
may aid the diagnosis ; but in most cases a diag-
nosis is most difficult, and sometimes  impossi-
ble  It is also very difficult to distinguish between
cancer  of the body of the womb and fibrous tu-
mour of the organ, but this will be  noticed here-
after (v 199, et seq.)
   182  The occurrence of haemorrhages, the non-
development of the lips of the uterus, and the
history of the case, will prevent uterine tumours
from being mistaken for pregnancy ; for which
the expansion of the lower segment  of the ute-
rus, and sometimes a sound resembling the uter-
ine souffle, attending the former,  may render the
diagnosis between it and pregnancy difficult, more
especially as the latter may take place during the
existence of an uterine  tumour.   In these, and
many other cases of tumour  of the uterus, diffi-
culties of diagnosis which need not be more par-
ticularly noticed will occur, and which  the acu-
men of the physician will readily  overcome.
   [We  have  found  the uterine  sound of Dr.
Simpson of very great value in  forming a diagno-
sis in cases of fibrous tumours ofthe uterus.  By
it we readily learn if the cavity of the uterus  be
elongated; and  if this be so, and the uterus  be
found enlarged, heavy, and somewhat hard, con-
nected  with  the causeless  occurrence  and fre-
quent return of uterine  haemorrhage, while the
os  and cervix  are healthy, we may very safely
conclude that there is a fibrous deposit in  the uter-
ine substance.   Reasoning by exclusion is here
ofthe highest importance, where  the question is
between uterine and  ovarian enlargements—be-
tween fibrous tumours and pregnancy, or fibrous
tumours complicated with pregnancy;  and the
use of the sound is often indispensable  in  order
to furnish us the necessary data.   Much may  be
learned from the previous history of the case, and
from the equal or unequal density ofthe tumour.
In  one case of Prof. Simpson's, which  we were
requested to examine for the  purpose of forming
a diagnosis, and which had baffled several phy-
sicians, the employment of the uterine sound led
at once to the detection of an  immense fibrous tu-
mour in the walls of the  uterus, which had elon-
gated its cavity to an extent of 8 or 10 inches.]
   183. iv. The prognosis of  uterine tumours  is
not very unfavourable to the duration of life,  at
least  for several, if not  for many years, unless
they arc very large, or are productive of very se-
rious symptoms, or are associated with pregnan-
cy.  In this latter state the abortion they gener-
ally occasion, or parturition at a natural period, is
often attended by more or less danger.  When the
tumour is intra-uterine, constituting the fibrous
polypus above described  (§  164, et seq.), a cure
is then generally accomplished.  But the  other
states of the malady do not admit of cure, and not
always  of palliation, although this  latter should
always be attempted, inasmuch as it is  often  to
be attained, and nature,  in rare cases, seems  to
effect a cure in  such circumstances, especially
when the disease occurs at an advanced period
of life—the cessation of the menses tending  to
favour this result.  The prognosis  may also be
somewhat more favourable when these lesions oc-
cur in an unmarried female, or in a widow, than
when they affect  a  married  female during the
epoch of sexual activity.
   184.  v.  Treatment.—Although the  treatment
of tumours ofthe uterus is chiefly palliative, yet
more active means should not be neglected, with
the view of promoting the gradual absorption of
the morbid deposit.   The  patient should  avoid
sexual excitement; if married, she ought to sleep
apart from her husband, and be as physically  and
mentally tranquil as circumstances  may permit
her to be.  Walking much, or standing long, more
especially riding on horseback, or even in a car-
riage, should be altogether avoided;  and the re-
cumbent posture adopted as long as possible,  and
without any intermissions during the  existence of
uterine haemorrhage.   The bowels  ought  to be
kept gently open by cooling  laxatives, and more
particularly by such as  neither irritate  the larger
bowels, nor  sympathetically  excite  the uterus.
With this intention the carbonates, the tartrates,
or the acetates, or the phosphates ofthe fixed al-
kalies may be prescribed, either alone or with  the
infusion of senna or rhubarb, or with the extract
of taraxacum. Haemorrhages are among the more
urgent  symptoms  for which  palliation is requi-
site.  These generally at first occur as'an excess-
ive menstruation, and  recur with each  period;
and ultimately they often appear intcrcurrently,
or between each period. The  means which I have
advised above (() 169) for arresting  the haemor-
rhage and expelling the tumour when seated with-
in the womb, might prove of doubtful  benefit, or
even  injurious, if prescribed when the  tumour is
not thus situated, or when seated as  described in
this chapter.  Therefore the  recumbent posture,
undeviatingly observed, and  astringents and  re-
frigerants taken from the commencement of the
haemorrhage, are indispensable.
   185.  WThere there is either pain or tenderness
in the lower part of the abdomen on the  acces-
sion of this discharge, a few  leeches may be  ap-
plied on this paTt;  or a small cupping over  the
sacrum be  ordered ; or dry-cupping on  this  situa-
tion may be substituted for it, when the abstraction
of blood appears injudicious ; but in these  cases
the modern fashion of applying leeches  to the ute-
rus itself should not be followed.  The turpentine
embrocation may be afterward applied over  the
hypogastrium.  Sedatives and refrigerants should
be given with astringents ;  and if the pain be ur-
gent, narcotics and  the other means advised for
neuralgia ofthe uterus (y 14-17) may  be added.
The nitrate of potass may be thus prescribed with
the liquor ammoniae acetatis,  with the acid in  ex-
cess, and with the spirit of nitric ether and tinc-
ture of henbane; or the hydrochlorate of ammonia
with hydrochloric  acid, and  hydrochloric  ether,
may be taken in the infusion  of cinchona, or sim-
ple infusion of roses, in different circumstances
ofthe disease.  If the haemorrhage be excessive,
the more energetic anti-hsemorrhagic remedies, as
the infusion or tincture of matico, gallic acid, tan-
nin, the spirits of turpentine, the extract of log-
wood, &c, may be had recourse to.  When  the
patient is anaemic, or when there is a more con-
tinued draining of blood, the muriated tincture of
iron, with an additional quantity ofthe acid, will
be given with benefit, with the compound tincture
of camphor, or with the infusions of calumba or
quassia.
  186. I have had reason to  believe  that a judi-
cious  recourse to the iodides has not  unfrequent-
ly been productive of some benefit.   The iodide
of potassium should generally be" preferred, and
be conjoined with the solution of potass, or with 
1402
UTERUS—Cancer of the
Brandish's alkaline solution, or with either ofthe
carbonates ;  but it ought always to be prescribed
in small doses, and be long persisted in.  In oth-
er, or in anaemic cases, the iodide of iron may be
given in  sirup of sarza.   The bromides of mag-
nesium and of potassium have been  considered
as beino-  equal, if not superior, to the iodides, but
chiefly from the circumstance of their presence
in certain mineral springs, as those of Kreuznach,
which  have  been much employed, both internal-
ly and as baths  and hip-baths daily, in cases of
uterine enlargements arid tumours,  and with ap-
parent benefit in many cases. These waters may
be had in this country.  M. Velpeau  suggested an
operation consisting of the enucleation of fibrous
tumours  of the uterine  parietes by an incision
through  the os uteri or the lower segment ofthe
womb.   M. A.mussat performed this operation in
1840, and it has been subsequently resorted to by
others—by Berard, Boyer, Simpson, and others;
and  with success by my friend Dr.  Pancoast of
Philadelphia, by Mr. Teale of Leeds, M. Amus-
sat, in two  cases, and by M. Maisonneuve ; but
as the number of  unsuccessful  cases is  much
greater than that of the successful, and  as  their
details are by no means encouraging, the haemor-
rhage  and other consequences  being alarming,
this  operation should not be recommended.
   187. X. Tubercular Degeneration of the in-
ternal  surface of the uterus is sometimes met with,
in the form of a dirty yellow matter, closely re-
sembling the substance of a tubercular bronchial
gland  at an early stage of softening.   This mat-
ter is about an eighth of an inch in thickness, ex-
tends  over the whole internal surface, but rarely
into the  cavity of the cervix, and more frequently
into the Fallopian tubes, which  it  more or less
distends, and is sometimes associated with tuber-
cular degeneration ofthe ovaries.  I observed this
association in a young  lady who died of consump-
tion at nineteen years  of age, and who had never
menstruated.   Rokitansky thinks  that  it never
occurs primarily in the cervical canal.   Upon
scraping off this deposit from the internal uterine
surface,  it is found that the whole of the internal
membrane is removed  and replaced  by it, and that
it is closely applied to  the proper structure of the
organ, which, with its cavity, is more or less en-
larged.   At an earlier stage the internal  mem-
brane  is seen to be opaque, more  vascular than
natural,  and to present small yellow spots, which
are  found to be distinct tubercular deposits when
examined by the microscope.  This subject has
been investigated by Louis, Kiwisch, and Geil,
the  last  of whom has furnished Dr. West with a
table, according to which it appears that in 68
 cases  this lesion has  been observed at  all ages,
 from  10 years to 80;  but most frequently from
 20 to  50 years  of age ;  and, according to the ap-
 pearances in 45 cases, the uterus  alone was af-
 fected only  in 1 case ;  the uterus  and tubes in 12 ;
 the uterus, tubes, and peritoneum in 19 cases;
 and the  tubes alone in 8 cases.*
   188.  The symptoms of uterine tuberculosis are
 amenorrhoea, or dysmenorrhoea,  often associated
 with  leucorrhcea—very common phenomena of
 tubercular phthisis, of which this uterine lesion is
   [* That this is a rare  affection appears from the fact
 that, among 200 phthisical females, I.ons only met with
 three who furnished examples of tuberculous disease of
 the  uterus.  When the affection has been accompanied
 by a discharge, the vagina often presents spots of ulcera-
 tion, exhibiting a' relation analogous to that of the tra-
 chea in pulmonary phthisic!.]
generally secondary, or, if not secondary in very
young subjects, at least coexistent with tubercu-
lar deposits in the lungs and other organs or parts.
  189 XI. Fatty formations have been depos-
ited in the cavity of the uterus in  very rare in-
stances, and have been thrown off by the contrac-
tions  ofthe organ when they had reached a large
size.  Dr. West refers to two instances, recorded
by Drs. Busch  and Seeger, where this  product
was expelled from females ofthe ages of fifty and
fifty-three.   In one the tumour was the size of
the fist, and was composed of fatty matter closely
resembling cholesterine.  In the other case the
tumour was the size  of a child's head, was con-
nected by a broad pedicle with the whole margin
of the os uteri.   It was removed by ligature ; and
the patient, who had suffered from menorrhagia
for  a year previously, recovered.   The  tumour
weighed three pounds and a half, was said to have
been  an ordinary fatty  tumour, having  an in-
vestment of dense cellular tissue, septa of which
dipped into its substance.
  190. XII  Cancer  of the Womb—Of Can-
cer and of Scirrhous and other Tumours, as well
as Fungo-hjematoid, and of other malignant dis-
eases, full notice has been taken under their re-
spective heads    I  shall now only  briefly notice
the malignant lesions which are found in the ute- a
rus, and the treatment which has been advised for
them. Before the chronic inflammatory states of
the cervix uteri were investigated and their con-
sequences shown, more especially by the writings
of Dr. Henry  Bennet, several of these conse-
quences were viewed  as incipient cancer of this
part ofthe organ ; and the mistake was the more
readily made as cancer uteri in most cases com-
mences in this  part, and  often resembles the
changes, more especially hypertrophy, hardening,
pain, &c, which result from protracted inflamma-
tory irritation.   The profession is much indebted
to the writings of Dr. H. Bennet, and more re-
cently of Dr  West, for the researches they con-
tain into the diagnosis of malignant  diseases of
the womb by the former, and into the pathology
and treatment  of them  by  the latter  physician;
and 1 would advise the  reader not to be content
with the brief view I  shall now take of these mal-
adies, but to  peruse the more copious details, fur-
nished  by these able writers, not  only of these
but also of other diseases of the uterus.
   191.  I have  defined Cancer, when treating of
this malady  generally;  but  much confusion has
existed in consequence  of the want  of precision
in the  use of  this term;  for some pathologists
 have employed it as  representing  the genus of
 malignant alterations of structure, commencing or
 manifesting themselves locally; while others have
 limited it to the carcinomatous state or variety
of the genus.   The  generic definition of  cancer
 given by Muller is as follows : " Those growths
 may  be termed  cancerous which destroy the nat-
 ural  structure  of all  tissues, which are constitu-
tional from the very commencement, or become so
in the natural  process of their development, and
which, when once they have infected the consti-
 tution,  if extirpated, invariably return, and con-
duct  the person who is affected by them to inevi-
table destruction."  To this definition no objec-
tion  can be offered, inasmuch as it comprises all
the varieties of morbid structure usually denomi-
nated malignant or cancerous.  Much confusion,
however, has arisen from the  different terms by
which these have severally been denominated, the 
UTERUS—Forms of Cancer  of the.
1403
desire of originating a name, rather than of con-
veying a precise idea of the thing named, and of
adopting foreign terms, being among the ludibria
to which modern medical  writers  expose them-
selves.   Cancerous diseases of the uterus, not-
withstanding the microscopic researches of those
anatomists who have dignified themselves by the
name of Histologists, have  not as yet been distin-
guished  by any  determinate character, by which
they can be undoubtedly known  under the mi-
croscope, as far as  the describers of these charac-
ters or appearances have  furnished us  with the
means ;  and this failure of microscopic diagnosis
is most  remarkably manifest in respect of  those
lesions of structure which have been viewed  as
cancerous by some, and which have been  as stout-
ly denied to be such by others, and which are
considered by  the  latter as  separate  and specific
forms of disease, especially epithelial cancer, me-
lanosis, lupus,  &c*
   192.  i. Forms.—Although no form of cancer
is peculiar to the uterus, yet they do not all  occur
with any thing approaching to the same frequen-
cy.  On this subject Dr. West remarks : " Fun-
goid or  medullary carcinoma is by far  the most
common; next in  frequency may  be  classed the
epithelial varieties of the disease, if indeed it  be
not more correct, as some  men of high  authority

   [* I'nder the  article "Scirrhous and other  Tumours"
will be found the histological  characters of true cancer,
as laid down by Bennet, and  to that article the  reader
is particularly referred.  Before referring  to  the views
of Paoi'.t, it maybe well to recall the following opinions
of Vogei., as contained in his " Pathological  Anatomy'
(Am.ed., p. C66): "Carcinomatous structures are  distin-
guished from the preceding class, the slightly organized
epigeneses" (t pbus and scrofulous deposits and tubercle),
"by a higher degree of organization; they not only show
a more highly developed cellular structure, but frequent-
ly also fibres, ve sels, and granulations enter into their
composition.  They  are  not,  however, strictly limited
from the former class; for, although the tumour, as a
whole, can be easily distinguished from one of the former
class, it frequently contains particular portions which
cannot be distinguished with  certainty from  tubercular
deposition. Neither is there any strict limit betwein thrse
and certain forms of non-malignant tumour, namely,
fibrous tumour; and cases frequently occur in which it
cannot with certainty be determined whe'her a  tumour be-
longs to the carcinomatous or fibrous group, i. e., whether
it be malignant or non-malignant  The malignancy  de-
pends here, as in the former class, on softening and a
disint gration of the  elements, commencing with the cel-
lular structures, but  gradually proceeding to the fibrous
parts, and the elemental tissues of the affected  organ.
The anatomical and  histological relations of carcinoma-
tous tumour exhibit  the greatest variety; indeed, even
in  the same tumour, different parts often present very
different characters.  Their characters farther vary with
their stage of development.  These tumours are some-
times soft, resembling cerebral substance;  sometimes
firm, like lard; and sometimes  hard, like cartilage.
Sometimes they are  highly vascular,  and of a reddish
tint; sometimes pale; s-ometimes they are dii-tinctly sep-
arated  from the adjacent parts, while in other case*
there is no line of demarcation between them and the
surrounding tissues"  (p. 266).
   We are indebted to Mr. Paget for a very full and  ac-
curate  description of the various forms of the true c.-tn-
cer-cell (" Surg. Pathol.," Amdfeed.), and he.very truly
observes  that "the experienced microscopist will very
rarely fail in the diagnosis of a cancer by its minute
structures; but  he only discriminates them  as specific
modifications ofthe nucleus, nucleated  cell, endogenous
cells, and other forms, of which the types are  in natural
parts" (excretory gland-cells and epidermal cells).   He
finds among them no new type-forms.  Still, this pathol-
ogist admits (Loc. cit, p. 664) that there are cancerous
tumours which are not composed ofthe true cancer struc-
tures', and remarks that we should do right " to  choose
modes of life rather thnn structures for determining the
affinit'es of morbid products, and for arranging them un-
der generic names.  As of all tumours, so especially of
cancers, the  true nature is to be apprehended only by
studying them as living things."]
believe, to  refer them to a separate category dis-
tinct  from genuine cancer.  Next to them, but
divided by  an interval which widens in exact pro-
portion as fresh evidence is brought to bear on
the subject, may be classed scirrhus or hard can-
cer ;  while almost as rare, or perhaps  even more
uncommon, stands the  colloid or alveolar variety
of the disease." (Op. at., p. 336.)   Rokitansky
says also that fibrous or scirrhous  cancer of the
uterus is of extreme rarity, while medullary car-
cinoma occurs with the greatest frequency.  This
opinion accords with those of Mr. Paget and Dr.
West.   But Professor Kiwisch states that scir-
rhus  or hard cancer occurs  in about three in ev-
ery ten cases of cancer of the womb ;  and he re-
marks, that with the softening of fibrous  or scir-
rhous cancer the characters of this growth grad-
ually disappear, and, becoming more vascular, the
mass is more easily broken down, and contains a
brainlike substance, the  ulcer which forms pre-
senting  the  same  character as those  which are
observed in medullary cancer.   Dr. West states,
that of 120 cases  of uterine cancer, the  disease
appeared, from  an examination  during life, to  be
medullary  in 108, epithelial  in ten, and colloid in
two; and  of 120 cases, the  disease occupied the
body  of the uterus only  in two.
   193.  A.  It is  fully shown that the cervix, or the
part of the womb which projects into the  vagina,
is that in  which cancerous disease commences,
and that the exceptions to this are very few.
The mode  of its commencement, however, varies
in the different forms.   The medullary form be-
gins  with  a  morbid deposit in the substance  of
the cervix, enlarging or thickening it  more than
elongating.  The  lips  of the os are enlarged,
hard, and tense, and, at the  same time, irregular,
nodulated, and wide or gaping.   W:hen the cervix-
is incised, the  structure is occupied by a white,
firm, and  semi-transparent  matter, which seems
infiltrated  in parts, and has displaced the struc-
ture  in others.   This deposit is more abundant
near the internal  or mucous surface  than near
the  external.   Softening  of the diseased part
soon takes place, death of the mucous covering
follows, and an ulcer,  with  ragged and  uneven
surface, and with raised, irregular, hard  edges,
supervenes,  and  is covered by a dirty  sanies.
As the disease  proceeds, the lips and cervix are
altogether destroyed, and the  eroded parts are
covered by a soft, dirty white, and often offensive
substance.   The carcinomatous ulceration may
commence either in the  softening of the morbid
deposit, extending externally or superficially,  or
in erosion ofthe surface, the consequent ulcera-
tion proceeding more deeply;  but the formation
of the open sore takes  place sooner or later, and
advances with very different degrees of celerity ;
foul  granulations  and  fungous  growths  spring
forth ; a fetid pus, mixed with a fetid, greenish-
brown, or  sanguineous fluid, or bloody debris,  or
with more or less abundant haemorrhages, mark-
ing  the progress  and  destruction of the lower
segment and upper portion of the vagina.   In
the more retarded  cases, cancerous deposits take
place in the substance, in the cavity, or on the
external surface, and even in the close vicinity,
of the organ ; and ultimately the disease invades
more or less the whole body of the uterus, often
extending  to the ligaments and ovaries, and some-
times forming malignant polypi within the cavity.
Cancerous tumours also form on the uterine peri-
toneal surface. 
1404
UTERUS—Forms of Cancer  of the.
   194. B. The scirrhous variety of cancer uteri is
described by Rokitansky as very rarely affecting
the uterus, the most common form being the me-
dullary, either by itself or complicated with the
former.  Fibrous or scirrhous cancer always com-
mences in the cervix, its primary occurrence in the
body ofthe uterus being extremely rare.  When
closely examined, it appears to  consist of dense,
whitish, retiform fibres, differing from the healthy
texture, and in their minute meshes a pale reddish
yellow or grayish translucent substance is  depos-
ited.   This morbid growth  invades  the uterine
structure,  and furnishes no  marked  boundaries.
It is  various in extent, and accumulating  at cer-
tain points, gives rise to irregular, nodulated ele-
vations and indurations, and enlargement  of the
cervix, or portio vaginalis uteri.
   195. Cancerous  degeneration of the uterus in
either of these  forms  is generally confined for a
considerable time to the vaginal portion ; but the
disorganization often  extends with more or less
activity  not only to the body and fundus  of the
organ, but also downward involving the vagina,
thus  associating with it vaginal cancer.  It  may
even  extend in  other directions, and thus  invade
the rectum, the bladder, the  cellular and adipose
tissues of the pelvis, and  at  last the ovaries and
the peritoneum, cancerous growths either forming
upon it, or perforating it chiefly in the state of me-
dullary masses.  The  destructive process, when
extending to  the vagina, predominates on either
the anterior or on the posterior wall;  sometimes
to both  equally, and occasionally almost  to  the
external orifice.  In these cases it often involves
the parietes  of the bladder  and rectum, produc-
ing in the most advanced  states communications
between their cavities, and  the  most distressing
conditions, consisting  of a large fungoid cavity,
occupying the vagina, the uterine cavity, opening
into the cavities of the bladder  and rectum, and
closed superiorly by the parts agglutinated around
the fundus, by the medium of adhesions between
the peritoneum covering  the adjoining viscera.
The  formation  of these adhesions increases  the
distressing symptoms  of  the last stage  of  the
malady.
   196.  Cancer of the  uterus is generally a pri-
mary malady, and continues for a long time, if not
throughout, the only  cancerous affection  of the
body.   It is, however,  sometimes developed con-
currently with, or consecutively upon mammary
or ovarian cancer ; or it may be accompanied with
or followed by degeneration ofthe structures just
mentioned and ofthe lymphatic  glands.  It more
rarely becomes associated with cancer  of the
stomach, or liver; more frequently with that ofthe
mammae and peritoneum, and occasionally with
a  universal cancerous deposit, or with mollities
ossium.  Uterine cancer seldom terminates  fatally
without  extending  to the upper portion ofthe va-
gina.   It is commonly allowed that cancer uteri is
confined to the part it commences in for a consid-
erable period, and for  a longer time  than cancer
of any other organ.   M. Lebert states that sec-
ondary deposits in other parts occurred only  in a
third  of forty-five cases of uterine cancer.   Pro-
fessor Kiwisch found the  disease  present  in the
bladder in 42  per  cent, of his  cases  of uterine
cancer.  But in this, as well as in other diseases,
statistics cannot be depended upon,  and for rea-
sons I have stated in other places.
   197. C. Epithelial cancer, or Cauliflower excres-
cence  ofthe os uteri, and which is doubted by some
to be cancerous, is of very rare occurrence.*  It
presents a  cauliform appearance,  or,  according
to Rokitansky, the  appearance  of a confervoid
growth, consisting of lenticular, pale-red, trans-
parent, and tolerably hard bodies, strung together
like the beads of a rosary, projecting on the orifice
of the uterus into the vagina, and bleeding on the
slightest touch.   The only case  in which I have
seen it came only once before me in consultation,
and it then seemed to me as a fungoid form of
cancer; and, from the local changes, the bleeding
upon examination, and the cachectic and anaemic
appearance of the patient, as undoubtedly a  va-
riety of carcinoma or cancer.  The  case observed
by Rokitansky is stated  by him to have grown
from an evidently cancerous base ofthe medullary
variety.   Dr. J. Clarke and  Sir C. M. Clarke,
who first described this malady, have viewed it
as less  formidable,  and  have stated that it  is
sometimes  curable.  It is  not improbable that
the medullary form of cancer of the cervix may
present fungoid or confervoid growths, of a cauli-
flower appearance; and that an intractable but
non-cancerous ulcer of the os uteri  may give rise
to large fungoid granulations,  bleeding on the
slightest touch, and both lesions  may be thus
confounded, the former, however, not admitting
of cure, the  latter in rare cases.  Both these
lesions are attended by frequent, exhausting, and
dangerous haemorrhages.  These morbid growths
  [* According to Paget, only a part ofthe cases to which
the name of  " Cauliflower Excrescence"  has been as-
cribed have been epithelial cancers;  of the rest, some
were medullary cancers, and some, perhaps, simple, non-
cancerous, warty, or papillary growths.  Vischow, Le-
ise^t, and Paget, agree in opinion that there are three
different kinds of papillary tumours at the os uteri—the
simple, the cancroid, and the cancerous (that is, the epi-
thelial cancerous and the medullary cancerous); the first
two forms together constitute the cauliflower grow-tli.
This begins as a simple, papillary tumour, and at a later
period passes into cancroid (epithelial cancer).  At first,
one 6ees only on the surface papillary or villous growths,
which consist of very thick layers of peripheral flat,  and
interior cylindrical, epithelial cells, and a very fine inte-
rior cylinder,  formed of an extremely little connective
tissue with large vessels.  The outer layer contains cells
of all sizes and stages of development, some of them
forming great parent structures witH endogenous cor-
puscles.   The vessels are, for the most part, colossal,
very thin-walled capillaries, which form either simple
loops at the apices of the villi, between the epithelial
layers, or towards the surface develop new loops in c in-
stantly increasing number, or, lastly, present a reticulate
branching.  At the beginning of "the disease, the villi
are simple and close-pressed, so that the surface appears
only granulated; it becomes cauliflower-like by  the
branching ofthe papillae, which at last grow out to frin-
ges an inch long, and may present almost the appearanre
of an hydatid mole. After the process has existed for
some time on the  surface, the cancroid alveoli begin to
form deep between the  layers of the  muscular and the
connective tissues ofthe organ.  In the early stages of
the disease, the cavities may be simply filled with epi-
thelial structures;  there may be, however, alveoli, on
whose walls new, papillary, branching growths may bo
seated — a kind of proliferous, arborescent formation.
Such is the description of the cauliflower excrescence by
Visohow, endorsed by Jeiieiit and Paget; and, as the
last writer remarks, illustrates the usual history of the
most exuberant epithelial cancers, the "simple,  papil-
lary tumour" being an excessive papillary outgrowth of
epithelial cancer; the later stage of the same, when it
passes into cancroid, being the usual extension of such a
cancer into deeper parts—a continuous growth ofthe same
thing in a new direction, inasmuch as papillary  struc-
tures, composed of epithelial cells w ith blood-vessels, and
a little connective tissue, are the essential characters of
the epithelial  cancerous outgrowths.  Dr.  Paget, in-
deed, remarks that he believes the same composition has
never been seen in any  papillary or warty prowths that
did not, if time were allowed, proceed to the formation
of epithelial structures in the deeper parts, and thence
through the usual progress of malignant disease.] 
UTERUS—Symptoms of  Cancer of.                        1405
 consist, microscopically, of " hypertrophied papil-
 lae, composed of epithelial cells, richly supplied in
 their interior with large and delicate vessels, and
 covered by a thickened layer of epithelium.   The
 enormous looped capillaries of the cauliflower
 excrescence explain  the abundant haemorrhages,
 and the profuse serous discharges which attend it;
 while the absence of that solid structure which is
 found in other forms of epithelial cancer accounts
 for the favourable results  that have followed its
 extirpation "*
   198.  D.  Corroding ulcer ofthe os and cervix
 uteri, first described by Dr. J. Clarke, begins in
 the mucous membrane, and involves the whole
 circumference of the os, utterly destroying both
 it and the subjacent parts.  It differs from cancer
 in the absence of thickening, hardness, or deposit
 of heterologous matter, and in its prolonged exist-
 ence—sometimes for several years without being
 attended by any dangerous symptoms. It appears
 to be analogous  to lupus, and is  more strictly a
 rodent form of ulcer than a variety of cancer.
   [The corroding ulcer of the uterus is a very
 rare, as well as  dangerous form  of uterine dis-
 ease.  According to Ashwell, for one case of it,
 we meet with 90 or  100 of cancer of the organ.
 It generally attacks women of spare and lymphatic
 temperament, and rarely before the age of forty.
 It may go on from one to five years before it prove
 fatal; but its progress may be greatly retarded by
 the use of caustics.   The fatal result is at length
 brought on  by repeated haemorrhage, or by the
 prostrating effects ofthe disease.  The speculum
 will  usually be  necessary to form an  accurate
 diagnosis between it and cancer.  Its progress
 is slower than that  of the latter disease, while
 the pain, discharge, and  other  inconveniences
 are generally less.    Occasionally, the discharge
 is very offensive  and acrid.  The pain and weak-
 ness  in the back and loins are usually  constant
 and distressing, though sometimes no pain is ex-
 perienced.  The  patient gradually emaciates, the
 discharge  increases, with gastric derangement,
 diarrhoea, or constipation, and in some instances
 fatal  peritonitis results.  The disease, in the pres-
 ent state of our  knowledge, must be regarded  as
 the result of inflammation of a specific kind.   The
 leading marks of distinction between it and cancer
 are briefly pointed out by our author.  But besides
 the absence of carcinomatous or other deposit,
 when examined  through the speculum,  the  sur-
 face  of the ulcer will be seen to be. red, rough,
 and  granular, with a  distinct line marking its
 extent.   In  cancer,  the new deposits and carci-
 nomatous growths tend to fill up the pelvic cavity ;
 in this disease, corrosive action tends to enlarge
 the cavity.  The prognosis in this affection is,  in
 nearly all cases, unfavourable.  The general prin-
 ciples of treatment are the same as in cancer uteri.

  [* It is the opinion of Professor Simtson that cauli-
 flower excrescence,  in the earlier part of its progress, is
 a morbid tissue, but not necessarily of a  malignant  or
 carcinomatous character.  His chief reasons  for this
 opinion are, its appearing sometimes before the twentieth
 year; its occasional shrinking and almost total disap-
 pearance upon the application of a  ligature, or after
 death; the apparent absence of diseased deposit-? in the
 neighbouring tissues and parts upon the dead body; the
 frequent slowness of its general progress during life; and,
 lastly, the alleged restriction, and even complete removal
 ofthe tumour, in some instances, by the use of astringent
 applications and other means.  Mr. Paget, however, has
conclusively shown  that this affection, in every stage of
its progress, is generally but a form  of epithelial can-
cer, and consequently malignant, especially in its later
stages. ]
The nitrate of silver acts very beneficially, by re-
lieving and lessening the quantity and fetor ofthe
discharge.  As palliatives, the narcotic sedatives
are to be used freely, both locally and generally.
The excision ofthe cervix has been recommended
as the most appropriate remedy, especially in the
early stage of the disease ; but, however much it
may promise, there are few patients who will be
found willing to submit to  it.  In  some  cases,
doubtless, it would  be justifiable.   (For a very
full  and accurate  account of the Rodent  Ulcer,
see " Lectures on Surgical  Pathology," p. 588.
By James Paget, Philadelphia;  8vo,  1854.)   It
will suffice to state it is  of irregular shape, gen-
erally tending towards oval and circular; the base
deeply and unequally excavated, not warty, nod-
ular, nor granulated ; in  these respects, contrast-
ing with cancerous growths.   It is also compara-
tively dry and glossy, yielding, for its extent, little
ichor or  other discharge,  and has commonly a
dull reddish-yellow tint.  Its border is  slightly, if
at all, elevated ;  the adjacent skin appears quite
healthy ;  the base and border feel alike tough and
hard, as if bounded  by a layer of indurated tis-
sue  about a line in thickness.  In corroding ul-
cer, we see more destruction ; in  cancerous,  we
see  destruction  with more than  commensurate
growth ; with the microscope we see no structure
resembling epethelial or any other form of can-
cer.]
   199. ii.  Symptoms of Cancer  Uteri.—The
symptoms which are most constantly observed in
cancer uteri—namely, pain, haemorrhage, and vag-
inal discharge—may attend  other lesions  of the
organ ; but in all cases where they, or even  any
two of them, are present, a careful vaginal  exam-
ination ought to be made.—a. Pain, accompa-
nied with haemorrhage  or leucorrhcea, is a very
frequent, but not a constant, symptom.  It varies
much in character and intensity, both at the com-
mencement and in the course ofthe malady ;  and
very often, when the haemorrhage is profuse, but
little pain, or merely a backache,  is felt.   At an
early stage the pain  is generally not severe, nor
is it always referred to the uterus, but  more com-
monly to the loins.   The organ is seldom tender
to the touch, and sexual  intercourse is not often
productive of suffering.   The pain, as the disease
advances, is referred to one or other of the iliac
regions, and either comes on, or is exacerbated in
paroxysms, and a lancinating pain referred to the
uterus occurs suddenly and at intervals.  Menor-
rhagia may be either attended, or not attended, by
pain.  In  many cases it is, when very profuse,
followed by severe pain.   With the progress of
the malady the pain generally  becomes more  se-
vere ; but towards the close, when the cachexia
and anaemia are most remarkable, the sufferings
of the patient generally abate more or less. But
before this ultimate  stage appears, pain in the
uterus is added to that in the back and hypogas-
trium, and to the other distressing symptoms ex-
perienced.  The pain is,  in some cases, described
as burning, darting, cutting,  &c.; and it is gen-
erally aggravated into intolerable paroxysms,  es-
pecially towards or during the night, stabbing  or
lancinating pains recurring after short but irreg-
ular intervals.  When an attack  of haemorrhage
supervenes on severe pain, some degree of relief
is sometimes afforded for a short period.  As the
disorganization extends to the bladder, the vagi-
na, or rectum, or even to them all more or less,
the sufferings of the patient are  accordingly  in- 
1406                       UTERUS—Prognosis of Cancer of.
 creased;  and when utero-vesical fistula is form-
 ed, the distress is farther aggravated, and ren-
 dered still more harassing.  In a very few cases,
 however, the disease runs its course entirely, or
 almost entirely, without pain.  But  it is not so
 rare for pain to be absent through a great part of
 the course of the malady, and appear only at a far-
 advanced period.   The absence of pain through-
 out the disease, or until an  advanced stage, oc-
 curs chiefly in  the epithelial and medullary forms
 of cancer uteri.
   200. b.  Hamorrhage is  the next symptom in
 importance, but is not always a sign  of the com-
 mencement of the ulcerative  stage of cancer ute-
 ri ; for it is, in a very large proportion of the cases,
 the earliest sign, preceding,  and unattended by,
 either pain or watery, offensive leucorrhcea, for a
 longer or shorter time.  The occurrence of haem-
 orrhage, whether with  or  without  pain, without
 any sufficient  cause, should  always induce to a
 vaginal examination.  The bleeding may not be
 profuse, but continuous and prolonged, or resem-
 ble the ordinary menstrual period, excepting only
 its non-occurrence at the proper period, or  its
 frequent recurrence.  It sometimes assumes this
 character  in females past the catamenial epoch
 of life, and in whom the menses had ceased for a
 longer or  shorter time.  When it thus appears,
 the existence ofthe malady should  be suspected.
 When cancer uteri  commences at an early period
 of life, the haemorrhage most frequently occurs
 at the menstrual periods, or  a day or two after
 their cessation  ; but menstruation is generally ir-
 regular during the course of the disease, being
 either too early, or  passing  over  a  period,  the
 next being excessive.  With the progress of the
 malady, pain is generally added to  haemorrhage.
 The source of this discharge appears to be chiefly
 the internal surface of the cervix and  body ofthe
 womb; for the haemorrhage may be excessive be-
 fore ulceration has taken place, and even when this
 has  undoubtedly supervened, the bleeding may
 still proceed from  the surface of these parts,
 rather  than  the ulcerated part;  for in  many
 cases this discharge has been the least where  the
 ulceration has  been the greatest, and proceeded
 the farthest.   The  paroxysmal  expulsive  pains
 often  attending the haemorrhage are usually due
 to the efforts of the womb to expel coagula form-
 ed within it.
   201. c.  The leucorrhaal discharges differ in the
 forms  and stages of cancer uteri.  A mucous  or
 muco-puriform  discharge is frequent at an early
 period, and is then generally  not offensive.  But
 as the malady advances, it is commonly more or
 less  offensive,  and  it becomes more  watery,  or
 appears as a dirty and very offensive sanies. An
 offensive  discharge  may accompany  any of the
 chief organic lesions of the uterus ; but, although
 it  may exist in  these, it  seldom occurs  in  so
 marked a  manner  as in cancer.  The continu-
 ance, the quantity, offensiveness, and  other con-
 ditions of the  discharge depend upon a variety
 of circumstances—upon the  stage  and form of
 the malady, upon the extent to which ulceration
 has advanced, upon the retention or non-retention
 ofthe  morbid fluid, upon the  frequency  of its  re-
moval by injections, haemorrhages, &c.   In a few
instances, an offensive  discharge has preceded
either  the pain, or the haemorrhage, or both, al-
though much more  rarely; and, still  more rare-
ly, this has existed for so long a period, and has
given rise to  so little suffering or cause of com-
 plaint otherwise, that when  at last recourse to
 medical  aid has been had, the cervix uteri  has
 been destroyed, and  the  finger.has passed into
 the cavity ofthe organ.
   202. These symptoms, the most severe which
 attend cancer uteri—the pain, the  haemorrhage,
 and the offensive leucorrhcea—cannot undoubt-
 edly  prove the  existence of the malady.   They
 may individually, or even conjointly, attend other
 organic lesions ofthe uterus.   But viewing them
 severally and in connexion with the  evidence fur-
 nished by a vaginal examination, and with the
 constitutional symptoms characterizing the course
 and the advanced stage of the malady (see art.
 Cancer, y 20, et seq.), especially the cancerous
 cachexia, the existence of cancer uteri cannot be
 mistaken.   The  remarkable disorder  of  the  di-
 gestive organs, the impaired assimilation, and the
 waste of the red globules of the blood, and even
 also of the tissues, and the  consequent cachectic
 or cancerous anaemia ; the frequent recurrence of
 disorder of the  bowels, more  especially of diar-
 rhoea, with both abdominal and hypogastric pains;
 the distress often caused by defaecation, and more
 particularly by the state  of the urinary organs,
 and by the urinary discharges, are  all indicative
 of the nature of the malady.
   203. Cancer uteri does not prevent a female
 from becoming pregnant at  an early stage of the
 malady; but the process  of parturition, and the
 changes  in the uterine organs  and in the  female
 economy that follow, generally accelerate, often
 with  great rapidity, its course.  Parturition, ow-
 ing to the effect  of this  act  upon  the diseased
 parts,  especially the cervix,  often is  accompanied
 by dangerous haemorrhage, or followed by severe
 or fatal inflammation.  In some of  these cases,
 both mother and child  have died before delivery
 has been accomplished ; generally the process is
 difficult and prolonged.  In some cases, gestation
 is also prolonged beyond the natural period, and,
 in rare instances, death has occurred without the
 efforts of the uterus having been sufficient to ex-
 pel the foetus.
   204. Dr West has  given, in his interesting
 lectures, a table of the result of seventy-four cases
 of cancer ofthe cervix uteri complicating labour;
 and of these 41 died soon after labour, and 33 re-
 covered for a time from the effects  of this proc-
 ess.   Of 72 children, it is stated that 47 were
 dead-born, and 25 born alive.  He found that the
 average  duration  of 17 cases of cancer  uteri,
 which he carefully observed, was 15 months ; and
 that of 39 cases, as  given by Lebert, was  16
 months.   It is thus apparent that cancer uteri is
 more rapid in its  progress than cancer in other
 organs  The average duration of all forms of
 cancer is stated by this writer to  be 18 months,
 and of cancer of the mamma and of  the testis,
 the most prolonged,  not  to exceed  three  years
 and a half.
   205  iii.  The Prognosis of cancer uteri may
 be inferred from what I have stated above,  and in
 the article  Cancer (v 20-22).   Rokitansky re-
 marks  that " cases of spontaneous recovery from
 uterine cancer are of extreme  rarity, but they do
 occur; the carcinoma and the  cancerous ulcera-
 tion are then limited to the cervix,  the internal
orifice  forming the boundary.   The  loss of sub-
stance heals with a funnel-shaped cicatrix "  (Op.
at., p.  303.)  In a case, the progress of which
was constantly observed by me, recovery  took
place while a diet and regimen, hereafter to be no- 
UTERUS—Treatment of Cancer of.                         1407
ticed, was strictly observed.   The cicatrix, which
was formed  low in  the vagina, was  shaped as
Rokitansky has described it—not more than half
an  inch  of the  vagina above the urethra having
been left uncontracted*
  206. iv. Causes of Cancer Uteri.—These are
the same as have been stated respecting cancer
in  general.   But  there are certain  particulars
which require notice with reference to this mala-
dy, when originating, as it commonly does, in the
neck  of the womb.  The mortality of cancer in
females  is nearly three times greater in London
than in males, and more than double the number
of the deaths from  cancer in males  throughout
England ; the excess in females being evidently
due to the frequency of cancer of the  womb and
of the breast among them.   According  to Tan-
chou, the deaths from cancer ofthe womb, stated
in the Mortuary Registers of Paris, as compared
with those from cancer ofthe breast,  were as 2£
ofthe former to 1 ofthe latter.
  207. Age manifestly predisposes to cancer; but
this disease  appears to occur at  an earlier period
in the uterus than in the mamma; for in the lat-
ter it  is rare at the age  of thirty, whereas it is
not so rare  at  this age in the  former situation.
Cancer uteri increases in  frequency with the ad-
vance in life, as Dr. Walsh  has shown : but in
order to render the  increase more manifest, the
number  of cases at a given age  should be calcu-
lated  with reference to the  number of females
supposed to exist at the same progressive periods
of life.   The inference deducible from this fact is,
that the occurrence of cancer is in some degree
favoured by the depression or exhaustion of vital
power taking place from the progress of age, as
well  as  from other  causes of vital depression.
  * Mrs. C---,  at the age of 36, first complained of
 symptoms indicating an early stage of cancer uteri.  The
 disease advanced, and several medical men were consult-
 ed at her  own or my  suggestion.  The cervix had be-
 come much affected, and the disease extended far down
 the vagina with distressing irritability of the  bladder.
 At this time she found  Dr. Lambe" s work on "A peculiar
 Regimen, d-c, in the Treatment of Cancer, &c," in my
 library.  He was consulted in her case, and he recom-
 mended her to remove to a dry and healthy locality in
 the vicinity of London, to strictly observe a vegetable
 diet, to drink only distilled water, and use only distilled
 water in cooking and  for infusing tea or other  substan-
 ces.   These injunctions were observed without any devi-
 ation, and  under his supervision.  In the course of a few
 weeks amendment was very apparent, and in somewhat
 less than twelve months a cicatrix, as situated and de-
 scribed above, was formed.  The patient continued this
.regimen for  nine or ten years, and enjoyed  excellent
 health.  After this period she began to  partake of fish,
 the fle.-'h of chickens or rabbits, &c.   She afterward ven-
 tured farther upon animal food, and occasionally took a
 glass of old wine. Five or six years more elapsed, when
 she complained of the right  mamma, and when exam-
 ined the disease was commencing in it; but no complaint
 was made of the parts in the vicinity of the first disease.
 The diet was now altered, but the  malady proceeded
 slowly; and having been unusually prolonged, extended
 inward, affected the pleura;  and ultimately the vaginal
 cicatrix was  attacked, and she ultimately sunk, more
 than twenty years from the commencement of the mala-
 dy in  the cervix, and after an interval of nearly fifteen
 yenrsof good health.
  [In  the American edition of Dr. Lambk's work, on "Wa-
 ter and Vegetable Diet in Chronic Diseases" (12mo.  New
 York, 185 i), there is the history of another remarkable
 case of cancer uteri, attended with an acrimonious and
 offensive discharge, where the pain, discharge, &c, were
 subdued, and the general health and comfort of the pa-
tient greatly improved by the use of a strictly vegetable
diet, without medicine, except opium.   The disease, at
the time ofthe report,  had been controlled for the space
of twenty-five months, without making any perceptible
progress, while the ulcerative process had been wholly
superseded.]
Dr. West  has given a table of the  ages of 426
cases  of  cancer  uteri,  collected from  various
sources:
			In the proportion of 1 to 10,000 of the whole pop-
		Actual	
		Number.	ulation existing at the
Between 25	md 30 years		respective ages.
		25 or	1 in 134
30	" 40 "	112 "	1 " 21
40	" 5a "	178 "	1 " 9-7
60	" 60 "	71 "	1 " 16 6
60	" 70 "	35 "	1 " 23-6
Above	70 "	5 "	1 " 108-
From these data it would  appear that, although
cancer  uteri becomes more frequent as life ad-
vances  up to  fifty  or sixty, it diminishes consid-
erably in frequency from these ages;  and from
this table, as well as from other sources of infor-
mation, it cannot be inferred  that the actual ces-
sation of the  catamenia has  any influence in fa-
vouring the occurrence of this malady in the ute-
rus.  Dr. West justly remarks that the state of
the uterine functions previously to the appearance
of cancer is  not without interest; and he adds
that, in 108 cases,  this matter was made the sub-
ject of special inquiry.   In 94 cases these func-
tions were in  all respects natural from their com-
plete establishment to the commencement  of the
disease ;  and  in 14 they were either habitually or
frequently unnatural, being painful, postponing, or
irregular.   Out of 116  married women affected
with cancer uteri, only 7 were sterile.  The  hered-
itary predisposition to cancer  has been well estab-
lished, as shown in the article on Cancer (y 23).
Mr. Paget found that this malady in all situations
was hereditary in  the proportion of one to 6 1;
Mr. Lebert, in the ratio of one to 7 2 ; and Dr.
West in  1  to 6 2.   The proportion of hereditary
cases is very probably higher than here  stated, as
it is  difficult  to  ascertain  from the patients the
nature of the  disease which caused the death of
either, or of both parents.*
   208. v. Treatment of cancer uteri is neces-
sarily confined to  palliating the suffering  of the
patient, and to attempts at delaying the approach
of death.   The symptoms which more especially
require mitigation  are hamorrhage, pain, and the
offensive discharge.   The means which should be
resorted to for the  first and second  of these have
been fully described in the articles Haemorrhage,
Neuralgia, and Cancer ; but there are a few top-
ics connected  with the treatment of cancer affect-
ing the uterus, and of the effects of this malady,
which require farther consideration.
  209. a. Hamorrhage is among the earliest and
most alarming  symptoms of cancer uteri.  The
obvious intention  is to  abate it when  severe or
too frequent,  and to prevent  its recurrence alto-
gether, or before the catamenial period.   The va-
rious means  usually employed for hamorrhage
from the uterus have been detailed (see art.  Hem-
orrhage, y 263-273);   but there are  a few  of
these which require a  more  particular  notice at
this  place.  The gallic  acid, in doses  of  six to
eight grains of every four or five hours, have been
often found of decided  service in  arresting the
hamorrhage.   The infusion of matico, used as an

  * I have noticed the question  " Is Cancer contagious?"
when treating of Scir.moi s anp other Tumoceb (5 79,
Sfl), and  have referred to caves, one of which  was under
the care ofthe late Mr. Mayo and myself, in which can-
cer of the glans  penis  in the huf band c mmunicated the
disease to the cervix of the  uterus.  I have there stated
my reasons for  inferring that the disease may thus be
communicated to the wife by the husband. 
1408                        UTERUS—Treatment of Cancer  of.
injection into the vagina, is also very efficacious.
Dr. West states that, in some cases of medullary
and of epithelial cancer, when the haemorrhage is
excessive, or prolonged, the morbid tissue may
be broken down with the finger, and the tincture
of the  sesquichloride  of iron  injected  into  the
midst of it.   The extravasated blood is thereby
coagulated,  and the vessels destroyed, the  whole
mass thus  treated sloughing  away.  Kiwisch,
who first resorted to this practice, remarks that
it is not attended by much pain or serious consti-
tutional disturbance.   He also advises a recourse
to the  actual cautery, where the  surface  is too
firm to be broken down.  In one case, after other
means  had  failed, I recommended  the  injection
of the  spirits of turpentine, in the  manner in
which the tincture of the muriate of iron has just
been advised, the same medicine being given fre-
quently by  the  mouth in small doses;  and the
haemorrhage was for the time arrested.   It is ob-
vious that sexual intercourse is liable to occasion
an attack of haemorrhage, and that it should  there-
fore be strictly forbidden whenever cancer uteri
is suspected.
  210. b  Pain is often so excessive as to require
energetic means  of relief; but, as long as it is not
acute, the gentler  remedies only should be em-
ployed.  The pain is  sometimes brought  on, or
aggravated  by an irritable state of the bladder, or
by the condition ofthe urine, and not unfrequently
by neglect ofthe functions ofthe bowels. There-
fore the states of both the urinary and faecal evac-
uations should receive due attention.  The former
may be corrected, and the irritable condition of
the bladder mitigated  by  the exhibition of the
solution or  the bi-carbonate of potash with tinc-
ture of henbane, or  by the  mineral waters  of
Ems  or of  Vichy.   If the  urine abound in  the
phosphates, the  means I have  advised  for this
condition, when treating of the morbid states of
the Urine  (y 90, et seq ), especially the hydro-
chloric  acid taken in the decoction  of pareira, or
in the infusion of buchu, may be prescribed  The
bowels  may be regulated by means of the gentle
cooling aperients ordered above (v  184).
  211.  When the pain becomes so severe as to
require  anodynes, then plasters of opium or bella-
donna may  be applied  over the sacrum or  above
the pubes;  and  chloroform may be tried  as  an
epithem, by means  of spongio-piline.   Internally
the pilula saponis cum opio, or tincture of opium,
may be  given at night; and if these occasion nei-
ther headache nor sickness in the morning, they
may be continued without increasing the  dose.
The preparations of morphia,' unless  conjoined
with aromatic stimulants, often  cause unpleasant
depression.   The black drop and Battley's seda-
tive solution are often preferred to other opiates,
but they are efficacious chiefly in their  more
powerful narcotic effects, the subsequent distress-
ing sickness, &c, being not less compTained  of.
Henbane and conium  are often employed.   The
former, without alleviating pain, or with  slight
alleviation only, often  affects the head, occasion-
ing restlessness  and headache.  I have, howev-
er, found the two conjoined with camphor—three
grains each of camphor and  of the extracts  of
henbane and conium, being more or less of serv-
ice.   Dr West says that after  henbane he gen-
erally makes trial  of  the Indian hemp; for, al-
though  it is an uncertain remedy, it does not dis-
order the stomach, or occasion headache.   But I
have not always found it so pleasant in its ulti-
mate  effects.   In severe paroxysms of pain, the
inspiration of the vapour of chloroform has been
resorted  to;  but the relief has been  only very
temporary.   I  have in a few  cases directed the
application of the tincture of belladonna  to the
diseased  part, in the manner advised and resorted
to by the late Dr. Moore ($ 15), with very  mark-
ed relief  Taken  internally, belladonna seldom
affords much relief, unless in  large doses,  which
are usually followed by much depression, unless
they are  conjoined with aromatic stimulants ; and
these latter often fail in correcting the  evil.
   212. c. The discharges, owing  to their great
excess, or their very offensive odour, require, be-
sides the usual attention to cleanliness,  the means
which have  been  advised  for the more severe
cases of Leucorrhcea, more especially the infu-
sion of matico, or tannin ; the decoctions of oak-
bark, of buchu, of cedar-bark, or of pomegranate-
bark, &c.  Weak acid lotions, and various other
astringents, have also been recommended. Dr.
West mentions the use of an injection of jj. of
sulphate of iron, and 3iij ofthe extract of coni-
um to a  pint of water ;  and he adds that a solu-
tion of 9j  * to 3ss  of nitrate  of silver to an ?j.
of water, injected immediately into the diseased
structure, has the effect of hastening the separa-
tion of  the  slough  and of destroying the bad
odour.   I  have  most  frequently  employed, for
these purposes, the chloride of lime, or creasote,
or both,  in injections, consisting chiefly of mu-
cilaginous  fluids, in quantity and  frequency ac-
cording to  the progress  and urgency ofthe case.
When the disease was very far advanced, and the
use of these appeared likely to occasion inflam-
mation of  the peritoneum  or adjoining parts, I
have preferred to have recourse to  powdered car-
bon, with tincture of belladonna, or extract of
henbane, mixed in any  mucilaginous fluid, as a
vaginal injection.  It has generally the effect of
deodorizing the discharge and  soothing the pain.
   213 d The complication of pregnancy with
cancer uteri must be treated according  to the pe-
culiarities of each case, but its treatment cannot
be entered upon at this place.   It is fully consid-
ered in  Dr. West's work, already referred to,
where the reader will also find the results of ex-
tirpation ofthe uterus and of its cervix very sat-
  [* Dr. Ashweu. strongly recommends a strong solu-
tion of nitrate of silver (80 grs. to fj. of water), applied
through a speculum, with a hair pencil, or tow fastened
to the end of a piece of cane, smearing carefully the af-
fected parts.  It rarely produces much pain, being quick-
ly decomposed by contact with the fleshy cervix.   The
eschar is usually detached about the third or fourth day,
being thrown off in shreddy films, when the abraded sur-
face will have acquired a redder and healthier aspect
The caustic should be early repeated, and if, after the
fresh eschar, there is still farther topical improvement,
the treatment should be persevered in ; and Dr. A. thinks
that a "hopeful prognosis may be given," as often after
these renewed applications, extending over many weeks,
and aided by the black wash  or oxide of zinc, he has
"healed abrasions and  commencing ulcerations ofthe os
and cervix."  We think  it very doubtful,  however,
whether these were cases of  true cancerous disease.
From  considerable experience  in the treatment of this
disease, we prefer very much the  nitrate of silver to any
other local application.   The other caustics, as corrosive
sublimate, chloride of zinc, arsenic, nitrate of mercury,
&c, are apt to cause heat, pain, tension, and inflamma-
tion, and some of them cause  dangerous constitutional
effects from absorption.  However beneficial  the actual
cautery may have proved in such affections, the prejudice
against it in this country will effectually preclude its em-
ployment.  The practitioner need  not be cautioned in re-
gard to the danger of a hasty diagnosis, few ulcerations or
hardenings of the cervix uteri being malignant, although
attended with haemorrhage and other doubtful symptoms.] 
UTERUS—Treatme
isfactorily discussed.   To this work, and to sur-
gical writings on  this subject, I  must refer the
reader.
   214.  e. The constitutional treatment of cancer
uteri, or the  means most appropriate to the ex-
isting cancerous cachexia, is not different from
what I  have  advised  in  the articles on Cancer
(see t)  27, 44), and on Scirrhous  Growths  ((>
113, et  seq).  The chief objects proposed are  to
promote the digestive and assimilating processes,
and to support constitutional power, and vital re-
sistance to the progress  of the  malady.  Subor-
dinate^ to, and forming  a part of these, may be
mentioned, due attention  to the secreting and ex-
creting functions, and the alleviation of the more
distressing symptoms.   The ansemia  attending
the advanced stages  of  the malady should also
claim our attention ; and  chalybeate  preparations,
and chalybeate mineral waters, ought to be con-
joined with such other means as the circumstan-
ces of each case will suggest.
   215.  /. In respect  of  diet and regimen, little
need be added to  what has been already stated
in the places just now referred to.  A digestible
and nourishing food, in moderate quantity, and a
temperate and dry air, are generally beneficial
It  has  been  questioned  whether much, or even
any, animal food be of service, or rather, whether
it be not detrimental in this malady.  This mat-
ter has been  fully and ably discussed by my late
friend,  Dr. Lambe, a very learned physician, and
an original thinker and  observer.  He imputed
this malady,  as well as scrofula, gout, consump-
tion, and some other chronic diseases, to the use
of animal food and to impure water ; and advised
vegetable food of all kinds  in  sufficient abund-
ance, and distilled water for all purposes of in-
ternal use, and exercise in a dry and open air,  to
be resorted to for the cure of this as well as of
those diseases.  He did  not believe that, when
cancer was far advanced, this diet could then ef-
fect a cure, but he recommended it to be tried;
and, at  the same time, all fermented and distilled
liquors, or other beverages  than  distilled water,
to be relinquished.   This diet and regimen were
employed with apparent success, as long as  it
was strictly  adhered to, by a  married female,
whose case I have briefly noticed in a note at  p.
1407, $ 205.
   [Some farther remarks  in regard to cancer uteri
may not be out of place.   Although it is gener-
ally conceded that confirmed carcinoma of the
uterus is incurable either by surgical or medical
remedies, yet we  agree  with Ashwell, Bouil-
laud, and Breschet, that  much may  be  done
by  a very early, well-sustained, and persevering
prophylactic  management.   It  is  undoubtedly
true, as stated by Ashwell, that  scirrhous or
hard tumours of the womb are  sometimes cured
or become innocuous by altered nutrition, the in-
durated  masses being deprived of their softer cel-
lular tissue,  and being converted into  cartilag-
inous, cretaceous, or calcareous concretions.   It
may, however, be objected that such cases were
not true carcinoma; and  those  who  take the
ground that cancer is never cured will, of course,
assume  that  such was the  fact  But this is a
point which yet remains  to be established by far-
ther observations.   Admitting that in  these in-
stances  the disease was true carcinoma, it yet re-
mains to be  proved how far remedial  measures
had any thing to do in the cure or recovery.  Our
views on these points will be in accordance with
    III                89
;nt of Cancer  of.                       1409

 our pathology.   If, with Bouillaud, we regard
 cancer merely as the result of inflammatory in-
 duration, or, with Breschet and Bichat, as re-
 sulting from some error in the " organic sensibil-
 ity,'' we shall,  a prion,  come to the conclusion
 that it is a curable disease ;  and this opinion will
 not be abandoned until multiplied and uniformly
 unfortunate  experience brings us to a contrary
 conclusion.  We are, however, unwilling, from
 other considerations, to  admit that cancer is al-
 ways an incurable  disease.   Facts  do not war-
 rant such a conclusion.  It has been truly re-
 marked, that no malady can be cured by those
 who are determined to  regard it as  incurable.
 Diseases so regarded must be left, as cancer gen-
 erally is, to quacks and quackery—to those who
 promise any thing and  every  thing for  money.
 It  is not  long  since tubercular disease of the
 lungs  was  regarded as incurable, and this class
 of patients were assigned to the tender  mercies
 of empirics.  Cancer is sometimes said to be
 hereditary, but in all cases it is a declaration of
 the impression  of long-standing  and injurious
 influences.   Seme  of the secretory or excreto-
 ry organs are at fault.  There have been some
 serious errors in diet and general hygienic meas-
 ures.  The treatment is to  be based on a most
 careful investigation of all the functions of ani-
 mal and organic life, and the influence  exerted
 upon them by the previous  habits, mode of life,
 food and drinks, &c, of the patient.  The late
 Dr. Twitchell, of  New Hampshire, was cured
 of an  epithelial cancer of the face by confining
 himself strictly to a diet  of bread and milk.  We
 have seen true  carcinoma of the breast remain
 dormant for years by allaying  the  fears of the
 patient,  and by  a course of  strict dieting and at-
 tention to the excretory organs.  A tumour hav-
 ing all the characters of true carcinoma will, un-
 der such management, not unfrequently become
 absorbed, and its elements, doubtless, eliminated
 from the system.  At first,  we see the  tumour
 become loosened as  to its subjacent connexions,
 a tucked-in  nipple resumes  its natural  appear-
 ance ; it loses its characteristic  stony hardness
 by a process of gradual absorption, until at length
 no vestige of the disease  remains.   We have
 witnessed a case in point recently in a near rel-
 ative.   Paget  has truly observed that a cancer
 adds a new element of disease to those that were
 already in progress, and that if we  assume a
 constant process of nutrition in cancers, it can-
 not but be that the blood will be affected  both by
 what they take from it  and by what  it  derives
 from them in the process of nutritive absorption
 What  returns to the blood  must necessarily be
 morbid, and exert a very injurious influence upon
 it, even if incapable  of being developed into can-
 cer.  Hence the importance of its early and thor-
 ough elimination by an  active condition  of the
 liver, kidneys,  and  skin, together with  the ali-
 mentary canal, the greatest  and most  important
 emunctory of the whole body.   Here we have
 the secondary poisoning  ofthe blood superadded
 to the original cancerous cachexia ;  and no won-
 der that, with the cancerous  material circulating
 in the blood of every organ,  the disease  returns
 after  the original  tumour  has been  removed.
 After the disease has progressed to the stage of
 ulceration, with pain, haemorrhage, discharge, hec-
 tic, with a poisoned  condition of all the circulat-
 ing fluids, and a general cachectic  state, with a
 despairing state  of the mind,  the situation of the 
1410
UTERUS—Treatment of  Cancer of.
patient  may  well be  regarded as hopeless,  al- j
though the local disease be removed.   But even
here the case is by no means to be abandoned.
Here  come in  the  palliatives described by our
author, which are of great service in alleviating
the sufferings ofthe patient.  But many facts go
to show, as Paget  remarks, that "not only the
progress ofthe peculiar constitutional part ofthe
disease  is nearly independent of the local part,
but also that the  constitutional  part  generally
contributes most to  the  fatal issue" (p.  667).
And again (p.  525), " The removal of the local
disease makes no material difference in the aver-
age duration  of life."   If so, then our remedies
must  be general, and  not merely local.   Roki-
tansky  has observed  that spontaneous  natural
processes of healing often occur in even medul-
lary cancer, one of the most fatal of all cancerous
affections ; and Paget admits that "a medullary
cancer may gradually decrease, becoming harder,
as if by  shriveling and condensing, and at length
may completely disappear   I have seen," he re-
marks, " the  same happen after partial removal
of cancers."  He also speaks at length ofthe de-
generation of cancers, so as to be incapable of in-
crease, or, to use a term of Rokitansky, applied
to the same structures,. " obsolete "  Walshe
states that " we need not wholly despair, after
the removal of encephaloid ;" and that " M. Vel-
peau has  excised well-marked specimens of this
species, and seen the  patients in perfect health
two, four, six, and in  one case ten years after-
ward."    Sir Astley Cooper thinks that scir-
rhus does not return  in one fourth of the cases
of removal; Dr. J. C  Warren, that one case in
three is  cured ; and Mr. Travers states that " re-
covery generally ensues when the disease is  re-
moved before  the supervention of pain."  Pro-
fessor Meigs remarks (" Females and their Dis-
eases."   Phil., 1848, p. 274) that he has seen  "a
cancerous mamma  as hard as cartilage ulcera-
ted, and firmly adherent, that was totally removed
by absorption in a  long  paraplegia "   The  re-
sults of Dr. Gross's investigations in regard'to
the curability of cancer are, however, more un-
favourable (Trans, of Am. Medical Association,
1854).
   But in considering  the question ofthe curabil-
ity of cancer, whether ofthe uterus or any other
organ, we are to remember that " it is an organ,"
as Simon expresses it, " for excretory purposes"
(" General Pathology," 8vo.  Phil., 1852), and
that this  eliminative  effort has its root in some
peculiar condition of the  general system, called
cancerous cachexia, the essence of which we by
no means understand.  Why it is that the blood
sets about constructing an organ, so to speak, for
the appropriation and discharge  of its own blas-
tema : why the secretory and excretory organs
are not adequate for  the elimination of those
products which result from the disintegration of
the tissues, and, indeed, whether, by the influence
of secretory and excretory stimulants, alteratives,
and a regular diet, such products  may be wholly
eliminated, are questions  which,  for the present,
must remain undecided, and probably will remain
so until we fully understand the  chemistry  of
cancerous bodies and of the whole body, together
with those natural changes which take  place in
the progressive and regressive metamorphoses of
the blastema ofthe blood.   We believe, with Si-
mon (Loc. at), that the more the nucleated fibrous
material abounds in a cancerous tumour, the less
malignant it may be regarded, and the less likely
to return if removed by the knife ; for all  pathol-
ogists agree in the  opinion that fibrous  transfor-
mation, so far  as it extends, illustrates the opera-
tion of common, not of specific developmental in-
fluences in the part, just as, on the other hand, the
compound  granular corpuscles  constituting  the
yellow  softening material in cancerous growth
represent, asVutcHow maintains, the degeneration
of cells, and, consequently, a retrogressive tend-
ency in the effusion  where  they occur.   If we
assume that the unknown albuminiform material
of cancer requires  a special cell-growth  for its
elimination, and cannot avail  itself of any  known
cells for its removal, then our prognosis must
necessarily be unfavourable  as  regards a cure;
but as cancer-cells  have their analogues  in the
normal  cells of other tissues (as the  excretory
gland cells and epidermal cells), we may reason-
ably conclude  that, under the influence of  special
stimulants and proper ingesta, the latter may per-
form the function vicariously assumed by the for-
mer.
   If cancer, then, is  to be treated successfully,
the treatment  must be founded on the pathology
above indicated, viz., that  the disease is  a local
manifestation  of certain specific morbid states of
the blood; that it  is both a  constitutional and
local disease, specific in the sense that it depends
on some peculiar material in the blood,  different
from all others, normal or abnormal, and present-
ing structures, to  some extent  at least, specific
and peculiar, both in form and mode of life ; and
the cancerous diathesis or cachexia, as consisting
in  the  accumulation  of such materials  in the
blood, while accidental  circumstances determine
its localization.
   Simon has  truly remarked that all cancerous
diseases have  a chronic period of latency,  during
which their cachexia acquires intensity from ac-
cumulation, till at length it suffices  to establish
the local vent; and we may argue farther, that
the disease can be again reduced to this state of
latency  and to the  accompanying difficulties of
evolution, if all such local conditions be  removed
as favoured the first localization of its products.
We have no  rule by which  to  measure the in-
tensity  of the  constitutional cachexia, but after
the disease has reached a certain point, there are
signs which speak  infallibly  to  the experienced
eye—the pale and anxious countenance,  with a
slightly leaden hue;  the  pinched features, with
slightly livid lips and  nostrils ;  the constant hec-
tic, increasing emaciation, frequent  pulse, acrid
and offensive  discharge, and severe pains  All
these speak a  language not to be mistaken; and
if to them be added nausea and weakness of di-
gestion, a tickling cough, stitches in the  side, a
faltering pulse, cadaverous and  anxious expres-
sion, we may  safely predict  a speedily  fatal re-
sult
   Cancer of the uterus is, as  a general rule, very
slow in its development, and the symptoms of
the incipient stage are not  strongly marked , in-
deed, they are so slight as  scarcely to call atten-
tion  Were the physician called at this period,
he would probably find the muciparous glands in
the interior of the cervix hard, and of the size of
small shot, and somewhat  painful on pressure;
the os may be hard and fissured, and the  cervix
enlarged and indurated, and of a deep flesh col-
our, both within and externally   At this  period
we have found the whole  uterus enlarged, and 
UTERUS—Treatme
having a more solid feel.  At a still later period,
a careful  examination  will disclose, probably, a
knotted and indurated state  of the vagina, and
the mucous membrane thickened where it  is at-
tached to the cervix;  the uterus  may be  more
fixed, as if consolidated with  the neighbouring
organs ; and there may be softening, abrasion, or
commencing ulceration.   But a longtime may
elapse before the disease has  reached this stage
If the female be married, she  will have for some
time previously complained of pain in sexual in-
tercourse,  followed, perhaps, by a discharge  of
blood, while she labours under irritability of blad-
der, uneasiness in the central pelvic region, and
a failure  of general health.   The prophylactic
treatment  of cancer uteri is the same as for  all
other chronic affections—attention to all  those
hygienic measures which tend to  invigorate  the
general health.  Ashwell, however, recommends
rest in a recumbent posture as absolutely  indis-
pensable to  a  cure; but it is evident there  are
many cases where the enforcement of such a rule
would be very inexpedient, as it  would tend to
impair digestion, lessen secretory and excretory
action, and increase general irritability.
  The diet should be very simple and unstimu-
lating; for the most part, milk and vegetables.
Macilwain  (" The  General Nature and  Treat-
ment of Tumours," 8vo.   London, 1845)  thinks
the diminution of carbon, in  the interdiction  of
grease, sugar, and alcohol, very important.   The
same writer recommends aperients combined with
narcotics, as blue-pill and colocynth, with opium
or henbane.   Dr. Montgomery recommends  an
alterative  course of mercury in the early stage *
Our  countryman,   Professor  Dewees,  recom-
mends  the  occasional  abstraction  of  a few
ounces of blood, especially if the catamenia have
ceased ; and if there is severe throbbing pain just
above the  sacrum, he enjoins losing six or eight
ounces of blood by  cups or leeches.   Purging,
Dr. D  thinks, is never to be omitted ;  " for there
is no one remedy," he  remarks, "that is  of such
decided efficacy in  this disease."  The salines
are preferable, as sulph. mag., tart, pot  and soda,
sup. tart, pot., phosph. soda, &c  ;  or equal parts
of sulphur and magnesia, or crem. tartar and sul-
:nt of Cancer of.                        1411

phur, or rhubarb and aloes, castor oil, or magne-
sia.  The use  of purging in this  affection, ac-
cording to Dr. D., is to solicit  large serous dis-
charges  from the intestines, with a view to re-
lieve the engorged state of the pelvic  viscera,
and at the same time  not  to  weaken the sys-
tem too much  by its excess.   Care must also
be taken not to cause mucous discharges, and to
observe closely the  effects produced.  Great at-
tention, too, according to Professor Dewees, is
to be paid to diet, the blandest  food, as milk and
vegetables, only to be allowed,  as bread,  rice, In-
dian or rye mush, or unbolted wheat-flour mush ;
the fruits of the season  ; tapioca, oatmeal gruel,
sago,  arrow-root, &c.   " The  influence of this
course of diet," says Dr. D., " is much more effi-
cient than we might at first be  willing to admit;
but the fact is  unquestionable,  that it almost im-
mediately relieves pain  after it has been adopt-
ed."   All kinds of alcoholic drinks are to be for-
bidden, as well as spices and other condiments.
Great care is to be observed in regard to cleanli-
ness ; the acrid and offensive discharges are to be
regularly removed by injections  of tepid water,
flax-seed tea, or the hip-bath ;  and carbonic acid
gas, lime, pyroligneous aad,  or  chloride of lime or
soda, are to be  employed for the correction  ofthe
fetor by their chemical effects.   The use of car-
bonic acid gas, which has been recently recom-
mended  as a new remedy for the relief of neural-
gia and other painful affections ofthe uterus, was
introduced by Dr. Dewees in the same cases, and
especially for carcinomatous affections of this or-
gan.   "We have enabled several  patients,"  he
remarks, " to  derive much  comfort, as  well as
temporary relief, from the extrication of this gas
within the cavity of the  vagina, by means of a
flexible tube of a sufficient  length and  size, at-
tached to the mouth of a bottle, in which there is
mixed diluted  sulphuric acid and the carbonate
of lime.   This may be introduced into the vagina
several times in the twenty-four  hours.  In two
or three instances this substance has relieved the
severity of pain whenever it was  employed, as
well as diminished the offensivenesss of the dis-
charge."   (".4 Treatise on the Diseases of Fe-
males," 8vo.   Phil., 1833, p. 264.)  Dr. D. also
regards rest, i.  e., a horizontal position,  without
intervening exercise, as a sine qua non in the
cure  of this disease.  The pain is to be  relieved
by "morphia  or denarcotized  laudanum;" and
when rejected  by the stomach, it must be  given
by enema.  If vegetable food disagrees, or  is not
sufficiently nutritive, it is to be exchanged for
animal, and the gastric acids are to be  neutral-
ized by the alkalies.  Sometimes the sulphuric
or nitro-muriatic acid fulfils this indication best.
We refer  to the work  above mentioned for the
details ofthe treatment  advised by Dr. D., as we
are satisfied that little, if any,  improvement has
been made upon it since.
   In the early stages of cancer  uteri, we  think
we have  observed  good  effects from the topical
use of iodine to the cervix  by the speculum, in
the form of the compound ointment, as follows:
B  Iodine, sss.; iodide of potassium, 3J.;  alcohol,
3J., lard, fij.   The friction should be persevered
in for several minutes ; or the comp. tinct. of iodine
may be applied by means of a  sponge.  By the
persevering use of this  means  such indurations
have, in several instances, been  entirely removed.
The nitrate of silver, in the form of the saturated
solution, will be preferable to the iodine in  cases
  [* Dr. Mackenzie (London Lancet, 1856) has publish-
ed an able paper, in which he traces uterine to hepitic
disease, in three ways: 1st, through the medium ofthe
direct sympathy subsisting between the uterus and liver;
2d, through the derangement ofthe assimilative process-
es which invariably results from  chronic hepatic dis-
turbance; and, 3d, through the debility of the nervous
system which sooner or later inevitably follows  upon
long-continued derangement of any important organ of
the body. To the first of this series of causes' he attrib-
utes  many uterine affections of a variable and casual
character, such as hysteralgia, leucorrhcea, and menstrual
irregularity;  to the second, many functional and struc-
tural lesions of the uterus, of a more fixed and persistent
character, such as congestive and  inflammatory condi-
tions, indurations, hypertrophies, fibrous  growths, cer-
tain forms of leucorrhoea, and rheumatic hysteralgia, to
which cancer might be added;  to the third, a predispo-
sition to uterine disease generally, the precise character
and nature of which would vary with the nature of the
exciting and other occasional causes.  The treatment of
these cases,  admitting this pathology to be correct, he
says, should be conducted with reference to three indica-
tions: 1st, to restore the tone and functional activity of
the liver by the persevering employment of small, unde-
bilitating doses of mercury, keeping strictly within the
tonic and stimulating range ofthe remedy; 2d, to im-
prove the assimilative functions generally by careful at-
tention to dietetic and hygienic measures,  together with
various therapeutical means; 3d, to restore the tone and
vigour of the nervous system, which has been impaired
by the long continuance of hepatic derangement. These
views are well worthy of consideration.] 
1412         '            UTERI'S—Bibliography and References.
where the lining membrane ofthe os, or around
its margin, is tender and red, or where the same
parts are softened or  ulcerated, or where ulcera-
tion is dreaded, or the discharges are copious and
fetid.   It not only changes the unhealthy condi-
tion of the parts, but affords marked relief to the
pain.   If the case be beyond the reach of art, life
may be prolonged and  comparative comfort  af-
forded by the frequent employment of these local
applications, in connexion with anodyne and de-
mulcent injections, and  the proper regulation of
hygienic means.  We  have in some  instances
seen the best effects from a pill of rhubarb, iron,
and quinine ;  and in two cases. Fowler's solu-
tion of arsenic seemed to arrest the disease.   It
is better, however, to treat the disease  on general
principles than to trust to any supposed specifics.
It must, however, be acknowledged that, as yet,
cancer of the uterus must be ranked among the
epprobria medicorum.
  Excision of the neck of the uterus has been  re-
peatedly practised, both in this country and Eu-
rope, for cancer of this  organ; and Dr  Simpson
is an advocate for the operation under the follow-
ing  circumstances:  1st, great  morbid hypertro-
phy, by elongation of the vaginal portion of the
cervix  uteri; 2d,  corroding ulcer, when limited
to the lips ofthe cervix, and pathologically iden-
tical with the form of lupus or malignant  ulcer,
so  well known on the  face ;   3d, circumscribed
and local forms of carcinomatous  disease, or ex-
crescence of the lips  and lower  segment of the
cervix uteri.   Few, however, will  coincide in the
opinion that simple hypertrophy ofthe cervix ei-
ther justifies or requires so severe an operation,
and the generally insidious and irregular  prog-
ress of corroding ulcer seldom  renders it amena-
ble   to  operative  treatment.   We would rather
say that excision ofthe cervix should be confined
to cases of epithelial cancer, in which we  know
that a removal of the entire diseased part often
effects a permanent cure ;  for  it is of these that
M.  Paget remarks that,  " among all the cancers,
they present the  general or  constitutional  fea-
tures  of malignant disease in the least intense
form.   They commence at the  latest average pe-
riod of life ; they appear to be most  dependent
on  local conditions; they are least prone to mul-
tiplication in internal organs and they are asso-
ciated with the least evident diathesis or cachex-
ia."   In one case, Dr  Simpson has operated suc-
cessfully, conception having taken place within
ten  days after the operation.  The conclusions
of Ashwell are doubtless correct, viz., 1st, that
the  operation is an easy one ;  2d, that excessive
and dangerous bleeding is  not a necessary  ac-
companiment ; 3d, that in some instances, for the
time over which  subsequent observation has ex-
tended, cancerous ulceration of the cervix  uteri
has been cured by it.   The dangers are, hsemor-
rhage, uterine or peritoneal  inflammation,  ma-
lignant ulceration of the excised surface, or of
any portion ofthe diseased structure which may
have been left behind   We  can scarcely con-
ceive  of any circumstances which would justify
the extirpation ofthe entire uterus for a cancer-
ous affection ofthe organ ]
  Biuliog.  and Refer. —The Bibliograjihy and Refer-
ences which I have apponded to this article are almost
entirely modern; for it is only within a  recent period that
the diseases of the Uterus have been fully investigated.
- Sennertus, De  Morbis Mulierum, lib. iv., cap. i\.—J.
G. Prennel, Novo Artificio  Curandi proeidentim* Uteri,
i-.i Halleri Disput. Chirurg., t. iii.—P. C. Fabricius, De
Foetus vivi  Extractione  ex Utero  prolapso, in Halleri
Disp Chirurg., t iii.— J. E. Reinick, Dc Uteri dclapsu,
&c  in Ibid., t. iii.—F. B. Wachter, De prolapsu et inver-
sion^ Uteri, &c, in Ibid., t. iii.—A. Levret, Observ. sur
la Cure radicale de plusieur Polypes de la Matrice, 3d ed.
Paris, 17T1, plates.— J. Lynn, in  Med. Observ. and Inq.,
vol. iv., p. 3SS.— IU. Cockell, an Essay  on  the Retrover-
sion  of the Uterus, with cases  and  illustrations, 4to.
Lond., 17S5. — It. Cleyhorn, Inversion  of the Uterus, in
Med  Coinmunicat., &c, vol. ii.,  I>. 220.— J. G. Schmidt,
be Concrenientis Uteri.  Bait-, 1750, in Ilallei's Disp.
Med. Pract., t. iv.—J. G. Rceeder, in Ibid., t. iv.—Her-
biniaux, Traito sur divers Accouchem. Labor, ct sur les
Polypes' de la Matrice, 8vo, 2 vols.  Brux., 1T8J, 1793.—
E. Sandiforl, De Tumoribus Utero Anruxis,  in Observ.
Anat. Pathol., 1. i., cap.  8.—.4. Louis, Mom. sur les Con-
cretions Calculeuses de la Matrice, dans Mc'-m. de l'Acad.
Royale de Chirurg., 4to, t. ii., p. 151.—G.  L. Bayle, He-
marques sur les Llceres de la Matrice, in Journ. de Med.
de Leroux, Corvisart, &c, An. xi., t. v., p.  238; et Ibid.,
p. 6!; ct in Diet, des Sciences Mud., t.  vii., lSlu, p. 63.—
X. Merriman, on Retroversion of the Womb, 8vo.  Lond.,
ISDK_«/. F. Osiander, in Med. Chirurg. Zeitung, B. iv.,
ISOS, p. 170.— Richter, Synopsis Praxis Medico-Obstt trica?,
4:o.  Mosg.,1810  (Uterine Sound first recommended for
Displacement of Uierus by Osiander and  Richter.) —G.
Rees, Observations on the Diseases of the Uterus, 8vo.
London, 1305.— IK. Lambe, Inquiry into Constitutional
Diseases,  particularly Scrofula,  Consumption, Cancer,
and Gout, 8vo.   London, 1845, pluries; Additional Re-
ports on the  Effects of a Peculiar Regimen  in Cancer,
Scrofula, Consumption,  &c, Svo.  Lond., 1815. (Treat-
ment of Cancer Uteri by Vegetable Diet and Distilled Wa-
ter, &c.)—Paletta, Exercitationes  Pathologic*, &c, t. ii.;
it in Journ. des Progiei des  Sc.  Med., t. viii., p. 2C4.—
J.  Windsor, on Inversion of the  Uterus, in Transact of
Med. and Chirurg. Society, vol. x., p. 358.  —J. JSauche,
Des Maladies de 1'Uterus, Svo.   Paris, 1810;  ct dc-i Ma-
ladies pioprcs aux Femmes, 2 vols., 8vo.  Paris, 18.0.—
P. J. Roux. Sur les Polypes Uterins, dans Melanges de
Chirurg., 8vo.  Paris, ISO!).— Johnson, in Dublin Hospi-
tal Reports, vol. iii.—F. L. Meisner, Ueber die Po.ypen,
&c.  Leipz., Svo, fig., 18-0.—C M. Clarke,  Observations
on the Diseases of Females attended by Discharges, 2
vols., plates, Svo.  Lond., 1821.—Schmitt, Bemerkungen
ueber Zuruckbengung der Gebilrmutter bei Niehtschwan-
geren, Svo.  Wien, 1820.— C.  Wenzel, Ueber die Krank-
heiten der Uterus.  Mayence, fol., 1816, with plates.—E.
G. Patrix, Traito sur le Cancer de la Matrice et sur les
Mai. de Voies Lterines,  Svo.  Paris, 1818, plates.—F. G.
Kummer, De Uteri Steatomate Annot. quadam, insignis
ejusmocli Tumoris Observat.  Hlust., 4to.   Leipz., 1819.
—J. C. Y.  Joerg, Aphorismen  ueber die Krankheiti n des
Uterus, 8vo.  Leipz., 1819.—E. E.  v. Siebuli, Ueber den
Gebiirmutterkrebs, dessen Entstthung und Verhiitung,
&c, 8vo.  lierl., 1828.— J. B. Palttta, Mnliebria, in Kxer-
citaiiones  Pathologies, p. ii., 4to.  Milan, 1826.—Schmig-
hduser. Das Gebiiven nach der beobachteteii Natur, 8vo.
Stiasb., 1S-.5, p. 134. —It'. F. Montgomery, Cases of Can-
cer Uteri,  &c, in Dublin Ilosp.  Reports, vol. v , p. 412;
and in Dublin Journal of Medical t-ciences, Jiin. . sl2.—
Schmitt Ueber die  Zuruckbengung der Gebtirmntter,
8vo.   Wien, 1820. — Lallemand, in  Revue Med., t. ii., p.
191. 1824.— Moreau, in Ibid., t. ii., p. 46Z.—Bellanger, in
Ibid., t. i., p. 229, 1824.— J. M. Arnott in Med. Gazette,
June 11, 1836.  (On  Extirpation of Polipus.) — F. W.
Lippich, Observata  de  Metritide Sentica  in Puerperas
Grassante, 8vo.   Vien., 1824. —  S. Merriman, Synopsis
of Difficult Parturition, 4th ed.,  Svo.  London, 1820, p.
3i!6.   (Extirpation of Inverted Uterus.)—W.  P. Dewees,
on the Diseases of Female?, 8vo.  Lond., 1826.—E. G. J.
v. Siebold, De Scirrho et Carcinomate Uteri adjutis tri-
bus totius Uteri Extirpationis Observationibus, 4to, 1826,
with plates.—J. B. Dance, Observ. sur plusieurs Attect.
de 1' Uterus, dans Archives Gener. de Med.  Paris, 1829,
t. xx., et xxi.— Lair. Nouv. Mcthode du Traitement des
Ulceres, &c.,de l'l'terus, Svo.   Paris, 18C8.  (Advises the
use of a Uterine Sound.)—J.  C. A. Recennier, in Journ.
Gener. de  Medicine, t cix.. p. 91.  Paris, 1829. — A. X.
Gendrin, in Ibid., t. cix.  (On Extirpation of the Uterus.)
—R. Gooch, on the more important Diseases  of Women,
2d ed., 8vo.   London, 1831, p. 332 —Dance, in Archives
Gener. de  M'dicine, t. xviii.,  p. 286, 473; t. xix., p. 161.
 — Cassan, in Ibid., t. xiii.,  p. So.  —Putin,  in Ibid., t
xviii., p. 217.— Dance, in Ibid., t. xx., p. 521. t. xxi., p.
196.— Recamier, in  bid., t. xxi.,  p. 73, 23S   (On Extir-
pation of Ut) —Louis, in Ibid.,  t.  x.,  p. 337. — Luroth,
in  Ibid., t. xvii., p 403.  (On Softening of Ut. )-See also
Ibid., t. xx.. p. 281— M. Boivin et A. Duges,  Traite pra-
tique des Maladies de l'Uterus et  de ses Annexes, 2 vols.,
8vo.   Paris, 1S33, with  atl. of plates. — Hervet dc Chi--
goin, De quelques  Displacements de la Matrice. &c, in
Mem. de l'Acad. Roy. de Med.,  t. ii., 1S33,  p. 319.— J.
Roberton,  in Edinb. Med. and Surg. Journ., vol. xvi., p.
3'3.—F. Churchill, Dublin Journ. of Med. Science. July,
1S36, p. 442 ton Corroding Ulcer of Ut),  and Outlines 
BIBLIOGRAPHY  AND  REFERENCES.
1413
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eases peculiar to Women, selected from British Authors
previous to the  18th century; Sydenham  Society, &c,
8vo.  Lond., 1849. — T. Radford, in Dublin Journal of
Medical Science,  No. 34, p. 7 ;  No. 15, p. 215, 1837 (on tlie.
Manner in which Inversion of the Utirus is prcduceu);
also. Galvanism  applied to  the Treatment of  Uterine
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—M. Boivin  et Duges, Traito  Pratique des Maladies de
l'Uterus et de ses Annexes, &c, Svo.  Paris, 1833.  Atlas
in fol. — Pauly, Maladies dc 1'Uterus,  &c., Svo.   Pari^,
1^36.— B. Hooper, The Morbid Anatomy of the  Human
I terns and its Appendages, 4to.  London, 1S34.—J. C.
Zimmermann,  Erfahiungcn  und  Mittheilungen, &c,
ueber  Prolapsus und Carcinoma Uteri, &c, fol.   Leipz.,
1SC4, plates.—Teallier, Du Cancer de la  Matrice, de ses
Causes, de son  Diagnostic ct. de son  Traitement, Svo.
Paris, 1S30.—C.  M. Gibcrt, Remarques prat, tur les Ulce-
rations du Col de la Mutr.ce, in Revue Medicale, t. iv.,
1S37. p. 305; ct Mem. sur l'Erosion granulve  du Col dc
1'I'tents, i:i Ibid. —S. Ashwell, in Guy's IIosp. Reports,
vol. iii., 1SC8, p. 107.  (On Tumours of tie  Uterus, &c.)
—Duparcque, BritiLh and For. Med. Review, Oct., 183G,
p. 511; see  also Ibid., July, 180S, p. 71. — J.  Pou-ell,
Transactions of Med. and Chirurg. Society, vol. xii., p.
5.7.— J. Windsor, in  Ibid., vol. x., p. 358.—P. X. Scott,
in Ibid.,  vol. xi., p. 392. — Hunt, in Ibid., vol. xxi., p.
277.—Graham, in Ibid., vol. vi., p. C01.  (Inflammation
of Uterus terminating in Gangrene.)—J. Browne, Con-
tributions to the Pathology ofthe Uterus, in Dubl. Jour.
of Medical Science, vol. xii., p. G48.—Sal"mi, in Journ.
des Progres des Sc. M.'d., 2d ser., t. ii., p. 204.—J. Mack-
intosh. Practice of Physic, 4th ed., Svo.  Lond., 18C6, vol.
ii., p. 4C2, et seq.—Pauly, Maladies de l'Uterus, &c, Svo.
Paris, 1S26, p. 473.—J. Balbirnie, The Speculum applied
to the Diagnostic and Treatment ofthe Organic Diseases
ofthe Womb, &c, Svo.  Lond., 1830.— M. Treille, Mem.
sur  les Maladies dites Cancereuses de la .Matrice, 8vo.
Paris,  1S38.—Otterburg, Lettres sur les Ulcerations de la
Matrice ct leur Traitement, 8vo.  Par., 1839.—Duparcque,
Traito sur les Alterations Organiques de la Matrice, Svo.
Paris,  1839;  et Traite Theor.  et Prat, sur les Alterations
Simples et Caneereuses de la Matrice,2d ed., 2 vols., 8vo.
Paris, 1839.—A.  Vidal, Essai sur le Traitement Metho-
dique  de  quelques Maladies de 1'Uterus, 8vo.    Paris,
1840.  (Advises  chiefly Intra-vaginal and Infra-uterine
Injections.)—C. Waller, a Practical Treatise on the Func-
tions and  Diseases of the unimpregnated Womb, Svo.
London, 1S40.—R. Lee, Clinical Reports of Uterine and
Ovarian Diseases, p. 170; and on Fibro-calcareous Tu-
mours and Polypi of the Uterus, in Trans, of Roy. Med.
and Chiiurgical Society  of  London, vol. xix., p. 94;  in
Ibid., vol. xxxiii., p. 201 (on the Speculum Uteri); et in
Ibid., vol. xxxiii., p. 273; et in Ibid., vol. xxxiii., p. 274v
<On Ulceration ofthe Seek of Uterus.)—J. C.  W. Lever,
in Ibid., vol. xxii., p. 107 (Statistical Xotices of 120 Cases
of Carcinoma Uteri)  ; and  on Diseases  of the  Uterus,
8vo.   London, 1S43___H. Hunt  in Ibid.,  vol.  xxi., p.
277.  (On the use of Arsenic in some Diseases of  Uterus.)
— Gosselin. in Archives  Gener. de  Med.,  t. ii.,  1814, p.
129.  (On Ulceration ofXeck of Uterus.)—Busch, Sur les
Polypes Uterins, in Ibid., 1813,  t. ii., p. 355.—E. Ken-
nedy, in DHbl. Journ. of Med. Sci. for 1828.   (Hypertro-
phy of Cervix Uteri.) — Tanchou, Observat. de  Polypes
de l'Uterus,  in Gaz. Medicale de Paris, 1842, p. 714.-
Lisfranc, Clinique Chirurgicale de la Pitie, 8vo.    Paris,
1842, t. ii., p. 182, et seq.—M. Langenbeck, De Totius
Uteri Extirpatioue, 4to.  Gott., 1842.— J. C. W. Lever,  a
Practical  Treatise on Organic Diseases  of the  Uterus,
8vo.  Lond., 1813.—X. Amussat, Sur l'Anat. Pathol, des
Tumeurs  Fibreuses de l'Uterus, &c, Svo.   Paris, 1843.
— E. Pcrreira,  in Gaz.  Med. de  Paris, 1845, p. 71  —
Meisxtwr,  Frauenkrankheiten, 8vo.  Leip., 2 vols., 1845.
—J. Y. Simpson, in  Lond. and Edin. Monthly Journ. of
Medical Sciences for 1843.  (Advises the only useful and
practical  Uterine Sound.)—Warden, in II id., Dee., 1844.
— Cambernon, in Gaz. Med. de Paris.  1844, p. C5.  (Of
the Causes of Polypi and Tumours of  the Uterus.)— Co-
lomlat, on Diseases of Females, translat. by Meigs, Svo.
Phil.,  Ii45.-/f. Oldham, in Guy's Hospital Reports, 2d
ser., vols. vi. and xi.—E. Lacroix, De l'Anteversion et de
la Retroversion  de l'Uterus,  in Annal. de  la Chirurg.
Franc, et Etrang, t. xiii., p. 420.  Paris, 1SJ.5. — J. White-
head, Treatise on Abortion and Sterility, 8vo.  London,
1847, p. 47; and Diseases ofthe Uterine System,  2d edit.
ofthe work.  Lond., 18.r;4. — C. Rokitansky, a Manual of
Pathological  Anatomy, Sydenham  Soc. Transl.,  vol. ii.,
p. 204, et seq.—Marchal de Calvi, in Annales de la Chir.
Ang., 1S43.   {24 Cases of Fibrous Polypus of Uterus.) —
Menzies, in Glasgow Med. Journal, vol. i., p. 120, 18C3.
(Canes of Cancer Uteri and lJregi<aney.) — T. S. Lee, on
Tumours ofthe Uterus, Svo.  Lond., 1847. — Pancoast,
Boston Medical Journal, Oct., 1844.—.X G. Crosse, Es.-ay,
Literary and Practical, on  Iiiversio Uteri, 2 parts, Sv'o.
Lond., plates, U45 and 1847.—Smart, in Amer. Journal
of Medical Sciences, vol. xvi., p. 81.—G. Forbes, on In-
version ofthe  Uterus, in Transact, of Med. and Chirurg.
Society, vol. xxxv., p. 127.  (Account of numerous  Cases
of.)— W. F. Montgomery, on Polypus of the Uterus, in
Dublin Journal of Med. Sciences, Aug., 1846.—Huguier,
in Mem. de la  Soc. de Chirurg. de Paris, t. i.. 1847,  p. 35.
—R. Lee, Pract. Observations on Diseases ofthe Uterus,
2 parts, fol.  London, 1S49.—Lair, Des Abus de la Cau-
terisation, &c, dans les Maladies de la Matrice, Svo.
Paris, 1S:6.—Miller, in Edin. Monthly Journal of Med ,
Dec., 1851.  (Inversion of Uterus, a Case if.)—Walter,
I'cbcr Fibrose  Korper dir Gebiiimutter, 4o.   Dorpat,
1S52.—J. Paget, Lectures on Surgical Pathology, 2 vols.,
Svo.   Lond., 1653, vol. i., p. 173;  vol. ii., p. 131. — Har-
rier, in  Archives Generales  dc Medeeine, May, It-52 p.
10.   (Inversion of Uterus reduced under the Injuence
rf Chloroform.)—Braun and Chiari, Klinik der Gtbti;ts-
hiilfe und Gyniikologie, 2 parts.   Erlang., IS.' 3, p. 397.—
J. Y. Si.mpt.on. on the Detection, &c, of Intra-uterine
Polypi, &c, in  Edin. Monthly Journal of Medicine. Jan.,
18">0; and in Obst  trie  Memoirs, &c, vol. i., p. 122 (Dia-
tation by the Sponge-tent);  abo  in Dul.lm  Journal of
Medical  Sciences for 1848.   (Mi:placements of  Uterus.)
—Forget, Etude Pratique et Philosophique dn Col de la
Matrice, Svo.   Par., 1S49.— S. L. Hardy and M Cdnlock,
Practical Obser\at. in  Midwifery, p. 2.3.  (Inversionof
Uterus.) — Somn.er, Zur Lelue der Infractionen  und
1 loxionen der Gebiirmutter, 8vo.  Giessen, 1S50.—/•'. A.
Kiwis, h, Klinische Vortriige ueber Specielle 1 atl.ologie
und  Therapie der Krankheiten des Weiblichen Gescl.lec-
tes, 2 vols., Svo.  Prag, 1S46, '4S.  Dritte Auftage, nach
desten Tode fo.tgesetzt von F. W. Scanzoni, 3 b.. 8vo.
Prag, 1S51.T5.  tA Woi k of the hie,/ est Merit.)—Villcix,
Des  Deviations Uterines, Svo.  Paris, 1852. — Lee, Bul-
letin  de I'Academie  de M decine, t. xix., p. 77S,  et scq.
Paris, l,c53, 'f.4.  (Opjjosite opinions as to Displacements
of Uterus stated.)— 1 ire Iow, Utber die Knickungen der
Gc bi'.rmutter, in Verhandlungen der Getelbcbaft fur Ge-
burtshulfe, b. iv., 1S51, p. SO.— F. H. R msbo ham, Prin-
ciples and Practice of Obstetric Medicine aid Surge'y,
&c,  8vo.  Lond., plates, 1851, p. 720.   (On Inversion of
Uterus.) — J. Henry Bennet, Treatise on Inflammation
of the I terus, &c, 3d ed., Svo.   1 ond., 1853.  (An orig-
inal and able Work.)—A Review of the Present Stute of
Uterine Pathology, Svo.  Lond., 1S56.  (Ably and tem-
perately exposed.)— Lebert,  Traite des Maladies Cance-
remes, Svo.   Par., 1S51, p. '.17.—Genscul, Nolv. I  ro-edo
pour operer les Polypes de la Matrice, 8vo.  Lyons, 1-51.
— W. Busch, in Midler's Archiv., If 51,  p. £58. — E.J.
Tilt, on  the Diseases of Women, 8vo, 2d ed.  London,
1853; and on the Change of Life in Health and Liseat-c,
&c, Svo.  London,  1S56, chap,  vi.,  p. 132,  160.—F. W.
Mackenzie, Lond. Journal ot Medicine, vols. iii. and iv.,
Svo.  Lond., 1851, '52.—C. West, on the Pathological Im-
portance of Ulceration  ofthe Os Uteri, &c, 8.o.   Lond.,
1S54; and Lectures on the  Diseases  of Women, part i.
Diseases of the Uterus, Svo.   Lond., 1S56.  (Able and
interesting Lectures.)—J. B. Broun,  on some Diseases
if Women admitting of Surgical Treatment, 8vo.  Lond.,
1854.  (Practical and excellent.)—Velpeau, Maladies de
l'Uterus, 8vo.   Paris, 1S-54.—//.  Mller, Lectures  in Re-
ply to the Croonlan Le( tnres, for If 54, of C. West, of Lon-
don, on the Pathological Importance of LTct ration ofthe
Os Uteri, 6vo.  Louisville, U. S.,  1SC5. — W. T. Smith,
The Pathology and Trentm. of Leucorrhcea, Svo.  Lond.,
Iff 5. pluries.—J.  V.  Simpson, Obstetric Memoirs and
Contributions, edit, by W. O. Priestley and H. R. Storer,
Svo.  Edin.,  1S55, pluries. — T. F. Grimsdale,  Case of
Artificial Enucleation  of a large libroid Tumour of the
Uterus, with Remarks on the Surgical  Treatment of these
Tumours, in Liverpool Medico-Chirurg.  Journal,  No. 1,
p. 54.   (A very su cessful and interesting Case, with able
practical Remarks.)  For references of older dates than
those ofthe foregoing, see the works of Ploucquet and
Rfups.
  [Am. BtiiLtoo. and Refer.—There  are  but few  mono-
graphs  by American physicians on the subject  of the
Uterus and its  diseases, but numerous essays and cases
relating to this subject  are scattered throughout our nu-
merous medical journals.   Were the facts  which they
contain properly collected and digested, they would form
the basis of a very valuable work.  The principal au-
thors on this  branch of medical  science are  Dew ees,
Meios, Millf.r, and Bedford.  But the American  prac-
titioner bus access, through the medium of reprints, to
the best foreign works on Diseases of Females, such as
Ashwell, Gooch, Wast, Churchill, Simpson, Tyler Smith,
Montgomery, Colombat  de I'Isere, Bennet, &c, &c, &c.
The following are but a small portion of the references 
1414
VACCINATION—History  of.
 which might easily be made to works or papers connect-
 ed with the subject of this article.—C. D. Meigs, a Treat.
 on Acute and Chronic Diseases of the Neck of the Ute-
 rus, 8vo,  Phila.; also, Report on same subject, with col'd
 plates, in Trans, of Amer. Med. Assoc, vol. vi., p. 365,
 1S55; also, " Woman and her Diseases," " System of Mid-
 wifery," and Translat. of Colombat de I'lsere on Diseases
 of Females, &c, Svo, p. 719.  Philad., 1845.  (One of the
 ablest Works extant on this subject; more than 1000 writ-
 ers on tlie subject are quoted or referred to in its pages.)—
 Samuel Annan, on a New Method of Relieving Persons
 affected with Prolapsus Uteri, in Am. Journ. of Medical
 Science, vol xviii., p. 334. — W. L. Sutton,  Two Cases of
 Inversion of the Uterus, in Ibid., vol. iv., N. S., p. 83.—
 A. D. Chaloner, Fibrous Tumour ofthe Uterus, in Ibid.,
 vol. x., N. S., p. 75.— J. E. Taylor, on Rheumatism of the
 Uterus  and Ovaries, in Ibid., vol. x., p. 45; also, Cases
 of Engorgement of the Uterus, Irritable Uterus, and Pro-
 lapsus,  in N. Y. Journ. of Medicine, vol. iv., p. 70.—J. C.
 Beales,  Remarks on  Engorgement or Congestion of the
 Cervix  Uteri, in Ibid., vol. iv., p. 10.—Edward Rigby, on
 the Constitutional Treatment of Female  Diseases, 12mo,
 p. 25j.  Phil., 1857.   Uterine affections of every kind are
 regarded by this author as secondary, not primary, idio-
 pathic  diseases,  and  requiring chiefly constitutional
 treatment, especially purgatives, inasmuch as torpid  liv-
 er and constipated bowels are generally in fault.  Leech-
 es and caustic  applications to the cervix are not, how-
 ever,  wholly proscribed, as "solid lunar caustic" in ul-
 ceration.  In cancer uteri, sulphate of iron  and iodide of
 arsenic  are  recommended.   This writer also describes
 Prolapsus of the Ovary, it descending into the recto-vag-
 inal pouch—a rare affection,  we imagine___Chirles West,
 an Inquiry into the Pathological Importance of Ulcera-
 tion ofthe Os Uteri, Am. ed., Svo.   Phil.,  lS5r. — W. P.
 Dew.'es, a Treat, on Diseases of Females, 10th ed., 8eo, p.
 532, with  plates.  Phil., 1857.—Fleetwood  Churchill, on
 the Diseases of Women, &c, Amer.  ed., by D. Francis
 Condie, 8vo, p. 684   Philad., 1857.—Samuel Ashwell, a
 Pract. Treatise on Diseases peculiar to Women, 3d Am.
 ed., 8vo, p. 530.  Phil., 1S57. —Henry Bennet, a Pract.
 Treatise on  Inflammation of the Uterus, its Cervix, and
 Appendages, and on its connexion with Uterine Disease,
 4th Am. ed., 8vo, p. 430, with wood-cuts.   Phil., 1857.—
 J. B.  Brown, on some Diseases of Women  admitting of
 Surgical Treatment, with  cuts, Am. ed., 8vo.  Philad.,
 1857.—J. Leconte, on Carcinoma, in New York Lancet,
 p. 2S4, 299—J.  B. Strachan, Case of successful  Excision
 ot the Cervix Uteri in a Scirrhous State, in Am. Journal
 of Medical Science,  vol. v., p. 307. — Edwmrd John Tilt,
 Dis. of Menstruation and Ovarian Intiam. in connexion
 with  Sterility,  Pelvic Tumours, and Affections of the
 Womb, Svo.   N. York, 1850.—Gunning S. Bedford, The
 Diseases of  Women  and Children, 4:h ed., Svo, p. 602.
 N. Y., 1S5.\— H. V.  Wooten, a Case  of Procidentia Uteri
permanently cured by Excision ofthe Vaginal Fold, with
Remarks, in  South. Med. and Surg. Journ.,  Augusta, vol.
i., p. 310.—G. G. Smith, a Case of Uterine  Hydatids, in
Ibid.,  vol.  i., p. 250. —J. M. B. Harden, Cass of Proci-
dentia Uteri during  Labour, in which artificial  means
were necessary to effect delivery, &c,  in Ibid., vol. i., p.
24S.—J. Painchaud, a Remarkable  Uterine Tumour, in
Bost. Med. and  Surg. Journal, vol. xix., p.  265.—James
McKeen, Case of Retroversion ofthe Uterus, in Ibid., vol.
xii., p. 201.—J. C. Warren, Extirpation of half the liodf
of the Uterus and a portion of the Vagina for Cancer, in
Ibid.,  1829.—T. B. Toby, Case of Prolapsus Uteri, in Am.
Journ. of Med. Science, vol. iv., p. 532.—B. Smart, Case
 of Inverted Uterus, in Ibid., vol. xvi., p. 81.— W. L. Atlee,
 Case of successful Extirpation of a Fibrous Tumour  of
 the Uterus by the large Peritoneal Section, in Ibid , N.  S.,
 vol, ix.—E. Fisher, Inversion of Uterus, in  Illinois Med.
 and Surg.  Journ., Dec, 1S45.—D. P. Condie, Review  of
 J. H.  Bennet on Dis. of Uterus, in Am. Journal of Med.
 Science, vol. ii., N. S., 1840.— W. P. Buel, Report of Dis.
 of Females,  treated  at New York Dispensary, in Ibid.,
 vol. vii., N.  S.,  p. 96.-3'. J.  Garden,  Polypus of Uterus
 expelled by Ergot, in Ibid., vol. vii., p. 303.—E. Warren,
 Iutlam. of the  Uterus, in Bost. Med. and Surg.  Journal,
 vol. xxxiii.,  1845. — T. Chadbourne, Polypi and Malig-
 nant Tumours, in Ibid., vol. xxxii.—L. Perkins, Uterine
 Tumour, in  Ibid., vol. xxxii., p. 370. —S. Sargent,  on
 Operation for Uterine Tumour, in Ibid.—D. Gilbert, Re-
 moval of Uterine Tumour, in  Bost. Medical  and Surgical
 Journal, vol. xxxi., p. 249—J. Pancoast, Successful Re-
 moval of a large  Fibrous Tumour from the Uterus, in
 Ibid., vol. xxxi., p. 1S9.—Jas. Deane, Polypus in Utero,
 in Bost. Med. and Surg. Journ., vol. xxx., p. 449___J. F.
 Gray, on Prolapsus  Uteri with reference to the Modus
 Operandi of Dr. Hull's Utero-Abdominal Supporter, in
 Trans, of Med. Soc, State of New York, vol. iv., p. 31__
 J. Chapman, Retroversion of Uterus relieved by Percus-
sion, in Maryland Med. and Surg. Journal, 1842.—Drs.
 Hermann  and Werneburg, Case of Extirpation of Uterus
 for Cancer, in Boston Med. and Surg. Journ., vol. xxvii.,
 p. 307.—C.  Waller, Treatment of Cancer of the Womb, in
 Ibid., vol. xxiii., p. 10.— D. V. Folts, Osteo-Sarcomatous
 and Fibrous Tumours of the Uterus, in Ibid., vol. xxii.,
 p. 325.  (A very interesting Case of true Oxteo-Samnna-
 tous  Tumour of the  Uterus.) — B. Carpenter, < uses of
 Uterine Inflammation, in Ibid., vol. xvii.,  p. 233.— Jos.
 Warrington, Translation of Duvnrcque. on Diseases of the
 Uterus,  with  Notes,  8vo,  p. 455.  Philadelphia, 1837.
 (An excellent  Work.)—J. Ward, Congenital Retroversion
 of the Uterus, in Boston Med.  and Surg.  Journal,  vol.
 xviii., p. 270.^.1f. Hibbard,  Case of Uterine Tumour re-
 moved by Operation,  in Boston Med. and Surg. Journal,
 vol. viii., p. 68.—Jos.  Comslock, Case of Inverted Uterus,
 in Ibid., vol.  viii., p. 245.   (Caused by pulling on the
 Cord; no res'orahon took place, but regular Menstruation
 occurred afterward.) — J. Cotton, Case of Cartilaginous
 Cervix Uteri,  requiring an Operation to accomplish  De-
 livery, in Ibid., vol. iii., p.  28. —J. F.  Peebles, on Dis-
 placements of the Non-gravid  Uterus,  their Local arid
 Constitutional Effects, and  their best modes of Treat-
 ment, Fiske Fnnd Prize Dissertation, in Am. Journ. of
 Med. Sciences, July, 1853.   (A very comprehensive and
 valuable Essay.)—O. C. Gibbs, on Polypus Uteri, in Am.
 Medical Monthly, April, 1854.  — W. C. Roberts, on  the
 Isolated Tumour of the Uterus, commonest on the poste-
 rior wall, in N. Y. Journal of Med., vol. iii., p.  191).—£
 R. Gilman, on some  Diseases of the Os Uteri,  and  the
 mode of investigating them, in Ibid., vol. iii., p. 181;
 also,  Case of Corroding Ulcer of the Uterus, with com-
 plete Destruction of all the Internal Organs of  Genera-
 tion,  in Am. Journ. of Med.  Sciences, vol. ii., N. S., 1S41.
 — J.  V.  P.  Quackenbush, Case  of R moval of  Uterine
 Polypus, in Ibid., vol. ii., p. 13. — W. H Hanhitt. Case
 of Hydatids of the Uterus,  in Ibid., vol. ix., p. 49.—;v.
 R. Davis, an Essay on the Nature and Curability of Het-
 erologous Tumours, in Ibid., vol. x., p. 3S2.—John II.
 Griscom, a Case of Abstraction of the Uterus after Deliv-
 ery, in N. York Joum. of Med., vol. i., p. 74.—John A.
 Sivett, an Essay on Cancer ofthe Uterus, in Ibid., vol. i.,
 p. 34.  (.1 very valuable Contribution to the Pathology of
 this subject.)—A. C. Post,  Ca.-e of Retroflexion of the
 Uterus, in Trans, of the Am. Med. Trans., vol. ii., 1S49,
 p. 253. — B. W. M'Cready, Case of Retroflexion of the
 Uterus, in Ibid., p. 255. —  Washington L. Atlee, Prize
 Essay, The  Surgical Treatment of certain  Fibrous Tu-
 mours of the  Uterus  heretofore considered beyond the
 resources of Art, in Trans, of Am. Med.  Assoc, vol. vi.,
 p. 547, 1S53.—J. K. Mitchell, Case of Racemiferous Hyd-
 atids of the  Uterus, in Med. Exam., vol. i., p. 7.1,1S45.—
 E. A. Halyoke, The History of a Retrovert.d Uterus, in
 Com.  of  Mass. Med. Soc, vol. i., p. 13.—George  Osgood,
 a Remarkable Uterine Case,  in Med. Com. of Mass. Med.
 Sue, vol. i., p. 30.— William Moore, Uterine  Hydatids, in
 N. Y. Med. and Phys.  Journ., vol. i., p. 151, 1S22.—J. C
 Hatch, Case of Inverted Uterus, in Boston Medical and
 Surgical Journal, vol.  xl., p. --77.]


 VACCINATION. — Synon. — Vaccinia   (from
  Vacca, a cow), Variola vaccinia;  Variola vac-
  ana; Vaccine,  vaccination.  Fr.   Kuhpocken,
  Schutzblattern, Germ    Vaccina,  Vaccinazione,
  Ital    Vaccine, Coio-pox
     Classif —III.  Class, III. Order (Author
       in Preface,  <$-c.).
  1.  Defin—Variola vacama—a vesicular dis-
ease  developed in the  human subject  by inocula-
tion of cow-pox, or of the lymph from the variolous
vesicles  affecting the cow
  2   I.  History of.—It would appear from an-
cient Sanscrit writings, that vaccine inoculation
had been practised in India from the earliest ages,
and  that the preservative influence of vaccina-
tion was known, and had recourse to, in different
parts of the East. Mr Bruce, Consul at Bushire,
states that vaccination was  well  known in Per-
sia for many ages    Humboldt found among the
inhabitants of the  Cordilleras of the  Andes the
belief that  the eruption on the udder of the cow
preserved them  from  small-pox.   These indica-
tions  of the  practice of vaccinations were, how-
ever,  unknown at the time  when Edward Jen-
ner,  a general practitioner in Berkeley, observed
the protective influence  of the  vaccine disease
from  the natural and  inoculated  small-pox, and
when he submitted  this  influence to the tests  of
experiment and  practical observation   In 1775 
VACCINATION—History of.
1415
 Dr. Jenner remarked, that a number of persons
 in Gloucestershire could not be inoculated with
 small-pox : and, having become aware that there
 was a popular belief that persons who had caught
 the cow-pox, from milking  the cows, were not
 subject to small-pox, he was induced to investi-
 gate the grounds for this belief.  In the course
 of his researches, and after encountering numer-
 ous  difficulties  and  opposing  opinions, which
 would have  discouraged all but those who pos-
 sessed a determined will and powerful genius, he
 found  that the  cow was subject to a variety of
 eruptions on the teats, all of which  had received
 indiscriminately the name of cow-pox.  He  learn-
 ed to distinguish between these, and ascertained
 that one only was possessed  of a specific protect-
 ive power over the human body.   This he  called
 the true cow-pox,  the others the spurious.  He
 next ascertained that the true cow-pox underwent
 progressive changes; and that it was only at one
 period of its progress, or in the acme of eruption,
 when it was endowed with specific or preventive,
 or anti-variolous properties.    During the investi-
 gation of this branch of the  subject, Dr. Jenner
 was struck with the brilliant idea that it might be
 practicable to propagate the disease by inocula-
 tion, first from  the cow, and successively  from
 one human being to another.  It was  not, how-
 ever, until 1796 that he was enabled to take the
 decisive step of  inoculating for the cow-pox, upon
 the success of which his grand scheme mainly
 rested.   An  opportunity of testing  his ideas by
 satisfactory experiments was not afforded him un-
 til that year, when cow-pock matter in an active
 state was found, and parents were met with pos-
 sessing sufficient confidence to submit their chil-
 dren to the important trial.   On  the  14th of May,
 1796, James  Phipps was vaccinated with matter
 taken from  the  hands  of  Sarah  Nelmes.    He
 passed through  the disorder in  a  satisfactory
 manner, and  was tested by variolous inoculation
 on the first of July following.  The small-pox in-
 oculation took no effect.   Jenner now prepared
 to communicate the result of his long investiga-
 tions concerning cow-pox, but delayed his  work
 in the hope of furnishing additional proofs ofthe
 success of vaccination.  These  he  was enabled
 to procure; and in June, 1798,  he published, in
 London,  his  original  essay,  entitled,  " An  En-
 quiry into the Causes and Effects ofthe Variolar
 Vaccinas; a  Disease discovered in  some of the
 Western Counties of England, particularly Glou-
 cestershire, and  known by the name  of the Cow-
 pox."   This  work  deserves  a particular notice.
 In it Dr. Jenner states his  belief that this dis-
 order does not originate in the cow, but is com-
 municated to this animal from the horse, where
 it  appears on the heels, and is known by the name
 of the grease;  the  hands of farm-servants and
 milkers  being the medium  of  communication.
 He next suggests that  the small-pox itself may
 have been originally morbid matter of the  same
 kind, which circumstances had changed and  ag-
 gravated  into a  contagious  and malignant form
 He afterward states his conviction that cow-pox
 inoculation leaves the  constitution forever  after
 secure from  the infection of small-pox ;  and he
 concludes by enumerating four classes of persons
 to whom cow-pox inoculation holds out the pros-
 pect of great benefit: 1st. Those who, from family
predisposition, may be presumed  likely to  take
smallpox unfavourably ; 2d.  Persons of a scrofu-
lous diathesis ; 3d. Those who, from idiosyncrasy, I
resist small-pox inoculation  in  early life;  and,
4th. Those  who are  labouring  under  chronic
forms of disease, in which  counter-irritation is
desirable.*
  3. At the end of July,  Mr. Cline made the
first experiment with cow-pox in London, which
succeeded perfectly ; and soon afterward recourse
was had to vaccination  in  many  places.   In his
second  publication,  dated  April, 1799, Dr.  Jen-
ner judiciously recommended calmness and mod-
   [* Some vaccine virus was forwarded by Gro. Peak-
 son, of London, to Dr. David Hosack, of New York, in
 the year 1797; but the discovery was not announced in
 the United States till 1799, in the Medical Repository of
 New York.  In July, 1800, Dr. B. Waterhoue, of Cam-
 bridge, Massachusetts, first  successfully practised vac-
 cination in this country on four of his own children.  Dr.
 Valenti>e Seaman was conspicuously active in intro-
 ducing the practice into the  city of New York.  He ob-
 tained the virus from Dr. Watei house, and with it vac-
 cinated his own son and  many others.  From this time
 forward the practice became general.
   An act was passed in Massachusetts, in 1810, providing
 that " it shall be the duty of every town to choose per-
 sons to superintend the  inoculation of the inhabitants
 with the cow-pox." This law was repealed in 1836, and
 the Revised Statutes provide "that each town may make
 provision for the inoculation of the inhabitants."   This
 change, as Mr. Sha-ituok states (" Rejiort of the Sanitary
 Commission of Massachusetts."  Boston, 1850, p.  180),
 leaving it optional with the towns to do or not to do it,
 has probably caused the  loss of many lives.  Under the
 operation of the old law,  many towns were accustomed,
 once in five or more years, to have a general vaccination
 of the  inhabitants; but this custom, it is stated, has been
 generally discontinued, and the inhabitants are left liable
 to the disease from every fresh exposure.  The same re-
 mark  will apply to most of the States, and  even large
 cities  that have independent boards of health.  Boston
 has provided  that no child shall be admitted into the
 public schools without a certificate from some physician
 that it has been vaccinated.   It also, as well as New York
 and most of our cities, provided for the gratuitous vacci-
 nation ofthe poor; but the means provided are very in-
 adequate to the end proposed.  It is not yet safe exactly
 to presume on the intelligence of the lower classes in our
 large cities; and as long as this is the case, compulsory
 measures  will be necessary.  Not  only cities, but all
 towns  and villages, however scattered the population,
 should have local boards of health, acting under a gen-
 eral State law, empowered, among other things, to pro-
 vide for and enforce, if necessary, a general vaccination
 of the inhabitants as often, at least, as once in five years.
   Strange, indeed, it is, that  no police or sanitary regu-
 lations exist regarding the spread of small-pox in many,
 if not all  our large cities.  In New York city, a small-
 pox hospital has been provided on Blackwell's Island for
 the poor who may be attacked with small-pox; but re-
 moval  thither is not made compulsory, nor are the sick
 from this disease placed under any quarantine whatever.
 So in Boston.  Since the laws relating to small-pox in
 Massachusetts were repealed in 1837, no more restraint
 has been laid upon persons sick with this than any other
 disease, and the consequence is, it is rarely, if ever, ab-
 sent from the large cities. During more than 30 years
 prior to 1807, the  disease caused but 37 deaths in Boston
 only, and most of these were at Rainsford's Island; very
 few cases ever occurred in the city.  But during the 12
 years ending Dec. 81, 1849, since the repeal, it caused
 the deaths of 533 persons; and in the first six months of
 1850, 146 died with it  There can be no doubt whatever
 that the prevalence of this disease  in our large cities
 might  be  nearly, if not  altogether, prevented.  They
 should  be  divided into small districts, a health-warden
 appointed for each, who is a medical man, whose duty it
 should  be to visit every family, whether invited or not,
 and to vaccinate or revaccinate every person, if necessary
 or expedient.  By this plan the disease would soon dis-
 appear.  If a case of small-pox should occur, means
 should  be taken for its isolation, or removal to a small-
 pox hospital, or to a safe position out of the city.  The
 600 lives which are annually lost in New York city by
 this disease might in this way be saved, as well as the
 expense imposed on the city for the support of small-pox
 widows and orphans. In the present state of our knowl-
 edge on this subject, it is safe to say that every State,
 city, ur town, which docs not interpose its legal authority
 to  exterminate the disease, incurs the responsibility of
 permitting the destruction of  the lives and health of its
citizens.] 
1416
VACCINATION—History of.
eration in researches into the efficacy of cow-pox
inoculation ; but in 1800 he expressed his con-
viction that the cow-pox is capable of extirpating
small-pox from the earth; and in his fourth pub-
lication, May, 1801, he again expressed the same
sanguine opinion.   The commencement of this
century was remarkable for the progress of vac-
cination.   In 1801 upward  of six  thousand
persons had  been  vaccinated,  and  the greater
part had been tested with small-pox.   In  1800,
1801, and 1802, vaccination  was introduced into
France, Germany, Italy, Spain,  and  the  East
Indies.  In 1802, Parliament voted  Dr. Jenner
a reward of £10,000 for the discovery, and  in
1807, the additional sum of £20.000 ; and in 1808
vaccination was  taken under the protection  of
Government
  4. In 1809, Mr.  Brown, of Musselburgh, pub-
lished the opinion that the prophylactic virtue  of
cow-pox diminished as the time from vaccination
increased.  In 1818 and '19, an epidemic small-
pox  pervaded Scotland, and  many vaccinated
persons passed through a mild form of variola.
The term " modified small-pox" was now adopt-
ed.    Dr. Monro,  in  1818,  published a volume
on  "the different kinds  of small-pox,  and espe-
cially on that which sometimes follows vaccina-
tion;" and in 1820, "An Account of  the Varioloid
Epidemic"  was published by Mr. Thomson,  of
Edinburgh.   Between this date and 1823,  when
I wrote on the subject,  as well as subsequently
to the latter  year, some very  remarkable  cases
came before me in both  public and private prac-
tice, occurring in the same and  in different fam-
ilies,  proving the  impairment  of the  protective
influence of vaccination with the growth of the
body, and  the lapse  of time,  until it  entirely
ceased,  at least  in many cases,  after puberty,
when vaccination was performed in infancy.
  5. In 1825  the  Bills of Mortality announced
1300 deaths  by  small-pox,  among  whom were
several persons who had been vaccinated. Small-
pox was epidemic in France  in  1826 and '27,
and in the  northern parts of Italy in 1829 ; and
in consequence of  the numbers  of the vaccinated
who had been attacked by small-pox  more or less
modified or unmodified, the practice  of revac-
cination commenced in Prussia and the German
States, and was subsequently encouraged by their
governments.  This  practice has more recently
been voluntarily adopted by many in  this country
  In 1833-4, small-pox prevailed epidemically in
Ceylon, when a considerable number of the vac-
cinated died;  and it made great devastations in
Hindostan  on several occasions, both prior and
subsequent to this date, and  many of the vaccin-
ated have been carried off by it.  Dr.  Gregory
states that the admissions  into the Small-Pox
Hospital, in 1838, more than doubled the average
number received annually, prior to the discovery
of vaccination, and that two fifths of the admis-
sions consisted of  persons who  had  been vaccin-
ated.  Many had the disease severely,  and more
than twenty ofthe number died.  Recently Par-
liament has legislated on vaccination and  small-
pox, but in a way which is neither satisfactory to
our profession nor beneficial to  the community.
  6.  Having  now stated, from the history and
certain  of  the results of vaccination,  what has
been urged against it, and having, when treating
of  small-pox  and  variolous  inoculation, noticed
what appeared in favour of the latter (see Small-
pox, v  104-114), it now becomes a duty to ad
vert  to  the evidence which  opposes what has
been advanced both at this place and in that re-
ferred to.   The facts evincing the failure of vac-
cination in many cases, and ofthe impairment of
the protective influence of it with the growth of
the body,  and  with the course of time, are here
stated, with no disfavour to the practice  of vac-
cination, but with a due regard to what appeared
to be the truth as respects the results of this prac-
tice.   When treating of variolous inoculation, I
took  occasion to compare the results of it with
vaccination more especially as observed in East-
ern and inter-tropical countries.   Much of the
difference  and  of  the difficulty in   this  matter
must  be  attributed to  imperfect,  careless, or
abortive vaccination,  and  to the influence  of
small-pox, when prevailing as a severe or malig-
nant epidemic,  on  persons thus imperfectly pro-
tected
   7.  Among the more recent evidence in favour
of the protective influence of vaccination, there is
none which seems to deserve more attention than
that which has be.en furnished by Dr. Balfour.
His deductions  have been founded on the returns
of the Army, the Navy, and  the Royal Military
Asylum.   But although these appear very favour-
able, they  are actually not so much so as a mere
glance at  the tables he has given might evince;
for he adds up the aggregate numbers  of the
several years to which lie refers, and places these
numbers opposite  to  the  number of cases  of
small-pox.   It should be premised that  soldiers
are all protected by vaccination, or by small-pox.
Thus, from the returns forwarded annually to the
Army Medical  Board, during eight years,  from
the 1st of April, 1844. to the 31st of March, 1851,
inclusive,  he constructs the  following table of
cases of, and deaths from, small-pox, out of the
aggregate  strength, or rather the strength multi-
plied by the years:
Among troops serv-ing in	Aggregate strength.	e?	ji!	Annual ratio per K'O of strength	
		o S	!j	Cases	Deaths
The United King-	251,507 557,112 314 131 1,125840	£57 1fi1	5G 29	2 1SS •2S7 ■08.) "lie i"	■2C0 •f5-J •0-5 OglT
Temperate Colo-					
Tropical Colonies Total........		28 745	8 93		
  8  This table is, however, fallacious, as the ag-
gregate here given  is not the actual number of
different individuals, for the much larger propor-
tion, if not the great  majority, of the average
number of troops in these eight years (140,730),
are actually  the same  individuals enumerated
again and again, or even for several years, unless
the discharges and deaths have been remarkably
o;reat; while the number of cases  and of deaths
are the total amount furnished during the eight
years from among the  individuals  actually serv-
ing;  for it  cannot  be  shown that during these
eight years the army was formed of  1,125,840
different persons
  9. The fallacy now  pointed out exists in the
other tables, more especially in  that giving the
results as respects the Navy,  and from  it no  cor-
rect inference can be drawn.   His Report, how-
ever, of vaccination of the boys of the Royal Mili-
tary Asylum is a much more important document,
and this I adduce.  " Of 5774 boys taken on the
strength ofthe establishment from  its opening in
August, 1803,  to the  31st  of December  last 
VACCINATION—C
'OW-POX IN THE Cow.
1417
(1851),  1950  are  recorded as having  marks of
small-pox, 3636 marks of vaccination, and 188
no satisfactory mark of either.   The last having
been  all  vaccinated on  admission, there  were
1950  protected by previous small-pox, and 3824
by vaccination."
	E § 2	Of whom subsequently		Ratio per 1000.	
		M ■3 a.		Cases.	Deaths.
Boys with marks of Boys with marks of	1950 3824	12 27	4	615 7 0G	2-05 000
   It must be presumed that  the  boys leave the
asylum when they reach puberty  or manhood, or
before this latter epoch.  The results subsequent-
ly are not known, and cannot well be ascertain-
ed ; and let it be remembered, that the liability to
small-pox, modified or  otherwise, then becomes
greatest.  Nor should it be overlooked that expos-
ure to  the  infection of small-pox cannot be as
great in garrisons and in  an asylum as in the
general community.    Besides, when a case of
small-pox occurs  in  either garrisons  or  in an
asylum, it is removed to the infirmary, or other
places of seclusion;  whereas among the public,
with  few exceptions, a case, whenever it occurs,
becomes a focus of infection, from which the dis-
ease spreads in all directions among the unpro-
tected.*
   10.  There can  be no doubt  that  vaccination,
satisfactorily performed, with recent lymph of a
proper description—the vesicles having regular-
ly maturated, without  hindrance or accident, and
with a sufficient number of punctures—is a most
valuable protection from small-pox ;  and if this
protection be not  afforded during the whole life
of the individual vaccinated, in some cases ; it at
least, in all, is a  protection for many years, the
variolous disease, when caught subsequently, not-
withstanding this  protection, being, with few ex-
ceptions, a comparatively mild disease—these ex-
ceptions,  especially when they are fatal, still ad-
mitting of doubts as  to the proper performance
of vaccination, and as  to the efficacy of the lymph
or matter employed.   It cannot, however, be de-
nied that the protection from small-pox furnished
by vaccination to  persons who have been vaccin-
ated in infancy, and have  grown up, is not so
fully manifested when small-pox  is epidemic, as
at other times ; nor does it appear to be as com-
  [* The above admissions cover about the whole ground
claimed by the strongest advocates for vaccination.  Dur-
ing a dispensary practice of several years among the poor
of New York city, where 500 deaths annually occur from
small-pox, I rarely met the disease among those unpro-
tected by vaccination, while it was very common among
others; and where it did occur among  the former, it was
rarely, if evei\ attended with any danger.   I might also
appeal to my own personal experience to prove that the
influence of the vaccine disease is not  wholly lost at pu-
berty; for having been vaccinated in early childhood, I
took the varioloid at the age of 26, from  attending a
small-pox patient, and had the disease in its very mild-
est form, not more than half a dozen pustules appearing,
and the constitutional symptoms very light.  As our au-
thor concedes that the vaccine disease "is a protection
for many years;" and as  all concede that it protects till
about the age of puberty, and that revaccination at that
period re-tores to the constitution that exemption from
small-pox which it previously enjoyed, while we have a
powerful argument in favour of revaccination, we lose
none of our admiration and appreciation of that great
discovery, whose unspeakable value and importance time
and experience only tend to confirm and establish.]
plete when vaccinated persons migrate to warm
climates, and are there exposed to small-pox in-
fection, as when they remain in temperate coun-
tries ;  but this requires farther inquiry.*
   11.  II. Of the Cow-pox in the  Cow—This
disease is not of frequent occurrence.  It appears
as an epidemic, and  rarely or never unless where
cattle  are collected  together in herds.   It  then
breaks out at irregular periods, and  from causes
unknown.  Dr. Jenner's experiments concern-
ing it were often interrupted by its complete dis-
appearance.   Dr. Jenner at first considered that
cow-pox in the cow was generally a local disor-
der confined to the udder ; and  such  it has ap-
peared to be in some, if not in many  instances.
Subsequent observations,  however,  have shown
that it is really a febrile  constitutional  disease,
accompanied with eruption, although the febrile
symptoms are often not  very manifest.  True
cow-pox shows itself on the nipple  of the cow,
in the form of irregular pustules, or more strictly
as vesicles  passing  into  a  pustular state.   At
their first appearance they are commonly of a
pale-blue colour, or  rather of a hue  approaching
to livid, and surrounded by an erythematous or
erysipelatous  inflammation.    They  sometimes
degenerate into phagedenic ulcers.   The animal
appears  indisposed,  and the secretion  of milk is
much  lessened.   The cow is subject to other
pustular sores on the nipples,  which are of the
nature of common inflammatory  sores, and pos-
sess no  specific quality.  They  do  not  present
any bluish or livid tint, or any erysipelatous red-
ness around  them.   They desiccate  quickly, and
create no apparent constitutional disorder in the
animal.   Such a complaint is frequent among
cows in the spring, when the calf  is suckling.
It was called by Dr. Jenner  the spurious cow-
pox.
   12.  Casual cow-pox in man is caught by milk-
ers of affected cows, and  appears on the hands
and  wrists in the form of inflamed  rpots, which
go on to suppuration, forming pustules  of a cir-
cular form, having elevated edges and  depressed
centres,  and are of a colour  inclining  to blue.
After  a  time  absorption takes place, and swell-
ings appear in the axilla.   Fever succeeds with
headache, sometimes with vomiting,  and  in some
cases with delirium.  The febrile symptoms de-
cline in three or four days; but the sores on the
hands often remain, very painful and difficult to
heal for a considerable time.  No  eruption oh
the skin follows the decline of the febrile symp-
toms.
   13.  III. Inoculated  Cow-pox. — i.  Regular
Cow-pox.—When vaccination  has been success-
fully performed on a healthy child, the puncture
may be felt slightly  elevated on the  second day ;
and on the third, and even on the second, a slight
efflorescence may be distinctly seen, by  the aid
of the microscope,  surrounding the inflamed
  [* In the 26th volume of the American Journal of
Medical Sciences I have described an epidemic  varioloid
disease, which occurred in  the town  of Gorhant, New
York, which, from the  great variety in the character of
the eruptions, gave rise to a warm and angry controversy
among  the neighbouring practitioners, some contending
that the disease was small-pox, others that it was vari-
cella.  A majority of those attacked had been vaccinated
in early infancy,  and, in general, the disease assumed a
milder form in proportion to the recency of the vaccina-
tion.  The eruption, in different cases,  had all the speci-
fic characters of varicella, varioloid, confluent and distinct
small-pox, pemphigus, purpura, erysipel s, and  even
other forms of cutaneous disease.   (See additions to art
"Small-pox," p. 898.)] 
1418
VACCINATION—Irregular  or Anomalous.
point.   On  the fifth  day a  distinct vesicle is
formed, having an elevated edge and a depressed
centre.   On the eighth day it appears distended,
with a clear lymph.   The vesicle on this, its day
of greatest  perfection,  is circular,  and  either
pearl-coloured or  slightly yellow.   In its form
and structure it resembles the pustule  of small-
pox.   Its margin is  turgid,  firm, shining  and
wheel-shaped.   It is composed of a  number of
cells,  by the walls and floors  of which the spe-
cific matter of the disease is  secreted.  On the
evening of the eighth day, an inflamed ring be-
gins to  form  around the base  of the vesicle,
which continues to increase during the two fol-
lowing days.   This areola, or ring, is circular, its
diameter extending  from  one to  three  inches.
When at its height, on the  tenth day, there is
considerable hardness and swelling of the  subja-
cent cellular tissue.   On the eleventh day the
areola begins to subside, leaving, as it fades, two
or three concentric circles of a bluish tint.  The
vesicle has previously burst, and its  surface ac-
quired a brown colour.   The lymph  which re-
mains becomes opaque and  gradually concretes;
so that about  the end of the  second week the
vesicle is converted into a hard, round scab, of a
reddish-brown colour.  This scab contracts, dries,
blackens,  and  about  the twenty-first  day falls
off, leaving a cicatrix, which is  permanent in
after life, is circular, somewhat depressed, stria-
ted, and indented  with six, eight, or  ten  minute
pits, corresponding  to the  number of cells  of
which the vesicle has been composed.
   14.  Slight  constitutional  disturbance  is  ob-
served about the seventh or eighth day, or some-
times  a little earlier.  The child is hot, restless,
or feverish, and the bowels slightly disordered;
but this subsides  in two or three days.  A  few
children, however, present no sign of constitu-
tional disorder, which is not  by any means es-
sential  to the  success of the vaccine process
About the  tenth day a papulous  eruption, of a
lichenous character,  sometimes appears on  the
extremities, occasionally extending to the trunk
of the body.   It  continues  for  about  a  week,
or even lasts after the scab has fallen off.   This
vaccine lichen  is  met  with  chiefly in children
of a full habit, where numerous vesicles  had been
raised on the arm, which discharge freely.  It is
an accidental occurrence, which, like  the  consti-
tutional irritation, indicates  a full effect of vac-
cination on the system; neither the one nor the
other, however, being deemed  requisite to ensure
such effect.
   15.  In adults, vaccination  exhibits the same
succession  of phenomena as  in  infants.  The
vesicles,  however, are thinner and more  easily
ruptured.   The lymph is usually of a yellowish
tinge, and the  areola  is  more extensive.   The
glands of the  axilla frequently swell, which is
rarely  observed  in children;  and constitutional
irritation is more frequent and greater.  Second-
ary lichen is less frequent and less marked.  Dr.
Heim,  of Ludwigsburg, considers that the adult
lymph -is more energetic than infantile lymph,
but this requires farther investigation.
   16. ii. The irregular or anomalous Vaccine Ves-
icle.— The above  normal course of the vaccine
vesicle is liable to be disturbed in various  ways,
and by various  causes.   Imperfect vaccination
presents no uniform sign, but exhibits different
appearances in different cases, such as  pustules,
ulcerations,  scabs, and irregular vesicles.   The
irregular vesicle is attended at its commencement
by urgent  itching; provoking scratching or rub-
bin"-, to which  the subsequent appearances are
unjustly attributed.   The  vesicle throws out a
premature efflorescence, and advances too rapid-
ly ;  so  that on  the fifth  day it has attained its
height, when  it will  be found raised on a  hard
inflamed base.   '• It is  accumulated, or conoidal,
and  gives the appearance of a common festering
sore produced by a thorn."  It is generally of a
straw colour, and contains some  opaque matter
or pus,  instead of a clear transparent  lymph.
The scab produced by it is small,  of an amber
colour,  and drops off by the tenth day.
  [We believe that too little attention is paid to
these irregularities and anomalies.   Where the
vesicle  has been broken, so  that the characteristic
marks of the disease are  wanting, where the lo-
cal inflammation is very severe and results in the
formation of pus, where there is a papular erup-
tion over the body of the child, where, especially,
the  operation is followed immediately,  or,  in a
day or two, by a pustule, without a previous  vesi-
cle,  irregular  in shape, yellow in  colour,  acu-
minated, easily broken, and terminating in a soft,
yellowish,  ragged-looking  crust,  falling off on
the  fifth, sixth, or seventh day, no confidence
should  be  placed in the genuineness of the dis-
ease, and revaccination should be performed at an
early period.  Too much caution cannot be ob-
served in this regard.  We believe that the spurious
forms of cow-pox are by no means uncommon in
this  country, and that to this cause  must chiefly
be attributed the loss of confidence in this prophy-
lactic,  and the still-lurking preference of some
for inoculation over vaccination.  These  irregu-
lar forms, it is true, are very common in cases of
revaccination;  but this only proves  that the in-
fluence of the  former vaccination is still expe-
rienced, and  that  the system is  still protected
from small-pox. There are  two kinds of spurious
vesicles ; the first  bears a strong resemblance to
the true in many  respects; its edges are com-
monly elevated,  its contents nearly limpid, and it
continues the usual time;  but it commences  with
a creeping scab  of a pale-brown or amber colour,
making a long, slow progress, sometimes unat-
tended by any efflorescence ; the vesicle is more
transparent, and the pellicle is generally thinner
and  easily  torn.  The second kind appears early
and  increases rapidly; is  elevated in the centre,
and  globular, with more or less the appearance
of a common phlegmon, and when punctured,
there issues opaque fluid, resembling what is pro-
duced in any  other festering sore.   It  is more
easily ruptured; at the sixth or seventh day, it
generally runs  into  a  perfectly purulent state.
The  areola is irregular  or notched, resembling a
large blotch ; has a fiery  or livid aspect; is not
shaded  off into  the  surrounding  skin; seems
rather to be under  than upon its surface, while,
at the same time, it is less  extensive, nor is the
hardness around it so evident; a ragged scab  pre-
maturely covers the vesicle, or, when the black
crust should form, a yellowish sore appears, dry-
ing and breaking out  again, with an oozing  from
under it.
  Imperfect vesicles are, in general, smaller and
more globular than the true kine-pock; they  have
not the turgid, convex  margin, but  a somewhat
punctured  base  appearing to slope off into the
surrounding skin ; they have not a cellular struc-
ture ; the contents 'are  not a clear  transparent 
                           VACCINATION—I

lymph, but  a  straw-coloured, opaque, or puru-
lent fluid ; the areola not defined, nor of so vivid
a rose tint, but  ragged and diffuse, appearing
about the seventh or eighth day, or earlier; on the
fifth or sixth, of a dark red colour, with less hard-
ness than the true areola, and disappearing soon-
er ; the succeeding crust is smaller,  of a light-
brown or amber  colour,  irrtgular and  friable,
forms earlier, separates sooner, and leaves an in-
distinct and not pitted  cicatrix.*]
  17. The causes of  this abortive .or irregular
vesicle are not well ascertained.   Sometimes the
bad quality of the lymph employed may occasion
the irregular vesicle, three  or  four children,  or
more, vaccinated from the same source, exhibiting
the same irregular appearances.   Dr. Gregory
supposed that it  might arise from the influence
of weather or season, as he  observed  it  in many
more cases  on the approach of  winter than  in
the spring or summer.   Some believe that this
irregularity  arises from the use  of lymph taken
at too late a period ofthe disease.  But although
lymph taken after the tenth  day will often fail to
reproduce vaccinia,  yet when it does  succeed,
the vesicle goes regularly through its course, and
is perfectly effective in preserving from small-
pox.  Besides, the scabs  of cow-pox, moistened
with a little lukewarm water, will often produce
the disease in all  its purity.
  18. Irregularity ofthe vaccine  vesicle is some-
times attributable to a  bad habit of body.  " The
proof is,  that one child only out of many vaccin-
ated with the same lymph, shall show  the anoma-
lous form of cow-pox.   It is a singular but very
important fact, that an imperfect vesicle, the off-
spring of a perfect one, degenerated by some pe-
culiarity  of habit in the  individual  vaccinated,
shall sometimes reappear in  all its original purity
and perfection, when transplanted into a healthy,
well-disposed subject."
  19  In some instances  the specific inflamma-
tion, or areola, is very severe, extends from the
shoulder to the elbow,  or even invades the trunk,
requiring recourse to cold lotions, active purga-
tives, and  febrifuges.   The vesicle,  instead  of
scabbing in  the natural way, is converted into  an
ulcer, discharging freely.  The inflammation thus
arising is, however, only temporary  ; and,  if it
have commenced  at its proper period,  it does not
appear to weaken, or  in any degree to  interfere
with the protective virtue ofthe vaccination.  The
vesicle about the fifth or sixth day occasionally
becomes  scaly; a species of psoriasis taking the
place of  the areola.   In a  few other cases  true
erysipelas supervenes.   These anomalies deprive
the cow-pox operation of all claim to protective
influence.  A  much  more frequent and success-
ful anomaly is retarded cow-pox ; the advance  of
the vesicle being without any apparent cause sus-
pended.  The areola does not form before the tenth
or twelfth, but ultimately the process  is complet-
ed, the success of the vaccination being in no de-
gree prejudiced.
  20. iii.  Complications of Cow-pox.—A child is
sometimes vaccinated after having been infected
by measles or scarlatina, and before their respect-
ive eruptions have appeared.  In such cases the
cow-pox  is generally retarded.   In a case record-
ed by Dr Gregory, it  was retarded sixteen days
while the measles ran their course.   Genuine
chicken-pox  (varicella  lymphatica) will  run  its
course along with cow-pox, without  interfering
          * See Labatt on Cow-pox, p. 90.
ecurrent Cow-pox.                      1419

with any of its  phenomena.  The modifications
which cow-pox undergoes when small-pox invades
the system about the  same time, are interesting.
When vaccination  is performed during the in-
cubative stage of casual small-pox, this latter be-
ing yet latent, the vaccine vesicle either does not
advance,  or advances  tardily and  imperfectly.
Sometimes, however, cow-pox and casual small-
pox may be seen running their full course in the
same person at the  same time.  In no case, how-
ever,  does the cow-pox so inserted modify the
course of the small-pox.    When the variolous
and  vaccine fluids  are inoculated on the same
day each disease occasionally proceeds, preserv-
ing its original character.   In some cases, how-
ever,  they  mutually  restrain and  modify  each
other.   The vaccine  vesicle in these  is smaller
than usual and irregular in its progress, while the
variolous pustules which follow are of the  kind
termed variola verrucosa, or commonly  swine-
pock, stone-pock, or horn-pock (see art. Chicken-
pox, v 2, et seq.); are  hard and shining, surround-
ed by little inflammation, and suppurate imperfect-
ly ; the little matter they contain being absorbed,
leaving the cuticle hard  and elevated for some
days afterward.  The eruption on the extremi-
ties does not pustulate, but is papulous, minute,
and terminates by desquamation.  Although the
eruption be modified  in most cases, there is gen-
erally considerable disturbance of the constitution
under the joint influence of the variolous and vac-
cine poisons.
   21.  When  vaccination precedes variolous in-
oculation by a period not exceeding four days,
both diseases  advance locally.  " Sometimes an
eruption of small-pox papulae follows.   At other
times the variolous fever is slight, and unaccom-
panied by eruption.   Under these circumstances,
matter  taken  from the primary  vesicles  shall
sometimes communicate cow-pock and small-pox
respectively;  but more commonly the variolous
poison predominates, and contaminates the lymph
ofthe  vaccine vesicle."  Variolous inoculation at
any period  not exceeding a week from the date
of vaccination will take effect and be followed by
a pustule : after that time no effect is produced.
Dr. Woodville on several occasions  inoculated
with a mixture of variolous and vaccine matter.
The result was not to be depended upon, but in
general pure small-pox succeeded.  When small-
pox  inoculation precedes by  three or four  days
the insertion  of vaccine lymph, the vaccination
advances, but  after  the tenth day the  fluid in the
vaccine  vesicle  becomes purulent, and in  that
state will communicate small-pox.  Those  who
have undergone variolous inoculation in early life
are generally  unsusceptible of cow-pox.   Vacci-
nation, however, in  such circumstances produces
a certain degree  of effect, the disorder manifest-
ing itself in an imperfect and modified form.  The
fluid in the resulting vesicles cannot be trusted
to for producing the genuine cow-pox.
  22.  iv. Recurrent  Cow-pox.—When cow-pox
has completed its regular course, the constitution
is left, for a very considerable time at least, un-
susceptible  of the same disorder.  But this law
does not obtain if the revaccination is  performed
at very short or at very distant  intervals:  (a)
At a very short interval, or on the fourth, fifth, or
sixth day after a regular primary vaccination, the
vesicles of the second vaccination are accelerated
in their course, so  as to overtake  the  first crop,
and the whole maturate and scab together.   The 
1420
VACCINATION—Nature  of Vaccinia.
 second crop of vesicles, however, is not more than
 one fourth the  normal  size, and the areola is
 equally contracted.   Mr. Bryce  (On Cow-pox,
 Edin , 1802) ingeniously availed  himself of this
 circumstance, and, by testing by revaccination on
 the fifth day, he endeavoured to ascertain the full
 influence  and actual security of vaccination.   The
 plan, well known  as Bryce's test, has been ex-
 tensively adopted.   To obtain this test in  greatest
 perfection, he advises the revaccination to be per-
 formed at the end  ofthe fifth or beginning ofthe
 sixth day ;  and  if no acceleration of the second
 crop of vesicles  be observed, it is to be concluded
 that no constitutional effect has resulted from the
 first vaccination.  The second is then to be re-
 garded as the primary affection, which, in  its turn,
 is to  be tested by  a third vaccination,  and so on
 until we are satisfied that the constitutional effect
 has been  fully  produced    Dr Gregory adds,
 that "some persons have claimed for this sugges-
 tion the highest honour,  and have even consider-
 ed  Dr. Jenner's discovery as incomplete without
 it.  Dr. Jenner, however, never laid much stress
 upon it.   In doubtful cases it is a prudent  prac-
 tice, but  it has been extolled far  beyond its  real
 merits.   It shows whether  or not constitutional
 influence  has been exerted by the primary vesicle,
 but it does not determine what has been the de-
 gree of such  influence—in other words, it  does
 not show  whether the constitutional  effect has
 been complete or otherwise."
  23. (b)  Revaccination  at distant intervals  from
 the date  of primary vaccination, is  deserving of
 notice.  Dr. Jenner, in his original essays, stated
 that the human body, after  a time, had the  sus-
 ceptibility of  cow-pox renewed.   Dr. Gregory
 describes  four different effects of revaccination at
 distant intervals:  1st.  In many cases,  especially
 if the interval from the primary to the  secondary
 vaccination has not exceeded five years, the  skin
 appears completely insensible to the vaccine  mat-
 ter ; 2d. At intervals exceeding ten years, the vi-
 rus irritates locally.  In three, or  at farthest four
 days from insertion, an areola of irregular shape
 appears around  a minute,  itching, acuminated,
 and angry vesicle.   The  glands ofthe  axilla fre-
 quently swell; and in particular habits of body,
 especially in adult females, irritative fever is su-
 perinduced.  A  scab forms on the  eighth  day,
which soon falls oft", leaving no permanent cica-
trix ;  3d.  In other cases, a  vesicle forms more
 gradually, without either local  or constitutional
irritation ;  a slight areola succeeds, and the vesi-
cle  yields, on the  seventh  day,  a  considerable
quantity of thin  lymph ;  but this  lymph  is inca-
pable  of propagating the disease ; 4th. In  this set
 of cases, the second vaccination runs a perfectly
regular course.  A circular areola forms on the
 eighth day, and the lymph propagates a genuine
cow-pox.
  24. IV.  Nature of Vaccinia.—The  Identity
 of Vaccine and  Variolous Disease.—When  Dr.
 Jenner announced vaccination as an antidote to
 small-pox, he  was strongly impressed with  the
 idea ofthe common origin of human and epizo-
otic maladies; and, conformably with  this idea,
 he viewed small-pox as the most remarkable mal-
ady which equally  affects  man  and the higher
animals; and  that this malady, in its less malig-
nant forms, assumes the  form of cow-pox, chick-
en-pox. and swine-pox.  This, however, had been
long a vulgar opinion, and  is somewhat analo-
gous to the view I stated when treating of scarlet
 fever, which, I remarked, had appeared within the
 last three hundred years, and was derived from a
 similar disease in the horse.  Jenner believed not
 onlv that small-pox and cow-pox were essential-
 ly  the  same disease, but that the  former was a
 malignant variety of the latter, the parental mal-
 ady being the cow-pox.   This opinion was  ex-
 pressed by the term variola vaccina, the name he
 gave cow-pox, when first introduced to the notice
 of the scientific community.  The  researches of
 Mr  Ceely have  more recently confirmed the in-
 timate  connexion Dr. Jenner contended for  be-
 tween cow-pox and small-pox ;  inasmuch as he
 has shown  that the inoculation of the  cow with
 variolous matter produces in that animal the true
 vaccine or cow-pox ; and that inoculation of the
 human subject with the vaccine matter thus gen-
 erated in the cow from variolous inoculation prop-
 agates  genuine cow-pox in man.  He has farther
 adduced some facts, which, however, require  far-
 ther investigation, but which appear to prove the
 origin ofthe cow-pox, or vaccinia, in the  infection
 of the  cow by small-pox when occurring  epide-
 mically or sporadically in human subjects. Among
 other observations, Mr Ceely states that he went
 to  examine some cows affected with cow-pox;
 and that  their proprietor, Mr  Pollard, "at  the
 same time, expressed his conviction that his cows
 had been infected from  human small-pox effluvia,
 to which he considered they had been exposed."
  25. The above facts, although scanty as they
 are, go  to prove the following :  1st.  That cow-pox
 originates  in small-pox infection  or contagion
 caught  by the cow ;  2d. That  the infection ofthe
 cow by  small-pox gives  rise to vaccinia—an erup-
 tion which  resembles the pustule  of small-pox,
 but  which cannot  communicate small-pox,  al-
 though  it propagates itself as true  vaccinia;  3d.
 That, unlike, or differing from, variola  or small-
 pox, vaccinia is not communicated, at least from
 the  cow to  man, or from one  human subject to
 another, by an effluvium or emanation proceeding
 from the affected at any stage of its course; 4th.
 That, like  variolous  inoculation, vaccination  is
 capable, when properly conducted,  of protecting
 from small-pox, with few exceptions, and at least
 for a considerable time ; 5th. That the amount of
 evidence favours the opinion  that  vaccinia is a
 modification of variola,  the modification proceed-
 ing  from  the  virus of the  latter having infected
 the  cow, and occasioned  the  vaccine eruption;
 6th.  That the amount  of evidence also favours
 the  inference that vaccination protects, at least in
 many instances, from small-pox only for an indef-
 inite time, and that the  length of that time is  in-
 determinate or indeterminable ; 7th That the du-
 ration of the protection may depend upon cli-
 mate and various unascertained circumstances,
 and  that there is reason to infer  that,  in such
 cases and  circumstances where the protection
 fails after several or many years, the impairment
 of the protective influence is gradual,  and pro-
 gressive with the duration of time.
  26. From the  foregoing it  will be seen that,
 while I  believe, with Dr. Jenner, in the intimate
 connexion of variola with vaccinia, and with chick-
 en-pox and swine-pox, yet we  have  no proof that
 variola has sprung from cow-pox ;  the  evidence
being in favour rather of cow-pox, and the other
kinds of pox  being varieties or species of small-
 pox, arising out ofthe passage of this latter mal-
ady through the  higher of the lower animals—
more conclusively of the passage of the variolous 
VACCINATION—Pr
morbid poison through the cow, as respects vac-
cinia.
  27. Such appears to be the relation subsisting
between cow-pox  in the  human subject and in
the cow and small-pox ;  it may next be inquired
what connexion  exists between vaccinia in the
cow  and the grease in  horses.  Dr. Jenner be-
lieved that they were both identical, and that cow-
pox  never occurs in dairy districts, except where
there is access to horses ;  he thereby denied the
spontaneous origin  of the disease in the cow.
Later  observations  have,  however, proved  not
only the identity of cow-pox and grease, but have
shown, at the same time, first, that cow-pox does
originate  in  the cow without access to  horses ;
and, secondly, that cow-pox  is communicable to
man from the horse without the intervention of
the  cow, and with nearly equal facility as  from
the  cow itself.   Dr. Gregory states that  this
branch  of the theory of vaccination has been in-
vestigated  with great diligence by Dr. Loy, of
Whitby, Dr. Sacco, of Milan, and Dr. De Carro,
of Vienna.   The last-named  author states, " that
the matter in use at Vienna from  1799  to 1825
was partly British vaccine, and partly originated
from the grease of a horse at Milan without the
intervention of the cow.   The effect was so sim-
ilar  in every respect that they were soon mixed ;
that is to say, that after  several generations, and
in the hands of innumerable  practitioners, it was
impossible to distinguish what was vaccine, and
what was equine."  " The whole British settle-
ments," he  adds, "were  equinatcd;  for the  first
liquid drop  sent thither was  the second  genera-
tion of Milanese equine,  or greasy matter, trans-
planted at Vienna."  It cannot be inferred that the
grease in  horses was the origin of variola;  and
there is as  little evidence of the  grease having
caused vaccinia in the cow, as there is of the lat-
ter having produced the former.  It is, therefore,
by no means improbable  that both vaccinia  and
grease, being capable of communicating and prop-
agating an identical affection, viz., that common-
ly called  cow-pox,  to human subjects  in  end-
less succession, are  variola modified in its  mani-
festations and properties by  its passage through
these two species  of animals.  The grease of
horses, being proved, or  admitted, conformably
with the  above evidence, to communicate  and_
propagate an affection in every respect  identical
with vaccinia, the  same inferences which I have
deduced respecting this latter, apply also to it, if,
indeed, this branch ofthe subject of vaccination be
not viewed as still requiring farther investigation,
more especially as respects the protective  influ-
ence of the  affection propagated from the grease
in horses.
  [If the researches of Dr. George Gregory
("Med  Chir  Trans." vol. iv., N S.) are to be re-
lied  on, the  morbid secretions of the cow, which
possess the power of protecting the human sys-
tem  against  the  assaults of small-pox, may be
produced in that animal  in four different modes.
1st  They  are  generated spontaneously in  the
cow, under certain circumstances of soil, season,
and locality, and are  often met with in cows soon
after parturition, in the spring  season, and when
feeding upon young grass;  but they arise also
spontaneously from other and less known causes,
and the  disorder spreads like other epizootic mal-
adies   It  was this form  of vaccine disease Jen-
ner chiefly studied.
  2d. The very same malady, developing the very
rECTivE Influence of.                    1421

 same morbid secretion, is often observed to spread
 by contagion, that is, by the application of the dis-
 eased secretion, thus generated, to the  teats of
 healthy cows,  differently circumstanced, by the
 hands ofthe milker.
   3d. The same morbid secretion, possessed of
 the same  qualities, is often generated  in the teats
 ofthe cow by the  application to  them  ofthe mat-
 ter formed by the heel  ofthe horse, when affected
 with  the  disorder called  "the  grease."   This
 greasy matter may also  be transplanted to man
 directly, without  the  intervention of  the  cow,
 proving that the anti-variolous property does not
 depend on any peculiar change which the  virus
 undergoes in passing through that animal.
   4th. The same morbid secretion may be excited
 artificially in the cow by applying to the teats, or
 the mucous surfaces ofthe vagina, vaccine lymph
 from the arm of a child, even though twenty years
 had elapsed  since that lymph had been human-
 ized or assimilated to the human constitution.
   5th.  To these four modes of exciting a morbid
 secretion in  the.cow,  called vaccinia, Mr. Ceely
 has added a fifth, by showing that the same object
 may  be attained by applying to the mucous sur-
 faces ofthe  cow the matter of human small-pox.
 The vessels ofthe part are excited to  the produc-
 tion of a fluid or humour, identical in  all its prop-
 erties with that which arises from a constitution-
 al and febrile  disturbance  of the cow's system
 from contagion, from the matter of grease, or the
 long-humanized vaccine  virus.
   Dr. Gregory supposes that other modes of ex-
 citing this morbid secretion  in the  cow  exist,
 which may yet  be  discovered, and that we are not
 justified in concluding that the  last  mode  men-
 tioned is  the most important, or as affording the
 true  clue to the mystery of vaccine  protection.
 This writer also contends that, as vaccinia is non-
 contagious, and febrile disturbance is not essen-
 tial to its perfect development, the  vaccine is prob-
 ably a poison sui generis, and its relation to vari-
 ola still hypothetical;  that the real and intimate
 nature ofthe protection it affords is still unknown
 to us ; and that a thorough knowledge of its anti-
 variolous  powers must be derived not  from analo-
 gy, but from  an extended and  careful  observation
 of facts, continued  through a long series  of years.]
   28. V. Protective Influence of Cow-pox.—
 This  subject  has occasioned much discussion dur-
 ing the last quarter of a  century, and  more espe-
 cially during the last few years ;  and  the amount
 of protection  which cow-pox affords against small-
 pox has been often entertained, bnt as yet by no
 means satisfactorily ascertained.—a. There are
 various circumstances  which render it most diffi-
 cult to determine  this  question ;  for the idiosyn-
 crasy of some individuals seems to oppose infec-
 tion by the  vaccine virus,  either for  a time or
 through life ; and, if such  an insusceptibility of
 the disease be admitted, it may be farther inferred
 that in others, the insusceptibility being less, the
 vaccine infection may be  incomplete, and the pro-
 tection afforded be proportionately imperfect.  It
 may be conceded  that, where the disposition in
 the constitution to receive the vaccine infection
 is either  wanting or incomplete, the protection
 must be equally deficient; and hence,  to estimate
 the protective influence of vaccination, it must be
 considered that the  process has  not been  duly
 completed, and that no protective influence  can
 be claimed from it,  unless the vaccine vesicles and
 the local phenomena proceed regularly, and leave 
1422                    VACCINATION—Pro-

a cicatrix, as described above.  But, independent-
ly of the indisposition of the constitution to re-
ceive the vaccine disease, or of the disposition to
receive it imperfectly, the health ofthe individual,
and the state of the  season or weather, may ren-
der vaccine infection either  abortive  or incom-
plete.   It has been proved that attempts to vac-
cinate have often failed in hot countries, and in
the warm localities of temperate climates, during
hot and dry states ofthe atmosphere ;  and a sim-
ilar temporary insusceptibility to small-pox inoc-
ulation, during the same state of atmosphere, has
been observed.  The impaired health of a person
also may render him insusceptible of vaccination,
until his health is restored; and  various  unas-
certained  circumstances  may have  the same ef-
fect, either permanently or for a time.   It may be
inferred, all things being considered, that, where
an insusceptibility to vaccination exists, an equal
indisposition to small-pox may be expected  ; but,
as a rule, there may  be many exceptions to this,
and it would be unwise to confide in it.
  29. b. Besides circumstances more immediate-
ly connected with the individual, there are oth-
ers depending upon the virus itself.   The vac-
cine lymph may be deteriorated by long-keeping,
or by a warm and  humid, or a very warm and
dry atmosphere, if it  be even  for a short time ex-
posed to these states of the air.   It may also be
either inert, or imperfect in its operation and con-
stitutional  as  well as local effects, owing  to  its
having been taken from the vaccine vesicles at a
too early, or a too late stage ofthe process of mat-
uration, as already noticed ($ 17);  or even to  its
having  been too long kept, or to its insufficient
protection  from the  action  of the atmosphere.
The manner in which the inoculation of cow-
pox is  performed—or the  efficient or imperfect
operation of inoculation—may in some way also
affect the results.  The number of the incisions
or punctures, and the actual deposit  of the vi-
rus within the  sphere of the action  of the ab-
sorbents or veins, may not merely produce  either
a full and satisfactory effect, or no effect at all,
but also an imperfect or an insufficiently protect-
ive effect.
  30. c. Imperfect vaccination has been referred
to a variety of causes.  It has been  very general-
ly supposed that the vaccine virus becomes dete-
riorated by its passage through numerous human
bodies, or that the protective influence is weaken-
ed by the length of time, and  the long succession
of subjects  through  whom it has  been perpetu-
ated, from its direct inoculation from the cow.
Of this, however, there appears to be insufficient
proof.   It has been  remarked, that persons who
have been vaccinated by  Dr. Jenner himself, be-
fore deterioration could possibly have commenced,
have nevertheless been attacked by small-pox in
after-life.   A recent  writer remarks, that, " so far
from believing in any deterioration of virus from
successive inoculation, there  is reason to believe
that, by a careful selection  of well-predisposed
children, the pock may even be restored from  an
imperfect to a perfect state, and by proper care,
therefore, may be retained indefinitely in that con-
dition.  If children  are  successively  vaccinated
from  each other, all of whom are from various
causes ill disposed to take on the perfect disease,
the virus may unquestionably degenerate, and at
length wear out altogether.  In tropical countries,
and in confined localities, such an occurrence cer-
tainly takes place, but this is very different from
tective  Influence  of.

 the notion of a virus deteriorated by the mere in-
 fluence  of time."
   31. d. Imperfect vaccination, as a cause of fail-
 ure of protection from small-pox, was much in-
 sisted on by Dr. Jenner.   Vaccination is said to
 be  imperfect  when any  considerable deviation
 from the ordinary course of the vaccine vesicles
 takes place.  The deviations from perfect vaccin-
 ation are imputed to one or more of the follow-
 ing causes:  1st.  To spurious matter, or matter
 taken from the arm at an improper period ofthe
 process ; 2d. To an insufficient number of vaccine
 vesicles;  3d.  To preoccupation of the  skin by
 some disease, in which a fluid is exuded capable
 of conversion into a scab, such  as tetter, scald-
 head, ringworm, erysipelas, &c.;  4th. To robbing
 the vesicle incautiously  of its contents, particu-
 larly when one only has come to maturity; 5th.
 External violence done to the vesicle, as rubbing
 or scratching it, especially during its early stages.
 That causes may, and often do, interfere with the
 success of the vaccine process, cannot be doubt-
 ed ;  but the influence imputed to them cannot be
 determined ;  for it has been proved, by very  few
 instances, it should be admitted, that vaccination,
 which, according to all indications, should have
 been considered perfect, has afforded only imper-
 fect or  only  temporary  security; while, on  the
 other hand, cases in which one  or other of the
 above causes has interrupted the regular process,
 have  notwithstanding  afforded perfect  security.
 The instances in  which single vesicles have pre-
 served from small-pox, both casually and by in-
 oculation, Dr. Gregory states to be so numerous
 that no reliance  can be placed on  the notion
 which would connect the security ofthe individ-
 ual with the  number of maturating vesicles.  A
 case of small-pox  after vaccination will sometimes
 occur in a member of a family, all of whom have
 been vaccinated in the same manner, by the same
 practitioner, and  having  similar marks on  the
 arm, and equally exposed  to contagion, that  one
 alone having become infected.   It should also be
 recollected that vaccination under the same  cir-
 cumstances, especially  of the members of  the
 same family, may, upon exposure to  small-pox
 infection, be followed by this malady, in  its vari-
 ous grades of modification, according to the time
 that has elapsed  from vaccination.  It has even
 been ascertained  that persons  have caught small-
 pox after having  been  subjected to Bryce's  test
 of the perfect constitutional affection of the orig-
 inal vaccination.  It should, however, be recollect-
 ed that these are  merely exceptions to the gener-
 al rule of protection; and as exceptions  have at-
 tracted  greater attention than those which prove
 the rule.
   32. e. The  presumed decadence of vaccine in-
 fluence and protection has been believed by many
 from an early period ofthe history of vaccination.
 Dr. Jenner, in his third  publication, in 1800, re-
 marked that there were some " who suppose that
 the security  from  small-pox, obtained  through
 cow-pox, will be of a temperary nature only. This
 supposition is refuted not only  by analogy with
 the habits of diseases of a similar nature, but by
 incontrovertible facts, which appear in great num-
 bers against  it."   That analogy may be consid-
 ered opposed  to  this supposition may be allow-
 ed, although the analogy is  neither very close
 nor very conclusive; but the facts opposed to
 it were certainly neither  strong  nor very mani-
 fest, inasmuch as time, the necessary element of 
VACCINATION—Prot
their manifestation, had not then elapsed.   That
Dr. Jenner was, however, convinced, or at least
most sanguine in this matter, is shown in his pe-
tition to Parliament, where he states that his dis-
covery had the "beneficial  effect  of rendering,
through life, the person inoculated with it perfect-
ly secure from the infection of small-pox."  He
rested his arguments as to the permanency ofthe
protection of vaccination upon  his belief, which
subsequent researches have  proved  to  be well
founded, in the identity  of vaccinia and variola;
but, even  granting  the  identity, a very marked
modification of the former from  the latter, by the
passage  of the  poison through the body of the
cow, must be admitted, the result being a conver-
sion of a frequently malignant and generally se-
vere malady, into a mild disorder.  Are we, there-
fore,  from the mere admission of identity thus
modified, to infer  protection by means of the
milder form of disorder 1  May it not be as justly
inferred, that whatever protection is  actually af-
forded by the milder form of the disease may pos-
sibly be sometimes overcome by the contagion of
the more severe malady 1 and that the protection
of the former, being weaker  or milder than that
furnished by the latter, may not be so endurable,
especially in  some constitutions and circum-
stances, and more  particularly if the  process of
vaccination has not been perfect or  complete in
all respects.*
   33. It  was admitted by Dr. Jenner, Dr. Wil-
lan,  and others, who believed in the permanen-
cy of vaccine protection, that, when the vaccine
process  has been imperfectly gone through, and
when, from some peculiarity of constitution, the
system receives only a  portion  of, or is insuffi-
ciently imbued  with, that  protective influence
which cow-pox is  capable  of imparting, then
" small-pox would  recur, and thus the degree in
which its phenomena were  modified was  pro-
portioned to the  degree  of perfection  which
the vaccine vesicle  assumed  during  its develop-
ment, "t
   34. This partial  protection from small-pox, ad-
mitted in the circumstances just stated, has, how-
ever, been extended by many to the more perfect
processes of vaccination ;  and  there are  many
medical men and others who believe that the pro-
tection is complete only for seven, or ten, or four-
teen, or twenty-one years ; but that the small-pox
caught after vaccination is modified in proportion
to the shortness of the time which  has elapsed
from vaccination ;  and that, after the longest of
these periods, little or no modification is observed.
This opinion has manifestly been pushed too far;
for it cannot be  correctly inferred that these facts,

   [* For this reason, laws  against inoculation exist in
most of the New England and Middle States, and ought
to exist in all.]
   [+ When we consider the numerous causes which mod-
ify the kine-pock, and may cause a failure  in the vaccin-
ating process, we Bhall not  be surprised at the frequent
occurrence of small-pox, or varioloid, among the vaccin-
ated.   Among the causes which modify the protective
powers of vaccinia, Dr. Gkegory enumerates puberty,
change of climate, a severe  attack of fever, and an epi-
demic constitution of the season.  Among the former
may bo reckoned, as most common, the employment of
virus before it has undergone sufficient elaboration, the
absence of constitutional affection from rupture of the
vesicle, and certain individual idiosyncrasies.  There is
no reason whatever for supposing that vaccine virus de-
teriorates by passing through numerous human bodies;
for the vaccine vesicle of Jenner is the true vaccine vesi-
cle of to-day, and the distinctive signs by which its in-
cubation and progress are marked are the same now as
they were then.]
■ective Influence of.                    1423

which have undoubtedly been often observed, es-
pecially in certain families and persons, in whom
peculiarity of constitution, irregularities or imper-
fections in the vaccine process and other circum-
stances, tending to account for the imperfect or
non-permanent protection, by  any means prove
that such imperfect protection exists in all cases,
or even in a very large  minority of cases.   The
circumstances  which  secure the desired protec-
tion, or which weaken it, or even destroy it alto-
gether, are  as yet not known with  sufficient pre-
cision, and  are such  as  admit of very different
opinions,  being undetermined on  this very  im-
portant matter.   It need only be inferred  that the
vaccine process should be studied, so as to secure
its perfection as far as possible, and in this state
that it should be generally practised with the be-
lief that, although not an undoubted, or an uni-
versal, or  always a  permanent protection from
small-pox, it nevertheless  proves a  permanent
protection in the great majority of instances,  and
that, where the protection fails, it  renders in  the
vast majority the small-pox a comparatively mild
disease.
   35.  It has been attempted to calculate the pro-
 portion of the vaccinated who take small-pox.   On
this topic it is impossible to arrive  at any approx-
imation to the true result.  The degree of sever-
ity of a small-pox epidemic, occurring in a com-
munity containing many vaccinated persons, may
be expected to influence  the result.  Dr.  Crosse,
in his account of the variolous epidemic of Nor-
wich,  in 1819, stated "that  ofthe vaccinated, not
more  than one in twenty will be  in any way af-
fected by the most intimate exposure to small-pox
contagion ;  and less than one in  fifty will have
the  disease in a form answering to the  general-
ly received descriptions  of modified small-pox."
These calculations may have been justified by the
epidemic  in 1819 ; but they cannot be viewed as
applicable to other circumstances, and more espe-
cially  to later periods in the history of vaccination
 and of small-pox prevalence.  This is  one of the
many instances in which statistics  cannot be con-
 fided in when  applied to  disease.
   [Owing to the large  number of unvaccinated
 immigrants into the  city of New-York, and per-
 haps  other causes, the  number of deaths from
 small-pox in this city has been for several years
 gradually on the increase.  The following are the
 number of  fatal cases of this disease for the  cor-
 responding years, taken from the city inspector's
reports:
|«*- «o			U. to	l<~ m	[«« n		I*- *		.
tl O^j									°3
		£			a: . ^		4 [ .^		
									
* N		£	zfi	> |*£	X lag		£ l|	><	*p
1804|1(U		^813	2	1822. 00	1831	224	1839 ~68	18471 53	
1805 6"		1814	2	18'3( 18	1832	S'	1841 232	ls48 544	
1800	4S	185 94		1824 394	1833	25	1841 200	1840 326	
1807	<<9	1810	197	18 5| 40	1834	233	1842 181	1850 231	
1808	6	1817	14	1826| 58	1835 358		1843 11"	1851 502	
1809	66	18 8	1'	18 T|140	1830 173		1844 21	1852 4(7	
1810	4	1819	00	18 8 93	18.77,164		1845 425	1=.R3 656	
1811	117	1820	00	18 9 16	1838 91		1846146	1854I	
1812	21	1821	00	1830 170			1 1	I	
Perhaps this increase in the number of deaths by
small-pox out of proportion to the increase  of
population may  be  owing more to some general
epidemic or atmospheric, or  other cause, than the
failure in the protective powers of vaccinia, inas-
much as we find also a great and corresponding
increase in the number of deaths from scarlet fe-
ver in the same city, as follows : 
1424                         VACCINATION—Small-pox after.
• c =s 18271 41 13 8 Hi 1S29 18-i, 183H 246j 1831 25SJ	u |"3.2 2 US > zs 153: 221 1833 179 lvi4 4'8 iS35 174 1836 202	4 1837 .83-5 1839 1840 1-41	57.Mi1S42 4 6 •25: 118 3 228 153 11844 227 3 1 11845. 63 36 i|| 1846'114	5 ■ — _^_l|| l84i|14-2 1S48 93 .849 266 ,850311 i851 627	£ 1852 1853 .851 1855 1856	° J3 6 * *£ 6t3 454
  36. VI.  Small-pox  after  Vaccination. — I
have  adverted  to this topic when  treating of
Small-pox (§ 38), but I may make a few remarks
respecting it which were then omitted.   Variola,
as it occurs after vaccination, is generally a mild
disease.  The pustules are usually small, hard,
and tuberculated, few of them maturating perfect-
ly.  Yet the small quantity of matter they do con-
tain commonly produces small-pox in others ; and
the exhalation  from the affected also communi-
cates the disease.*  This modified state of variola
is not usually followed by pits or  scars.  Cases
of much greater  severity do, however, occur, and
even assume the  worst of confluent forms, or ter-
minate  fatally, as I have observed on several oc-
casions.  In some  instances, a fatal termination
may be imputed to  the accompanying or second-
ary fever of small-pox attacking a delicate  or
scrofulous frame—or persons advanced in life, of
a plethoric habit, or affected by some visceral dis-
ease—or those predisposed to. or actually labour-
ing under, pulmonary or other maladies.  In such
case the physician perceives the true source of
the fatal result, while the friends  of the patient
impute  the  event to small-pox.  Soon after vac-
cination was introduced, cases of failure were im-
puted to imperfections in the vaccine process in
these cases ; and not unfrequently the varioloid
disease which followed was so slight as to induce
doubts  of its nature; and  very  probably there
were sometimes grounds  for  entertaining  the
skepticism.   But with«the lapse  of time, facts,
proving the failure  of the protective influence, be-
came more numerous, and were observed most
frequently among adults.   Dr. Gregory, who was
for many years physician to  the small-pox hospi-
tal, states that "  very few children have been re-
ceived into the hospital under such circumstances
(after vaccination); and those few have invaria-
bly had a mild Sisease, more allied to chicken-pox
  [* The late Dr. Fonav found a higher ratio of success-
ful vaccinations among  those who had previously had
small-pox than among those who had been simply vac-
cinated.  Thus, of those who had been vaccinated, there
were 141 succ-ssful, and 364 unsuccessful cases; 55 im-
perfect.  Of 71 who had had emall-pox previously, 2.1
were successful vaccinations, and 45 failures.  Of 52 who
had not been vaccinated, 25 were successful, and 27 fail-
ure-f.  Total, 686.  Thus he found that the successful vac-
cinations among those who had had small-pox amounted
to 1 in every 2\, while in the revaccinations this ratio
is only 1 in 4.  So, also, Dr. John Davy ("Malta Statis-
tics") shows that, although the influence of vaccination
in preventing small-pox was less than that of small-pox
itself in preventing a second attack, yet of those attack-
ed by small-pox after  having been vaccinated, the  mor-
tality was only 4-2 per cent., while the cases of recurrent
small-pox gave a mortality as high as 9-3 per cent.  So,
also, at the small-pox hospital of Philadelphia, in 1823,
'24, Drs. Mm-ii.vLi and  Hell report but a single death
out of 64 vaccinated;  3 died out of 9 who had been inoc-
ulated with variola; 3 died out of 7 who had had small-
pox before; and of 155 wholly unprotected, 85 died. So
of 14,470 persons who were attacked with small-pox while
it prevailed as an epidemic in France, in 1840,1683 died ;
out of -24 cases of recurrent small-pox, 3 died; while out
of 40J persons attacked subsequent to vaccination, but 6
cases proved fatal! proving that, while small-pox has a
mortality among the  unprotected of 1 in 8J, the vario-
loid affection is generally mild, seldom destroying more
than 1 in 100.]
than to small-pox :  whereas all the severe cases,
and the greater proportion ofthe mild ones, have
occurred in adults, in whom an interval varying
from  10  to 30 years  (the average  eighteen) had
elapsed since the date of vaccination."
   [Dr.  Stewart  (Ed  Med.  and Surg_ Jour.,
1840) maintains, 1st. That vaccination affords an
imperfect protection from small-pox at all periods
of life;  2d.  That the  protection becomes more
imperfect as the,individual advances in life; 3d.
That at  the age of puberty the influence of vac-
cination (provided it has been had recourse to in
infancy) nearly  ceases—at any rate, in  the ma-
jority of cases, at the age of 20, vaccination, he
thinks, ceases to exert an,y protective  influence
whatever.  These  conclusions, it is stated, are
confirmed by Dr. Gregory, of the London small-
pox hospital, in a letter to the author.
   The benefits, however, of vaccination in pro-
tecting against attacks of small-pox will be very
manifest when we look at the record of orphan
asylums, and other institutions for the receptancy
of children, where the greatest care is  bestowed
on vaccination.  In the orphan asylum of Charles-
ton, SC, which in 1829 contained 150 children,
not a single case of small-pox or varioloid occurred
during the prevalence of that disease, though no
additional restriction  was  imposed upon their
intercourse with the citizens.  (Am. Jour. Med.
Sci, Nov ,  1831 )
   Over one thousand children were received into
the different orphan asylums  of Philadelphia up
to 1841, and ofthe whole one only died of small-
pox, although 65 cases of the disease  occurred.
Ten  of these had no cicatrix, including the one
that died, and probably had never been vaccinated.
   Of several  thousand children received in the
different orphan asylums of New York since their
foundation, no deaths have occurred from small-
pox, although the varioloid has broken out at dif-
ferent times, in a light form, in several of them.
The  same is true  of the New York House of
Refuge, which had received 2657 children up to
the year 1845.
   Baltimore presents the like return, out of 3500
children that have been inmates ofthe Almshouse
and different orphan asylums of that city.  Thus
we have an aggregate of over 11,000 children un-
der 14 in these different institutions, and but one
death from small-pox.   Thus 5856 children were
received into the New York Almshouse, from Nov.
 1st, 1834, to May lst,1843, and though the varioloid
prevailed extensively in that  institution during
that  period, there were but eight  deaths from it
among the whole number;  total, 16,000 children
vaccinated, 8 deaths   Compare this  with  the
mortuary statistics of Glasgow in former times.
From Sept., 1671, to April, 1672, there were 800
deaths from small-pox in that  city, with a popu-
lation of 13,000.    At the present time, with a
population of over 250,000, the cases of this dis-
ease which prove mortal do not amount annually
to one sixteenth part of the number which then
occurred in one third ofthe time, among a popu-
lation about one twentieth as large as at present.
   During the prevalence of a most malignant and
 fatal small-pox in  Philadelphia, in 1827, but one
 well-ascertained death from that disease was dis-
 covered to have occurred among 80,000 vaccinated
 persons. According to Drs Mitchell  and Bell
 (" Report to Med. Soc. of Phil"), of 248 cases of
 variola  and varioloid treated  at  the   small-pox
 hospital of that city, 155  were unprotected, of 
VACCINATION—of Revaccination.                       1425
whom  85 died;  64 were vaccinated,  of whom
only one died;  9 were inoculated,  of whom 3
died ; 7 who had had small-pox before, of whom
3 died; and of the 13 whose condition was un-
known, none died.]
  37. VII. Operative Measures.—A. The per-
formance  of vaccination, although a  simple, is a
nice operation, requiring much attention  to sev-
eral circumstances.   Care  should be  taken to
avoid a failure, as it often causes a delay, or a
neglect of the repetition ofthe operation.   Fail-
ures arise chiefly, 1st. From the selection ofthe
lymph ; 2d. From the mode of operating;  and,
3d. From the constitution or state of  health of
the individual  operated upon.—a. The vaccine
lymph should  be recent, if it can be  obtained in
this state.   It should be perfectly clear and lim-
pid, and the earlier it is taken from the vesicle the
better.  Lymph may be taken with every prospect
of success after the fifth day, and up to the eighth
and ninth days.   That taken  on the tenth day
should  not be confided in.  When  vesicles are
too often or too roughly opened, on  the seventh
or eighth day, the serum of the  blood may com-
mingle  with the lymph, and impair, or  even alto-
gether destroy, the efficacy ofthe latter.  A vesicle
should always be treated gently.—b. The lancet
used in the operation ought to be  clean and sharp
A vaccinating lancet should have a broad shoulder,
as well as a sharp point, to enable it  to retain an
adequate portion of virus.   The skin  should be
kept tense during the operation,  and  six or  eight
punctures be made at convenient distances from
each other, and to a slight depth.  Provided that
a genuine lymph of due intensity comes  in con-
tact with the absorbing surface of the cutis  vera,
it matters not whether much or little blood  flows
from the punctures.   The quantity of blood that
escapes depends more upon the  child's habit of
body than on the operator.  A plethoric child gen-
erally bleeds freely when vaccinated, but generally
exhibits the most perfect appearances as to the
effect—c. The child operated  upon should  be in
perfect  health.   Vaccination ought to be delayed
during the existence of any disease—at the period
of dentition—when  the skin is  affected  by any
eruption—or when the digestive canal is disor-
dered—unless some pressing occasion should re-
quire it.  The best age for vaccinating is between
the third and fifth month after birth, before den-
tition has commenced.
  38  B. Preservation of Vaccine  Lymph—Fresh
lymph should always be preferred when it can be
obtained;  but there is  often no other resource
than preserved lymph.  Being liable to spontane-
ous decomposition, as well  as to other changes
too slight or delicate to admit  of demonstration,
unless  in its effects  after inoculation, and either
impairing or destroying its efficiency, great  diffi-
culty has been experienced in  preserving it, and
more especially in transmitting it to  tropical cli-
mates in an active state.  Dr. G. Gregory states
the following to be modes of preserving lymph
which are now adopted : 1.  It  may be preserved
fluid for several days between two pieces of glass,
about an inch square, which fit each other accu-
rately.   When dry, the lymph will often, if  care-
fully moistened by the breath, propagate the dis-
ease.   2. Vaccine lymph  may be preserved  on
ivory points, shaped like  the  teeth  of a comb.
These should be twice dipped in  the fluid ofthe
vesicle, and allowed to dry slowly. They should
be retained, when used, in the wound  or puncture
    III.               90
for about hah a minute.  They are considered very
effectual.  3. The lymph may be kept in a fluid
state in capillary tubes, having a bulb at one end.
They  admit of being hermetically sealed.  But
to prevent spontaneous decomposition the lymph
should be collected  in minute  quantities only.
4. Mr. Bryce, in 1802, stated that vaccine scabs
niay be used for communicating  the disease, and
it has been ascertained that  this  is the most cer-
tain mode of transmitting cow-pox  to warm cli-
mates.  When about to be used they ought to be
rubbed to a powder, and  moistened with a little
tepid water.  When thus reduced to the consist-
ence  of thin mucilage, they form  an  artificial
lymph.  Punctures should be numerous where
the lymph  is employed.   5. Dr. Jenner occa-
sionally used dossils of lint, saturated with the
fluid of an  eighth-day vesicle.  These he placed
between glasses, one surface  of which had a small
central  cavity; the glasses  being tied together,
their  edges sealed, and the  whole covered with
sheet lead.   Preserved in this  manner vaccine
lymph will retain its fluidity and efficiency for a
considerable time.
  39. VIII.  Revaccination.—The  phenomena
presented by  revaccination  after comparatively
short intervals have been noticed  (§  23).   It,
however, becomes necessary to take a brief sur-
vey of  the  practice of this  measure after long
intervals, with  the view of affording a complete
protection  against  small-pox.    It  having been
believed by many medical men, and it having
become the popular belief, in several countries,
that vaccination, however completely performed,
is weakened in its protective influence by the
lapse of time, or growth of the frame, a recourse
to revaccination has been had, in some  countries
to a great  extent.  Dr. Goldson, in 1804, first
announced this doctrine, but assigned the remark-
ably short period of three or four years for the de-
cadence of protection.  In France, MM. Caillot,
Boulu, Berlan, Genouil, and others both in this
and in other countries, supported  this opinion, but
assigned much longer periods for this occurrence,
the time assigned by them varying in the opinions
of each from ten to twenty-four years, but they
all agreed in believing that the loss  of protective
power was  gradual and progressive.  M. P. Du-
bois endeavoured, in 1825, to refute this doctrine
as a general inference, although  he  admitted the
facts upon which the opinions of  these physicians
were founded.  The epidemic prevalence of small-
pox soon afterward in France, Germany, and Den-
mark, confirmed, by the  numbers of vaccinated
attacked, the opinion that vaccination lost, after
the lapse of a number of years, its powers of pro-
tection  from that malady.   From this period—
about 1829—revaccination began to be practised
on the Continent, and  on great numbers in Ger-
many, Sweden, Denmark, Prussia, and in France.
In 1833, it was adopted in the Prussian army, and
was performed on 48,047 persons, and was suc-
cessful  in 15,269.   In 1834, 16,673  successful
cases  were  obtained in 44,454   operations.   In
1835,15,315 were successful in 39,192 revaccina-
tions.  In 1836, in 42,124 revaccination s, 18,136
fully succeeded, and 9040 presented an irregular
form ofthe eruption.  Of 14,048 persons, in whom
revaccination failed, 1569 were successful on the
repetition of the  operation for the second time.
In  1839, 41,481 soldiers of the  Prussian army
were revaccinated ; of this number, the cicatricei
of the first  vaccination were distinct in 33,225, 
1426
VACCINATION—of  Revaccination.
imperfectly distinct in 5889, and not detected in
2367.  Revaccination  succeeded in 19,249, and
was  imperfect in 8534.   Similar results  have
been obtained from revaccination in several of
the German states, in Hanover, &c, between the
years 1835 and  1842.  In France, revaccination
has not been much practised, and in England still
less.*  During the reign of Louis Philippe, the
Royal  Academy of Medicine  of Paris  was  con-
sulted respecting the propriety of having recourse
to revaccination.   This body were opposed to this
measure, as they  believed that it would weaken
confidence in  vaccination.   M. Dezeimeris  pro-
tested  against this decision, and was successively
followed by MM. Fiard, Hardy, Pressat, and
others, who published memoirs on the subject in
the  French journals.  M. Villaret, in  1843,
practised revaccination in 401 soldiers ofthe 7th
regiment of dragoons ; it was successful in 307 ;
and  in 153, who had  formerly had small-pox, the
operation fully succeeded in 97.  In a second se-
ries of 447 persons, who presented perfect vaccine
cicatrices, 402 had cow-pox a second time ; and
of 123 persons marked by small-pox, 89 presented
a successful vaccination.   MM. Bosquet, Fiaro,
Guersant, and Blache, who, in 1828, expressed
their belief in the permanent security furnished
by cow-pox inoculation, have  subsequently alter-
ed their opinions, and have practised revaccination
in numerous cases ; and have  strenuously advised
this measure as the only certain means of prevent-
ing small-pox, by sustaining the prophylactic in-
fluence of vaccinia.
   [Dr Wendt, in Copenhagen, revaccinated 3964
persons, of which 2756 were successful, and 1208
failures.  Dr. Aggeus, of Silesia, revaccinated 962,
of which 822  were successful, 72 failures, and 68
spurious or imperfect.   The Vaccine Committee
of France, in 1839, revaccinated 6652, of which
718 were successful, and 1283 spurious  or non-
successful.   In 1840, the  same committee  found
270 successful out of 2214 cases of revaccination,
 1717 failures, 227 spurious or imperfect.  M. Vil-
leneuve, the same year, found 223 successful out
of 2199 cases of revaccination, and 1976 failures.
The late Dr. Forry, of New York, vaccinated
560 soldiers  at Fort Wood,  in 1840, of which
 141 were successful, 364 failures,  55 spurious
or imperfect.   Dr. Kirkbride,  of Philadelphia,
 revaccinated  209 in  1840;  44 successful, 165
 failures.   We  copy  the  following Tables  from
 Dr. Forry's "Prize Essay on the Protective Pow-
 ers  of Vaccinia" (N. Y. Jour.  Med., Sept., 1844)
   These statistics contain the results of revaccina-
 tion in the Prussian army, the Vaccine Committee
 of France, and all other known authentic  sources,
  [* M. Villeneuve, chairman of the committee on vac-
cination of the Royal Academy of Medicine, Paris, after
examining the reports of 41 departments of France in
relation to vaccination and revaccination, deduced from
them the following conclusions in 1840: The whole num.
ber vaccinated for the first time was 30,413; in 560 of
these it was unsuccessful.  The number of revaccinations
was 2199; of these, 1976  were unsuccessful.  Of those
who had been already vaccinated, 365 had the varioloid,
and 6 died.  Thus it appears that the proportion of cases
in which vaccination does not succeed is only one in 54J,
while others who have investigated the subject place it
as high as i or 1-10.  Of the 2199 revaccinations per-
formed in persons of different  ages and sexes, who had
been successfully vaccinated at some previous time, 223
were successful.  So the  proportion of successful cases
was as 1-13 or 1-14.  In  365 cases of varioloid occur-
ring after well-established vaccination, the proportion of
deaths was only 1-45 or 1-46, while the sporadic small-
pox kills i to 1-10; and when the disease is epidemic, i,
or even more, perish.  (Annates cFHygiene.)]
Year.	Number Vaccina-ted.	CICATKICIS IN THOSE RKVACCINATBD.			
		Of these had Imper-perfect ifectcic-cicatrices. I atrices.		No cicu-trices.	RevaccinatioD successful in
1834 1S36 1S37 1833 1S41	44,454 42,124 47,25S 42,041 44.'J41	33,634 32,635 37,'-99 33 819 36,182	7,134 6,543 6,9113 5,645 6,193	3,686 2,946 3,050 2,577 2,567	IS, 136 15,315 21,308 19,117 13 523
Total.	220,818	173.569	32.418	24.S32	87.399
BESULTS OF A SERIES OP EEVACOINATIONS.
Second re-		Tot	al successful
vaccina-	Successful.	firs	and second
tion.		re	■accination.
4,530	866		19,002
14,043	1569		16,8S4
15.313	2243		23,551
14,252	2300		21,423
13,523	2.54		15 7T7
61,746	9238		96,637
	
Year.	revaccinations.
1834	15,488
1836	14,048
1S37	15.393
1833	14,252
1-41	13,523
Totals	72,704
and it is believed that they afford conclusive evi-
dence of the necessity and importance of revac-
cination, under all possible circumstances.  It is
worthy of note that, prior to the order for revac-
cination in the Prussian army, it was not unusual
for the different barracks to be a prey to varioloid
disease ; but now the whole army, notwithstand-
ing its  repeated exposure to  similar causes pro-
ductive of the disease,  enjoys  an almost entire
immunity ]
   40. In 1845 the Academy of Sciences of Paris
published a Report, containing the following con-
clusions : 1.  The protective influence of vaccina-
tion is complete as regards the great majority of
the vaccinated, and temporary as respects a small
number only , and in these latter  it is almost ab-
solute up to the period of puberty.  2. Small-pox
rarely attacks the vaccinated before the age often
or twelve; and it is from this age to thirty or thir-
ty-five that they are chiefly exposed.  3.  That in
addition to its preservative influence, vaccination
endows the constitution with an influence which
renders the symptoms of small-pox much milder
and of shorter duration.  4 Cow-pox, directly or
recently derived  from the cow, is attended by a
much more intense local phenomenon, and by a
more certain and permanent effect than that which
has passed through a great number of human sub-
jects, this intensity of local action subsiding after
many successive vaccinations.  5. The preserva-
tive influence of vaccination appears not to be in-
timately connected with the intensity of its local
effects; nevertheless, in  order to preserve the
properties of vaccinia unimpaired, it  is  prudent
'to renew it  as frequently  as possible from the
cow.   6. Revaccination is the only  means we
possess of distinguishing the complete  success
of vaccinia from the less complete grades of pro-
tection   7.  Revaccination, however,  is not cer-
tain evidence that the vaccinated  in whom it had
succeeded would have  been destined  to contract
small-pox, but merely that it was probably among
those that this latter malady was most likely to
appear, if they became  exposed to its infection.
In ordinary times revaccination may be practised
after fourteen years ; during  epidemic small-pox
it may  be practised after a shorter period.
   41. It would appear from the circumstance of
so many persons having presented the  regular
vaccinia after 6malI-pox (Y 39), as stated above,
that the complete development of the local action
after revaccination cannot justly  be viewed as a
certain proof that the successfully vaccinated could
have been infected with small-pox, although they
might have been infected if they had been exposed 
VACCINATION—Bibliography ano References.                    1427
to  the more concentrated  sources of  infection.
Nor can successful revaccination, nor its failure,
be viewed as absolutely indicating a state of con-
stitution which shall resist the infection of small-
pox on all occasions, more especially when this
malady is present in an  epidemic form, although
it may resist this infection on nearly all occasions,
or with  very few exceptions;  these exceptions,
however, being a mild or modified small-pox, in
the great majority of instances.

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Small-pox, 8vo.   London, 1805;  and an  Answer to Dr.
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Inoculazioni Jenneriane escqnite in Pistoja, Svo.  Fi-
renz., 1809.—T. Brown, Inquiry into the Antivariolous
Powers of Vaccination, 8vo.   Edinb.,  1809. — J. Bryce,
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della Vaccina il Vajuolo Peccorino, 8vo. Firenz., 1809.
L. Sacco. Trattato di Vaccinazione, con Oseervazioni sul
Giavardo  e Vajuolo Peccorino, 4to.  Milan, 1S09__O.  W.
Bartley, an Attempt to Vindicate  the Practice of Inocu-
lation, &c, Svo.   Lond., 1810.—T. Brown, a Correspond-
ence with the Board of the National Vaccine Establish-
ment,  8vo.  Musselburgh, 1810.—Segand, Precis Histo-
rique de la Vaccination Pratique  a Marseille depuis son
Introduction  en France jusqu'a ce Jour., 8vo.  Mars.,
1812. —J. JV. Halle, Exposition des Faits recueillis jus-
qu'a present, concernant le6 Effets de la Vaccination, &c.,
Svo. Par., 1812.—E. Leese, an Explanation of the Causes
why Vaccination has sometimes failed to prevent Small-
pox, Svo.  Lond., 1812.—,/. Ring, a Caution against Vac-
cine Swindlers  and Impostors, Svo.   Lond., 1816. — F.
Miihl, De Varioloidibus et Varicellis,  8vo.  Copen., 1817.
—J. Moore, The History and Practice of Vaccination,
8vo.  Lond.,  1817.—A. Monro, Observations on the dif-
ferent  kinds of Small-pox, especially on that which fol-
lows Vaccination, 8vo.   Lond., 1818.— E. Jenner, on the
Varieties and Modifications of the Vaccine Pustule occa-
sioned by an Imperfect State of the Skin, 8vo.  Chelten.,
1819.—G. Blanc, a Statement of Facts tending to estab-
lish an Estimate of the True Value and Present State of
Vaccination, 8vo.  Lond., 1820.—J. Crosse, a History of
the Variolous Epidemic of Norwich in 1819, with an Es-
timate of the  Protection afforded by Vaccination, 8vo.
Lond., 1820.—J. F. Hulbert Observations on Variolous
Inoculation and Vaccination,  8vo.  London, 1S20. — iV".
Chambon de Monteaux, Comparaison des Effets de la Vac-
cine avec ceux de la Petite Verole inoculee par la Methode
des Incisions, 8vo.  Par., 1821.—V. Leman, a Discourse
on  Vaccination,  8vo.   Lond., 1822.—J. Thomson, an Ac-
count ofthe Varioloid Epidemic in Edinburgh, &c, 8vo.
Lond., 1822;  and Historical Sketch  of Opinions on the
Varieties of Small-pox, &c, 8vo.   London, 1822.—J. J.
Cribb,  Small-pox and  Cow-pox, 8vo.   Camb., 1825.—W.
Ferguson, Letter to Sir H. Halford on Inoculation, 8vo.
London. 1825. — T. Greenhow, an Estimate of the True
Value  of Vaccination as a Security  against the Small-
pox, 8vo. Lond., 1825.— J. Baron, The Life of Edward
Jenner, Svo.  Lond., 1827.— J. Marshall, Treatise on Vac-
cination, 8vo.   London, 1830. —Anon., Report and Evi-
dence ofthe Select Committee  on  the Vaccine Board, foL
Lond., 1833.—G. Gregory, in Cyclop,  of Pract. Med., vcL
iv., p. 402.— Rayer, in Diet de Med. et de Chir. Pratiques,
t xv.,  p. 532. — J. B. Bouiquet, Traite de Vaccine, 8vo.
Paris,  1833.—G. G. Macpherson, Account of some Exper-
iments relative to Vaccination, in  Transact, of Med. and
Phys. Society of Calcutta for  1833, vol. vi., p. 169.—IT.
Cameron, of Vaccination in Bengal, in Ibid., vol. v., p.
385.—H. S. Mercer. Effects of Vaccination in India, in
Ibid., vol. vi., p. 265.—Guersant  et Blache, in Diet, de
Mud., 2d ed., art. Vaccination.—Rilliet et Barthez, Traite
Pratique des Maladies des Enfants,  t. il., p. 543.—Le-
gendre, in Archives Gener. de Med., 4th ser., t. vi., p. 38.
— Dezevmeris, De la Revaccination  dans  l'Experience,
1838, t. ii., p. 3S5. 529.—Tiard, Necessity de la Revacci-
nation, in Ibid., 1838, t. ii., p. 412.—Gaultier de Claubry,
De 1'Alteration du Virus Vaccine et de l'Opportunite des
Revaccinations,  8vo.   Paris,  1838;   et dans  Archives
Gener. de Med., 3d  ser., t. iii., p.  372.— R. Ceely, Obser-
vations on the Valiola? Vaccina as they occasionally ap-
pear in the Vale of Aylesbury, with an Account of some
Recent  Experiments in the Vaccination,  Retrovaccina-
tion, and Variolation of Cows,  in  the Trans, ofthe Pro-
vincial Medical and Surgical Association, vol. viii., Svo.
London, 1840, p. 287; and Farther Observations  on the
Variola? Vaccina?, in Ibid., vol. x., p.  209, with coloured
plates.   (Very interesting Papers.)—J. Sedillot, Mciuoire
sur les  Revaccinations,  dans  Mem. de l'Acad. Roy.  de
Med., 1840, t. viii., p. 568. — T. G. Balfour, on the Pro-
tection against Small-pox afforded by Vaccination, illus-
trated  by the Returns of the  Army,  the Navy, and the
Royal Military Asylum,  in Royal Medico-Chir. Society's
Transactions, vol. xxxv., p. 403.   See also the  British
and Foreign Medical  Review,  vol. i., p. 609; vol. ii., p.
250, 251; vol.  iv., p. 223, 392. 547; vol. v., p. 207; vol.
vi,, p. 247; vol.  vii., p. 189, 527;  and in many places in
most of the vols, of this work.  See the copious Index
forming its xxvth volume.
  [Amer. Busliog. and  Reper.—Cazenave and Schedel,
Manual of Diseases of the Skin, Am. ed., by H.  D. Buck-
ley, 12mo, p. 341.  N. Y., 1846.—Fleetwood Churchill, on
the Diseases of Infants and Children. Am. ed., by  Wm.
V. Keating, Svo, p. 736.  Phil., 1856.' — S. H. Dickson,
Elements of Medicine, Svo, p. 750.  Philad., 1856.— R.
Dunalison, The Practic of Medicine, 3d ed., 2 vols, Svo,
p. 15!i0.  Phil., 1856.—T. Xeligan Moore, a Prat Treat.
on  Dis. of the Skin, 12mo, p. 334, with nn Atlas of 100
plates.   Phil., 1856.—Thomas Watson, Lectures on Prin-
ciples and Practice of Physic, 3d Am. ed., Svo, p. 1100.
Phil., 1856—Charles West, Lectures on the Diseases of
Infancy and Childhood, Am. ed.,  Svo, p. 600.  Philad.,
1S56.—James Stewart, a Pract Treatise on Diseases of
Children, 8vo.   N. Y., 1845.—J. Forsyth Meigs, a Pract.
Treatise on the Diseases of Children,  2d ed., 8vo,  p. 711.
Phil., 1853.— John EUiotson, The Principles and I*ractice
of Medicine, Am. ed., by T Stewardson, 8vo.  Philad.,
1844.— Erasmus Wilson, on Dis. of Skin, 3d Amer. ed., 
1428
VAGINA  AND  VULVA—Diseases  op  the.
 8vo, p. 500.  Thil., 1856.—W. P. Deuees, a Treat on the
 Phys. and Med. Treatment of Children, 10th ed., 8vo, p.
 54S.  Phil., 1855.— D. F. Condie, a Pract. Treat, on the
 Diseases of Children, 4th ed., 8vo, p. 7.">0.  Phil., 1857.
 —John S. Rohrer, on the Identity of Variola, Varioloid,
 and Variola Vaccina, and on the Prophylactic Power of
 the Vaccine Disease, in Med.  Examiner.  Phil., 1846.—
 H.  T. Child, Report on Vaccination, in Ibid., Feb., 1846.
 —J. M. Xewman, Cases illustrating the Protective Influ-
 ence of Vaccination  against the Contagion of Small-pox,
 in Buffalo Med. Journ., vol. x., p. 458.—T. D. Mitchell,
 a Candid Inquiry into the Present State of Vaccination,
 in Am. Med. Recorder, 1822.—Horatio G. Jameson, Some
 Account of the Small-pox which prevailed at Baltimore
 during the Winter of 1821, '22, in Ibid., 1822.—T. Davis,
 Observations on  the Vaccine and Varioloid Diseases, in
 Ibid., 1822.—Benjamin Waterhouse, History ofthe Prog-
 ress of the New Inoculation  in America.  Cambridge,
 1S"2;  and in Amer. Medical Recorder, 1828.—E. Jenner
 Coxe,  D. F. Condie, C.  D. Meigs, Report on Small-pox, in
 Phil. American Medical Recorder, 1828.—J. R. Coxe, on
 Cow-pox, 8vo.  Philad., 1802.—D. B. Slack, on the  Pro-
 priety of superadding Inoculation with Small-pox Mat-
 ter  to Vaccination, in Bost. Med. and  Surgical Journal,
 vol. xxix., p. 478.—A. H. Wright, Vaccination introduced
 into Persia, in Ibid., vol. xxix., p. 352. — D. P. Bissell,
 on Vaccination, in Trans, of the  Med. Soc. of the State
 of New York, 1857.-7. McCall, J. Eights, Wm. Bay, T.
 Romeyn Beck, Report of a Committee on Varioloid, and
 the  Means of Counteracting its Progress, in Ibid., vol.
 iii., p. 13, 40. —D. B. Bradley, Vaccination in  Siam, in
 Boston Med. and Surg. Journal, vol. xxiii., p. 158. — C.
 II'. Spofford, Anomalous Vaccination, in Ibid., vol. xxii.,
 p. 138.—Silas Brown, Facts in relation to Vaccination, in
 Ibid.,  vol. xxii., p. 280.—Luther V. Bell, an Attempt to
 Investigate some Obscure and Undecided Doctrines in
 relation to Small-pox, Varioloid, and Vaccination,  8vo.
 Bost.,  1836.— B. B.  Appleton, The Influence of the Vac-
 cine Virus on Scrofula, in Ibid., vol. xv., p. 176.—Vari-
 cella and  Varioloid, editorial, in Ibid., vol. xv.,  p. 125.—
 T. Wallace, Several Cases of Small-pox in one Family, in
 Ibid.,  vol. xi., p. 252. — S. Brown, Prize Dissertation on
 Small-pox, Varioloid, and Vaccination.  New York, 1829.
 (Dr. B. maintains that the dry scabs only should be used
 for vaccination, as laceration of the vesicle proves detri-
 mental to the virus.  Great care is to be taken lest it be
 lacerated.  Vaccination should not be practised during
 the  summer months.  Dr. B. also recommends that all
 children of phlegmatic parents, and all persons of phleg-
 matic  habit, should be revaccinated, or have a second in-
 sertion, and repeated till a full impression be made on
 the system.)—George Hayward, Remarks on-Vaccination.
 in Bost Med. and Surg. Journal, vol. i., p. 177, 305, 406
 (1828).— W. Channing, on Revaccination, in Ibid , vol. i.,
 p. 279.—Thomas Henderson, on Revaccination,  in Ibid.,
 vol.  i., p.  401.—Chandler Bobbins, on Vaccination as a
 Preventive of Varioloid, in  Ibid., vol. i., p. 21;  and on
 Revaccination, in Ibid.,  p. 225, 267, 309, 385,  419.— J.
 Southworth, Hooping-cough and Vaccination, in Boston
 Med. and Surg. Journ., vol. xxvi., p. 61.—X. Williams,
 The Method of Practice in the Small-pox, with Observa-
 tions on the Way of Inoculation, Svo, p. 16.  Bost, 1752.
 —J. II. Flint, on Small-pox, Bost. Jour., vol. xxi., p. 354.
 (Dr. V. maintains that  the small-pox of the present  day
 is as distinct from the small-pox described by Sydenham
 and  the earlier writers as chicken-pox is from varioloid ;
 that it corresponds to the anomalous small-pox of Syd-
 enham.)— J. H. Coggeshall, in Ibid., vol. xxi., p. 324.
 (From considerable experience as vaccinator at the Health
 Office,  Boston, Dr. C. derives the following conclusions:
 1st, that every individual is susceptible ofthe kine-pock ;
 2d, that revaccination is  not necessary before puberty;
 3d, that the system  undergoes a change at puberty, and
 that revaccination is then necessary;  4th, that vaccina-
 tion is a sure preventive of small-pox; 5th, that revaccin-
 ation is a sure preventive of the varioloid; 6th,  that the
 third vaccination is inert; 7th, that the  system is sus-
 ceptible of varioloid after puberty, whenever the individ-
 ual is exposed to small-pox without revaccination; 8th,
 that revaccination is not necessary if the first operation
 was performed since puberty; 9th, that those who disre-
 gard vaccination are always liable to small-pox whenever
 exposed to that disease; 10th, that if every individual
 were vaccinated before puberty, and revaccinated after
 that period, there would be no such disease existing as
 small-pox or varioloid.)—John D. Fisher,  Description of
the Distinct, Confluent, and Inoculated Small-pox, Vari-
oloid Disease, Cow-pox, and Chicken-pox, fol., p. 73: 13
 col'd plates.  Boston, 182:); and Trans, of Am.  Medical
Association, vol. iii. — William Brown, on  the Influence
 of Vaccination in Counteracting the Effects of Small-pox
Contagion, in Am. Journ. of Med. Sciences, vol. xv., 1834.
—S. Forry, Essay on the Protective Powers of Vaccinia
(Boylston Prize Essay for 1844); also, in N. York Journ.
of Medicine, vol. iii., p. 151; and in Am. Journ.  of Med.
 Sciences. April, 1842.   (See Report of the Committee of
 Vaccination made to the Academy of Sciences of France,
 Feb., 1845, in Am. Journ. of Med. Sciences, vol. x., 1845;
 and Vaccination in France, in Ibid., vol. iv., N. S., 1842.)
 —S. A. Cook, Nature of Vaccinia, In Boston Medical and
 Surgical Journal, vol. xxxiii.; and Origin of Vaccinia, in
 Ibid., vol. xxxii., p. 49, 73.—Dr. Gregory, on Vaccination
 and Inoculation, in  Ibid., p. 179.—J. C. Martin, Experi-
 ments  on the  Development of Vaccine Virus, in  Ibid.,
 vol. xxv., p. 266.  (Dr! M. inoculated the cow with small-
 pox matter in 1835, and proved that the matter resulting
 therefrom was the true vaccine disease, by vaccinating
 three children with the same.  The disease, though more
 severe, had all the characteristics of the genuine kine-
 pock.)— Steph. W. Williams, Remarks on Vaccination, in
 Ibid., vol. xxiv., p. 152.  (Dr. W. believes kine-pox to be
 an effectual and permanent preventive of small-pox, that
 the virus does not become weakened  or degenerated the
 farther removed it is from the cow, but advises revaccin-
 ation where there is the least doubt ofthe genuineness of
 the original matter.)—C. A. Lee, Account of the Vario-
 loid  Disease in the Town of Gorham, Ontario County,
 New York, in Amer. Journ. of Med. Sciences, July, 1S53;
 and in  New York Journ. of Medicine, Sept., 1853.—F. C.
 Stewart, Report  of Cases of Vaccination and Revaccina-
 tion in 135 Cases of Children  under the age of 15 years,
 in New York Journal of Med., vol. vi., p. 16, 1846.  (Of
 those possessing large and evident scars,  the result of
 previous  vaccination,  there were 71; of those in whom
 the signs of previous, vaccination were undecided, or the
 scars doubtful, there were 13; of those in whom no trace
 of previous vaccination could be detected, there were 51.
 Total, 135.   Of the 71, vaccination succeeded in 19—26J
 per cent.   In these cases  there were some very well-
 marked vesicles close  alongside of the old scars.  Of
 those in whom there were doubtful  traces of previous
 vaccination, 9 out of 13 took—70 per cent.   Of the 51 in
 whom no trace of previous vaccination could be detected,
 the operation succeeded in 43—80 per cent.)— William T.
 Taylor, Variola in the Fcetus,  in Am. Journal of Medical
 Sciences,  1853. — Robert Ceely, Farther  Observations on
 ■Variola Vaccina, in New York Lancet.—J.  A. Houston,
 in Ibid., vol. ii.—Thorn. Brown, an Investigation of the
 present Unsatisfactory and Defective State of Vaccina-
 tion, &c,  pamphlet.   Lond., 1842; in  Ibid., vol. ii., p. 5.
 —G.  Gregory, Lect on the Eruptive Fevers, edit, by H.
 D. Bulkley. 12mo.  N. Y., 18r>5.— T. Y. Simons, Observ.
 on the  Protective Influence of Vaccine  when efficientlj
 performed, in Charleston Medical Journal, vol. iii., p. 34,
 1848.—Robert Browne, on the Influence of Vaccination
 in Counteracting the Effects of Small-pox Contagion, in
 Am. Journ. of Med. Sciences, vol. xv.,  p. 399.—Report on
 Vaccination, read at the Annual Meeting of the Massa-
 chusetts Med. Society, 1803, in Com. of Mass. Med. Soc,
 vol. i., p.  89.—James M. Pendleton and J. Smith Rogers,
 Facts on  Vaccination, in New York Medical and Phys.
 Journal, vol. i., p. 320, 1822. — Have Variola, Varioloid,
 and Varicella a common origin ? in New England Med.
 Journal, vol. i., 1843.— Felix Pascalis, an Attempt to As-
 certain  the Value of the Vaccine Virus,  &c, in N. York
 Med. and  Phys. Journ., vol. iv., p. 22, ls-_5. —John Bell,
 a  Dissertation on the Vaccine Disease, in  X. York Med.
 and Phys. Journal,  vol. vi., p. 441. — C. C.  Blatchly, on
 Degenerated Cow-pox, in N. Y. Med. and Phys. Journal,
 vol. ii.,  p. 973.-^1. B.  Williman, on the Use of Original
 Vaccine Lymph,  in Charleston Med. Journ., vol. vi., p.
 063. — Wm. S. Wragg, on the Connexion between Varicella
 and Varioloid, with Cases tending to show their identity
 in  Nature, in Charleston Medical Journal  and Review,
 vol. iv., p. 133,  1849.—D. F. Condie, T. T. Hewson, J. W.
 Moore, Report on the Protective Powers of Vaccination,
 in Med.  Examiner, vol. iii., p.  G9.  Phila., 1847.]

   1. VAGINA AND VULVA —Diseases of
 the.—Affections  of the  vagina and vulva are  as
 frequently  surgical as strictly medical. As, how-
 ever, certain of them require  internal or consti-
 tutional  means, either  altogether  or  chiefly,  in
 their treatment, they may be viewed as belonging
to the latter category, although I can  see no just
reason  for separating  the  two departments of
practice,  or for assigning them more  to  the one
than to the other.
   2.  I. The Vagina is liable to several congenital
alterations, or vices of conformation.   The chief
of these  are    1st. Its  opening  in  an abnormal
situation; 2d  Its  separation by  a  partition into
two canals ; 3d. Its imperforation ; 4th.  Its  con-
striction ; and,  5th.  Its  entire  absence.    As  to
either of these, I can add nothing- to what will be 
VAGINA AND  VULVA—Vaginitis described.
1429
found  in  the many excellent  recent  works  on
surgical pathology.  The last of these  conditions
is of great importance  as respects the  diagnosis,
and the results proceeding from  it.  It may be-
come the  subject of medical investigation as re-
spects especially the retention  of the catamenia,
and the propriety of an operation,  on this account,
after due deliberation.  The absence of  the vagina
may be only partial; but even in this case, and
when the exact state is ascertained, the question
as to the propriety of attempting an operation for
the establishment of the canal should  not be en-
tertained, unless  there be a pressing occasion for
having recourse to it,  as it may compromise the
life of the patient.  But what occasions may sug-
gest recourse to a surgical operation in  such
cases?  These are:  1st  Excessive uterine disten-
tion from  an  accumulation of the menstrual fluid ;
2d. The supervention  of metritis, or peritonitis,
or both; and, 3d.  Contamination ofthe  circulation
from  the  absorption of a portion of the retained
and altered blood from the uterus.  This opera-
tion has been, therefore, performed successfully
by Cabaret, Ventura,  Desgranges,  Delpech,
Willaume, Jefferson, and Coste ; but unsuc-
cessfully  by Langenbeck, Macfarlane, and
Fretau (Velpeau, Mcdeane Operatoirc, t. iv.,
p. 356).   The accumulated menstrual fluid may
be discharged, in the  urgent circumstances just
stated, by puncture either by the rectum  or  by
the bladder.
   3. The diseases  and organic lesions to which
the vagina  is  liable,  are  inflammations, ulcers,
constrictions, or contractions and obliteration, tu-
mours of various  kind,  polypi, fistula, cancer, pro-
lapsus, wounds, laceration, hernia, and  the  im-
paction of foreign bodies.  Several of these belong
more to the province of the surgeon than to the
physician, or rather require surgical, in addition
to medical means.
  4. i. Inflammation of the Vagina.—Synon.
— Vaginitis,  Vaginite,  Fr.
  Classif. — III. Class,  V. Order (Author in
     Preface).
  5. Definit. — Heat, soreness, or pain, in the
course of the vagina,  sometimes  attended by  in-
crease of pain, or by uneasiness upon sitting down
on a  hard seat; and always by pain and tender-
ness on vaginal examination, and, by a  whitish or
a muco-purulent discharge, with slight febrile dis-
turbance, increased or returning at night.
  6. Inflammations of the vagina rarely occur,
unless in connexion with inflammation  of the
vulva,  or  with inflammation of the  neck of the
uterus; most commonly with both, unless it  be
caused by violence, by excessive sexual indul-
gence, by  irritating injections,  and by foreign
bodies, as  pessaries, &c, lodged in the vagina.  It
commonly presents an acute or  sub-acute form,
whether simple  or thus complicated; but  it is
also often chronic, especially when it is  associated
with disease  of the neck or body of the uterus,
and in many cases which  are commonly viewed
as simply those of leucorrhcea.   In these chronic
and sub-acute cases the mucous  follicles of the
vagina, and  often also of the cervix and vulva,
are more  or  less implicated—either partially  or
chiefly
  7. A. Acute vaginitis rarely occurs in a simple
or sthenic form, unless  when it is specific, or gon-
orrheal.   In  rare cases, also, it is asthenic or dif-
fusive, owing to  the occasions about to be men-
tioned.  Acute  sthenic vaginitis, and the  sub-
acute states, are most  frequently consequences
of the causes just stated, or of sitting on cold or
damp seats, especially during, or soon after, the
menstrual period.   In these circumstances, it has
been termed, by some physicians, vaginal catarrh,
or catarrhal inflammation ofthe vagina, especial-
ly in its slighter or sub-acute state.  In this state,
it  is not unfrequently  met with in pregnancy,
and, in rare instances, as a complication of hem-
orrhoids.   In  these  simpler  forms, vaginitis is
attended by a copious whitish, or grayish,  or
nearly colourless mucous discharge, which soon
passes into a muco-purulent and yellowish mat-
ter, especially  when  retained  for some time in
the vagina; there are also soreness and tender-
ness in the course of the vagina, sometimes with
frequent micturition and slight dysuria.   I have
met with  several cases, in  public  and private
practice, of this form  of vaginitis, as a sequela of
measles, but  much more  frequently of scarlet
fever,  especially in  children  among the  lower
classes.
   8. B.  Acute and  sub-acute vaginitis  is often
mistaken for gonorrheal vaginitis, or the blennor-
rhagia of French pathologists, especially of M.
Ricord and his disciples ; and it is generally very
difficult to distinguish between the simple and
specific forms  of the disease.   Generally, how-
ever,  the latter,  or  gonorrhceal, is  attended  by
characteristic  signs referable  to the vulva ;  by
itching, smarting, or  stinging in this situation;
by frequent painful micturition, by inflammation
and swelling of the labia nymphs and  urethra;
pain and soreness being greatly increased  when
sitting.   The  local signs  and  febrile symptoms
are more acute, and the swelling, tenderness, and
intolerance of  an examination are  greater, than
in the non-specific states  of vaginitis,  and the
discharge more copious and more completely pu-
rulent.   In all the cases of gonorrhceal vaginitis
which I have seen the disease extended to the
uterus, and in  three to the ovaria.   In this form
of the disease,  the history of the case, especially
with reference to the affection of the vulva, and
the probability of its  being caused by an impure
connexion, will much assist the diagnosis.   In
most ofthe cases which I have seen, the disease
was communicated by  the husbands of the  fe-
males affected, the fact of this having been the
cause having been acknowledged by the former.
In some instances, much difficulty has occurred in
the diagnosis, especially when vaginitis has been
produced soon  after marriage, in consequence of
excessive sexual indulgence, and ofthe states of
both the male and female organs previously, and
even of the constitution and  habit of body  of
the female.  A similar difficulty is sometimes met
with in the vaginitis,  follicular or mucous, which
occasionally appears during pregnancy.   In both
these circumstances,  the  discharge may  infect
the husband, in such a manner as to be distin-
guished with great difficulty,  or not at all,  from
gonorrhoea in the male.   The  urethritis thus pro-
duced  on rare  occasions is somewhat  different
from the specific disease, as far as my observation
of a few cases  enables me to state.  The earlier
signs referable to the  opening of the urethra,
and the  distressing chordee  characterizing, are
either wanting, or are slight  in the simple ure-
thritis ; while micturition is neither so painful nor
so difficult as  in the specific disease.  The in-
flammation, however, of the former is more dis-
posed to extend to the mucous surface of the 
1430
VAGINA AND VULVA—Vaginitis described.
urinary bladder, and less disposed to affect the
testicles, than that of the latter malady.
  9. C.  Asthenic vaginitis, or diffusive inflam-
mation ofthe vagina, has been hitherto unrecog-
nised.   I have referred  to two instances  of its
occurrence associated  with adynamic dysentery
in  married  females, when treating  of metritis
(see art. Uterus, $ 54), the inflammation having
extended from the  vulva to the vagina and ute-
rus ; and having been produced by the septic and
infectious exhalations evolved, during a long con-
tinuance of warm weather, from full, open priv-
ies.   In these cases the vaginal discharge was
muco-purulent,  streaked  and  discoloured  with
blood,  and  rusty,  at  times  of a  brownish, or
greenish brown hue,  and very abundant, with
remarkable swelling and tenderness of the  parts,
and with the symptoms accompanying acute me-
tritis (see Uterus, § 55, et seq.).  The pulse was
rapid, weak, small, and  compressible; the vital
prostration and the other symptoms of adynamia
being so marked as to require powerful tonics and
restoratives.  Recovery ultimately took place, but
after a very protracted illness.  This  form  of va-
ginitis may be complicated with asthenic dysen-
tery, as observed in the cases now referred  to.
  10. D. Phlegmonous inflammation may attack
the connecting cellular tissue of the vagina, es-
pecially that between the vagina and rectum, and
occasion a small abscess, which may open  either
into the vagina or into the rectum.   Inflammation
also of some portion of the pelvic cellular tissue,
or of the cellular tissue connecting the uterine
appendages (see Uterus, $ 122, ct seq.), may ex-
tend in this direction, and  open into the vagina,
occasioning more or less  inflammation of this
part or of the  rectum, or even a fistulous com-
munication  between the  vagina  and  rectum.
When the inflammatory action is limited to the
cellular tissue of the vagina and its immediate
vicinity,  and occasions only a small abscess be-
tween  the vagina and  rectum, the  opening into
either  part  is  generally followed  by quick re-
covery,  unless the  constitution be  in  fault, and
then ulceration, or a fistulous communication be-
tween the vagina and rectum, may result.
  11. E.  Consequences of  Vaginitis.—a.  Con-
traction and obliteration of the vaginal canal is
seldom observed, the latter especially.   Either of
these lesions may,  however, occur after inflam-
mations caused by injuries, wounds, lacerations,
ulcerations produced by pessaries, foreign bodies,
and irritating injections; but contractions in va-
rious grades and extent are much more frequent
than obliteration, which is a very rare occurrence.
Injuries  or lacerations during delivery are  the
most frequent causes of these lesions.  The in-
jection  of irritants and  stimulants to provoke
abortion  has in a very few  instances been re-
corded as a cause of both contraction  and  oblit-
eration  of the vaginal canal.   These changes
may occur in any part of the canal, but  most
frequently in the part next to the vulva, unless
when they are caused by malignant disease, and
then they generally commence in the cervix  uteri,
and extend to the portion of the vagina adjoining,
and progressively to more or less of this canal.
In the article Uterus (y 205) I have mentioned
a case where nearly the whole of the vagina was
obliterated by cicatrization  consequent upon a
rare instance of the spontaneous cure of malig-
nant disease ofthe cervix uteri and vagina.  Simi-
lar occurrences have been noticed by Rokitansky.
   12.  b.  Chronic inflammation, limited or more
 or  less extended, sometimes either  follows  the
 acute  and subacute  states of vaginitis, or occurs
 primarily, but much more frequently as a conse-
 quence of the irritation caused by morbid secre-
 tions from the cervix uteri, or from the  internal
 surface of the cervix or body of the uterus, and
 it is often complicated with inflammation of the
 cervix. This form ofthe disease may occur either
 in the puerperal or in the non-puerperal states,
 and it may, moreover, be complicated with, and
 then be masked by, the uterine disease, or by in-
 flammation ofthe vulva, or by the leucorrhoeal dis-
 charge, with which it is attended, both in its sim-
 ple and complicated forms.  Chronic inflamma-
 tory irritation, thus  originating  and related, may
 be followed by organic changes of an  important
 nature, especially when it more particularly  af-
 fects the  mucous follicles, or extends to the con-
 necting cellular tissue.  In such cases ulcerations,
 and even perforations, of the vagina are not very
 rare occurrences. The ulceration may be common,
 scrofulous, syphilitic, or cancerous.  The first of
 these  usually occurs in consequence of inflamma-
 tion, chiefly ofthe phlegmonous character noticed
 above (§ 10, et seq.), and commences either in the
 mucous follicles  or in the connecting cellular tis-
 sue.  In these follicles scrofulous ulcerations may
 also commence, or be chiefly seated.   These lat-
 ter have been well described by Dr Carswell ;
 and Dr. Hooper states that these ulcerations as-
 sume  the character  of scrofula in other parts.
 " The sides  of the ulcerations are tumid;  solid
 puriform depositions are found about them in the
 cellular structure between  the membranes; and
 there  are perhaps fistulous communications with
 the urinary  bladder, rectum, or psoas muscle."
 Common  and scrofulous ulceration may be devel-
 oped  either primarily or consecutively  in the  la-
 cunae and glandular  bodies with which the lower
 part of the  vagina  is so  abundantly  supplied.
 When these glands  are primarily affected, there
 is generally an abundant milk or cream-like dis-
 charge from the vagina, constituting a form  of
 leucorrhcea, and depending upon chronic irritation
 or inflammation of them.   This state of morbid
 action when  prolonged, especially in cachectic or
 scrofulous constitutions, may go on to ulceration,
 or even to fistulous perforations.  Disease of these
 glands, and chronic  inflammation of the vaginal
 surface, may also be developed or perpetuated  by
 the morbid secretions from an inflamed or other-
 wise diseased cervix uteri, or internal surface  of
 the uterus,, or of its cervix.   The most extensive
 ulcerations and perforations with  fistulous  com-
 munications with adjoining parts are produced  by
 pessaries or other foreign bodies lodged in the va-
 gina.   Syphilitic and cancerous ulceration of
 the vagina are noticed in the articles on Cancer
 ofthe Uterus and on Venereal Diseases.
  13.  Complications of Vaginitis. — Acute  or
chronic vaginitis  may be associated with  inflam-
mation of the  cervix uteri, or with vulvitis,  or
 urethritis, or even with two or all of these.  It is
chiefly in  girls under twenty that the  complica-
tion with vulvitis  is observed. In some instances
of this complication an abscess forms in the labia
majora, especially when  inflammation of the va-
gina and vulva is severe; and when the inflam-
mation extends to the subjacent cellular tissue  of
cachetic habits, phagedena ofthe parts may super-
vene.   Gonorrhojal vaginitis is generally associ-
ated with urethritis  and vulvitis, and often also 
VAGINA AND VULVA
with sympathetic bubo, this latter being the con-
sequence of inflammation ofthe lymphatic vessels
and glands.   Vaginitis is, in some cases, compli-
cated with endo-metritis, and more  rarely also
with inflammation of the uterine appendages, es-
pecially when it is of  a specific kind, as noticed
above (y 8, 9).   In this complication  the inflam-
mation may originate  either in the uterus or in
the vagina, and extend to  the other parts.  Va-
ginitis may also occur during pregnancy, and dis-
appear after parturition.
   14.  ii. Treatment.—The treatment of the non-
specific or common states of inflammation of the
vagina is generally simple, and is locally and
constitutionally antiphlogistic.  In severe attacks,
leeches should be applied to the upper parts  of
the insides ofthe thighs, or to the groins or peri-
neum, and the bleeding be promoted by warm  fo-
mentations, &c.   Tepid  or warm baths, general
or local; cold,  tepid, or warm injections into the
vagina; cooling aperients, and cooling diaphoret-
ics, and an antiphlogistic regimen, are the chief
means of treatment, especially in the  more acute
cases, and in the early stage.   Aperients which
irritate or excite the large bowels should be avoid-
ed ; and those injections, alvine and vaginal, which
produce a cooling and an emollient effect, not only
on the large bowels, but also on the vagina, should
be selected.  The injection of cold or tepid water
into the vagina washes away the morbid secretion,
which by remaining even for a short time, and  ac-
cumulating in this part, increases or perpetuates
the inflammatory irritation.  Several medicated in-
jections, either emollient, astringent, or anodyne,
may also be prescribed. When the irritation, ten-
derness, or pain, is considerable, milk-and-water,
linseed tea, decoction  of marsh-mallows, either
tepid or cold, may be  administered, with a little
sirup  of poppies,  and  with either a small quan-
tity of the nitrate of potash or of the  biborate  of
soda.   If the  inflammation be severe, the emol-
lient injections may contain either these in some-
what larger quantity,  or a small quantity of the
hydro-chlorate  of ammonia.  Or instead of those
the decoction of poppy-heads may  be employed,
with the saline substances just mentioned, or sim-
ple water with the acetate of lead and a few drops
of laudanum.
   15.  When the more acute and severe symptoms
have  subsided, then the more energetic astrin-
gents may be prescribed, such as the sulphate of
alumina, the sulphate of zinc, acetate of lead, so-
lution of the nitrate of silver, decoction of oak-
bark, and solution of tannin.  Dr. H.  Bennet
states  that the first three he generally uses in the
proportion of a drachm to a pint of water, increas-
ing or diminishing the  strength according to cir-
cumstances ;  and  after much experience he con-
cludes that alum is the most efficacious of all these
agents, with  the exception of nitrate of silver.
In order that injections may be  efficacious,  they
should  be administered  abundantly,  frequently,
and with such  appliances as may allow them to
remain for some time in the vagina.
   16.  For gonorrheal vaginitis, the antiphlogistic
treatment advised for the early stage of common
or simple vaginitis should be energetically pre-
scribed, and cooling diaphoretics and aperients,
with demulcents, emollients, and diluents, freely
used.  The irritation of the urinary bladder and
urethra, and the associated vulvitis, will be most
surely allayed by these means, aided by fomenta-
tions, warm local and  general baths, and by the
L—Vulvitis  described.                    1431

 emollient and anodyne injections advised above
 (y 14).  The patient should partake freely of mu-
 cilaginous diluents containing the nitrate of pot-
 ash or of soda, and the carbonates of the fixed alka-
 lies, with very small doses of camphpr.  After the
 acute symptoms have been subdued, the more as-
 tringent injections  mentioned above may be re-
 sorted to.  If gonorrhceal rheumatism should oc-
 cur, which is seldom observed  in  females, the
 treatme«t for that species of rheumatism, advised
 in the article Rheumatism (y 163), should be di-
 rected.   Gonorrhceal vaginitis  extending to the
 cervix uteri, or occasioning endo-metritis, requires
 the  means advised  for this  complication in the
 article Uterus (v 124).
   17. Asthenic vaginitis, in the form which  I no-
 ticed above,  as having fallen under my observa-
 tion, requires a frequent recourse to vaginal in-
 jections.  Those which I prescribed consisted of
 alum, or of sulphate of zinc, with a little camphor
 and laudanum ; the decoction of cinchona, with
 the  compound tincture of cinchona, nitrate of pot-
 ash, and bicarbonate of potash, being taken inter-
 nally ; and full doses of Dover's powder at night;
 lime-water, or potash-water, with milk, being the
 beverage generally allowed.
   18.  As regards otha lesions implicating the va-
 gina, especially ulcers, fistula, lacerations, or ex-
 tensive ruptures, wounds, hernia, polypi, tumours
 of various kinds, foreign bodies lodged in the va-
 gina, prolapsus of  the vagina,  and cancer of the
 vagina  (see art. Uterus, y 190 et seq.).   I  must
 refer the reader to  surgical works, or to the arti-
 cle Vagina, by MM. Desormeaux and P. Dubois,
 in the second edition of the Dictionnaire de Mede-
 ane, where these lesions are very ably described.
   19.  II. The Vulva is liable to diseases which
 are  either local or constitutional.,  The latter re-
 quires internal or constitutional treatment chief-
 ly, and sometimes  local means also; the former
 seldom receives permanent benefit from local ap-
 pliances, without having  recourse  at the  same
 time to general or  internal medication.  The af-
 fections of this part, as well as of several others,
 show that no distinction should be made respect-
 ing  those which are commonly called medical and
 those which are usually termed surgical; although
 I am obliged, by the scope and limits of this work,
 to observe this distinction to a considerable ex-
 tent. Diseases ofthe vulva are of frequent occur-
 rence at all ages, and in all classes of society. They
 often assume serious  characters, owing to con-
 cealment, neglect, or delicacy of feeling, more es-
 pecially in childhood, or in early or mature age.
 They most frequently proceed from  want of due
 cleanliness, from infection, from eruptive and oth-
 er fevers,  from diseases of the  uterus and ap-
 pendages, and from masturbation.  The puerperal
 states have also some influence in causing them.
 They may occur primarily  or consecutively ; and
 in either case they may be simple, or complicated
 with whatever disorder  they may induce, or  be
 induced by.
   20. i.  Inflammations  of the Vulva.—Vulvi-
     tis.  Classif.—III. Class, V. Order.  (Au-
     thor.)
   21. Definit.—Pain, soreness,  and tenderness
 of the vulva, frequently with swelling, painful mic-
 turition, and  more or less symptomatic fever.
   22. Vulvitis may  assume every grade of sever-
 ity, from the slightest pruritus and  inflammatory
 irritation, to erythema, to phlegmonous, diffusive
 erysipelatous, and to ulcerative or gangrenous in- 
1432                   VAGINA AND VULVA—Vulvitis described.
 (laminations, simple, or complicated.  I shall brief-
 ly notice these, as well as other forms of disease
 of the vulva which fall under the category of in-
 flammatory, either sthenic or  asthenic, and  offer
 some remarks on these varieties of vulvitis which
 have fallen under my observation at the Infirmary
 for Children and  in private practice,  and com-
 mence with the slightest or least inflammatory in
 appearance, and proceed to  the more violent and
 dangerous.                           •
  23. A.  Catarrhal  Vulvitis.—This form  of
 the disease is usually slight, unless it be neglect-
 ed or aggravated by neglect of cleanliness.  It is
 not unfrequent in children ; and in grown-up fe-
 males it occurs as a form of leucorrhcea, or as a
 symptom of disease ofthe neck or body ofthe ute-
 rus.  In infants and children especially, it assumes
 a catarrhal appearance, the discharge being at first
 chiefly mucous, and afterward muco-purulent; the
 surface of the vulva being slightly red and swol-
 len ; but neither very irritable nor excoriated, un-
 less  neglected.  It is most  frequently  caused by
 cold, by sitting on cold or damp seats, by general
 debility, and the irritation of ascarides in the rec-
 tum, or by disorder ofthe digestive organs.  It is
 sometimes a sequela of low and eruptive fevers in
 childhood, especially of scarlet fever; and if it be
 overlooked, or continue long, it may give rise, es-
pecially if aggravated by filth and an improper reg-
imen, to one or other of the more serious forms of
vulvitis about to be described.
  24. B.  Irritable Vulvitis.—As observed  in
 some states of the disease  of the uterus, so  in
 some affections of the vulva, the inflammatory ap-
pearances are either slight or not very remarka-
ble ;  yet the pain and  tenderness are very great,
or even acute.  Sensibility is so morbid as not to
 admit of the slightest touch ;  and in married fe-
males sexual intercourse  cannot be endured.   On
examination, the parts are  slightly red, or rose-
colored, and covered in parts by a whitish exuda-
tion, especially about the entrance of the vagina;
in some cases there is also slight swelling or ful-
ness of the labia.  The patient complains  of a
sense of heat, or lancinating pains ofthe parts, of
smarting,  painful micturition,  and of inability of
walking.   This complaint is sometimes  caused by
the state of the menstrual discharge, and is most
frequently met with in young  persons about the
age of puberty, or shortly before or after the first
appearance ofthe catamenia, in females after mar-
riage and during their first pregnancy, and in wid-
 ows, but less frequently in these last.  It is some-
times associated with one or other of  the forms
of hysteria, or with spinal irritation.
  25. C. Pruriginous Vulvitis.—Primes of the
vulva is often a very distressing disorder.  The
 itching or pruritus ofthe parts is sometimes such
 as cannot be endured without resorting to friction
 in some way or other to  allay  it.   There is gen-
 erally a sense of heat, but seldom much pain,
 tenderness, or soreness ofthe  parts, unless what
 may be caused by the frictions resorted to.  Nor
 is there much redness or swelling, unless such as
 may be referred to the  same cause.   But there is
 obviously  more or less vascular erythism of the
 parts, or of others in their vicinity, sometimes with
 increased  secretion from the surface or interior of
 the labia and orifice ofthe vagina, or even a more
 copious discharge, owing to the frictions resorted
 to.   This  disorder is not  unfrequent previously to
 or after puberty, and often is attended by inordin-
 ate sexual desire, amounting in some instances to
nymphomania, and frequently suggesting mastur-
bation, which, although it may assuage the irrita-
tion for a time, generally tends to perpetuate or
aggravate the disorder.   Pruritus vulvae is also a
frequent consequence of pregnancy, especially of
the first pregnancy, in young plethoric habits and
sanguineous temperaments, of the discharges aft-
er parturition, and of morbid states of the  cata-
menia.   In both  girls  and married females it is
often caused by the state of the secretions from
the follicles  of the vulva and vagina, especially
when they are allowed to accumulate and irri-
tate, owing to their  alteration by the oxygen  of
the atmosphere, the sensitive mucous and erectile
tissues of these parts.  It is also at all ages some-
times symptomatic of worms, especially of ascar-
ides in the rectum.
  26. D. Eczematous Vulvitis.—An eruption
of an eczematous character (see art Eczema, y 9)
is sometimes met with on the internal or external
surface of the labia vulvae, and is  either dry  or
humid, and occasionally extends to the adjoining
parts of the thighs.  It generally presents a cop-
per-coloured redness, is liable to recur at inter-
vals, and often continues for an indefinitely pro-
longed time.  It is attended by a sense of heat  or
burning, with a stinging itching.  It seldom oc-
curs in young females, but is very common after
35  or 40 years  of age, and  especially after the
cessation of the  catamenia; and in those it may
continue for years, particularly in  females  of a
full habit of body, or who are corpulent.  It  is
not necessarily connected with  any venereal in-
fection or with leucorrhcea, although this latter
may be associated with it.
  27. E. Erythematous Vulvitis.—The inter-
nal surfaces of  the labia are  not  unfrequently
slightly swollen, diffusely red, painful and smart-
ing, and  intolerant of touch.   It presents  no ap-
pearance of phlyctena, is smooth or shining, the
surface being hot, with a sense of more or less of
painful heat.  It soon becomes covered by an ex-
udation of a whitish or ichorous lymph ;  and  in
some cases which I have seen at the Infirmary for
Children, the labia have become adherent, and so
firmly adherent as to require surgical aid in sep-
arating them. This form of vulvitis is not un-
common  in children of all ages, especially in those
of a very full habit of body, and in these, as well
as in corpulent females advanced in life, is owing
to the acrimony of the secretions from the parts
in their vicinity, to the state ofthe menstrual dis-
charge, or ofthe lochia, and to the neglect of clean-
liness. In many cases the discharges from the va-
gina, and cervix and os uteri, occasion or perpet-
uate the  inflammation ofthe vulva.  Although a
comparatively slight  disease, the neglect of it may
be followed by more serious results; suchasphleg-
monous or supparative inflammation, by inflamma-
tion ofthe  lymphatics, or even, in rare instances,
in young children, by adhesions ofthe labia.
  28. F. Erysipelatous  Vulvitis.—This  form
of vulvitis generally  resembles  the erythematous
at its commencement; but owing to the state  of
the secretions producing it, or  the habit  of body
ofthe patient, or to both, it is soon characterized
by great  swelling, and  a disposition to terminate
in suppuration, or sphacelation ofthe more super-
ficial parts.   It is attended by a quick pulse, and
by more or less severe constitutional disturbance.
This often becomes a serious disease, and goes  on
to diffuse phlegmon, or phlegmonous erysipelas.
In the most unfavourable  cases, particularly  in 
VAGINA AND VULVA—Vulvitis  described.
1433
cachectic habits, it is liable to occasion gangrene
ofthe integuments, extending even to the adjoin-
ing parts.   It results most frequently from the
same causes as the foregoing varieties of vulvitis
acting  on cachectic habits of body, and during
morbid conditions of the circulating fluids.
  29  G. Pellicular Vulvitis.—Since M. Bre-
tonneau described inflammation of mucous sur-
faces with the  exudation of lymph—forming a
false membrane over the inflamed surface—a form
of disease which he termed diphtheritis—inflam-
mation of the vulva with the formation of a false
membrane—Vulvitis diphtherique, of French pa-
thologists, has been occasionally  observed in cir-
cumstances  similar to those which occasion this
form of inflammation in the cavities ofthe mouth,
pharynx, &c, or when this disease ofthe mucous
surfaces is endemic or epidemic.  This form of
vulvitis differs from all others in the rapid forma-
tion of a false membrane on the inflamed, but very
slightly swollen, surface.   As it is observed in the
mouth and pharynx, so it is found to extend to the
adjoining canals, advancing up the vagina to the
neck ofthe uterus, or into the urethra.   This state
ofthe disease is obviously the result of constitu-
tional disorder, in which the circulating fluids are
in some degree, although not always demonstra-
tively, affected.  It is most frequently observed  in
girls or young females, at certain seasons or lo-
calities of a cold and humid description ; and the
febrile disturbance attending it  presents an as-
thenic, rather than a sthenic character.
  30. H.  Phlegmonous  Vulvitis.—Inflamma-
tion of a phlegmonous form may commence either
in the  cellular tissue beneath or connecting the
mucous and cutaneous structures, or in the more
deep-seated mucous follicles ofthe vulva, or at the
commencement  of the vagina.   It has been as-
signed to one or other of these scats exclusively
by  various pathologists;  and it may very possi-
bly originate in either, although most probably in
the mucous follicles, in consequence of obstruction
in their ducts.   This affection generally appears
with heat and tension of the parts, followed by
a dull and sometimes a severe pain, and affects
chiefly, or more frequently, the  lower halves of
the substance of the labia majora.  Pain, and a
sense of weight, tension,  and fulness,  extend  to
the perinsRum, and more or less febrile disturbance
is developed, which may, in the course of two  or
three days,  assume a severe inflammatory char-
acter.  The bowels are confined, and  the  urine
scanty,  high-coloured, and passed with  pain.
The whole vulva becomes hot, and  one or other
ofthe labia is  thickened and swollen, the inflam-
mation and  tumefaction  extending near to the
perinseum.  In the course of five, six, or seven
days, an abscess commences in the centre of the
inflamed tissues ; and although it cannot be per-
ceived  externally, it may be felt  by firmly grasp-
ing between the fingers of one hand the swollen
labium.  A tumour the size of an egg, or smaller,
will then be found in the midst ofthe tumid struc-
ture ; and if the abscess be at all advanced, fluc-
tuation will  be perceived by a finger of the  other
hand.
  31. Abscess ofthe vulva occurs only on one side
at the same time, and very rarely attacks both  in
succession.   It  is observed chiefly in  young fe-
males, and especially in the recently married, and
very rarely at a greater age than 40 years.  M.
Velpeau  met with a case in a female aged 44.
I was consulted  in a case of a lady who admitted
her age to be 45.  This distinguished physician
states that it is commonly a result of excessive
coition, of disproportion between  the  sexual or-
gans, or ofthe introduction of a foreign body into
the vagina; that it may also arise from neglect of
cleanliness, from  irritation of any kind, whether
externally and  mechanically,  or  internally and
pathologically ;  and that in 18 cases out of 20 it
occurs in girls who have prematurely had sexual
intercourse, in prostitutes, and in  young females
who have indulged  in excessive venereal  pleas-
ures or in masturbation.   It is sometimes a con-
sequence  of leucorrhcea and  of gonorrhoea, and
of any violence or irritation' to which the vulva
has been  subjected.
  32. The course of abscess of the vulva is gen-
erally rapid;  but owing to the structure of the
parts, and to the circumstance of females being
aware of the cause of the  complaint, medical ad-
vice is deferred as long as possible; and the his-
tory ofthe early symptoms and changes is not ob-
tained until the abscess has either burst or is ripe
for opening.    When  left to  itself, it generally
bursts  from the seventh to  the twelfth or thir-
teenth day ; when it has acquired a size varying
from that of a nut to that  of a  hen's  egg.   It
rarely  exceeds this  latter size.    Phlegmonous
vulvitis very rarely  terminates in  resolution, and
seldom  in sphacelation or gangrene, and then
only in cachectic habits of body.   When abscess
of the vulva opens spontaneously, it is generally
by a perforation  in  the direction of the vaginal
surface  ofthe labium.  In some  instances  more
than one perforation is observed when the abscess
has been large.   A fistulous communication may
even form, and, in rare cases,  extend to the rec-
tum, or by the side ofthe vagina to or around the
urethra.   In most cases, however, the abscess is
discharged and healed in the course of a week  or
two.  But if sexual intercourse take place during
this period, the abscess may be reproduced, owing
to the injury or irritation  of the cicatrix, and of
the tender parietes ofthe  former  abscess, and  to
the  greater susceptibility  of the  parts.   Hence
abscess of the vulva may  be  reproduced several
times in the same female.  M. Velpeau  has seen
it thus recur six,  eight, or  ten times  in the course
of a few years.
  33. I. Ulcerative  or Asthenic Vulvitis.—
Noma, Phagedanic  ulceration  of the labia vulva,
Gangrene of the vulva, Gangrenous  inflammation
of the vulva.   Velpeau.—This form of vulvitis is
observed chiefly in children from about the period
of weaning to the ninth or tenth year of age.   It
was first described by Mr. Kinder Wood, and oc-
curs chiefly in ill or insufficiently  fed children, in
those who live in low, unhealthy, or crowded lo-
calities or apartments; or who are the  subjects
of low, adynamic, or gastric forms of fever; and
in delicate, cachectic, and anaemic habits of body,
especially in large manufacturing or other  cities
and towns.  The disease may be preceded, as well
as attended, by loss of appetite, nausea, thirst, and
other febrile symptoms of an adynamic character.
The pulse is quick, small, or weak ; the counte-
nance and general surface  pale or sallow, and the
tongue is pale and covered by a dirty-looking  or
clayey coating or fur.  The patient first complains,
locally, of painful or scalding micturition, or cries
or struggles violently when voiding the urine. The
labia vulva are inflamed and  enlarged, and their
surfaces are of a purple or livid-red tint, the  in-
flammation extending over the clitoris, nymphae, 
1434                   VAGINA AND VULVA—Vulvitis described.
and hymen, and even into the urethra.  A thin
exudation may at  this early period be observed
covering these parts, which may proceed from
the irritation having extended to the lower part
of the vagina.  Twenty-four hours hardly elapse
until a number of small vesications appear with-
in the labia, as well as externally, and soon after-
ward  burst, quickly spread  into each other, and
form large ulcers.  In other cases the inflamed
surface  passes into the ulcerated state without
any manifest vesication.    The thin exudation
mixes with the secretion from the ulcerations;
the resulting discharge is dark-coloured,  sanious
or ichorous, copious, very  offensive, and irrita-
ting to  the  tissues, and rapidly extends the dis-
ease to the perinseum and anus, and to the thighs
contiguous to the labia.
   34. The constitutional symptoms are now most
seriously adynamic.  The pulse is rapid, irritable,
and compressible ;  the face and general surface
are white or blanched ;  the bowels torpid, and the
stools offensive.  The  patient lies constantly on
her back, with the knees bent and wide apart;
and the  distressing pain caused by  micturition
prevents her  from using any effort to void the
urine.   The ulcerations vary in appearance  and
depth.  In some cases they  are foul and deep, in
others they are superficial, and their bottoms pre-
sent small red granulations; their states varying
with the severity, constitutional tendency, and the
treatment of individual cases.
   35. The terminations ofthe disease also depend
much upon the circumstances just now stated.
When  the  ulceration is fully established,  the
swelling of the labia vulvae  diminishes, and the
redness disappears with the extension ofthe ul-
ceration, which is  deep, foul, and spreading, in
states ofthe system manifestly adynamic and ca-
chectic, and of the circulation not only anaemic,
but also contaminated.  The secretion from the
ulcerated surface extinguishes the vitality in suc-
cession of the tissues with which it is in  contact,
until  the external organs are  progressively de-
stroyed.  As the process of  destruction advances,
the face becomes  more  blanched, the pulse re-
markably rapid  and small,  the appetite lost, the
bowels  loose, the  stools offensive;  emaciation
and anaemia being remarkable,  and the discharge
from  the ulcerated surface  most offensive;  and
the patient expires in  the course of a few days,
the duration of the disease varying much with
the circumstances and  treatment  of individual
cases.
   36.  If, however, this affection be  seen early,
and be judiciously treated, the ulcerations become
clean and heal.   Yet, after  they heal, a yellowish
discharge often continues for a considerable time
from the vagina and affected parts; and causes,
where due precautions are neglected, a recurrence
 of the  malady.   In most cases, owing chiefly to
 the extent of the constitutional  disturbance—to
 the low grade of vitality, and to the contamina-
 tion and insufficiency  of the blood—the recovery
 of the patient is generally protracted, and is rarely
 of less  duration than eight or nine weeks.   When
 the ulceration is large and deep, the patient very
 rarely recovers, although the most decided means
 to arrest its progress be employed.
   37. The nature and morbid  relations  of this
 most dangerous  form of  vulvitis are manifest
 from the above.   It has been viewed by M. Vel-
 peau as a gangrenous inflammation of the vulva;
 but the destruction of tissues quickly following
the vesications 6n the inflamed, swollen, and livid
parts is not altogether similar to true gangrene,
but rather to that of phagedenic  or  rapidly de-
structive  ulceration.  It resembles in  most re-
spects cancrum  oris, or  that form of stomatitis
which I have described by the name of stomatitis
phagedanica (see art. Stomatitis, y 24, et seq.).
The causes of both maladies are the same—they
are both consequent, in rare instances, on low fe-
vers, continued, remittent,  and exanthematous,
more especially  on  scarlet  fever—and they are
both arrested when admitting of this termination
by the same or similar means.
  38. K.  Gonorrhceal Vulvitis.—Specific VuU
vltis.—This form  of the disease,  if not always,
is generally attended by more or less  irritation
of the urethra.  The following is nearly the de-
scription ofthe disease by M. Ricord, as quoted
in Mr. Acton's able work.   This complaint may
affect the epithelium of the mucous surface only,
or the vulvar glands also, these glands, according
to  M. Moulinier, being regarded as the organ
secreting the venereal virus.   At first the patient
complains of an unusual sensation in the vulva,
with a desire for sexual intercourse.  This is soon
followed by itching, heat, redness, and  swelling.
The normal moisture of the parts is  much  aug-
mented ;  but it soon becomes increased and irri-
tating,  and aggravates  the  inflammation.   The
discharge rapidly assumes a muco-purulent state,
owing to the affection of the mucous follicles.  As
the inflammation extends more deeply, the swell-
ing increases; and it may then become phleg-
monous (y 30, et seq.), or be attended by cedema.
If the nymphae become inflamed, they may be so
enlarged  as to protrude  beyond  the  labia.  Ab-
scess may follow  the swelling, or the inflamma-
tion may extend to the vulvar glands, and occa-
sion  small abscesses.  Owing to the extension
ofthe morbid action to the urethra, and to the state
of  parts now described, the urine is voided fre-
quently, and produces much scalding and smart-
ing.   Patients who  have been subject to leucor-
rhcea readily distinguish the difference  between
the discharge and other symptoms now experi-
enced,  and those  to which they have been sub-
 ject.  With very exaggerated sensibility of the
vulva, the  scalding  on  passing  urine  becomes
very severe, and in some cases retention of urine
occurs.  The inflammation may even extend along
the urethra to the neck of the bladder, producing
very painful and  constant desire of  micturition.
The existence of urethritis in these cases may be
ascertained, if the patient has not recently passed
water, by introducing the finger into the vagina,
 and then pressing  the urethra from behind for-
ward ;  if muco-pus be in the urethra,  it will be
 at  once evident.   Syphilitic ulceration of the vul-
va is noticed under the head of Venereal Dis-
 eases.
   39. L. Consequences of Vulvitis.—These
 are, as partially noticed above, oedema, abscess,
 ulceration, and molecular gangrene, sphacelation,
 extension of the inflammation to the vagina and
 cervix uteri, or to the urethra and neck of the blad-
 der, or to the lymphatics and lymphatic glands.
 QEdema vulvae, although sometimes caused by in-
 flammation, is more  frequently a consequence of
 organic disease ofthe heart, or ofthe kidneys, or
 of other internal organs ; and it is thus generally
 associated with anasarca.  It may also occur dur-
 ing the  advanced stage of pregnancy, or even
 after  parturition;  in the  former circumstances 
                     VAGINA AND VULVA-

often rendering delivery more serious or compli-
cated, and in the latter increasing the amount of
suffering, and  delaying recovery.  Inflammation
of the lymphatics and their glands rarely occurs
in the course of vulvitis, but chiefly of the phleg-
monous, ulcerative, and specific forms.   It is  sel-
dom detected until pain and swelling are experi-
enced in the inguinal glands, and  then  irregular
streaks  of redness may be perceived in the  ex-
ternal parts, with irregular hardness or swelling
of the labia, extending superficially to the groins.
   40. ii.  Treatment.—A. The treatment of ca-
tarrhal vulvitis (y 23) consists chiefly of frequent
ablutions with weak solutions "of alum or  sul-
phate of zinc, or with camphor-water, or sea-
water, &c.  If the parts present much inflamma-
tory irritation, the local means advised for the ir-
ritable and erythematous  states of the complaint
may be directed, and the treatment  be in other
respects the same.   In most cases, and especially
when connected with debility, or occurring as a
sequela of fevers, &c, then warm salt-water bath-
ing, followed by tepid or cold salt-water bathing,
or warm salt-water hip-baths;  tonics internally,
chalybeates, due attention to the digestive, assim-
ilating,  and excreting functions, and change of
air, &c, will be found of  very great  service.
   41. B. Irritable vulvitis (y  24),  Pruriginous
vulvitis (y 25), and Erythematous vulvitis (y  27),
are so closely allied states of inflammation,  and
so generally affect only  or chiefly the epithelial
mucous surface, as to require the same or very
similar means of cure.  At first emollient  or de-
mulcent lotions, containing a sedative or narcotic
tincture, or solution, in small quantities ; or weak
solutions of the acetates of lead, or of the nitrate
of potash, or hydrochlorate of ammonia, in  the
decoction of poppies ; or a saturated solution of
the biborate of potash, in camphor-water, or in
the decoction of marsh-mallows; or cooling  po-
mades, as cold cream, &c, may be prescribed.  In
the more obstinate or severe cases, pomades con-
taining  the  oxyde of zinc, or the chloride of mer-
cury, &c.; or lotions  with a small quantity of the
nitrate of silver, or bichloride of mercury, or of
the sulphate of zinc.   Or demulcent applications,
containing  camphor,  with one  or other  of  the
substances just  mentioned, may be  resorted to.
As these several forms of vulvitis are often  symp-
tomatic of disease  of some adjoining organ, more
especially of inflammatory irritation of  the neck
of the uterus, of leucorrhcea, of the  irritation of
worms in the rectum, of  gravel or calculi in the
bladder, &c, these morbid relations of the forms
of vulvitis now being considered  should  not be
overlooked; and the treatment ought to be di-
rected more especially to the cure ofthe complaint
of which they are severally a symptom merely,
but a symptom which also requires removal.
   42. C. Eczematous vulvitis, or  eczema  of the
vulva, may be treated by similar means to those
now recommended, or by  the local and  constitu-
tional remedies mentioned in the article Eczema
(see y 16, et seq.).
   43. D. Erysipelatous vulvitis is often  a serious
disease (y 20), and arises from the same, or nearly
the same, causes as those producing the erythe-
matous  variety.  In most of the cases of the  for-
mer, however, the constitution is  more in fault,
especially the circulating fluids, than in the  lat-
ter.  The treatment, therefore, of this form should
be more energetic, and be directed  chiefly with
the objects of depurating the blood, and support-
-Treatment of Vulvitis.                 1435

ing vital power and resistance.  The former in-
tention will be fulfilled by the exhibition  of  a
smart emetic at an early stage, followed by a mer-
curial  purge,  and by saline aperients and depu-
rants.   After  the prima via has been sufficiently
evacuated, tonics should  be conjoined  with the
alkaline carbonates, and such local means resort-
ed to as the state of the parts may suggest.  If
diffusive phlegmon, or abscess, or gangrene su-
pervene, the constitutional treatment should be
energetic, and the local measures the same as ad-
vised for the phlegmonous and  phagedaenic forms
of the disease  (y 45, 46),  especially scarifications
and incisions, which, when practised before sup-
puration or sphacelation  commences, often pre-
vent those serious consequences of the malady.
   44.  E. Pellicular vulvitis is generally most suc-
cessfully treated by applying to the affected sur-
faces powdered alum, or  calomel, or borax, with
mucilage or honey, or strong  solutions of the
nitrate of silver, or of the chlorides, &c.  Hav-
ing  arrested this form of the disease  by these
means, emollient or detersive lotions, hip-baths,
and the remedies advised for the milder varieties
of vulvitis may then  be  prescribed  (y 40, 41).
The constitutional  treatment should depend upon
the peculiarities and circumstances  of  the  case.
But generally this form of the disease is not ben-
efited, but it may be injured, by vascular deple-
tions ; while saline aperients, and alkaline, saline,
and other depurants of the blood, conjoined with
tonics, are beneficial.  The treatment of this va-
riety of the disease is  in most respects the same
as I have advised for pseudo-membranous Stoma-
titis (see y 14, 15).
   45.  F. Phlegmonous vulvitis (y 30, et seq.) may,
when  left to itself, especially in cachectic habits
of body, occasion  serious destruction  of parts,
sinuses and fistulous  openings  and  communica-
tions with adjoining organs, or prolonged ulcera-
tions.   To prevent these consequences: 1st.  The
patient should be kept in  bed, or on a couch, in
a cool  temperature, with  the thighs wide apart;
2d. A considerable number of leeches should be
applied between the labium and thigh, or  upon
the perinaeum ; 3d. To cover the phlegmon, twice
or thrice daily, with mercurial ointment previously
to applying linseed poultices;  4th.  To  direct a
warm  bath every second day, or a hip-bath every
evening or night (Velpeau).   The abscess may
spontaneously open, when thus treated, from the
fifth to the eighteenth day ; but it  is generally
more beneficial to  open the abscess as soon as
matter is formed, than to wait for a  spontaneous
discharge, which may take place in  an undesira-
ble situation, or after the abscess has occasioned
more or less serious alterations, such results be-
ing  not uncommon in unhealthy constitutions.
The question  as to the situation in  which artifi-
cial  opening  of abscess of the vulva should be
made has been decided by M. Velpeau in favour
of the external  surface of the affected labium,
and in the lower or posterior part ofthe swelling
or abscess, for reasons he has assigned in the ar-
ticle referred to in the Bibliography.
   46.  G. Phagedenic ulceration of the vulva (v 33,
ct seq.) is the result of a molecular loss of vitality
of the tissues poisoned by the contact of the irri-
tating  and  contaminating fluid into which the
dead molecules are resolved.  It is identical in
its nature with phagedanic stomatitis, as already
stated ; and the local as well as the constitutional
treatment is in every respect the same as I have 
1436                                  VEINS—Diseases of.
advised  for  that dangerous  malady.   (See  art.
Stomatitis, y 31-33.)
  47.  H. Gonorrhceal vulvitis (y 38) is treated as
follows by M. Ricord  and  Mr. Acton.   In the
commencement  a soothing  plan  should be  em-
ployed, and separation of the surfaces attempted,
followed by lotions of nitrate of silver, in the  pro-
portion of  jj. to  fij. of distilled  water, and by
warm  baths.   If the inflammation has gained the
deeper tissues, the soothing  plan should be adopt-
ed, or leeches should be  applied  to the groins.
If a phlegmonous condition of parts  occurs, de-
pletions should be chiefly relied on ; and the  mo-
ment that an abscess is formed an opening should
be made into it,  in order to prevent the pus from
burrowing through  the cellular tissue.   When
urethritis is  much complained of, cubebs and the
balsams, with demulcents, are then required.   Aft-
erward, balsams and lotions  of the solution of the
nitrate of silver  should be prescribed.
  48.  /. The  consequences  of  the several forms
of vulvitis  must  be  treated with  reference not
only to their actual states, but also to the circum-
stances, features, and complications of individual
cases.  General therapeutical principles will guide
the physician in respect of these as well as of oth-
er morbid conditions, recollecting,  however, as re-
spects the most of them,  that  strict  attention to
ablutions by suitable means; to the digestive, as-
similative, depurating,  and  excreting functions;
and to the promotion of constitutional power, and
of vital resistance to the extension of disease, are
the surest principles of successful practice.
   49.  III. Structural and other  Lesions of
the Vulva.—These consist chiefly  of hypertro-
phy of the nympha, of tumours  of the clitoris,
thrombus or effusion of blood  in  the labia after
injuries or parturition, fistula, cancer, hernia, ele-
phantiasis  of the vulva or of the nympha;, tu-
mours or cysts—erectile, sebaceous, follicular, or
others—the growth of  hair  within the vulva, &c.
These concern the surgeon  rather than the phy-
sician, and  require no  remarks from  me.   The
only exception may be made in regard of hyper-
trophy of the nympha:,  which may take place to
so great an extent as to require their extirpation.
In  unmarried  females,  advanced  in age,  this
change has  undoubtedly proceeded from mastur-
bation.  But  in very young females, to whom
this vice could not be imputed, and also in chil-
dren,  the nymphse arc sometimes  so  greatly de-
veloped as to protrude far below the labia majora.
Of this state of parts I  have seen several instan-
ces.   In one case  which came  before  me, the
very enlarged and prolonged nympha? were extir-
pated.   The hamorrhage was very considerable,
but recovery was  complete.   The clitoris  may be
enlarged as well as the  nymphae ; and in such
cases  the enlargement is probably  owing to mas-
turbation.   These parts have  been  observed by
Larrey, Gilbert, Clot-Bey,  Talrich, and oth-
ers, to have been the seats of  elephantiasis ; the
tumours which  resulted having been as large as
a child's head.  M.  Velpeau has  referred to sev-
eral cases, of this  nature,  which, however, are
not rare in Egypt and other parts  of Africa.
  Btni.ioo. and Refer.—i. Diseases of Vagina.—Cel-
sus. 1.  vi., t. 18, 19 —Morgagni. De Sed. et Caus. Morb.,
ep. lxix., art. 16.—Astrue.  Traiti des Mai. des l-'emmes,
t iv., p. 5.—Petit, Traitj des Mai. Chirurg., t. iii., p. 108.
—Pur ell, in  Philosoph. Transact., 1774.  p. 474.—Pole,
in Memoirs of Medical Soc.  of London,  vol. vi., art.  16.—
Horn. Archiv f ir Practische Medicin, b. i., p. 31.__Portal,
Cours d'Anatomie Medicale, t. v., p. 227, 4S3.—Fritze, in
Horn,  N. Archiv fur Med.  Erfahrung, b. iii,, p. 35.__Lo-
der, Journ. fur die Chirurgie, b. iv., p. 354.  (Gangrene
of.)— Watson, in Med. Cominun., &c, vol. i., p. 12.  (Pro-
lapsus from Dropsy.)— W. Goldson, Extraordinary Case
of Lacerated Vagina, &c.   Lond., llSI.—Sand.fort, Obs.
Anat. Pathol., vol. ii., p. 57.— Richter, Chirurg. Biblioth.,
vi  p. 742.__B. J. C. de Garengeot, Memoire sur plusieura
Hernies bingulieres, in Mem. de l'Acad. Koy. de Chirurg.,
t. i., p. 699. —J. C. Stark, De Hernia Vaginali, &c, in
Neuen Archiv fur Geburtshiilfe, t. i., p. 48. — J. V. Loder,
De Vaginse  L'terique Procidentia, 4to.   Jena,  1781. —
Journ. Complement,  des Sciences Medicates, t. xxxvi., p.
431.  (Recto-vaginal  Tumours.)—G. O.  Flemming, The
Follicular Origin of some Vaginal Tumours, in Kdinb.
Med. and Surg. Journal, vol. xxxv., p. 82.— Lallemand,
in Archives CKn.-rales de Medecine, t. vii., p. 481; in sec-
ond series, t. vii., p. 474;  in third series,  t. ix., p. 343.
(On the Tnatment.of Vesico-vaginal Fistulcv.)—Xaegele,
in Re pert, de l'Anat. et de Physiolog. Patholog., t. v., p.
147.  (Treatment of Vesico-vaginal Fistula.)—liognetta,
Sur la Cystocele Vaginale, &c, in Revue Medicale, t. ii.,
1S32, p. 394; t. iii., p. 39, 163.—Amussat, in  Gazette
Med. de l'aris, 1835, p. 785 et 817.   (On Malformaliom
of the Vagina, und Operations for.)—A. J. Jobert, in lb.,
1836, p. 145; et in Mcim. de PAcademic Roy. de  Med., t.
viii., p. 6J7.—G. Janselme, in 1'Experience, 1838, t. i, p.
257, 464.— S. Ashwell. a Practical Treat, on the Diseases
peculiar to  Women, 8vo.  London, 1844, p. 697__Leroy
d' Etiolles, Recueil de Lettres et Mem., 8vo.  Paris, 1844,
p. 161.—Maletaigne. in Journ. de Chirurgie, 1843,1.1—A.
Deville, De la Vaginite Granuleuse, in Archives Gener.
de Medecine, 4th ser., t. v., p. 305, 417.—Velpeau, Mede-
cine Operatoire, t. iv., pluries.—Desormeaux, et P. Du-
boi ,in Diet,  de Med., 2d. ed., art. Vagina.—C Jlokitaniky,
a Manual of Pathological Anatomy, transl. for Sydenham
Society, vol. ii., p. 266. —Jasinshi, in Journ. des  Progres
des 8c. Med., 2d ser , t. ii., p. 267.— J. H. Bennet. Pract.
Researches  on Inflammation of the Uterus and its Ap-
pendages, Svo.  Lond., 1849, p. 265.—C. West. Lectures
on the Diseases of Women, &c, Svo.  Lond., 1856, p. 150.
—R. Boyd, in Transact, of Medical and Chirurg.  Society,
vol. xxiv., p. 187.—J. C. W. Lever and J. Hilton, in lb.,
vol. xxxi., p. 315. — Lisfrunc, in British and For. Med.
Review, vol. xviii., p. 17.  (On  Polypi of.)—W. Acton,
Up. infra cit., p. 274. — Quain,  Ormerod, and Gibb, in
Transact, of I atholog. Society, vol. vii., p. 271-289.
  ii. Diseases of tub Vulva.—Oribasius, Synopsi?, L
ix., c. 51, 53. —Eisenmann, Tab. Anat. Uteri Duplicis,
Argent., 1752.   (Vulva DujAex.)—Lettsom. in Mem. of
Med. Soc. of Lond., vol. iii.—Macbride,  in Med.  Observ.
and Inquiries, vol. v.— Vallisneri, Opera, vol. iii., p. 337.
—T. Vogel,  Medic. Chirurg. Beobachtungen, p. 15.  (Car-
cinoma Vulva}.)—Wendelstatt, in Loder, .lourn., &c, b.
iv., p. 344.—S. Ashwell, a Practical Treatise on Diseases
peculiar to Women, 8vo.   London, 1844, p. 693. — F. H.
Ramsbotham, on Diseases ofthe External Organs of Gen-
eration, in London  Medical Gazette, vol. xvi., p. 289.—
Oldham,  on Follicular Disease of the Vulva, in London
Med. Gazette, May 15,1843.—Tripet, jn Archives Gen r.
de Med.,  Sept, 1845.—C. Rokitansky, Manual of Patho-
logical Anatomy, &c., Sydenham Society ed., vol.  ii., p.
264.—Fricke, in  Rust's Magazin, b. xxxiii., p. 143.—/''.
Churchill, Outlines of the principal Diseases of Females,
&c, 8vo.   Dublin, 1838. p. 11, 22, et pluries.—W. Adon,
Pract. Treatise on the Lis. of the Urinary and Generative
Organs, &c, 8vo.  Lond., 1851,  p. 271.—it Druit, The
Surgeon's Vade-Mecum, a Manual of Modern Surgery,
7th ed.  Lond., 1856, p. 602.  (See also the  Ribliogea-
phy  and  References to Art Uterus and itb Append-
ages.)
   [Amer. Bibliog.  and Refer.—X. Rozeman, Remarks
on Vesico-vaginal Fi3tule, with an Account of seven suc-
cessful Operations, with wood-cuts, p. 29.   Louisville
Keview, May,  1856; also  Urethro- vaginal and Vesico-
vaginal Fistules, Remarks upon their Peculiarities and
Complications, &c. (17 wood-cuts),  p. 23.  North Amer.
Medico-Chirurgi-al Review, July, 1857.—P. M.  Kollach,
The History and Treatment  of  Vesico-vaginal  Fistula:
a Report  read before the Medical Society of the  State of
Georgia (with nine wood-cuts),  p. 32.   Augusta, 1857.—
//. R. Stover, on "The Treatment of Vaginal Fistula."
Am. Jour. Med. Sciences, Oct., 1857, p.  387.]

   VEINS, DISEASES OF.—1.  This  order  of
circulating vessels has not received that share of
attention and research which it deserves  in sev-
eral states of disease,  either implicating  it more
especially, or affecting the  frame  generally, and
changing  more or less not merely the blood cir-
culating in it, but the  whole mass of blood sup-
plying all  the organs  and  tissues of  the body.
Hence alterations of these vessels should not be
viewed with reference to themselves only, and as 
VEINS—Inflammation of.
1437
local changes merely, but with a due recognition
of the effects produced by them on  the blood, and,
through the blood, upon the whole frame.  Even
this apparently comprehensive view is not suffi-
cient ,  it is only one aspect in which this subject
should be studied—one side  of the object—for
another presents itself to  the  experienced and
searching eye, viz , the many noxious agents, and
the numerous local changes and structural lesions
affecting primarily the several tissues and organs,
frequently altering either the blood  in these  parts,
or the veins originating  in them, or even both,
successively contaminating the blood and  circu-
lating  systems, and ultimately altering  the vital
cohesion and the ultimate organization of all parts
of the  living body.
   2  It would be impossible, even  were  it neces-
sary, to consider the diseases of veins, especially
in connexion with those of the blood, with that
amplitude which I might desire or others expect
This subject can be viewed only in its more prac-
tical and important relations, at this place.  The
full consideration which I have bestowed on the
several matters and topics intimately connected
with diseases of the blood and  circulating organs
and vessels, and on the treatment  of them  under
their respective heads, in the early parts of the
work,  prevents me from attempting more at this
place than to notice what has not already come
under  discussion.
   ^3. It is chiefly  to John  Hunter that we are
indebted for the earliest and best information re-
specting diseases of the veins, and especially as
to the treatment most appropriate to inflamma-
tion of them.  Since  his time the  researches and
works  of Baillie, Hodgson, Cruveilhier, Mec-
kel, Breschet, Davis,  Dance, Lee, Gendrin,
Ribes, Arnott, and others,  have tended most
essentially to advance  our knowledge  of these
important subjects.   Diseases of the veins resem-
ble those of the lymphatics and arteries (see those
articles) in  some respects, and differ from them
in others, particularly as regards the  constitu-
tional  symptoms.   The veins never exhibit  an
alteration in all respects similar to aneurism, be-
cause  their coats yield equally to pressure, and
are not  subject to the  forcible impetus of the
blood , besides,  their inner coats  are more sus-
ceptible of dilatation  without rupture than those
of the arteries; they are, however, more subject
to inflammation and varicose  dilatation  than the
latter vessels.
   4. Ossific formations, which are so often met
'with in arteries, are seldom found in veins.  The
difference of texture  is not sufficient to account
for this;  for, as M. Andral remarks, the  struc-
ture of the pulmonary artery is the same as that
of the  aorta, and the right side of the heart is or-
ganized precisely as  the  left; and  yet  ossifica-
tions are  much more  frequent in the  aorta and
left side of the heart than in the pulmonary  artery
and right side.  The more abundant supply  of
ganglial  nerves to the arteries than to the veins
may, perhaps, tend to create a difference as  to
the nature  and  frequency  of  diseases  of these
two orders of vessels.   The constitution of the
blood,  and peculiarities of the circulation  in each,
may also  contribute to diversify their maladies.
The circumstance of the blood being oftener coag-
ulated  and organized  in the veins than in the ar-
teries may be chiefly imputed  to this latter cause,
and to the more frequent occurrence of inflamma-
tion in the  former vessels.   Pus  is more com-
monly found in the veins than  in the arteries ;
this is owing to three causes : 1st, to the greater
frequency of inflammation of veins; 2d, to the
circumstance of this morbid secretion being car-
ried  into  the  veins  by absorption;  and, 3d, to
the probable metamorphosis or  alteration of the
pus-globules before they reach the arterial circu-
lation.  Perhaps the second and third causes are
the most influential.
  5.  The  constitutional effects of diseases ofthe
veins,  and the consequences of  inflammation of
them,  differ very considerably from  those which
characterize the maladies, of the other orders of
vessels composing the vascular  system .  but the
differences are chiefly apparent  in acute inflam-
mations of these vessels, as will be observed upor
referring to what has been stated respecting these
diseases
  6. I. Inflammation of Veins—Synon. Phle-
bitis (from <p?ieib, a vein)  Aderentziindung Bluta-
derentzundung. Germ.  Phlebite, Fr.
  Classif—III.  Class, I.  Order (Author in
     Preface).
  7.  Definit.— Tenderness,  tension, acute pain,
and  a knotted, cord-like swelling or hardness in
the course of a vein or veins, sometimes with  dis-
coloration, when the  veins are superficial, extend-
ing both  to and from  the centre of circulation,
with symptomatic fever, which often passes into an
adynamic state, with indications  of contamination
of the  blood, or purulent formations  in the viscera
or other parts.
  8.  The pathological anatomy  of phlebitis  will
be more  fully  shown in the  sequel; but it may
be stated at this place that inflammation  of veins
occasions, 1st. The formation of coagula adhering,
by means ofthe lymph exuded from  the inflamed
surface, to the internal membrane of the vessel;
2d. The secretion of pus, which may be surround-
ed by a false membrane, or by coagulated lymph,
or be contained in coagula adhering to the intern-
al surface of the vessel; 3d  The secretion of pus,
which is not surrounded either by plastic lymph,
or by a coagulum, but which has a free access to
the current of circulation; and, 4th The secre-
tion of an ichorous or sanious fluid  from the in-
flamed inner membrane,  which rapidly  mingles
with and  contaminates the blood, and generally
produces rapid and fatal changes ofthe structures.
Instead, therefore, of viewing phlebitis,  as here-
tofore, to consist of only two principal forms, viz.,
the adhesive and the suppurative, the latter being
either  confined or free, I would add a third, the
ichorous or poisonous.
  9. Inflammation of veins is of the  greatest im-
portance as respects both the local lesions  and
the consequent contamination of the blood.  It
is much more  frequently seen than inflammation
of arteries.  Its seat is the cellular tissue of the
vein, and the circular fibrous coat, in  as far as the
latter exhibits  any degree of redness or vascular-
ity ; and  its products are deposited in both these,
and in the non-vascular or internal  lining mem-
brane extending into the canal of the vessel.   It
more frequently is acute than chronic, the former
being distinguished by an exudation  on the inner
surface of the vessel.   When phlebitis—inflam-
mation of the coats of the vessel—is the  primary
disease, the changes ofthe blood, and other alter-
ations  within the inflamed vein, are consequences
of this inflammation, these changes being sec-
ondary.  But when the blood in  a vein is coagu-
lated, or is otherwise remarkably altered or pois- 
1438
VEINS—Inflammation  of.
 oned, it may, in such a state, irritate the intern-
 al membrane of the vein, inflame it, ot all the
 coats of the vessel, the phlebitis being thus con-
 secutive or secondary.  The disease may be seated
 in a single vein, or extended to several, or even to
 many, whether it be thus primary or consecutive.
   10. John  Hunter first demonstrated the path-
 ological changes and  the consecutive  phenom-
 ena of phlebitis.  Many years afterward, Sasse,
 B.  Travers, Abernethy, Hodgson, and Bre-
 schet directed  their attention to this disease;
 and more recently Ribes, Arnott,  Dance, Davis,
 R.  Lee, Mareschal, Bouillaud, Cruveilhier,
 Velpeau,  Blandin, Rokitansky,  and  others,
 have contributed facts and opinions respecting it.
 Nevertheless the subject is by no means exhaust-
 ed ;  for there still remain various topics connect-
 ed with it, both pathologically and therapeutically,
 requiring farther elucidation and confirmation.
   11. i. The Causes of Phlebitis.—Inflamma-
 tions of the  veins are much more frequent in the
 male than in the female sex, if phlebitis conse-
 quent upon  parturition be excluded  from the ac-
 count, and in ages from fifteen years to fifty. This
 greater frequency in males, and in the active pe-
 riods of life, is  probably owing to a greater ex-
 posure to injuries and other exciting causes in
 this  sex and age.  These  causes  are numerous,
 but  they chiefly consist of external injuries  of
 various kinds, more especially punctures, lacera-
 tions, abrasions, fractures,  and contusions ; punc-
 tures or divisions of veins, particularly with blunt,
 ragged, foul  or  poisoned  instruments;  wounds,
 punctures or injuries in anatomical dissections or
 during post-mortem inspections ; cuts or scratch-
 es when preparing or dressing animal food, espe-
 cially game, &c.; operations,  &c, when perform-
 ed in foul wards of hospitals, or in low, impure,
 and ill-ventilated localities  or apartments ;* frac-
 tures, compound or comminuted, in similar cir-
 cumstances ;  ligatures  or  surgical  operations on
 veins; the application  of  caustics or local  irri-
 tants ; the existence of ulcerated or tubercular
 cavities, or of abscesses or malignant formations,
 with  which  veins communicate, or  into  which
 either of these morbid matters pass ;  and the im-
 bibition of morbid matters by veins or sinuses,
 from  cavities in which  morbid secretions, fluids,
 or deposits accumulate, as the cavities ofthe ute-
 rus and cervix uteri, or  from ulcerated cavities in
the lungs, liver, &c, or from  necrosed bones or
 sphacelated structures,  or  from purulent  matter
lodged under the flaps formed in amputations.
  [* Inflammation of veins is more common after surgi-
cal operations  than is generally supposed.  We have
known several fatal cases,  not only from venesection in
 the arm, but also ligature of varicose veins in the leg and
 the  testicle,  and where every precaution  was used  to
guard against consecutive accidents. Such cases may be
found in all our medical journals and works on surgery;
in some cases  the fatal inflammation has resulted from
incision, in others from excision or ligature.  Mr. Travers
and Sir Astley Cooper have  recorded several such in-
 stances.  In regard to  inflammation from phlebotomy,
 Mr. Abernethy imputes it  to moving the arm soon after
bleeding.  Dr.  Thomhon, of Edinburgh, ascribes it chief-
 ly to  the dulness of the lancet.  ()ther good authorities
 believe that the latter is not sufficient to cause the dis-
ease, unless there be present a peculiar irritability of con-
 stitution.  Much, however, must be owing to atmospheric
conditions, as we find phlebitis far more common  at some
 seasons than at others. This is true both as  regards
 traumatic as well as other kinds of phlebitis.  Punctured
 wounds, if the  instrument  be charged with some putrid !
 or irritating matter, are very apt to produce inflammation
 of deep-seated veins; and instances have occurred where
 such a result has followed from using a lancet previously
 employed for vaccination, and  not thoroughly cleaned.]
 These last, venicsections, and punctured or other
 wounds, are  the most common  exciting  causes
 of phlebitis.
   12. In hospitals, especially during the  preva-
 lence of hospital  gangrene or erysipelas, cither
 within them  or in their vicinity ;  in camps or
 barracks, prisons or crowded vessels, especially
 transports ; and in low,  damp, crowded, and im-
 perfectly ventilated  situations, and in localities
 exposed to noxious exhalations, particularly in
 malarious states of the air, or when erysipelas is
 prevalent in them, and when the more common
 exciting causes are of frequent occurrence, phle-
 bitis may then assume an endemic or epidemic
 prevalence.  In these circumstances and seasons,
 venisection and other operations involving veins
 can seldom be performed without the risk of pro-
 ducing the asthenic, or most  dangerous form of
 phlebitis (§ 21, ct seq.); and, indeed, these opera-
 tions, especially venisection, should be on such
 occasions avoided as much as possible.
   13. Phlebitis is sometimes not only caused by,
 but  often also associated with, organic lesions of
 internal organs, especially with ulcerations  of
 the  intestines, with  abscesses in the liver, kid-
 neys, lungs, brain, ears, &c.; and is occasionally
 detected in the  mesenteric, the  portal, and the
 pulmonary veins, and even in the veins  and si-
 nuses within the cranium, upon dissection.  It is,
 however, most frequently associated with uterine
 diseases, and with inflammations and abscesses
 of the uterine ligaments; the iliac, spermatic,
 and  other veins, having become consecutively
 inflamed, as stated in the articles on diseases of
 the  Puerperal States, and of the Uterus.
   14. ii. Symptoms.—A. The symptoms of sthenic
 phlebitis may be divided into two stages, namely,
 1st.  Those which are local, and characterize the
 local limitation of the malady ; 2d. Those which
 indicate the contamination ofthe blood, and gen-
 eral  infection ofthe frame.  1st.  The local signs
 are  generally  very manifest  when any of the
 more superficial veins are attacked ; but they are
 very equivocal when the deep-seated and inter-
 nal veins are implicated.   Phlebitis usually com-
 mences with sharp or severe, sometimes  violent,
 pain in a part, or in the  course, of a vein.  If
 the  vessel  be superficial,  it will  be found  hard,
 tense, as if stretched, forming under the skin a
 cylindrical or knotted cord.   At the same time
 the  skin sometimes  presents  a  reddish  line or
 more extensive erythematous  blush, or even an
 erysipelatous appearance.   If the vessel is  more
 deeply seated, tension and hardness may be felt
 in the situation or course  of the pain.  Conges-
 tion  or engorgement of the capillaries ofthe cel-
 lular tissue adjoining or surrounding the inflamed
 vein  are  afterward  observed;  and if  several
 veins, or a large trunk is affected, this tissue, and
 the parts below or distal  to the  seat of disease,
 become oedematous, or very remarkably swollen.
 With the local lesion, the constitution  sympa-
thizes more or less remarkably, the general symp-
toms varying with the severity and extent ofthe
 inflammation,  and  with  the   temperament and
 habit of body of  the  patient;  but quickness of
pulse, heat  of skin,  headache, loss of appetite,
thirst, and impaired secretion and excretion, with
other symptoms of inflammatory fever, are com-
 monly observed.
   15.  In  favourable states of the constitution,
and  when judiciously and early treated, the dis-
ease  may not proceed  farther.  The coagulum 
VEINS—Inflammation  of, Described.                        1439
formed  in the  inflamed  veins adheres to the
parietes of their canals; a collateral circulation
is established, and the inflamed veins no longer
permit the circulation of blood through them.  In
some cases the inflammatory exudation on the
internal  surface of  the vessel, or the coagula
formed on its sides by means of this exudation,
leave a central canal, allowing a partial circula-
tion of blood along  it.   In other instances the
inflamed  veins  secrete pus, which may  be so
abundant as to  give rise to fluctuation, or  other
indications of its presence in the sub-cutaneous
cord, which is felt when the vein  is superficial;
and, if an artificial issue is not given to  it, the
matter makes its way into the adjoining cellular
tissue, and forms an  abscess, which follows the
usual course.  When the  local lesion does not
terminate in either of these ways ; and when the
morbid exudation, or purulent matter furnished
by the inflamed vessel, is carried into the blood,
the system becomes generally infected, owing to
the contamination of the  blood thus produced,
and the second  period or stage  of the malady is
developed—or the state of pyamia.
   16. 2d. This stage of phlebitis, or that of vas-
cular infection,  may  take  place rapidly, or not
until after a few days,  the rapidity of its  occur-
rence depending upon the nature of the exciting
cause and  the  constitution  of the patient.   It
usually commences with chills or rigors, followed
by  hot skin and other symptoms of fever, and
by  perspiration.  These paroxysms of chills, fe-
ver, and sweats generally return at irregular in-
tervals, assuming a remitting form ; but in some
instances they are periodic.   With these exacer-
bations, anxiety, distress, or slight or occasional
wandering delirium  appear; and  these are fol-
lowed by more continued delirium, which is gen-
erally low or muttering, rarely lively or excited.
The tongue,  previously  furred, now becomes dry
or encrusted, is trembling, or  imperfectly pro-
truded ;  the  teeth and  lips are fuliginous; the
countenance is sunk, dusky or pale, and  lurid,
and the symptoms assume  a  typhoid  or adynam-
ic character.  The pulse is small, very frequent,
and soft.  Ttkese  phenomena are observed  in
nearly all the cases at this stage ; and others are
less constantly present, especially retchings and
vomitings;  diarrhoea, the stools being dark and
very offensive, the urine turbid  and  fetid or am-
moniacal,  and  the surface  dark  or dusky,  or
slightly jaundiced.
   17.  During this stage, and often at  an  early
period of it, secondary  abscesses form  in  some
internal  organ,  with  indications of  oppression,
tenderness, or distress,  referred especially to the
regions in which  the affected organ is seated.
In some cases the larger joints become extreme-
ly painful and swollen, from the formation of pus
within their capsules.   Purulent deposits,  with-
out any very manifest indication of pre-existing
inflammation, sometimes form not only in the in-
ternal viscera, or in the joints, but also in the in-
tramuscular tissues, and even in the brain,  occa-
sioning profound coma.  If this stage continue
even  for  a  few days,  extensive bed-sores and
sphacelations occur  in  the  situations on which
the weight of  the  body chiefly rests;  and, the
sensibility of the urinary bladder being in  great
measure lost, the urine becomes ammoniacal, or
the functions ofthe kidneys much impaired, con-
tamination of the circulation is farther increased,
and its consequences accelerated, death generally
 ensuing with a celerity according to the extent
 and rapidity of these changes.
i   18. The extension ofthe inflammation is gen-
l erally in the direction  of the  heart, or of the
 current  of  circulation;  but  a fatal result often
 takes places before the inflammation reaches the
 vena cava, or even the larger venous trunks, ow-
1 ing to contamination of the blood by the exuda-
 tion, or purulent matter, from the inflamed parts."
 In some cases, however,  the disease  pursues a
 different course, and extends to the  smaller ram-
 ifications.   Mr. Abernethy met with a case of
 ph}ebitis after blood-letting atths bend ofthe arm,
 in which the  veins were affected down to the
 hand.  This more unusual  course is  very prob-
 ably occasioned  by the  complete  obstruction of
 the part of the vein first affected by a coagulum
 or exudation of lymph.   It may also be partly
 the result of the state  of constitutional power.
 It is not infrequent  in puerperal phlebitis, the
 cause of which is chiefly the imbibition of sanious
 matters from the internal surface of the uterus,
 aided by shock and vital depression, and by the
 predisposition produced by an impure air.
    19. iii. Ofthe different pathological Con-
 ditions observed  in  Phlebitis.—The  several
 pathological states constituting the  different va-
 rieties of inflammation  of veins have not been
 sufficiently  investigated and  demonstrated  by
 pathologists; and most writers have described
 two varieties only, namely, 1st, the adhesive or
 common;  and, 2d,  the  suppurative; and, while
 they have viewed  the former as  merely a local
 disease, they have considered the latter as pro-
 ductive of vascular contamination and general  in-
 fection.—a. Of these  varieties it may, however,
 be remarked, that, although  the adhesive is char-
 acterized chiefly by an exudation of lymph more
 or less  adhesive and concrete, on  the  internal
 surface  of the inflamed vein, and often  no  far-
 ther affecting the blood than causing the forma-
 tion of a clot within or near the  inflamed part,
 yet it is attended by more  or  less sympathetic
 febrile disturbance ; and that the coagulum thus
 formed  may be  productive of much consecutive
 disease of the vein, if the  local and  constitution-
 al treatment be not judiciously managed.  Even
 after the exudation of lymph,  or the formation
 of a coagulum, by means of which the extension
 of the inflammation  and contamination of the
 blood are prevented, if constitutional power and
 vital resistance be much reduced, the coagulum
 thus formed may irritate the internal surface of
 the vessel,  and either perpetuate or rekindle the
 inflammatory action.                   .
   20. b. The suppurative variety of phlebitis is
 generally productive of contamination ofthe blood
 and  of  most  dangerous constitutional  disease.
 Nevertheless, instances are occasionally observed
 in which  the purulent matter at first  formed,
 mingling with the blood in the vessel, causes  its
 coagulation, and the  coagulum thus formed ar-
 rests the circulation and the extension of the in-
 flammation in the direction of the heart, and  ei-
 ther allows the  morbid action to  subside, or  fa-
 vours the extension of it to the  more external
 coats of the vessel and to  the surrounding cellu-
 lar tissue, occasioning abscesses in the course of
 the inflamed vein, and  prolonging  the  disease.
 In these cases little or no contamination of the
 general  mass  of blood takes  place, unless  the
 constitutional powers  and  vital resistance to the
 extension ofthe  local  disease be much impaired, 
1440
VEINS—Inflammation of, Described.
either by the continuance and amount of the lo-
cal lesion, or by an injudicious or a too lowering
treatment.
   [We find the  law of symmetry prevailing in
the present as in the other diseases;  thus in the
viscera, as well as in the superficial  tissues, ab-
scesses, resulting from  phlebitis, are constantly
met  with at points  most closely  corresponding
with one another on  the two sides ofthe body.]
   21. c.  Asthenic, or diffusive, or poisoned phle-
bitis, has not hitherto been described as a very
important variety, although it is the most danger-
ous of any form which the disease assumes.   It
occurs in all the circumstances,  and  arises from
all the causes, which occasion the other forms of
phlebitis.  But it more especially  proceeds from
causes superadded to these, more especially from
those which depress the vital energies and infect
the system.   It  is generally the result  of two
classes of causes : 1st, those which  depress the
constitutional powers, and produce more or less
of general cachexia before the vein is injured or
wounded;  and, 2d, those which lower or exhaust
the energy of  the  body, and either prevent the
depuration, or  favour the contamination  of the
blood during or after the infliction of the  injury
or the  other  exciting causes of the  phlebitis.
The first class comprises malaria of all  kinds;
the foul air of crowded wards; or that  produced
from the discharges or exuvise of the sick or of
others; improper or insufficient food,  &c.; the
second includes  those already mentioned, when
they come into  operation during and  after the
infliction of the  injury,  or  subsequently to the
other  exciting  causes  of  the  disease,  violent
shocks to  the vitality  of the  frame,  poisoned
wounds, abrasions, &c,  infectious  emanations
from erysipelatous or gangrenous sores, or mor-
bid discharges; the  absorption  of purulent, pu-
trid, sanious, or diseased matters from  sphacela-
ted, necrosed, or otherwise  altered structures, or
of decomposed blood, or vitiated secretions and
excretions.
   22.  (a) This variety of phlebitis is character-
ized by the rapidity,  severity, and the fatal tend-
ency of the local and constitutional symptoms,
and  the marked depression of  vital  power, and
the contamination of the circulating  fluids, by
which they are attended.   Organic nervous en-
ergy is remarkably impaired,  and all the  mani-
festations  of life  more or less lowered.   The
functions of the brain  are early disturbed, and
the pulse  becomes rapid, soft,  open, and com-
pressible ; the surface ofthe body soon  losing its
vital appearance, and becoming  livid, dusky, and
sallow, sometimes  dry and  harsh, and  ultimate-
ly clammy and cold.   Delirium occurs early, and
passes  into stupor or coma.   Locally, cedema,
cellular infiltration, great tenderness on  pressure,
boggy swellings, and diminished temperature of
the affected limb, are often remarked  ; and if the
injured or affected vein be exposed, as  when the
disease follows venaesection in the circumstances
just alluded to, the  wound is gaping,  union of
the divided tissues not having  taken place, and
an ichorous or a sanious fluid  exudes  from the
part, or  slight hemorrhage occurs on  examina-
tion.   In addition to the above more constant
phenomena, others are  observed, arising out of
the varying combination of the predisposing and
exciting causes, and the state  of the patient.
These  are  chiefly a tympanitic state of the abdo-
men, retchings or vomitings, diarrhoea, the evac-
uations being offensive and unnatural;  the rapid
occurrence  of bed-sores;  offensive or auimoni-
acal states of the urine, severe pains and swell-
ings in the joints or extremities; congestions  op
puriform  infiltrations of  internal  viscera, with
tenderness and oppression referred  to the regions
corresponding with the affected organ,  &c.
  23.  When uterine phlebitis takes place, it may
assume either of the forms above described, and
owing to such forms, and to the circumstances in
which they severally appear, the different varie-
ties  of puerperal fever are  developed ;  the more
malignant kinds of these fevers being the results
of the ichorous  and sanious fluids  imbibed from
the interior ofthe uterus by the uterine sinuses
and  veins, or ofthe morbid exudation from the as-
thenically inflamed veins ofthe uterus and its ap-
pendages, and of the consequent contamination
of the blood, aided by the vital shock of parturi-
tion, and  by the  foul or infectious air in crowded
or ill-ventilated lying-in hospitals or wards.  (See
art.  Puerperal Diseases.)*
   24.  iv.  The appearances  observed in dissection
of fatal cases of phlebitis,  as respects the veins,
are described in  the sequel (§ 57, et seq.);  those
which regard the frame generally are fully given
under the head  Puerperal Diseases (§ 221,  ct
seq.),  and are nearly the same as those  observed
after putro adynamic Fever (§ 513, et seq.); and
those  which are found when phlebitis occasions
consecutive  and diffusive abscess are described  in
the  art. Abscess (§ 27, et seq.)]
  C* When the inflammation has been so violent as to oc-
casion very decided changes of structure in the coats of
the vein, the usual result is its complete obliteration.  In
consequence of this, extensive anastomoses often form, the
activity of the vasa vasorum  becomes conspicuous, and
continues till the venous coats are reduced to a  homoge-
neous lardaceous tissue. By their agency, also, the prod-
uct of inflammation obstructing the vein is very gradu-
ally assimilated and absorbed. Meanwhile the  walls of
the vessel become more and more thickened, contracting
in folds or wrinkles upon the narrowing canal, until at
length the whole vessel is  converted into a thin cellulo-
fibrous cord.  The obliteration of  the foetal vessels is
brought about by an analogous process, the only difference
being that in this  the process is purely a physiological
one, there being simply a slender plug of coagulated blood
to surmount, instead of the more heterogeneous  products
of inflammation.  The obliteration of the vein  is some-
times only partial, the plastic substance only blocking up
part of the venous channel.  '1 he  obliteration may be
permanent, or only temporary, for  a plug which closes
up a large venous trunk will often be resolved and melted
down in the  sanguineous  current, and that too without
exciting any constitutional symptoms from absorption.]
  t In the following case, by  M. Le Herisse, as quoted
by Mr. Aenott, some of the most remarkable secondary
effects of phlebitis are described.   "Gasper Goldinger,
subject for the last six  weeks to epilepsy, was bled twice
from the arm on the 1st of November, 1806; on the 8th,
from the foot; and on the 10th and 13th, from the jugular
vein.  On the 16th, he was again bled from the  arm (the
right), which on the following day felt painful; some red-
ness and tension were observetTround the aperture; 15th,
arm very painful and swollen from the shoulder to below
the elbow ; edges of the puncture red ; face and skin of
the body of a yellowish  colour, pulse  feeble and frequent;
19th and 20th, fever more intense; tongue, dry and coated;
great pain in the arm; 21st and 22d, lies supine; pros-
tration of strength; heat  of skin; tongue dry; pain in
the right side of the chest; respiration short;  23d, ten-
sion of the arm diminished, some pus flowed  from the
wound made in bleeding; respiration short  Lied at
night, Beven days after the receipt  of the wound in the
vein.
  "Dissection.—The wound in the cephalic open; the
vein filled with pus through the whole length, i. c, from
where it terminates in the axillary to the bend of the
elbow, where it divides into the medial cephalic and su-
perficial radial;  the latter of which contained pus for
two inches below its origin.  The coats of  the vein were
much thickened, indurated, and red.  In the interflbrilear
cellular tissue of the pectoral muscle of the right side was 
VEINS—Seats of Phlebitis.                           1441
  25. v. The duration of phlebitis is very vari-
able.   It is often very short in the asthenic and
puerperal states, and may, when  accelerated or
exacerbated by  the  foul  air in lying-in wards,
not exceed 48 hours, although more frequently
it continues several days, or even longer.   Phle-
bitis consequent upon venesection is rarely of less
duration than three or four days.   The suppura-
tive form of the disease generally continues from
ten to twenty-one days, and  the  adhesive form
much longer, or several weeks ; but the duration
of each of the varieties ofthe disease varies much
according to the causes,  the treatment, and the
constitution ofthe patient.
   26.  vi. Seats of Phlebitis. — Inflammation
may attack several  veins, or  only one vein, or
small part of a vein.   It generally  extends to the
whole circumference of a vein, and is very rarely
limited to one side ofthe vessel.  The veins most
frequently inflamed are those  of the extremities,
after  wounds and injuries ;  next, those of the
uterine organs and appendages, especially in the
puerperal states, and the pulmonary veins.  The
veins least frequently affected are the ramifica-
tions ofthe portal and hepatic veins; the sinuses
and veins of the dura mater;  the vena cava, and
the veins of the spine, and of the spongy  struc-
ture of bones.  Phlebitis of the umbilical cord,
or inflammation of the  umbilical vein in new-
born infants,  is  not  a rare occurrence.  Several
recent pathologists,  more especially MM. Ribes
and Cruveilhier, have supposed that the venous
capillaries may be the seats of inflammation, and
have ascribed erysipelas to phlebitis of the most
minute of these  vessels.
   27. (a) Inflammation of the veins of the arm is
most  frequently consequent upon venaesection,
and especially when this operation  is repeated.
It may, however, occur after  amputations, frac-
tures, punctured or other wounds, &c. It com-
mences with pain in or near the seat of incision
or puncture, extending upward.   If adhesion has
not taken place,  the margins separate, swell, sup-
purate, and  the  pus formed in the vein escapes
externally, especially if pressure be made on the
vein from  above downward.   If the incision
through the integuments has closed, the margins
swell, and the cicatrix opens.  The inflammation
may extend from the seat of injury to the axilla,
to the jugular, to the superior cava, or even to the
right auricle.  In this case death generally soon
ensues, although instances of recovery have been
recorded.  The  disease may also extend  along
the veins below the seat of injury, especially
when the circulation in  the vein  is obstructed
by lymph, coagula, &c.  Phlebitis in this  situa-
tion may present either of the forms described
above.
  28. (b) The veins ofthe lower extremities,  and
the iliac  veins, or either separately, may  be in-
flamed ; the former from the same causes as oc-
casion phlebitis in the arm, the latter most  fre-
quently as a consequence ofthe puerperal  state,
or ofthe cancer ofthe uterus, and of tubercular
a quantity of  thick greenish pus.  Eight or ten ounces
of yellowish opaque serosity were contained in the right
sac of the pleura.  The lung of this side was unadherent,
that of the left was adherent over its whole surface by a
delicate false membrane.  Both lungs presented a num-
ber of hepatized portions, varying in size from that  of a
nut to that of a large walnut, gorged with fluid, which in
Some of them was  puriform.  The  arachnoid membrane
was opaque, thickened, and indurated, effusion of fluid
between it and the  pla mater, and into the texture of the
latter.   Some yellowish serum in the ventricles."
    III.             91
disease.   Inflammation of the iliac veins is most
frequently manifested in the form of phlegmasia
alba dolens (see this Art.), although phlebitis  is
not the only pathological lesion of this disease.
M.  Toulmouche contends  that the  much  more
frequent occurrence of the  malady in the left
thigh than in the right is owing to the accumu-
lation offices in the sigmoid flexure ofthe colon,
and to the consequent pressure made on the iliac
vein, to the retardation ofthe circulation through
it, and to coagulation of blood in it.  (Gaz. Med.,
Avril, 1844.)
  29. (c) Inflammation of the vena porta has been
observed by MM. Ribes, Bouillaud, Dance, and
Frey, and they, as  well as others, have ascribed
redness ofthe internal surface ofthe ramifications
of the vena porta, and of the hepatic veins,  to in-
flammation ; but  it  is not improbable that this
appearance is more frequently owing to cadaveric
imbibition of the colouring matter of the blood.
True inflammation  of the  vena  porta  is a very
rare occurrence; it is attended  by a  sense of
weight  and of pain in  the right hypochondrium,
greatly increased on pressure; by regular  or ir-
regular rigors; by extension of pain to the right
shoulder ; by jaundice, more or less developed ;
by  nausea, vomitings,  and  sometimes singultus;
by  diarrhoea, more  or less  bilious, and ultimate-
ly by the usual indications of purulent infection
of the blood.  These symptoms are, however, in
most respects the same as those accompanying
acute abscess of the liver.
  30. (d) The sinuses of the dura mater are not
unfrequently inflamed, consecutively on injuries
to the cranium, membranes, and substance of the
brain, on inflammation of these parts, on inflam-
mation  of the ear,  on caries of the temporal  or
other bones of the cranium.  They may also be-
come inflamed in the advanced course of erysipe-
las  ofthe scalp, and of other maladies and lesions,
as I have fully described many years since.  (See
art. Brain, Sect., Inflammation of Sinuses  of the
Dura Mater, and ofthe Vessels ofthe Brain, § 37,
et seq.,  vol. i., p. 208, 9.)
  31. (e) The umbilical vein has been found in-
flamed in recently born children, by MM. Sasse,
Breschet, Duplay, Trousseau, and others ; and
has been referred to ligature ofthe cord.  It has
been observed associated with  erysipelas, with
peritonitis, and with enteritis.  The veins of bones
have also been noticed by M. Gerdy.   Uterine
phlebitis has been  considered in the  article on
Puerperal Diseases.  (See $ 189-197.)
  32. (/) Inflammation of the vena cava is met
with only consecutively upon inflammation ofthe
uterine iliac or other veins.  M.  Berard has
found inflammation ofthe vena cava extending as
high as the confluence ofthe renal veins in cases
of phlegmasia dolens : cases of inflammation of
the cava  have  been observed and described by
Travers, Hodgson, Dance, and  others.   The
symptoms indicating extension  of inflammation
and of its consequences to  this vessel are rather
inferential than positive.  These consequences
are  the exudation of lymph, the formation of pus,
or of coagula, or of all these, and more or less
obstruction ofthe circulation along the vena cava.
If there be  observed consecutively upon  phle-
bitis of either lower extremity acute or rapidly
developed oedema, or dropsy of both the extrem-
ities, especially during the  puerperal state, or  at
an advanced stage of fever, or at an early period
after the subsidence of fever; and if,  after the 
1442                VEINS—Pathology and Treatment of Phlebitis.
occurrence of oedema of both extremities, indica- !
tions of the development, in the surface  of the
trunk,  of a  supplemental venous  circulation, it
may be inferred with much probability that  in-
flammation and its consequences have extended
to the vena cava.
  33. Obliteration has been observed by Haller,
Wilson, Baillie, Cline, Reynaud, the writers
already named, and by others, to follow inflam-
mation and  obstruction of the vena cava.  The
cases which have been recorded of this remarka-
ble  lesion have presented extensive anastomoses,
not only between deep-seated veins, but also be-
tween the principal superficial veins ofthe  trunk,
these latter appearing uncommonly enlarged, and
anastomosing  with each other.   This very great
development and  free anastomoses of the  super-
ficial veins ofthe trunk have followed gradually
upon the  dropsical or  cedematous state of both
extremities ; but  in some cases, especially those
under consideration, and of most marked enlarge-
ment and anastomoses of the superficial  veins,
the cedematous state of the lower extremities
gradually  diminishes.  The particular veins  by
which the supplemental circulation is carried  on
are in some  respects different in different  cases,
according to the  seat of obstruction or oblitera-
tion of the cava, and to the trunks of veins, from
which the inflammation extended.
  34. vii. The Diagnosis. — Phlebitis may  be
mistaken, at an early  period  of its course,  for
lymphangitis,  or the latter may be  mistaken  for
the former.   But the  large  cylindrical  cords,
wreathing in diverse forms, appearing when the
superficial veins are inflamed, and the cedema of
the distal or more remote parts, cannot be readily
mistaken for the reddish, painful, small, straight,
and knotted lines passing in the direction of, and
enlarging, the lymphatic glands, above  the seat
of the complaint.   In neuritis  and neuralgia the
pain is more acute or pungent than in phlebitis,
and the appearances observed in phlebitis are
not present, especially the cedema of the parts
below the seat of pain, &c.  When the consecu-
tive or contaminating effects of phlebitis  super-
vene, the low  fever, the  dusky, sallow,  and dis-
coloured skin, the diarrhoea, the rapid weak pulse,
delirium, &c, although  assuming  the  form  of
adynamic fever, may be distinguished from this
latter, by the antecedent local symptoms, by the
causes, and  by the whole history ofthe case.
  35. viii. The Prognosis.—The danger of phle-
bitis is always considerable, because, although it
is by no means imminent as long as the disease
is merely local, yet infection and contamination
ofthe blood, on which great danger depends, may
unexpectedly  and suddenly  supervene.   The
symptoms described above (§  16, et seq.)  as  in-
dicating this contamination ofthe blood, and more
especially those which  attend consecutive  or dif-
fuse abscess in the lungs, liver, or other organs,
are always those of extreme danger.   Cases pre-
senting signs of internal consecutive abscess are
irremediable.
  36. ix.  Pathological Inferences.—(a) The
liability to phlebitis as a consequence of the oper-
ation of any ofthe exciting causes, or even with-
out any other cause than that which favours this
liability, is great  in proportion to the  amount of
haemorrhage, or of vascular depletion, which has
been the result ofthe injury or incision of a vein.
—(b) Persons addicted to the abuse of intoxicat-
ing liquors  or of tobacco are more liable  to this
! malady than others ; and the liability extends to
 those who are weakened or aneemied by pre-ex-
 isting disease, or who are of an unhealthy or ca-
 chectic habit of body.—(c)  In the circumstances
 now stated, and  in convalescents from, and even
 in the advanced stages of, exanthematous and ady-
 namic fevers ;  in the course of acute rheumatism,
 of pulmonary consumption, and of diseases ofthe
 womb and  its appendages, blood may coagulate
 in some situations in the veins, owing either to its
 remora, or to its altered state, or to defective vital
 power in such situations, and may inflame the in-
 ner coats of the vein in which it coagulates.—(d)
 The passage, or  imbibition of purulent, ichorous,
 sanious, putrid, or tubercular matter into a vein
 or venous capillary may either coagulate the blood
 as it circulates onward in a venous trunk, and in
 consequence of this coagulation inflame the vein ;
 or the morbid matter may irritate, inflame, or pois-
 on the internal surface ofthe vein, the inflamma-
 tory exudation from the inner coats of the vein
 coagulating the blood in it,  or, failing in this, con-
 taminating the blood circulating through it.  It
 must be difficult to determine the exact sequence
 of results, and probably either or all may super-
 vene.—(e) The morbid alterations in  the veins
 may extend far along the veins from the seat of
 injury, as that produced by blood-letting, or even
 to the vena cava, or to  the  heart itself; and they
 may proceed also in an opposite direction, or be-
 yond the injured part, although rarely to any con-
 siderable distance; the fatal issue,  however, is
 not owing  to  this  extension,  although aided by
 it, but is chiefly the result of the contamination
 of the blood,  and of the effects produced by this
 contamination on the organs and tissues of the
 frame.—(/) Consecutive diffuse abscess in the
 viscera, suppuration of joints, &c, are not occa-
 sioned by the transmission and deposition of pu-
 rulent or other morbid matters from  inflamed
 veins, or absorbed from primary seats of suppu-
 ration, caries, or other disease, but are the conse-
 quences of acute asthenic inflammations of those
 viscera or joints caused by the thus  poisoned or
 contaminated blood.—(g) The sequence of mor-
 bid phenomena, or the succession of alterationa
 from the commencement of irritation and inflam-
 mation in the vein until the disorganization con-
 sequent upon the diffusive suppurations ultimate-
 ly produced in the viscera or joints, is acceler-
 ated by means which  lower vital power and di-
 minish the amount of blood circulating in the
 body.*
   37. II. Treatment  of Phlebitis.—The con-
 cluding one of the above inferences  will indicate
 the principles  which, in my opinion, should guide
 our practice in phlebitis.   The following circum-
 stance may have had some influence in directing
 my attention and influencing my views regarding
 this important subject.   When  in London for a
 short time, in August, 1815, I  had  occasion to
 converse with a well-known public  man of that
 time, who informed  me that he had been, about
 thirty-five years previously, a patient of John
  * The above inferences formed the conclusion of n pa-
per read before the Medical Society of London in 1^23,
and were arrived at after an observation of many en sea
of phlebitis in France and Germany during 1815 and 1S16,
and during 1819 and 1820, and after duly considering the
treatment which was there generally adopted.  These in-
ferences, as well as the treatment which I have recom-
mended in consonance with them, have always been given
in my lectures on I'ractical Medicine, from 1824 until
1S42, when I ceased to lecture. 
VEINS—Treatment of Phlebitis.                          1443
 Hunter, he having suffered an attack of inflam-
 mation ofthe veins after vena:section, which had
 been twice repeated, to a large amount, for pneu-
 monia ;  and that the inflammation supervened on
 the last blood-letting.  But it was  not  only the
 occurrence of the phlebitis after the last depletion
 which  made the impression on my mind, but
 chiefly the treatment which he informed me had
 been prescribed by John Hunter  in his  case.
 This consisted,  as he stated, of preparations of
 bark conjoined  with  other medicines,  and of a
 very liberal allowance of port-wine—upward of
 a bottle daily—until  he recovered.   This treat-
 ment was altogether  so different from what was
 generally  taught in lectures and surgical works,
 that I continued to reflect  upon it, and to contrast
 it with the means of cure which I afterward saw
 adopted on the Continent and in this country for
 this disease, and which are still recommended in
 surgical and medical works.   When it is consid-
 ered that  a very large proportion of the diseases
 ofthe puerperal state, and most ofthe fatal cases
 of amputation,  proceed  from  inflammation  of
 veins, and from the imbibition of purulent or sa-
 nious matters by the veins into the blood, inflam-
 ing the veins and contaminating the circulating
 fluids,  or, in other  words, producing effects to
 which the term pyamia has recently been applied,
 but with little regard to pathological accuracy, the
 importance of determining the true intentions and
 principles of cure for this malady must be appar-
 ent.   Upon what rational grounds can we advise,
 as very generally advised, large local and general
 depletions, and  a strictly antiphlogistic  regimen
 for a disease which is frequently a consequence
 of such depletion and regimen 1*   Upon  what
 therapeutical principles  can means be recom-
 mended for the prevention or euro  of  phlebitis
 that  tend  to  promote  the imbibition, or absorp-
 tion, and  the circulation of morbid or poisonous
 fluids in the blood,  to prevent the formation of a
 healthy lymph whereby the extension of the dis-
 ease may be arrested, and  to prostrate  the vital
 resistance opposed by the constitution to the con-
 tamination, not  only ofthe blood, but also ofthe
 soft solids !—and to the production  of  all  these
 effects  the means usually  advised  for  phlebitis
 most certainly tend.   With what rational inten-
 tion are means prescribed to arrest the extension
 of inflammation ofthe veins and the contamina-
 tion of the blood that actually and incontroverti-
 bly favour both these results, and  that have a
 more certain tendency to  accelerate, if not to
 cause, a fatal issue than the natural course of the
 disease itself?   The operation of the means of
 cure in this disease require  to be studied and as-
 certained with as great care as should be devoted
 to  the pathological changes and the  consecutive
 alterations which constitute the nature, and occa-
 sion the imminent danger of the malady.  An em-
 pirical treatment of phlebitis more frequently in-
 creases than diminishes the danger; and  such
 empiricism, whether in phlebitis or in any other
 disease, being the result of ignorance, increases
 the number of fatal cases, and generates  and per-
 petuates in the mind of the practitioner who is

  * " Les premiers accidents inflammatoires que Ton ob-
serve  sur le trajet d'tine veine soront imm -diatement
combattus par les antlphlogistiqueslcs plus energetiques :
SSnigu -es ; applications de gangsnes en grand nombre, et
plus on moins rep t es, suivant la force des siyetf, fomen-
tations emoUientcs, tels sont les moyens qti'il convient de
mettre d'abord en usage." (Art. VEirE, Inflammation,
in Di.t. de Mid., 2d ed.)
thus imperfectly informed a skepticism in which
he takes refuge, and under which he attempts to
conceal his ignorance and to debase his vocation,
The skeptic in medicine  is ignorant not only of
the nature and procession of morbid phenomena.
but also of the operation of remedial agents.   He
is incapable of forming  rational views, and  is
quite impotent as to their accomplishment.   He
therefore decries what he feels himself incapable
of performing, and instead  of relinquishing his
efforts, he  endeavours to  impute his failures  to
the imperfections, if not to the total inefficacy of
the science ; and by continuing his practice, and
by thereby perpetuating his want of success, he
persists in furnishing evidence,  not only of his
own incompetency, but also of the insincerity of
his professions ; he at once admits that he prac-
tices a lie;  that he professes to perform what he
has no hopes of performing ; that he may delude,
but that he can not cure.*   But, leaving the med-
ical skeptic to luxuriate in his practice and in his
belief, and advising him to reconcile  the former
with the latter, if this be possible in any other
way than by relinquishing the one in favour ofthe
other, I proceed to consider those indications and
means of treating phlebitis which extensive op-
portunities  of observation disclosed ; opportuni-
ties, however, in which I was then  an  observer
only, not an actor, and which furnished more nu-
merous proofs of a practice which ought to have
been carefully avoided, than evidence of any re-
sulting benefit.                         <
  38. i.  A  view of the treatment which has
been advised for phlebitis may, not without some
advantages,  precede  the  consideration of the
means which I have long believed to be the most
appropriate to this malady.   Former writers have
generally advised very opposite means  for  the
different stages of the disease, for the local affec-
tion, and for the general  infection of the frame
consequent upon it.   Thus we find, in one of the
ablest treatises  on diseases of veins (in Did.  dc
Med., 2d ed.) which have recently appeared, it is
recommended to have recourse to general blood-
letting, to the  application of leeches in  great
numbers, and more or less frequently  repeated
according to the strength of the patient; to emol-
lient fomentations ; to refrigerants; to the appli-
cation of ice, or to cold  effusion to the seat of in-

  [* These remarks of our author furnish a very satisfac-
tory explanation of the abandonment of rational medieine
by some practitioners, and their adoption of homoeopathy,
hydropathy, and other forms of empiricism. Their igno-
rance of the true principles, of medical science, and con-
sequent want of success in  the treatment of disease,
gradually renders them skeptical in regard to the efficacy
of the science; and they fly to visionary systems which
promise greater certainty,  and require  no  industry, no
grasp of mind, or extent of knowledge to comprehend or
apply.  They do not seem to understand the causes of
their failure, and hence attribute to the imperfections of
the  science what is solely  due to their own ignorance
and folly.  There  is no profession, no study, which re-
quires such  high order of  intellect, such well-balanced
powers of mind, such rare judgment and nice discrimin-
ation, such close observation and unerring logic as med-
icine, and yet every man who finds himeelf incompetent
to gain a living in any other calling  feels fully compe-
tent, without preparatory  training, preliminary study,
or close application,  to assume the responsibilities of a
practitioner of the healing art; and our free republican
institutions, in their jealousy of encroachment on indi-
vidual rights or pursuits, give free license to every igno-
ramus to experiment on the lives and health of the public.
When tlie true objects of government shall  be better
understood, homoeopathic and other empirics will meet no
greater toleration than those who, under a less respectable
garb, take a still shorter cut to reach  the pockets of the
community.] 
1444                        VEINS—Treatment of Phlebitis.
flammation, in the first or local period of the dis-
ease ; and, in order to second the effects of this
rio-idly antiphlogistic  treatment, the application
of large quantities of mercurial ointment, so as to
rapidly affect the salivary glands.*
  39. M. Pasquier and others have had recourse
to the application of narcotics locally, in the form
of the  decoction  of poppy-heads, containing the
watery  extract of opium, or to  similar applica-
tions, placed along the course  of  the  inflamed
veins, and frequently renewed, so as to be always
wet.  M. Bonnet, of  Lyons, has had recourse to
a very opposite treatment, viz., to the application
of the actual cautery  to the part where the vein
is wounded, in order to prevent the absorption of
pus from the inflamed vein.   But the cases which
lie has adduced in support of his practice are too
few and inconclusive to found upon them so nov-
el a plan of cure.
  40. The local treatment advised by John Hun-
ter, and  advocated by Abernethy, Reil, Vel-
peau, and others, had  for its object to prevent the
extension of the inflammation towards the heart,
by enabling the constitution to throw  out coagu-
lable lymph at the inflamed part, by means of
which the blood might be coagulated or the vein
obstructed.   Compression of the vein above the
seat of  inflammation  was likewise  advised with
this intention.  These measures often were suc-
cessful, but they often also failed.  The remedies
prescribed, however, with this view, were not al-
ways appropriate to the period of the  disease, or
to the constitution and habit of body of the pa-
tient, and were often resorted to at a too advanced
stage, when  the blood had already  become con-
taminated, and when means calculated to neutral-
ize or to counteract the contamination, and to dep-
urate the blood,  were required.  M.  Breschet
attacked this very rational indication, or method,
of arresting the extension of the inflammation, by
contending that it was most difficult to obtain an
adhesive form of phlebitis by medical treatment.
But  the supporters of John  Hunter's  doctrine
had more extended views than the mere develop-
ment ofthe adhesive form ofthe disease by ena-
bling the  constitution to  throw  out  coagulable
lymph.  They knew,  or at least hoped, that the
lymph  effused  would  favour the coagulation of
blood in the inflamed  veins, whereby the circula-
tion in these veins would be entirely obstructed,
and the extension of the inflammation, as well as
the contamination of  the blood,  would be either
delayed or prevented,  as they also knew that the
best  means of limiting inflammation in  any sur-
face, more especially  in that of circulating ves-
sels, were  those  which supported or developed
constitutional power  and  vital resistance  to the
impression of injurious agents.
  41. If the views as  to the treatment of the lo-
cal stage or changes in phlebitis were thus diverse,
those proposed for the second stage,  or that of
vascular infection and contamination, were no
less so.   The young pathologists of Paris in this
matter displayed their  accustomed ingenuity ; but
beyond this quality no  farther praise can be award-
ed them.  Some, relying upon the  experiments
of MM. Leuret and Hamont, who stated that the
injurious effects of pus injected into the veins of
animals were delayed or prevented by repeated

  [* The late Prof. Physio advised  the use of blisters
over the vein affected, to prevent the extension of the in-
flammation ; and the practice  has been generally and
vt-rv successfully adopted in this country.]
blood-lettings, proposed this mode of evacuating
the morbid matters contaminating the blood ; but
they failed in showing  how these matters could
be removed with the blood which was taken away,
without leaving the same proportion in the blood
which was left in the body.  The fate of those
who were thus treated may be readily predicated.
Then was proposed the opposite system ;  name-
ly, to engorge the patient with diluents, by means
of which the poisonous  materials may be diluted,
their action rendered less injurious, and their elim-
ination promoted by means  of the skin and kid-
neys.  M. Piorry, the apostle of this doctrine, in
his memoir on " pyohemie," or pyaemia, adduced
some evidence in its support.   The due promotion
of all the depurating functions, not only those now
named, but also those of the intestines and liver,
by suitable means, and by appropriate combina-
tions, are important remedies for the second stage
of this malady, but in most cases more even than
these are required.
   42. Some writers have supposed that the mor-
bid materials  which have passed into the blood
may be  neutralized by disinfectant or  similar
agents,  such  as the  chlorides; and in  certain
forms they may be of service, and may with some
reason be resorted to.   But upon what rational
grounds can  repeated emetics, or antimonials, or
mercurials be advised, unless upon the pure em-
piricism  which is based on  imputed but very
doubtful success 1  Other writers have dreaded
the  prostration  of  vital power, and its  conse-
quences, in the second stage of phlebitis, and have
had  recourse to tonics, especially to  the prepara-
tions of cinchona, to  wine,  and various restora-
tives.  The propriety of the practice cannot be
doubted, especially if adopted at a sufficiently ear-
ly period, and if conjoined with means appropriate
to existing pathological states  and  to the circum-
stances of individual cases.
  43. ii. Treatment advised by the Author.—
A question, preliminary to entertaining the sub-
ject of treating phlebitis, suggests itself,  name-
ly, Is there any plan by which  the  disease may be
prevented 1  Phlebitis is most frequently a con-
sequence of amputations and similar operations,
and of operations on the veins themselves.  Of
these latter venisection is the most common ef-
ficient cause.  From long and diversified observ-
ation, I am convinced that, when phlebitis follows
venisection, this operation ought not to have been
performed, the states ofthe constitution and ofthe
circulation actually not requiring it; and that this
has  more especially been the case when  it has
been repeated moro than once, or  when the vas-
cular depletion has been carried too far.   Most
of the fatal cases of amputation result from phle-
bitis and its  consequences.   Now what are the
circumstances which  favour the  occurrence of
phlebitis after amputations]   These are chiefly,
1st. The  shock given to the constitution  by the
operation ; 2d. The an&smied state  of the system
and the  exhaustion of vital power in many cases
at the time when the  operation  is performed;
3d. The collection of purulent matter under the
flaps, and bathing the surface of the stump, and
the mouths of divided veins ;  4th. The state of
the atmosphere in hospitals, wards, and places in
which the operation is performed and the patient
is confined ; 5th. The treatment immediately after
the operation ;  and, 6th. The means  used to pro-
duce insensibility.   Each of these requires a few
remarks. 
VEINS—Treatment of  Phlebitis                          1445
  44. (a) The shock produced by the operation,
especially when great or prolonged,  is not only
the result  of reduced vital power, but also the
cause of coagulation of blood in the veins and of
the injurious action  ofthe coagulated blood on
the coats of the vein' (see art. Shock).   Hence
the more  severe and prolonged the  shock the
more likely are these effects to be produced.
  45. (b) Many cases require amputation, under
unfavourable circumstances, and in others it is so
long delayed, owing  to the fears of the patient,
until these circumstances are developed.   When
the constitutional power  and  vital resistance of
the patient to disease are reduced, and the blood
altered by impaired depuration and imperfect san-
guification—when organic nervous energy is de-
pressed, and  the blood diminished in quantity, in
crasis, or in red globules, or impaired in quality—
then a predisposition to phlebitis, when the veins
arc implicated in surgical operations, is thereby
produced.
  46. (c) The collection  of purulent matter un-
der the  flaps, often favoured by the union of the
integuments, acts most injuriously on the inter-
nal coats of the veins ; and it may even  be par-
tially absorbed by the mouths of the veins in the
surface ofthe stump, thereby producing pyaemia
and its  usual results.   These effects are the more
likely to occur in cases  where  vital power is
greatly  reduced, or where the quantity of the
blood is much  diminished and the quality much
impaired, and where  the patient breathes a close
or contaminated atmosphere.
  47. (d) The injurious  influence of a foul air in
cases where veins are implicated in surgical op-
erations is  sufficiently manifest; and the frequen-
cy of phlebitis and pyaemia in  hospitals, both civ-
il and military, from this cause, is often  greater
than is supposed.    I witnessed  this influence
and its  effects in numerous instances soon after
the Peace of 1815, both in France and Germany ;
and in  many more neither the cause nor the ef-
fect was recognised.  The treatment also in these
circumstances, and immediately after operations
implicating veins, was often injurious and calcu-
lated to occasion the mischief which it  was in-
tended  to  prevent.    At  the period now  alluded
to, notwithstanding the writings  of John  Hun-
ter, phlebitis and its consequences were but im-
perfectly understood.  It was not  until a few
more years had elapsed that the pathology of the
disease was  fully investigated, and up to a very
recent  period, and  even to the present time, nei-
ther the prevention nor the treatment of phlebitis
has been satisfactorily illustrated.  It has been a
much too  general practice to have recourse to a
too strictly antiphlogistic treatment and regimen
after amputations, thereby aiding other causes in
producing  phlebitis and  pyaemia.  The extent to
which  such  treatment, however,  should  be car-
ried, or how far its opposite  should  be  adopted,
as  well as the means  by which constitutional
power  may be promoted, and vital resistance to
the  invasion and extension  of phlebitis be up-
held, must depend upon the circumstances of in-
dividual cases and the  acumen and experience
of the physician.
   48. (e) The means used to  produce anaesthesia
during  surgical operations, not improbably may
favour  the occurrence of phlebitis and pyaemia.
This topic requires careful examination.   A re-
course  to  those  means has  its advantages and
disadvantages.  The former are, the greater readi-
ness ofthe patient to'submit to an operation at a
time when it is most likely to be successful, and
the feeling in the mind of the surgeon that he is
not inflicting suffering.  The latter are, the de-
pressing influence of anaesthetics on vital power,
the extinction of that  amount of pain in opera-
tions, which, when not too long protracted, tends
to develop a salutary reaction, and  to favour the
prevention of injurious changes after the opera-
tion ; and, more  especially, the alterations pro-
duced in  the constitution of the  blood by  the
passage ofthe anaesthetic vapour into it.  These
disadvantages were  urged by me on several oc-
casions  immediately after the discovery of the
means of  producing complete anaesthesia, and
subsequent observation has confirmed my opin-
ion respecting them.*
   49. From  the above it will be  inferred that
the avoidance, as  far as may be, of the several
circumstances which  favour  the production  of
phlebitis is of great importance ; that all opera-
tions implicating  veins should be  performed in
as healthy a state of the system as may be pos-
sible ; that vital power and resistance should be
supported, and not depressed; that all contami-
nating  influences  should be  avoided; that  the
healthy  constitution of the blood ought  to  be
studied before and after such operations,  and
nothing done to alter it; and that the confidence
of the patient  in  a successful result should be
upheld, and roused or increased when depressed.
Conformably with these propositions, it will be
manifest that a pure, dry, and temperate atmos-
phere ;  perfect repose of a limb or a part in which
a  vein has been injured or wounded ;  protection
of a wound in  a vein from  the access of the  at-
mosphere ; and a healthy discharge of the  di-
gestive  and  depurating  functions, and physical
and mental quietude, are among the most essen-
tial means of preventing phlebitis, and of coun-
teracting or neutralizing many of its causes.
   50. i.  Treatment  of the First  or Local
Period  of Phlebitis.—This should vary with
the  causes of the inflammation, with the symp-
toms complained of, with the habit  of body ofthe
patient, with the presumed extent to which the
disease has advanced, and with the situation of
the inflamed vein.   The causes and seat ofthe in-
flammation equally forbid general depletion; and,
unless in very plethoric  or robust subjects, even
local depletions are seldom required.   Pain and
tenderness are rarely  removed by  them, even  in
these subjects, and never in persons otherwise
circumstanced.  Fomentations, especially those
usually applied, sometimes assuage the pain, but
they favour the  extension of the inflammation
along the  vein,  and  prevent or  diminish  the
chance of procuring the occlusion of the vein by
   [* The experience of surgeons in the United States does
not coincide with that of Dr. Copland  in regard to the
influence of anaesthetics in favouring phlebitis. On the
contrary, it is believed that the mortality from severe
operations has been  much diminished in consequence of
their introduction and employment. The depression of
the vital forces, as well as the changes  produced in the
blood through their influence, is but temporary; while the
patient is wholly exempted from the violent effects ofthe
shock, which of  itself is far more dangerous  and  de-
pressing to the vital powers than any of the anawthetic
agents.  We have carefully watched the secondary effects
of both chloroform and ether in every variety of subject,
and under every mode of administration and quantity,
and we have never yet seen an instance where we thought
the reparative process was interfered with, or the cure
retarded by their use. Theoretical considerations  may
possibly lead to such a conclusion, but it will not be con-
firmed by observation or experiment] 
1446
VEINS—Treatment of Phlebitis.
   the production of coagulable lymph  in  the in-
   flamed part.  The chief objects, as to the local af-
   fection, are,  to  diminish inflammation and its
   usual products in the part; to render these prod-
   ucts as little  injurious as possible by causing oc-
   clusion of the vein, and by these means  to pre-
   vent the  contamination of the blood  and  the su-
   pervention of the second stage  of the disease by
   the usual exudations which take place into an
   inflamed vein.  The means which are most to be
   depended upon for the fulfilment of these inten-
   tions are generally those which also remove the
   more distressing local symptoms ; and, while they
   thus act, they tend equally to promote the three
   objects now proposed.  The  local as well as the
   constitutional means  may  be varied to meet the
   exigencies of particular cases,  and the circum-
   stances just  alluded  to; but even while the dis-
   ease  is still  local, internal  remedies should be
   prescribed, as well as local applications.   These
   laiter have been, for the cases which have come
   under my care, since the commencement of my
   practice, either one or other  of the liniments pre-
   scribed in  the  Appendix (see  Form.  295, 296,
   297, 300, 307,  311),  applied in  the  form  of an
   embrocation  over the seat of the phlebitis, by
   means of two  or three folds  of flannel or of
   spongio-piline; or an epithem  of spirits of tur-
   pentine, or the embrocation prescribed at p. 1257,
   ofthe third volume, applied in the way now stat-
   ed, the access of air  to the  wounded vein  being
   assiduously prevented.
     51. While  either of these embrocations is being
   applied, internal means should be prescribed with
   due reference to the state of vital power and vas-
   cular action, and  to  existing morbid sensibility
   and irritability.   Care, however,  should  be had
   that the  medicines  prescribed  are  not such as
   may occasion vomiting or excessive action of the
   bowels, as either or  both will promote the pas-
   sage  of  the  products of inflammation into the
   blood, or render these products more likely to
   pass  into the circulation.   The medicines pre-
   scribed internally during this period should have
   for their main  objects to prevent the  extension
   of inflammation along the veins, and to assuage
   pain  and irritability :  the former of these can be
   attained  only by developing vital power  and re-
   sistance ; and the means best calculated to attain
   this end  may be conjoined with those which af-
   fect the  latter  object.  With these intentions I
   have not unfrequently prescribed the  following,
   varying the  individual substances with the vary-
   ing circumstances of individual cases.
     No. 367. R  Quinse Sulphatis; Ferri Sulphatis; Oam-
   phorse, aa, gr. xij. :  Pilulse Galbani comp., 3ij.; Extr.
   Opii,  gr.  vj.  (vel Fxtr.  Hyoscyami, gr. xviij.);  Pulv.
   Capsici, gr. xij.; Bals.  Peruviani,  q. s.  M. Contunde
   bene et divide massam in Pilulas xxx.,  quarum bin*
   sumantur 4tis  vel 6tis horis.
     No. 368.  R  Ferri Sulphatis ; Quinse Sulphatis, fiii, gr.
   xv.; Camphors;, gr. xij.; Fxtr.  Hyoscyami, ?ss. ; Fxtr.
   Aloes purif., gr. xij. (vel Pilul« Aloe's cum Myrrhii, 3j.);
   Pulv. Capsici,  gr. xij. ; Olei Cajuputi, q. s.  Misce et con-
{  tunde bene.  Divide massam in Pilulas >tt   Capiat aager
   ij. 4tis vel 6tis horis.
     No. 369.  R Liquoris Ammonise Aect., fj.; Spiritus
   ^Etheris Nitrici, ?ss.; Ammonia? Sesquicarbon., ?ss. (vel
   Spirit. Ammonise Aromat. jijss.); Tinct. Cinchonsecomp.,
   ^vj.; Tinct. Serpentariie,  jijss.; Tinct.  Capsici, 7ss.;
   Infusi Cascarillse (vel Pecocti Cinchona) ad ?viij.  Misce.
   Cochlearia ij.  vel iij. larga sumantur quartis vel sextis
   horis.
     No. 370.  R Olei Terebinthinir, "ijss.; Spiritus iEtheris
   Sulphurici comp. (vel .Ktheris Hydrochlorici), ?bs. ; Tinct.
   (.'amphora1 comp., ?ss.; Olei Cajuputi, "ss.; Pulv. Traga-
   canth. comp., 3;iij."; Pulv. Glycyrrh., 3ij. ; Syrupi Rosa?
   et Syrupi Tolutani, aa, 3ij.; Infusi Cascarilla? (vel Infusi
Cinchonae) ad Sviy.  Misce.  Capiat seger Cochlearia ij.
vel iij. largu 4tis vel 5tis horis.
  No. 371.   R Fotassse  Hicarbon., "ij. ; Ammonia? Car-
bonatis, 36S. ; Tinct. Cinchona? comp., ;vj. ; Tinct. i-cr-
pentariae,  ^ij. ; Tinct. t apsici,  -ss. ad jj.; Infusi  (vel
Decocti) Cinchonte ad ?viij.  Fiat mist cujus cochlearia
ij. vel iij. larga sumantur ter quaterve in die.
  52. An apparently high or tumultuous vascu-
lar  action, or an open, broad  or even bounding
state of the pulse, should not deter from a re-
course to these or similar means ; for these phe-
nomena will much  more readily  subside  under
the influence of these than of those of an oppo-
site nature ; for vascular action is often the great-
est and the most tumultuous when vital power is
most deficient, especially when  any part of the
vascular system is inflamed.   By developing and
increasing vital power by suitable means, in these
circumstances, we more readily  overcome or ap-
pease morbidly increased vascular  action. Al-
though it is not desirable to produce much  ac-
tion on the bowels, still the depurating functions
should neither be impaired nor arrested.   Hence
the remedies may be combined as in No. 368, in
order to prevent this result;  or equal  parts of
castor-oil and oil of turpentine may be taken on
the surface of an aromatic water, or these sub-
stances, in larger quantity, may be administered
in an enema.
  53. During the local limitation or period ofthe
disease the system  sympathizes with the local
morbid action, occasioning much febrile disorder,
which, although the above  means may not for
some time either diminish or increase,  will not
pass into that adynamic  condition which readily
supervenes upon a lowering treatment of phlebi-
tis, owing to the effects  of such treatment upon
the local morbid action and to the passage ofthe
inflammatory products into the  blood.   If, how-
ever, notwithstanding the means, local  and con-
stitutional, now advised,  the inflammation  ofthe
vein either extends, or produces a puriform fluid,
or  in  cachectic  habits  of body  an ichorous or
sanious exudation, which readily passes into and
commingles with, and contaminates the blood, the
most strenuous efforts should be made to support
vital power and resistance, to counteract or neu-
tralize the injurious  action of the contaminating
materials, and to remove them from the circulation
by means of the depurating organs.
  54.  In this, the second or contaminating period
of ihe disease, the treatment will necessarily vary
with the states ofthe several depurating functions
—of those ofthe skin, bowels, and kidneys.  The
excretions from these must  be frequently  exam-
ined, and  the  means of cure prescribed appro-
priately to their several conditions.  If the urine
presents an acid reaction, the mixture No. 371,
last advised, may be continued, with or without
the addition ofthe chlorate of potass or nitrate of
potass, or both.  If the urine be neutral or alka-
line, or contain the  phosphates  in  excess, then
the nitro-muriatic acids may  be given instead of
these and of the alkalies contained in that pre-
scription.  If the skin be dry, or parched, or hot,
the mixture No. 369 will generally increase  the
cutaneous functions, especially if promoted by
suitable  diluents ($  56).  When it is  manifest
that neither the hepatic  nor the intestinal func-
tions are sufficiently discharged, then  the pills
already prescribed may be given; or pills contain-
ing a full dose of calomel and camphor may pre-
cede either them, or the castor-oil and turpentine
draught  and enema  above recommended (y 52). 
VEINS—Organic Lesions of.                          1447
If the bowels become inordinately relaxed, the
tonics already mentioned or others may be con-
joined with astringents, small and frequent doses
of creasote, absorbents and  antacids, and with
tincture of opium, or with compound  tincture of
camphor;  or with any of the several remedies
advised for Diarrhcea or Dysentery (see those
articles), according to the features of the case.
It should  not, however, be overlooked that re-
laxation ofthe bowels is a mode of vascular dep-
uration,  especially when the hepatic functions
are  duly performed, and that  this  relaxation
should not be arrested unless it increase, or re-
duce the patient;  but be moderated only, consti-
tutional power being duly supported by the means
already prescribed, aided by suitable nourishment,
and  by a sufficient supply of wine, at  regular in-
tervals.
   55. In these  and similar  cases, evincing not
only great depression of vital power, but also
more or less deficiency in the quantity and qual-
ity of the blood, the quinine, or the decoction of
cinchona, chalybeate preparations, and other re-
storatives, may be  given in increased or more fre-
quent doses; and wherever pain, oppression, or
uneasiness may be manifested, the embrocations
advised above should be applied and renewed from
time to time.  In  these and analogous states the
tonics will be advantageously conjoined with cam-
phor, ammonia, aromatics, &c, and with opium
in moderate doses.
   56. The diet, regimen, and beverages prescribed
for the patient ought to be restorative, and cal-
culated to promote nervous power.  Rich wines,
brisk, bottled malt liquors, or bitter ales; soda-
water or Seltzer-water with wine ; the alkaline
and  chalybeate mineral waters ; spruce-beer and
weak tar-water; Carara or lime-water  with warm
milk, &c, are the  beverages which will be found
most beneficial.   Free ventilation, and a warm,
dry,  and pure air, are also most important aids of
medical treatment.  In  most respects the treat-
ment ofthe second stage of phlebitis is the same
as that which  is most efficacious for  consecutive
abscesses (see art. Abscess, $ 62, et seq.), for the
effects of absorption of morbid matter from dis-
eased organs and  structures (see Absorption, $
15, et seq.), for inflammation of the Lymphatics
(§ 17, et seq), and for the consequences of ani-
mal  or food Poisons ($ 427-456).

II. Structural Lesions  of Veins.—Classif.
  —IV.  Class, III. Order (Author in Preface.)
  b"l. a.  Inflammation of veins occasions redness,
or a  reddish-brown or violet tint of their coats.
But  similar changes, usually however of a more
uniform  character, are often produced in these
vessels after death, by the imbibition  of the col-
ouring matter  of the blood.  Indeed,  this is the
most frequent source of the different shades  of
colour observed in the veins, these shades vary-
ing with the state  of the blood, and with  the pe-
riod  after death at which the  examination had
been made.  The redness proceeding from this
source is much more frequently met with in the
veins than in the arteries, evidently owing to the
constant presence of blood in the former after
death.  This change, however, differs  in  pervad-
ing all the coats of the  veins, whereas it is gen-
erally confined to the inner membrane ofthe ar-
teries.  Redness, therefore, unaccompanied with
other changes, cannot be considered  as a proof
of disease.
  57*. The veins, like other parts  of the body,
present alterations arising from the  secretion  of
coagulable lymph or albumen.  This plastic and
organizable matter, in which a number of morbid
formations originate,  is frequently found in the
veins, either extended into membranes or accu-
mulated in amorphous masses.   It  is always to
be viewed, particularly when connected with red-
ness or vascular injection, as a result of the  in-
flammatory  act.   The  experiments which  M.
Gendrin  instituted upon the veins, as well as
upon the arteries, have illustrated this point.
  58. b.  Coagulated lymph is found, 1st, in the
interior of the  veins ; 2d, between  their coats ;
and, 3d, on their external surface.  When this is
considerable, or obliterates  the canal of the ves-
sel, it generally becomes  partially organized, and
is changed to cellular  tissue, if the life ofthe pa-
tient continue for some time.  When the lymph
is secreted in smaller quantity, so as not to  in-
terrupt the circulation in the vessel, it generally
presents  the form of a  firm albuminous layer,
without any trace of organization ;  but  in some
instances, as pointed out by Ribes, Gendrin,
and Andral, it forms a delicate membrane, and
presents  evident traces  of organization, being
traversed by minute vessels.  The surface of the
vessel opposed to those membranes is sometimes,
most commonly in the more recent cases, of a
deep red  colour ;  but  in other cases, particularly
those of  older date,  it is  perfectly colourless.
The  coagulated albumen thus formed in the  in-
terior of the vein  may constitute small patches
merely, or  small circumscribed masses, or a
complete continuous layer extending through the
whole of one or several vessels.  The polypous
concretions described  by Reil  (Fieberlehre, bk.
ii., p. 215-297) belong to  the  second of those
varieties.
  59. c.  Purulent matter is frequently found in
veins.  M. Andral states that coagulable lymph
may gradually lose its physical characters, and
be insensibly transformed into pus.  That this
may happen previously to the coagulation ofthe
lymph, is possible; but we have no satisfactory
proof of its occurrence, and least of all, after the
coagulation of  this fluid has taken  place.   In-
deed, it must not be supposed that the purulent
matter formed in the  veins is generally, or even
frequently, produced in this  manner.  When it
is found in the veins, it evidently does not pro-
ceed from a transformation ofthe plastic matter
already noticed, but from a modification of the
morbid action of the  extreme vessels which se-
creted  that  matter, and  from a change in  the
vital condition and cohesion ofthe internal mem-
brane of the vessel; this  membrane being some-
what softened, and frequently tumefied or thick-
ened.  When the purulent matter is formed from
the vein  itself,  it is found,  1st,  in the cavity  of
the vessel; 2d, infiltrated  between its coats ;  and,
3d, surrounding.
  60. The purulent  matter  formed in the in-
terior of the veins is,  however, more frequently
conveyed  there from  some other part with  the
blood, than secreted by an inflamed vein.   When
detected in a vein, it is either pure, or mixed with
the blood  or with coagula.   When pus is found
connected with coagula,  it  has been, in some
cases, external to them, and in others contained
in them.   This latter phenomenon has led  to
some speculation on the  part of certain patholo-
gists.  M. Andral believes that pus contained 
1448                           VEINS—Organic  Lesions of.
within a coagulum has been formed there in con-
sequence  of some peculiar modification of the
blood itself.  But this is  merely a supposition,
and  is  opposed by the consideration that  the
blood-globule can hardly be changed to a pus-
globule, either during  or after the coagulation of
the blood.   It is much more  probable  that the
pus, whether poured into the vessel from its in-
flamed internal surface, or conveyed from a dis-
tant part with the blood, but particularly when it
proceeds from the former source, is first formed,
the blood  coagulating around  it, owing  to some
obstruction to the circulation in the vessel, or to
the effect produced by the morbid secretion  on
the fibrin ofthe blood favouring its coagulation.
  61. The irritation and inflammation producing
suppuration of veins  arise from various causes.
These  are stated when treating of inflammation
of these vessels (§ 6,  et  seq.),  where  I have
shown that inflammation originating in a part of
a vein  may be propagated both toward the heart
and in the course of the smaller branches.  The
connexion of redness,  thickening, softening, &c,
of the coats of veins, with the formation  of puru-
lent matter  in  them,  has  been  fully illustrated
by  the  researches of Ribes,  Davis, Velpeau,
Gendrin, Louis, Arnott, Lee, Tonnelle, and
Dance ; and similar appearances have repeatedly
come before me in the examination of fatal cases
of puerperal diseases.   But pus is often formed
in the  veins without any change  of structure  of
their parietes, particularly in those veins which
arise in parts in a state of suppuration.   I have
observed in several cases, in which the uterus of
puerperal patients  contained   purulent matter
either in its cavity or  in its sinuses, the uterine
veins,  and some of the veins  into which they
run, nearly filled with this matter.   Similar ap-
pearances have  been  noticed  by Dance, Louis,
and others.   Abercrombie and Tonnelle have
found pus  in the sinuses of the dura mater, in
cases of caries  of the bones  of the head, &c
Pus has often been found in the veins near dis-
eased joints, suppurating fractures, and unhealthy
stumps, by Ribes, Velpeau, and others.  Blan-
chard long ago found pus in  the vena cava, in
a  case  of abscess of the liver.  M. Gendrin
found pus in the veins in the vicinity of ulcers in
the intestines.   M. Andral has met with similar
appearances.   I have stated in the article Dys-
entery, that  abscess of  the  liver  sometimes
complicating  that disease  not  unfrequently pro-
ceeds from the  absorption of pus from the ulcer-
ated intestines  into the veins,  which, circulating
into the vena porta, excites diffusive or asthen-
ic inflammatory action, rapidly followed by the
formation of purulent matter  in the substance
of the  liver.  This view is confirmed by the re-
searches of M. Ribes,  who has  demonstrated that
the villi of the intestines  are principally com-
posed of minute branches of veins.  M.  Andral
found, on the examination of a case of diseased
intestines  and  liver, the  vena  porta  and  its
branches lined with a false membrane.  When
purulent matter  is formed in  a part, and after-
ward conveyed into the veins, as in the instances
now alluded  to,  their coats are  in some cases
apparently sound, and in others inflamed or soft-
ened, or their interior is lined  with a false mem-
brane, &c.  In the latter cases, either the inflam-
matory action has  extended itself to the veins
from  the part primarily diseased, or the morbid
secretions  which have passed into them have
irritated and inflamed their internal membrane,
at the same time that they have induced serious
changes in the blood and system generally.
  62. In asthenic or cachectic states of phlebitis,
or when the cause is  of a poisonous or septic
character, the exudation  from the interior of the
inflamed vein is neither plastic nor purulent, and
is so entirely of an ichorous and liquid nature as
to mingle readily with the current of the circula-
tion, and to rapidly contaminate  and poison the
blood and  the soft tissues, and to destroy life.
In such cases discolouring of the inner surface,
and softening and thickening of the coats of the
vessel affected, with an altered appearance ofthe
blood — a dark, semi-coagulated or uncoagulated
condition  of this fluid.   In these cases the  blood
is rarely, or if at all, coagulated, or very imper-
fectly coagulated in  the  diseased vein or veins,
there is no plastic exudation  on the internal sur-
face, and no trace of pus in the vessel.  The in-
jurious operation of this ichorous  exudation is
accelerated by the circumstance of its failing to
produce  coagulation of blood  in the vein; for
when the exudation is plastic or purulent a coag-
ulum is generally formed by these  latter exuda-
tions ;  and this coagulum often prevents the ex-
tension of the inflammation and contamination
of the blood  and its  consequences, while the
ichorous and more liquid  exudation hastens both
these most dangerous or fatal results.
  62*. Thus the morbid states of veins may orig-
inate either in themselves or in the parts in which
the veins  commence ; but, whether they be thus
primary or consecutive affections, they exercise
a powerful influence on the  system, and on dis-
tinct organs,  both through the medium of the
blood and  by continuity  of  tissue.   1st. Puru-
lent  matter secreted from an  inflamed vein, or
conveyed  into the veins from an adjoining part,
may mix  with the blood, occasion febrile symp-
toms of an adynamic  character, generally with
colliquative perspirations or diarrhoea, and be thus
eliminated from  the  circulation nearly as fast as
it passes into  it, by the several emunctories. 2d.
This matter, when once carried into the circula-
tion, may be secreted from it into the parenchy-
ma of some organ, the cavity of some joint, or
even into cellular or muscular parts.  3d. Puru-
lent matter circulating in the  vessels, whether the
pus-globules  be  metamorphosed or  no, during
their circulation, may induce inflammatory irrita-
tion, or such a state ofthe capillaries of an organ
or part previously disposed to disease, as will be
rapidly followed by the  formation  of purulent
matter in  such part,  or by disorganization.   4th.
Inflammatory irritation excited in the internal
membrane of a vein, more especially in the asthen-
ic forms, may extend in  every direction to  other
veins, especially in that ofthe heart, and thus im-
plicate other organs or parts.   This diffusive form
of phlebitis generally occurs  in debilitated or un-
healthy states of the frame, or when the disease
is consecutive on  other  maladies, or caused by
septic  or poisonous  agents.   5th. Inflammatory
disease of the internal surface of the veins will
give rise to a secretion varying with the state of
the vital powers  ofthe system, and this secretion
carried  along, and mixing with, the circulating
current, will remarkably  influence those powers,
and depress or otherwise modify them.  6th. In-
flammation attacking all  the coats of a vein  is
more likely to occur in a  healthy body than that
confined to the inner surface, and is more com- 
VEINS—Organic Lesions of.
1449
monly  productive  of  an effusion  of coagulable
lymph, which tends to limit the inflammation, to
prevent the admixture of the products of inflam-
mation with the blood, and thus to preserve the
blood from  contamination.  7th.  This  sthenic
form of inflammation most frequently occasions
obstruction and obliteration of veins ; and, if the
obliteration be seated  in large veins, serious local
and general effects may result, owing to the me-
chanical obstacle thereby presented to the circu-
lation.
  [Analogy justifies the assumption that pus is
secreted by the  coats of the veins.  Vogel has
fully demonstrated the  transition  of epithelium
cells into  pus-globules.   Schwann having  orig-
inally shown that all organic bodies are developed
out of nucleated cells, Henle followed up the ob-
servation,  and proved that from these primary
cells either normal or  pathological  forms may
spring: consequently, inflammation would give
rise  to pus-globules.   To  apply these views to
the formation of purulent matter within the veins :
the cells of the  epithelium lining  separate from
the internal membrane of the vein, so as to give
a dull appearance to the inner surface ofthe ves-
sel, and render  it  more susceptible of a morbid
tinge from imbibition.   The  passing blood-cor-
puscles next assume a spheroid, or a gibbous ap-
pearance,  advance with a slow revolving move-
ment, or cling to one  another,  parting with their
serum  and with their pigment.  The lining mem-
brane of the vessel generates new,  imperfect epi-
thelium cells which mingle with the altered blood,
and, finally, actual pus-globules, which, when con-
gregated in sufficient number, completely arrest
the current of blood, and affect the blood-corpus-
cles in the manner above mentioned.  The simul-
taneous effusion of both fibrin and  albumen now
serves to complete  the formation of a plug, which
differs  in  its external character according to its
more or less rapid development, and to the vary-
ing proportion of its constituent parts.   Suppos-
ing suppurative phlebitis has now commenced, or
is commencing, the plug, thus formed, grows soft-
er towards its centre ; it assumes a grayish, yel-
lowish-white, dotted appearance, and finally ex-
hibits a straw colour,  and a semi-fluid consisten-
cy.   Its laminated structure becomes more and
more indistinct, and it is finally resolved into pus,
which is usually confined within a fibrinous layer
more or less thin,  and rarely found loose within
the vein.  But the  contents ofthe veins being un-
ceasingly  propelled towards the heart, the  more
or less  solid products  of inflammation are neces-
sarily conveyed beyond the original site of inflam-
mation.  For this  reason it would  be premature
were we at once to conclude, in examining a body,
that the part of a vein at which we  might happen
to find  a pus-coagulum must be the true seat of
the disease.   That seat is frequently remote, and
difficult to discover: thus between  a purulent co-
agulum in the inferior vena cava, and a gangre-
nous spot or a varicose ulcer on the  leg, the whole
extent  ofthe iliac and crural veins, together with
their deep-seated branches, shall be  found perfect-
ly healthy, while  one or more branches of the
saphena vein above bear all the evidence of in-
tense inflammation.   But since pus, by mingling
with the blood, causes its coagulation, a decided
hinderance is thereby offered,  in the majority of
instances, to the product of inflammation passing
along with the venous current.   The pus becomes
isolated by the coagulation of blood both above
and below the place of its formation, and is thus
cut off from the remainder ofthe blood.  This has
been called by some pathologists the sequestration
of veins.  Under such circumstances, the pus may
be gradually removed by the process of absorption,
the vein in the mean time becoming obliterated ;
or it may make for itself an outlet through the pa-
rietes of the vein.  Then abscesses, varying in
size and number, according to the  amount of in-
flammation, form beneath the skin,  or between
the muscles, and  the  patient is thus  protected
against the dangerous consequences of a general
infection of the circulating fluid.  Is not such the
origin frequently of the cold, deep-seated abscess-
es so often  met with after injuries, and in viti-
ated constitutions 1  When pus has thus formed
within an inflamed vein, its  coats begin to un-
dergo a change;  their colour inclines to a gray-
ish white ;  they become softened and thickened ;
and can no longer be distinguished from each oth-
er, forming with the surrounding textures a near-
ly uniform  membranous layer of a Iardaceous
character and aspect.   Soon after,  a turbid, puri-
form fluid is often found  deposited  at intervals  in
the cellular  tissue; in some instances, where the
suppuration is active in  the vicinity of the vein,
the latter traverses the purulent channel for a con-
siderable space, denuded in its entire circumfer-
ence.  Here the membranes of the vein gradual-
ly soften, and at length melt down, until no far-
ther vestige of their texture is discernible within
the common centre of suppuration.
  If this process of sequestration  does not take
place, or but imperfectly, and the pus, or soften-
ed fibrin, passes at once into the general circula-
tion, then all those phenomena ensue described by
our author, the disease perhaps first assuming the
type of an irregular intermittent, and subsequent-
ly of a typhoid or putrid and malignant character.
  The morbid condition ofthe blood hence result-
ing leads to organic changes in every part of the
body; all being referrible to  stagnation of the
circulating fluid, and are divisible into such as oc-
casion a stagnation and interruption of the san-
guineous current in the  central portions of the
vascular system, and into such as have  their seat
in the capillary system.
  According to Hasse, the first series of changes
consist in the formation of pus, and  in coagulation
of blood within the large venous or arterial trunks
—even in the heart itself.  The product of inflam-
mation, whether pus or fibrin, follows the course
of the blood towards the heart, but, advancing
more slowly than the uncontaminated  blood, ac-
cumulates,  invests itself again and again with
fresh layers of coagulum, and ends by entirely
closing  up  the cavities of individual vascular
trunks, and  especially where a large quantity of
blood has to pass within a brief space of time,
and in which, therefore, the pus-globules and the
fibrinous particles accumulate the more rapidly.
  The pulmonary artery and its branches are most
frequently the seat of this coagulation ofthe blood
consequent on phlebitis, the plug which forms here
perfectly resembling that of the adhesive inflam-
mation of vessels.   It is  of a pale-brown colour,
with here and there a yellowish spot, composed
of concentric  layers, and attached more or less
closely to the walls ofthe  vessel.  These concrete
masses, which have been observed in  uterine
phlebitis, and phlebitis consequent ou uterine car-
cinoma, spread to the minutest extremities of the
pulmonary artery, generally of one  side only, and 
1450                           VEINS—Organic Lesions of.
causing  eath as soon, at least, as the main trunk
becomes obstructed.  In other cases similar co-
agulation occurs in the right cavities of the heart,
in the form of polypi of the heart, as they have
been  called ; which are of a grayish or pale vio-
let colour,  and having a stratiform and  fibrinous
structure.   Internally they are sometimes found
considerably softened, and occasionally containing
liquid pus, while externally they are attached to
the columnae carneae,  and the valves of the heart.
Hasse thinks that in order to produce such coag-
ulation, it is indispensable, not only that  a certain
amount of morbid matter should pass into the cir-
culating mass, but likewise that there should ex-
ist a peculiar predisposition of the body generally.
  The most important pathological result of phle-
bitis,  however, is that which involves secondary
organic changes  in the capillary system, called
by some pathologists " lobular inflammations" and
" lobular abscesses."   They occur most frequent-
ly in  organs through  which the greatest portion
of the blood is propelled within a short  space of
time,  viz., the lungs and liver.  They seldom oc-
cur in the  spleen, kidneys, external skin, or cel-
lular  tissue; more rarely still in the brain,  eye,
and muscles.   Serous membranes are not often
the seat of this puriforin effusion,  the  synovial
membranes and pleura  rather more  so  than the
others.   Puerperal peritonitis forms an important
exception,  though frequently the result of  con-
current metritis.  Veins, also, distant from those
originally diseased, appear to be obnoxious to this
secondary suppuration.   The above  explanation
applies to abscesses in the liver and other organs,
consequent on injuries  of the head and other
parts, which for so long a time were a source of
mystery to  medical  men.  These  phenomena,
then,  are due to a phlebitis, in which the pus form-
ed is  not isolated, but mingles with  the general
sanguineous mass.   As to the absorption  of un-
altered pus through the capillaries,  it is hardly
admissible  on physical grounds.   With regard to
the abscesses that form  in the lungs, liver, and
spleen, it is now agreed by the best pathologists
that these collections  are not at once purulent at
the outset, but the blood  stagnates at certain
points, producing suppurative  inflammation of
the surrounding tissue ;  or knots form of from the
size of a pea to that  of a  walnut, become infil-
trated with firm coagulated blood, and eventually
suppurate.   Formerly it was  supposed that the
pus formed within the veins at the part originally-
inflamed was transmitted through the current of
the circulation to the lungs, liver, &c, and thus
formed the abscesses  in question.  If pus be in-
jected into the veins of horses, lobular abscesses
will shortly afterward  be found in the lungs.  The
pus-globules having reached the capillaries of the
lungs, are  unable, from  their  size,  to permeate
them, thus becoming central points of stagnation,
and finally of extravasation in the minute branch-
es of  the pulmonary artery, and inducing inflam-
mation and suppuration.  Vogel, however, con-
siders it not impossible for single pus-globules to
pass  through the capillaries of the lungs,  and
Hasse remarks that it  may be assumed that in
some  cases the substances commingling with the
blood  pass  through the capillary system of the
lungs without inducing any change in the pulmo-
nary parenchyma.   Some such admission  seems
necessary to explain the origin of purulent collec-
tions  in other organs than the lungs and liver.
Perhaps, as Hasse  suggests, the nuclei of rup-
tured pus-globules may pass through the capilla-
ries  of the lungs into the general circulation, as
also fibrin altered by  the  inflammatory process
into finely-divided particles.]
   63.  d. Softening of the  inner  membrane of
veins  is often observed, and  is generally con-
joined with  redness when  it is-the result of in-
flammation.  Sometimes the softening is so great
that the inner surface of the vessel is readily re-
duced to a pulpy state by gently scraping it with
the back of the scalpel.
   64.  e. Thickening of this membrane is often
associated with the  foregoing changes;  it may
be either partial or general.  In the former case
the inner surface of the vessel presents  an un-
even appearance.  But softening and thickening
of the inner  membrane of the veins are  not al-
ways  connected with  redness;  this membrane
may present either of those alterations, or both
of them, accompanied with paleness or with dif-
ferent shades of colour.
   65.  /. The valves of the veins are subject to
the  same  alterations  as the  inner  membrane.
They  are often  deprived of their transparency,
thickened, or partially  destroyed ; presenting the
appearance of irregular fringes crossing the cav-
ity of the vessel, and having generally coagulated
blood  adhering to them.
   66.  g.  The middle coat of veins is often soft-
ened, generally at the same time as the inner.
When this is the case, the vessel is torn with
great ease.   This coat is also subject to atrophy.
When this exists the vessel presents an extraordi-
nary degree of tenuity.  Hypertrophy ofthe middle
coat has been minutely described by M. Andral.
When this change exists,  the  coat is more dis-
tinctly visible, and its  longitudinal fibres more
evident.  When the hypertrophy is considerable,
this  coat loses its transparency, acquires  a yel-
lowish colour, and becomes, to a certain degree,
elastic, so that,  when  cut  across, the vein re-
mains open as an artery, to which it closely ap-
proaches in appearance.  On minute dissection,
however,  the middle hypertrophied  coat  never
presents any trace of circular fibres, nor does  it
possess the same degree of elasticity as the mid-
dle coat of arteries.  M. Andral states that he
once detected, as he believes, muscular fibres in
the vena cava inferior, near the heart; the cava
was  greatly hypertrophied.  The hypertrophy in
this  case  developed a  structure similar  to the
natural condition of the vessel in some  of the
lower  animals.   In the horse, the structure of
the vena cava near the right auricle is evidently
muscular.
   67.  The middle coat, however, may be much
thickened without actual hypertrophy or develop-
ment of its fibres. This may arise from a depo-
sition  of fibrinous lymph in its  texture, which
becomes solidified by the absorption of its  serous
portion.  M.  Andral  accounts for this change
by supposing that a quantity of blood accumu-
lates in its tissue; that the colouring particles
are absorbed, and the  white fibrin remains be-
hind in a solid form, combined,  molecule to mole-
cule, with the coats of the  vein,  presenting the
lardaceous appearance  described by authors as a
particular tissue ; but instead of having recourse
to this complex  explanation,  would it not be
preferable to  consider this alteration as a result
of chronic  inflammatory action in  the coats of
the vein 1
   68, h. The external coat of the veins is subject 
VEINS—Organic  Lesions of.                           1451
 to the same  changes as have been observed in
 the external coat of Arteries, and which are de-
 scribed in that article (§ 44).  These alterations
 of both the middle and external coats are com-
 monly seen after chronic phlebitis.
   69.  t. Ulceration and perforation of the several
 coats of the veins are sometimes met with.  M.
 Andral thinks that the latter is more frequently
 observed than the former.   Perforation has been
 detected in the superior cava, both within and
 without the pericardium; in the inferior cava ; in
 the vena porta?, both within and without the  liv-
 er ;  in the splenic vein ; in the jugular; in  the
 subclavian® ; in the mesenteric  veins, and  in
 the veins ofthe extremities.  The perforation is
 sometimes seen without any appearance of dis-
 ease  in the  vicinity of the coats of the vessel,
 rupture taking place from  external violence  or
 muscular exertion.  This form of perforation, or
 rather rupture, is most frequently observed  in the
 vena cava and veins of  the internal viscera.  In-
 stances of rupture of large  veins  are numerous.
 Schenck,  Morgagni,  De  IIaen, Doubleday,
 Groquier, Lovadina, &c, have  recorded rup-
 ture of the  vena cava.  Morgagni  also  found
 the pulmonary vein ruptured.   In the  majority
 of these and other instances, the rupture was oc-
 casioned  by exertion or external injury.  It is
 probable, however, that the walls of the ruptured
 vessel  had  been previously diseased. In  cases
 of perforation  the vessel is commonly more or
 less inflamed, ulcerated, softened, atrophied, &c;
 and here, as  well as in  the case of rupture from
 exertion or violence, the perforation occurs from
 within outward; but the perforation may also
 proceed in a  different direction ; viz., from with-
. out inward, as when the vein is seated in diseased
 parts, as in carcinomatous ulcers of the stomach,
 or is pressed upon by a tumour.
   70. k. The calibre of  veins may be much alter-
 ed—may be increased or diminished—especially
 when  the coats  are diseased as described,  the
 change of diameter occurring in the parts of their
 parietes which are affected.—(a)  Dilated or var-
 icose veins present a variety of appearances : 1st.
 The veins may  be simply dilated,  in  respect
 either  of a whole vein or of portions  of it, with-
 out any affection of the  capillaries which  nourish
 it, but  more frequently with chronic inflammation
 of its coats;  most probably the  dilatation is the
 consequence  of inflammatory action, this state
 disappearing, but the dilatation continuing.  2d.
 They may be dilated, either uniformly or at  in-
 tervals, with  thinning  of  their  parietes.  3d.
 They may be dilated and their coats thickened,
 either  uniformly or at intervals, the vessel  being
 generally also lengthened, and consequently tor-
 tuous.   4th.  They  may be  dilated and  divided
 into compartments by the interposition of septa
 or partitions, between which the blood stagnates
 or even coagulates.  5th. They may  be  dilated,
 divided into compartments, and  the dilated por-
 tions perforated, so as to allow the blood to pass
 into the cellular  tissue surrounding the  vein.
 M. Andral thinks that the tumours described
 by the  name  of  erectile are in  reality  nothing
 more than a  cluster of small  veins communica-
 ting with one another and with the surrounding
 cellular tissue by the perforations situated as now
 described.
   71. The structure of every variety  of haemor-
 rhoidal  tumour may be referred to one or  other
 of the  foregoing varieties of dilatation or varix ;
but these lesions are not confined to the veins in
the vicinity ofthe anus.  M. Andral once found
the external jugular  altered in the manner de-
scribed in the last variety.  In some cases the
tumours occasioned by  dilated  veins  disappear
spontaneously.  When this occurs, the veins are
generally obliterated.   Some of the above kinds
of varix, according to this pathologist, depend
upon increased activity,  others upon diminished
activity ofthe nutritive process.  Such, however,
can be rarely the case.  They are generally the
results  of pressure on  the venous trunks into
which the varicose veins pour their blood, or of
some other obstruction to the circulation through
the former vessel.  In this case the varicose veins
are not  only  greatly  dilated and elongated, but
trfeir  parietes are also hypertrophied.
   72.  (b)  Contraction and obliteration are, ac-
cording to M. Andral, much more common  than
their  dilatation.  These  lesions are occasioned,
1st, by obstruction in the interior of the veins;
2d, by causes seated  in  their parietes; and 3d,
by mechanical  compression external to them,
generally from tumours,  &c. The most frequent
cause ofthe obliteration  ofthe canals of veins is
the spontaneous coagulation of the blood within
the veins.   That the blood may coagulate, during
the life of the patient, within a vein or portion of
a vein, and even within  the sinuses of the  dura
mater, has been proved by the researches of many
pathologists, particularly by Meckel,  Gendrin,
Bouillaud, Ribes, Andral, Cruveilhier, Ar-
nott, Reynaud, Rokitansky, myself, and others.
It has occurred in several which have come before
me in practice, especially in the advanced stages
of low fevers, of acute rheumatism, of puerperal
disease, and in dysentery.  It is often difficult to
assign the,particular cause ofthe coagulation.
It is,  in some cases, apparently owing to the low
state  of the vital energies and their effect on the
blood.  In other cases it is probably occasioned
by the morbid state of the valves already noticed
($ 65), or to lesion of the internal parietes of the
vessel.   Most frequently, however, it proceeds
from  coagulable lymph or pus secreted from the
internal surface of the vessel; this morbid secre-
tion adhering to the inflamed surface  producing
it, entangling the fibrinous and colouring  parts
ofthe blood, and thus  forming a coagulum which
either partially or entirely  obstructs  the canal.
This coagulum generally  varies in colour, density,
and firmness of adhesion to the sides of the ves-
sel ; and it increases in bulk until the passage is
entirely  obstructed by it.  Occasionally the co-
agulum becomes, in  some  respects,  organized.
Some of the  pathologists whose names I  have
just adduced suppose that these coagula live pre-
cisely as the veins in which they are formed,  and,
like every other part endowed with life, keep up
a constant process of nutrition and secretion, and
are also liable to become  diseased.
  73. The canal of a vein may  be altogether ob-
literated, and the vessel reduced to  a fibro-cellu-
lar cord.  This seems to be effectedin a similar
way to  that  observed in arteries.  Obliteration
of large venous trunks gives rise, as observed in
arteries,  to a collateral  circulation, kept up by
means either of small veins, or of one vessel  that
has acquired an unusual size. The most remark-
able instance of obliteration  was observed by M.
Reynaud in the superior vena cava.  The veins
on the lateral  surface  of the chest were remark-
ably enlarged, and anastomosed freely with the 
1452
VEINS—Organic Lesions of.
epigastric veins, which were also greatly en-
larged.   The circulation was carried on chiefly
by the vena azygos and inferior cava.   The con-
sequences of obstruction and obliteration of veins,
especially cedema  and dropsy, are well known.
Several instructive cases of  obliteration of the
cavity of the vena cava, of the iliac veins, and of
the sinuses of the dura mater, are recorded by
Bartholinus,  Rhodius,  Mantissa,   Bontius,
Albinus, Haller, Morgagni, Hodgson, Bre-
schet, Wilson, Tonnelle, Reynaud,  Andrajl,
and Rokitansky.
  74. I.  Ossific or calcareous formations are rare-
ly met with in the coats ofthe veins.  They have,
however, been  observed by Morgagni,  Walter,
Murray, Baillie, and Tilorier,  and  more  re-
cently by Macartney, Beclard,  and  Andral,
in the femoral  and saphena veins.  Sometimes
these concretions protrude into the cavity of the
vessel, either bursting its internal  membrane, or
carrying this membrane before them.   In either
case they may  at last escape into the cavity and
lodge there, without any attachment to the  sides
of the vessel;  for in  the latter case the mem-
brane may contract behind the concretion, form-
ing at first a peduncle attaching it to the vessel,
which at last is ruptured  or absorbed.
  75.  These concretions have received the name
of Phlebohthes;  they vary from  the  size of a
millet-seed to that of a pea.  They have some-
times  been found in  the centres of coagula,
which had evidently been formed  around them.
They have been observed by Columbus, Walter,
Soemmering, John, and Langstaff.   F. Tiede-
mann  has  described  them  minutely.  Those
which he has observed, as well as those noticed
by the pathologists just now named, were formed
in the uterine  and haemorrhoidal veins.  Tiede-
mann and Rokitansky state that they are formed
of concentric layers ofthe phosphate and carbo-
nate of lime, sometimes with magnesia, united by
albuminous matter, around a minute clot or co-
agulum ; and deny that they are  formed in  the
way which  I have just stated (§ 74);  and con-
tend  that they have been produced by a sort of
crystallization, or deposition, of the earthy par-
ticles  contained in the blood, around  a nucleus
which had  formed in the nearly stagnant  blood
in the veins.   M. Andral also considers it pos-
sible  that  they may have  been  formed in  the
blood itself.  It is difficult to assign limits to the
range of possibilities without  relation to the faith
of those  for whose belief they are adduced ;  but
the question is, whether or no these concretions
have  ever been actually ascertained to  have been
formed in  this manner.  I believe that no such
fact has  ever been adduced.*
  [* The mode of formation of these concretions, or vein-
stones as they have been termed, is for the most part as
follows :  Slow inflammation occurs  in pouches or dilated
portions of vein, and in the prolongations of small venous
twigs, suddenly  dilated, which results in coagulation of
the blood in distinct concentric layers.  These coagula,
which are mostly spherical in shape,  become the nidus
for the deposition of phosphate of lime and magnesia,
until at length the whole clot is transformed into a phle-
oolite or ossific mass, made up of concentric layers.  When
the dilated portion of the vein or pouch is thus filled up,
its walls  commonly become atrophied ; the inner surface
of the vein assumes more of a cellular structure, and
closes firmly around the vein-stone, sometimes making it
appear to be external to the vein. At other times the
coagulation of the blood extends beyond the point where
a vein-stone has formed, the calibre  of the vessel closes up,
and an entire portion of the implicated vein is obliterated.
In other cases there is good reason to believe that they
occur free and  movable within vessels  which continue
  76. m.  Fatty, suety, and atheromatous deposits
have been found in the parietes of veins, but not
nearly so frequently as in the coats of arteries,
where I have  first described  them  ($ 59, 60).
Bontius states that he has met with large masses
of fat in the vena cava, obstructing its canal.  I
have  sometimes found fatty and suety deposits
between the coats of the vena  porta?; and  M.
Andral has noticed similar deposits in this vein.
  77. n. Tuberculosis does not occur either in or
on  the coats of the veins.   If any  tubercular
matter, or  substance  resembling this  matter, be
found within the veins, it can  proceed only from
imbibition or absorption.  BvA before this matter
can be imbibed it must be softened, or metamor-
phosed, and thus have lost the  tubercular charac-
ters.
  78. o. Cancer is met with in veins in two
ways :  1st. The walls of a vein may be attack-
ed  by  a  cancerous  or carcinomatous growth,
penetrated by, involved in, and closed  or altered
by  this growth.  The portal, renal, hepatic, and
other veins may be  thus implicated:  2d. The
cancerous  matter,  especially  when  existing in
other parts of the body, may constitute in a large
vein  a variously-formed  mass, attached to the
interior of the vessel, that may either partially or
entirely All and  obstruct the  canal.   This can-
cerous formation obviously arises from the imbi-
bition or absorption of the cancerous matter or
cells into the veins, where they attach themselves
and collect into masses of various sizes and forms.
The cedema and swellings  occurring  in the last
stages of carcinoma  are, in some cases,  attrib-
utable  to  this  formation  in  the veins, and in
others to phlebitis, produced by the imbibition of
the cancerous matters.
  79. p. Gaseous fluids have occasionally been
remarked in the veins.   In  some cases they have
proceeded  from incipient  putrefaction, but in
others this could not  have  been the case.  The
vapours and gaseous exhalations from blood very
recently taken, or at the time  of its being taken
from veins, and those found in veins after death,
have not been sufficiently examined.   They man-
ifestly are  such as demand a much stricter inves-
tigation than they have hitherto received.   In
cases of surgical operations, when large veins are
divided, air not  unfrequently  enters  the  veins;
and if it rush in suddenly, and in considerable
quantity, it is soon followed by death.  The  ex-
periments  of MM. Magendie and   Piedagnal
have demonstrated this  fact  conformably with
what has  occurred during  several  operations;
but the mode in which this  result takes place is
not so evident.   The air seems to act in derang-
ing and arresting the  contractions of the heart,
and affecting the actions ofthe lungs.
  80. q. Entozoa have been  often  found in  the
veins of the lower animals.  The strongylus and
filaria have been  detected in  the  horse.  M.
Andral found individuals  of the  class  Nema-
toidea in the vessels of a porpoise.  In one only
case  he found  Acephalocysts (hydatids) in  the
pulmonary veins.
  Bibliog. and Refer.—Aretants, Cur. Morb. Acut., 1.

pervious to the current of the circulation.  Some patholo-
gists maintain that they form in peculiar sacs in the cel-
lular tissue, external to the vein ; others think they are
deposited between the coats of the vein, and ultimately
get into the interior  of the vein  by absorption; while
Otto, Tiedemann, Lokstein,  <'ruveiuiieb, 1'riquet,
Carswei.l, and Hasse suppose that they form originally
within the vein, in the manner above indicated.] 
VEINS—Bibliography and References.
1453
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in Ibid., vol.  xxvii., p. 41.—G. Breschet,  De  l'lnflamma-
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xii., p. 426.  (Tlie first to connect  Phlegmasia Dolens with
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Complem.  du Diet, des Sc.  Med., t iii., p.  38.—G. Bre-
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the  encephalic  Win*.) — Forbes, Trans,  of  Med.  and
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Ibid., vol. vii., p. 195.—A'. Lee, in Ibid., vol. xv., p.  369.
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—G. Breschet, Diet, de Med., art. Phlebite, t xvi.  Par.,
1826.—P. H. Berard, Diet, de Med., art. Cava.—Reynaud,
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t. v., p. 178.—Dance, De la Phlebite considered  sur le
Rapport de Causes, &c,  in  Archives Gener. de Med., t.
xviii., p. 520; t. xix., p.  S.—Godin, in Ibid.,  2d ser., t.
xii., p. 52.    1836.—Lambron, in Ibid., 3d ser., t. xiv., p.
127.  1K42.— Vidal, in Ibid.   Oct. 1845.— Frey, in Ibid.
Avril, 1S4C>.  (Inflam. of Vena Porta.)—Bonnet, in Ibid..
4th ser., t.  i.  1839.—Tonnelle, Memoire sur les Maladie?
des Sinus Veineux de la Dure-Mere, Svo.   Paris, 1S29.—
F. A. Balling,  Zur Veneuentziindung, 8vo.  Wiirtzb.,
1829.—Andral,  Anat.  Patholog., t. ii., p. 412.—Cruvei't
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Blandin, Memoire sur quelques  Accidens tres-communf
a la suite des Amputations, Journ. Hebdom. de Med.,
vol. ii., 8vo.  Par., 1829.—Reynaud, in Ibid., t. iv., 1829,
et t. ii., p. 110; et in Arch. Gener. de Med., t. xxi., p.
434.  (Obliteration of inferior part of Vena  Cava, and
part of the  Vena Porta.)—Bouillaud, in Ibid., t. ii., p.
188, et t. v., p. 94___J. Arnott,  a Pathological Inquiry
into the Secondary Effects of Inflammation of the Veins,
in Med. Chir.  Trans, of Lond., vol. xv., 8vo.   Lond.,
1829.— W.  Bloxam, Ulceration of Internal Jugular Vein,
'in Ibid., vol. xxvi., p. 112.— J. Thurnam, in  Ibid., vol.
xxiii., p. 332.—R. Lee, in Ibid., vol. xix., p.  4(1.  (Case
of Pulmonary Phlebitis.) — Cruveilhier,  Diet,  de Med.
 Prat., art. Phlebite, t.  xii.  Par., 1834.—T. B.  Peacock,
in Trans, of Med. and Chirurg. Soc. of Lond., vol. xxviii.,
p. 1.  (Obliteration of  Vena Cava.)—Blandin,  in Med.
Chirurg. Review, vol.  xxix.,  p. 592.—R. Lee, Cyc. of
Pract. Med., art. Veins, Inflammation of, t. iv.  Lond.,
1834.—E. Lacroix, in Archives Gener. de Med., 2d ser.,
t. xii.,  p. 5.  1S;;6.  (Pathology of Veins.)—Chapaignac,
in Bulletins de la Societe Anatom., anno 1S35, p. 67.—
Tessier, De la Diathese Purulente, l'Exp rience, t. ii., p.
87.—Duplay, in Ibid., t. ii., p. 49.—J. Copland, of the
Pathology and  Morbid  Anatomy of Veins, in London
Med. Gazette, vol. xxii., p. 797, 837.   Lond., 1838__Gau-
brie, in Bullet, de la Soc. Anat., 1S39, p. 104.—.A. Berard,
in Ibid., 1840,  p. 46.—Mazet, in Ibid., 1837, p.  234.-
Bouchut, in Ibid., 1835,  p. 8,  67, 102 ; et 1840, p. 17.—
Raciborski, in Mem. de l'Acad. Roy. de Med., 1841, t. ix.,
p. 447.  (Pathology of  Veins.)—Bouchut, in Gaz. Medi-
cale.   Avril, 1845.  (On the  Coagulation of Blood in
 Veins.)—Trousseau, in Gaz. des  Hospitaux.  Juin, 1844.
(Phlebitis of Umbilical Vein.)—E. Crisp, a Treatise on
the Structure, Diseases, and Injuries of the Blood-vessels,
with Statistical  Deductions, Svo.   Lond., 1847.—Diseases
of  Veins, p. 311,  et  seq.—C. Rokitansky, a Manual of
Pathological Anatomy,  vol. iv., transl.  for  Sydenham
Society by G. E.  Day, p. 335, et  seq.  (He furnishes
nothing additional to that contained in my Paper above
referred to.)
  [Amer. Bibliog. and Refer.—Charles E. Hasse, An-
atomical Description of  the Diseases of the Organs of
Circulation and Respiration, translated by  Swaine, Am.
ed.  Phil., 1848, 8vo, p. 377.  (This work  contains,  per-
haps, the best account of diseases of the veins in any lan-
guage.)—J.  Hope,  Principles and Illustrations  of Path-
ological Anatomy, being a complete Series of  coloured
and Lithographic  Drawings.   1st Am. ed., edited by L.
M. Lawson,  large Svo, p. 359.   Cincinnati, 1844.—S. D.
Gross,  Elements of Pathological Anatomy, illustrated by
coloured Engravings, &c, 2d ed., p. 821.  Phil., 1845.
—J. B. S. Jackson, a descriptive Catalogue of the Ana-
tomical Museum of the boston Society for Medical  Im-
provement, 8vo, p. 352.   Boston, 1847.— Wm. P. Dewees,
on  Phlegmasia Dolens, in Am. Jour. Med. Sci., vol. v.,
p. 66.   (The conclusion of Dr. D., after an elaborate dis-
cussion of the whole subject, is,  1st. " That the disease,
whatever be its seat, is of a highly inflammatory charac-
ter;" and, 2d. "That this inflammation occupies  exclu-
sively the white lymphatic vessels of the cellular mem-
brane of the several textures of the limb.")  Also, " On
Females," 8vo,  p.  591.   Phil.,  1333.—See Medico-Chi-
rurgical Review, vol. iv.. p.  51)9, for a very full analysis
of the symptoms of Phlebitis, compiled from " Recherches
Cliniques pour servir a l'Histoire de la Phlebite," par
M. J. Bouillaud, Revue Med.,  Avril et Juin, 1825;  and
from " Expose succinct des Recherches faites sur la Phle-
bite,"  par  M. F. Ribes, Revue Med., Juillet, lv25.  See
also Am. Jour. Med. Sciences,  vol. v., p. 177,  for a very
full  Synopsis of the paper of J. M. Arnott, contained in
the  Medico-Chirurg.  Trans., vol. xv., part 1,  1S29, on 
1454
VEINS—Bibliog.  and  Refer.—VENEREAL DISEASES.
the Secondary Effects of Inflammation of the Veins.—T.
S. Kirkonde, Phlebitis following the operation for Vari-
cose Veins, Am. Jour. Med. Sci., vol. xv., p. 79; and case
of Puerperal Phlebitis, Ibid., p. 352.—M. Bonnet,  Me-
moir on the Treatment of Varicose Veins of the lower
extremities, translated by A. G. Thompson, Jr., M.D.,
In N. Y. Jour. Med. an* Surgery, vol. iii., p. 377.—James
D. Trask, on the nature of Phlegmasia Dolens, Am. Jour.
Med. Sci., Jan., 1S47, p. 26.—John liaison. Observations
on Operations  on Haemorrhoids, &c,  N. Y. Jour. Med.
Coll. Sciences, July, 1-44; also,  An  Inquiry into  the
Pathology and  Treatment of Varices, Am. Jour, of Med.
Science, Jan.,  1843.— W.  D.  Purple, Case of Dissection
Wound, followed by great constitutional disturbance, and
death on the  eighth day, N. Y. Jour. Med.  Sci., Sept.,
1852, p. 209.—Moses Gunn, Syncope from entrance of air
into the Facial Vein, Ibid., May, 1862, p. 356.—X Chap-
man, Cases of Phlebitis, with some remarks on its Pa-
thology and Treatment.  (In this article Dr. C. gives sev-
eral cases of Phlebitis from diss, treated successfully by
leeches, fomentations, poultices, and blisters to the part,
and calomel, ipecacuanha, and opium internally. " Of
all remedies,"  he remarks, "the one deserving of the
greatest confidence is a blister.  Numerous are the  in-
stances in which I have witnessed its  superior  efficacy;
and I believe there is little division of sentiment as to its
extraordinary value among the profession in this part of
the country.   From what I have seen and heard, I can-
not entertain a doubt that it will  at once arrest a large
majority of cases.  But though coming from the late 1-rof.
Physic—published by him some 49 years ago, and since
frequently alluded to with the highest commendation in
the writings of this country—it seems to have attracted
scarcely any attention in Europe, or at least I do not find
it noticed in the treatises I have consulted on the subject,
with a solitary exception.  Cooper, in his Surgical Dic-
tionary, appropriates a paragraph to it, without  praise or
censure.  The manner of application is, to place a narrow
strip of epispastic plaster along the course of the vein as
far as it appears to be inflamed, cutting an opening in it
at the orifice,  over which a soft poultice is to be placed,
and the blister having drawn is to be so dressed as to be
kept freely discharging," &c.  Dr. C. also dwells on the
importance of supporting the limb, so as to secure an ab-
solute state of rest, and for this purpose recommends a
nicely adjusted case, if the vein be in the arm.)—Stephen
Smith, 1 hlebitis consequent on Otitis, Ibid., July, 1851,
p. 83.—George B. Wood, a Treatise on  the Practice of
Medicine, 2 vols. 8vo.  Phil., 1847, art. " Phlebitis." —
John Bell and W. Stokes, Lectures on the Theory  and
Practice of Physic, 8vo, 2 vols.   Phil.,  1848. — i.obley
Dunglison. The Practice of  Medicine, &c, 2 vols. 8vo.
Phil., 1848, art. " Diseases of the Veins,' vol. i., p.  509.
—Martyn Paine, Medical and Physiological Commenta-
ries, 3  vols. 8vo, p. 716, 815, 444,  vol. ii., art. " Philoso-
phy of Venous  Congestion."  (in this mot elaborate Es-
say, embracing 343 pages, the author has fairly exhausted
the whole subject of venous pathology, passing in review
all that has been written on the subject from Hippocrates
down to the present time. In it will be found fully and
clearly set forth what is known regarding the organiza-
tion and morbid anatomy of the veins, phlebitis, varix,
puerperal  fever, spontaneous hemorrhage, &c, consti-
tuting one of  the most learned and logical essays in  the
whole compass of medical literature.)— John A. Swett,
Review of the  above work, New York Journal of Medi-
cine, vol. iii.,  p. 403.  " In many points of view," says
Dr. S., " it certainly surpasses every other work that has
ever been issued from the American pres?," p. 31.   To
the correctness of this opinion we unhesitatingly sub-
scribe. —John  Watson, Review of same work, Ibid., vol.
iii , p. 14G.  " We know of but few works,"' says Dr. W.,
" and certainly none in the range  of American  medical
literature, to compare with this for the extent and variety
of professional research evinced in it."  " A work that
does honour to the medical character of our country," p.
172.—Samuel Jackson, Principles of Medicine and Ani-
mal Organism, 8vo.  Phil., 1832.—Joseph A. Gallup, (>ut-
lines of the Institutes of Medicine, founded on the Phi-
losophy of the Human Economy in Health and Disease,
in 3 party, 2 vols., Svo.  Boston, 1S39; also " Sketches of
Epidemic Diseases in the State of Vermont, 8vo, p. 419.
Boston, 1815.—David Hosack, Lectures on the Theory
and  Practice  of Physic, edited by Hcnru W. Ducacket,
D.D.,  Svo.  Phil., 1838,  p. 699.— William  E. Horner.
A Treatise on Path. Anatomy, 8vo. . Phil., 1829, p. 459;
and in Am. Jour. Med. Sci., Aug., 1835, p. 2^2. — Valen-
tine Mott, New Elements of Operative  Surgery, by A. A.
L. M.  Velpeau, &c, translated by P. S. 'lownscnd, 3
vol?., Svo. N. Y., 1S45; also I ectures in " The New York
Lancet," edited by./. A. Houston, 2 vols., Svo.  N.  Y.,
1S4'2^13.]
   VENEREAL DISEASES— Gonorrhcea —
Syphilis. — Synon.  Gonorrhoea,  Blennorrhagia,
Phallorrhaa virulenta; Lues venerea, Femelius,
Boerhaave, Juncker,  Astruc, &c.   Syphilis, Sa-
gar, Vogel, Cullen, Pinel, Young, Swediaur, &c.
Syphilis  venerea,  Sauvages.    Lues  syphilis,
Good.   Syphilis,  Sprengel.   Scabies  venerea,
Locher.   Lues syphilitica, Morbus Neapolitanus,
Morbus Galhcus, Morbus venercus, Auct.   Lust-
seuche, Vcnensche Krankhcit,  Germ.    Verole,
Verole commune,  Grande  Verole,  Maladie Vcne-
rienne, Fr.   Mai Francese, lue  Venerea,  Ital.
Pox,   French  Pox,   Venereal  disease,  Venereal
cachexia.
  Classif. — III. Class,  I. Order (Author in
     Preface).
  1.  Definit.—Specific inflammations,  or ulcer-
ations, or  both, affecting primarily the organs of
generation  of both sexes,  and very frequently the
whole frame, at subsequent and sometimes at re-
mote  periods, and propagated by contact.
  2.  Viewing venereal diseases as consisting of
two very distinct forms — distinct  in their  pri-
mary character and in their consecutive  effects—
I shall very briefly  notice,  first, gonorrhoea, or
blennorrhagia, or, more correctly, Blennorrhagia
specialis,  or virulenta, and afterward  syphilis,
or Syphilis venerea.   The relations between these
two venereal diseases  have been  for ages much
discussed  by both physicians and surgeons,  and
are not  even now entirely  disposed  of.  They,
however, possess this in common, that  they are
primarily seated  in the sexual  organs, with very
few exceptions;  that they generally result from
impure sexual  connexion, or contact; that they
are primarily either  inflammatory, or ulcerative,
or both ;  and that in many instances the frame
becomes  affected or  contaminated by them, but
in very different  forms and grades,  and  much
more frequently in the one form than in the other.
These constitutional  effects  render them of equal
importance to the physician and to the surgeon ;
and although both may sometimes require sur-
gical appliances  and aids, still they may be both
cured by  the prescriptions of the physician only,
which alone are appropriate in the consecutive
states of these maladies.
  3.  I.  Gonorrhcea. — Synon. — Phallorrhaa,
Phallorrhcca virulenta, Gonorrhoea virulenta, Blen-
norrhagia,  Blennorrhagia virulenta.
  4.  Definition.—A specific inflammation of an
acute form, affecting the  mucous surface of the
urinary and sexual passages in both sexes, with a
copious puriform or muco-purulent discharge, prop-
agated by contact, and in some instances occasion-
ing severe consequences.
  5. i. Description.—I have shown, in the arti-
cle  Vagina and Vulva, that those parts are often
the  seats of a  purulent  or muco-purulent dis-
charge, which  presents the following  states or
forms : 1st.  Leucorrhcea,  or Blennorrhagia, the
discharge arising from irritation or inflammatory
action, of a non-specific nature ;  2d. Acute Gon-
orrhoea, or Blennorrhagia virulenta, the discharge
being the result of a specific inflammation, caused
by the contact of this discharge ; and, 3d. Chron-
ic Gonorrhoea, or gleet, the discharge being more
mucous or less puriform, and generally consecu-
tive upon the acute form ; and unless when  thus
related, being distinguished with difficulty from
leucorrhcea in the female ; its contagious proper-
ty being doubtful, unless  the morbid  matter acts
on  very  predisposed parts.  These  forms  and
states of discharge are also met  with in males.
The first variety  may be communicated by the 
VENEREAL DISEASES—Gonorrhcea described.
1455
 female to the male, or by the former to the latter,
 owing to the fact of puriform discharges, the re-
 sult of inflammatory irritation of mucous surfaces,
 being capable of producing a similar state of mor-
 bid action in similar  surfaces when these dis-
 charges  are  allowed to remain in contact with
 them.   This result follows only in a few cases,
 and probably only when the recipient surface is
 predisposed to the infection.  Thus a non-specif-
 ic blennorrhagia, caused by excessive sexual in-
 tercourse, or by the discharges of the female or-
 gans, may be distinguished with  difficulty from
 gonorrhcea, or acute specific blennorrhagia, and
 with still greater difficulty from chronic specific
 blennorrhagia, more especially when the  acute
■ specific  disease is not very severe, or when it is
 a renewed or repeated attack.
   6.  A.  Gonorrhaa in the  female has been de-
 scribed in the article Vagina and Vulva (see $
 8, 38).   The chronic states of the disease have
 been noticed by Mr. Holmes  Coote  in his very
 able  work  on the  treatment of syphilis.  He
 remarks, " that chronic gonorrhoea is a disease
 from which the lower order of prostitutes is rare-
 ly free.   It exists also among the  better  class,
 who live highly, and drink without scruple.   In
 general it disappears when  the patient is kept on
 moderate and regular diet, and confined to bed;
 but it returns upon the least  excitement," &c.,
 and  is  perpetuated by  some internal ulcer or
 abrasion, notwithstanding  the treatment, until
 this  latter lesion  is cured.   The irritating  dis-
 charge often causes an abundant growth  of soft
 vascular warts, commencing at the lower part of
 the vagina, near the orifice, and extending  at the
 junction ofthe mucous membrane and the skin
 towards the superior commissure.  '• The' rapid-
 ity of this growth is quite striking.  When re-
 moved  by the knife they  return within a  few
 weeks, if the irritating discharge be allowed to
 continue."
   7.  Among other cases  adduced  by  Mr.  H.
 Coote,  showing  that a  female  suffering from
 gonorrhcea may remain for months uncured, un-
 less a proper examination be  made, and some le-
 sion  beyond the reach of ordinary inspection be
 detected and treated in an  effective way, the fol-
 lowing  deserves an especial notice.  A  young
 woman was admitted with a large growth of vas-
 cular warts from  the external organs, and a co-
 pious puriform discharge.    The usual means were
 applied, but they increased, and were removed by
 excision.  The discharge, however, continued, a
 suitable treatment was prescribed, but the warts
 recommenced their growth, and the patient's gen-
 eral health declined.   The os uteri was examined
 by the speculum, and it was found slightly ulcer-
 ated  and abraded.   Caustic was applied to  this
 part.  The discharge rapidly disappeared,  the
 general health improved, and recovery was soon
 complete. In another case of chronic gonorrhcea,
 the usual remedies were employed  with tempo-
 rary  benefit; but a recurrence of the symptoms
 invariably succeeded.   When examined by the
 speculum, a large  warty  growth, soft, red,  and
 vascular, was found two  inches and  a half from
 the orifice of the vagina.    This growth was  two
 inches in length, and an inch and a quarter across
 the base, springing from the anterior wall.   It
 was removed by the knife ; immediate relief, and
 complete recovery soon afterward, ensued.
   8.  B.  Gonorrhaa in  the Male.—This  is  not
 only  a very painful and troublesome complaint,
but, if injudiciously treated, it may induce changes
—or,  rather,  the  treatment  improperly adopted
may occasion lesions unconnected with the  dis-
ease,  which may imbitter,  or even shorten the
life of  the patient.   And  during a  somewhat
lengthened period of observation I can  assert,
that numerous instances have become known to
me of attempts made to effect a speedy cure hav-
ing been  followed by  the most distressing  and
dangerous results.  The complaint usually com-
mences from  three to ten days after morbid con-
tact ;  and the shorter the period of its  incubation
the more severe the attack; the stronger dose of
the virus hastening the effects.  A slight itching
is at first felt, then an irritation at the opening of
the urethra, and afterward a smarting pain, more
or less severe, upon micturition.  The lips ofthe
urethra become tumid ; a thin discharge, at  first
scanty,  but soon afterward more copious and pu-
riform,  flows from  the passage.   The  corpus
spongiosum urethra? becomes thickened and un-
yielding, owing to inflammatory exudation  into
it;  and when erection ofthe penis occurs, a bend-
ing downward, or chordee, is produced.  Haemor-
rhage sometimes takes place during this state and
affords  partial relief; and occasionally irritation
extends from the  urethra to  the glands of the
groin, causing slight swelling, which very rarely
goes on to suppuration, except in scrofulous sub-
jects.
  9. A form of gonorrhcea—gonorrhoea sicca—
is occasionally  met with, both in the  male  and
female, and has  been described by  Mr. Acton
and Dr. Druitt, in which the mucous  membrane
of the female organ is red, swollen, and tender,
but free from discharge.  In the male there are
severe  scalding  and pain on passing  the  urine,
painful erections, the  lips of the urethra being
red and swollen.  This form of the disease has
been called dry clap.
   10. C.  Secondary Effects and Complications or
 Consequences of Gonorrhaa in Females.—Owing
either to  neglect, to  improper treatment, or to
constitutional vice, or  to neglect of proper regi-
men, several very serious  consequences  ensue
upon the gonorrhceal disease.  Most of those
which occur in the female have have been noticed
in the articles Uterus and its Appendages (<$
43, 53,  122, et seq.), and Vagina and Vulva ((j 8,
 13, 38).  These consequences are, chronic gon-
orrhoea, suppuration  or abscesses in  the labia,
soft vascular warts (§ 6, 7), gonorrhceal inflam-
mations ofthe cervix uteri, extending to the  cav-
ity of it and of the uterus  along  the Fallopian
tubes to the ovaries, and even to the peritoneum ;
and, in rare instances, even to the uterine veins.
Gonorrhceal  ophthalmia and  gonorrhceal  rheu-
matism occur not less frequently in the female
than in the male.
   11. D. The complications of gonorrhaa  some-
times observed in males are, 1st. Balanitis (from
Ba/lavoc, glans), or gonorrhaa externa, is  an in-
flammation ofthe surface ofthe glans and inside
of the prepuce, with profuse purulent discharge
and excoriation of the  cuticle.  This affection
may be a complication of gonorrhcea, or may ex-
ist independently of it.   In  the former case it is
produced by  the gonorrhceal virus ; in the latter
by the  want  of cleanliness,  and by the excoria-
tions caused  by the secretions ofthe  part, which
have become acrid by retention.   In  these latter
cases the excoriations may be mistaken for chan-
cre.   2d. Phymosis and paraphymosis occasion- 
1456          VENEREAL DISEASES—Gonorrhcea described—Treatment.
ally arise, owing to the swelling of the glans and
prepuce. QSdema ofthe prepuce presents a semi-
transparent  or  diaphanous appearance.  These
states, although often complicating gonorrhcea,
not unfrequently occur independently of it, espe-
cially as a consequence of self-pollution ; and in
some instances they lead to very serious results.
They furnish additional  reasons, to others which
may be adduced, as to the propriety of circum-
cision during infancy.  3d. Irritation or inflam-
mation of the lymphatic vessels, extending to the
glands of the groin, is a common association  of
the disease; but  the affection ofthe lymphatics
may be so slight as to be imperceptible, although
the glands may be much swollen, inflamed, or even
suppurate.  4th. The mucous follicles ofthe ure-
thra may  be inflamed and obstructed, and may
even suppurate and burst either into the urethra,
or externally, or  both.  In these cases very se-
rious obstruction  to the discharge of urine may
occur.  5th. The inflammation may extend along
the urethra to the prostate gland and neck ofthe
bladder, and even along the  ureters to the kid-
neys ;  or  it may give rise to acute abscess  of
the gland and great suffering, especially during
micturition,  to  strictures, &c.   6th.  More  fre-
quently, inflammation extends along the vas def-
erens, causing  swelling of  the  epididymis, or
swelled testicle.
   12. Gonorrhcea is always  most severe on its
first occurrence, and in young  and robust subjects,
and in the irritable and scrofulous constitutions
and habits.  In these it is often attended by se-
vere inflammatory fever and disorder of the uri-
nary functions ; and it may even prove dangerous
to life, by inducing extensive inflammation and
abscesses in the vicinity of the prostate and blad-
der.   " But after repeated attacks the urethra be-
comes inured to the disease, and each subsequent
infection is  generally (although not  always)  at-
tended with fewer of the symptoms of acute in-
flammation.   In  some  instances, the  constitu-
tional affection is  extremely anomalous, and char-
acterized by severe and continuous rigors," or by
slight remittent or intermittent rigors and parox-
ysms of febrile  reaction.
   13. These complications, and more especially
those about to  be noticed, are chiefly to be as-
cribed to the local and constitutional influence of
the virus or infecting agent,  an influence mani-
fested in some cases more prominently than in
others, and not observed in cases of simple ure-
thritis.  Certain of the  above complications are,
however, merely the local extension ofthe gonor-
rhceal inflammation, often owing to the causes
above alluded to.   Other complications or conse-
quences ofthe disease are of a constitutional and
very  serious nature.  Mr. Holmes  Coote, in a
work published while this  was  being written,
corroborates the view I have  taken in the article
Vagina and Vulva (§ 8, etseq.), as to the specific
nature of gonorrhcea.  This very  able and rising
surgeon remarks: "  Is the  disease the conse-
quence of the  application of a simple irritating
fluid to the mucous membrane, or is there a mor-
bid poison acting on  the parts locally, and  capa-
ble of being absorbed into the system \   I  must
confess there appears to me to be a most marked
difference between simple urethritis and true gon-
orrhoea, as we daily see it among those exposed
to contagion."   Gonorrhcea in some cases  occa-
sions peculiar secondary affections, which never
proceed from simple  urethritis;  and not only is
it  occasionally followed by the local complica-
tions just mentioned, but also by one ofthe very
severest forms of inflammation  of the conjunc-
tiva (see art. Eye, Gonorrhaal Inflammation of,
y 56, et seq.), by the most severe and obstinate
form of rheumatism (see art. Rheumatism, gon-
orrhaal (v  44, 163), and  by a form  of papular
eruption.   The occurrence of purulent ophthal-
mia, or of  rheumatism, or the extension  of in-
flammation from  the urinary  bladder along the
ureters to the  kidneys, is of a most serious na-
ture, as respects both the immediate effects and
the more remote consequences.
   14. ii. Treatment.—A. Of Gonorrhaa in the
Female.—A copious use of diluents  and  demul-
cents ; a farinaceous and vegetable diet; avoid- •
ance of fermented and spirituous liquors, and of
salted provisions ;  a recourse to alkaline and re-
frigerant substances in mucilaginous drinks, and
repose on a cool couch or mattress, are generally
sufficient to remove the severer symptoms in a
few days, especially when aided by the following
local treatment judiciously advised by Dr. Dru-
itt : " During the acute stage, rest in the recum-
bent posture, fomentations of decoctions of poppy-
heads with chamomile flowers, frequent ablution,
lubrication with lard or cold cream, and very fre-
quent sponging with a weak solution of alum, a
piece of lint dipped in which  should be inserted
between the labia, with laxatives aud diaphoret-
ics, are the measures until heat,pain, tenderness,
subside ; afterward injections of nitrate of silver,
and sulphate or acetate of zinc should be used, as
recommended  for the other sex, and they should
be continued for some time after all discharge has
ceased." (Druitt's Surgeon's Vade-mecum, &c,
p. 175.)
   15. If the disease becomes obstinate and chron-
ic, the vagina  and cervix uteri should be exam-
ined by the aid of a speculum, as the disease may
be prolonged  by lesions of the cervix or of its
canal; and when this is the case, the means ad-
vised for such lesions, in the article Uterus ($
124, 125),  should be  resorted  to.   In chronic
cases, the solution of sulphate of alumina, or de-
coction of oak-bark, or both conjoined, may be
used as a  lotion.  Copaiba and cubebs may be
given thrice daily in  a mixture with mucilage,
the spirits  of nitric ether, and either mint-water
or camphor julep, in the  chronic, as well as in
the advanced progress of more acute cases.  In
the former, preparations  of iron, especially the
tincture  of the sesquichloride  of  iron, or the
tincture of the ammonio-chloride may be  pre-
ferred.  In irritable and sanguine temperaments,
camphor conjoined with nitrate of potash, with
acacia and  henbane, is often of much service, and
may be prescribed in the form either of pills, of a
mixture or draught.
   16.  B. Treatment of Gonorrhaa  in the Male.
—(a) Dr. Druitt has  advised, as a prophylactic
treatment, that a person exposed to the chances
of infection should wash out the anterior part of
the urethra with a syringeful of some astringent
lotion.  I much doubt the complete  success of
this plan, or of the more usually adopted one of
micturating immediately after sexual connexion:
both plans  may, however, be  often  successful.
If any  fissures or excoriations are perceived they
may be touched with lunar caustic, and dry lint
may be applied.
   17.  (b)  The  abortive  treatment of gonorrhaa,
or an  attempt to cut short the attack by means 
VENEREAL DISEASES—Treatment of Gonorrhcea.              1457
of strong injections, has been advised by some
experienced surgeons.  Ten grains of nitrate of
silver, or  four  grains of the chloride of zinc, to
the ounce of distilled water, have been prescribed
with this object, when  the  disease is only com-
mencing, and before scalding  on micturition is
experienced, or when the acute  symptoms have
passed.  Mr. Acton employs the nitrate of sil-
ver, and has recourse to only one or two injec-
tions performed by himself with due precautions.
He never prescribed this treatment in cases of a
first infection; and he states that he has not ob-
served the injurious effects which have been sup-
posed to result from it.   For the modes of using,
and the precautions to be taken when using, this
treatment, I must  refer the reader to Mr. Acton's
able work.  Mr. Holmes Coote considers it not
quite free from danger to  the urethra ; and he
remarks that it should  be remembered that it is
in cases where the structures of the urethra are
damaged that stricture occurs ;  the usual effects
of gonorrhoea, in their.acutest form, pass away,
if not aggravated, without leaving any structural
change.   " At the commencement of the disease
large doses of the tinctura ferri sesquichloridi, or
of the citrate of iron and quinine, have been pro-
nounced effectual in cutting short the discharge;
and such remedies possess  the advantage of in-
flicting  no damage, if they do not produce the
anticipated amount of good."
   IS.  (c) In the first or early stage of gonorrhaa
the antiphlogistic  diet and regimen should be
strictly enforced ;  and demulcents containing al-
kalies  and  refrigerants  freely allowed, with the
other  means already  noticed  (y 14, et seq.).
Cooling aperients ought to  be taken from time to
time; walking and horse-exercise should be pro-
hibited, and the patient confined to a cool sofa or
mattress.  The penis  and  scrotum should be
supported by a suspensory bandage, and be kept
constantly wet with tepid or cold water.  If the
acute symptoms have not  appeared, M. Ricord
recommends, according  to  Dr.  Druitt, the fol-
lowing plan, in order to arrest the course of the
disease : " Let the patient inject the urethra reg-
ularly  once in every four hours, with a solution
of two grains of nitrate of silver in eight ounces
of  distilled water; let this be  repeated twelve
times, desisting, however, sooner if the discharge
is rendered thin and bloody, which is the  ordi-
nary effect of the  nitrate.   Then let an injection
of  the  sulphate of zinc  be substituted, and be
continued until the discharge  ceases.  At the
same time the patient should take a mild aperient,
and after it, three times daily, a dose of copaiba or
cubebs."   He should continue a strictly antiphlo-
gistic regimen  for a week  or  ten days after all
trace  of the discharge  has disappeared.   The
penis should be wrapped in  a piece of rag dipped
in water.  Dr. Druitt proceeds to remark,  that
the " manner of injecting is of  no  small conse-
quence, as the efficacy of the lotion depends en-
tirely on its application to the  whole of the dis-
eased surface; and, as Dr. Graves observes, the
ordinary opinion that gonorrhcea is limited to the
anterior extremity of the urethra  is unfounded
and mischievous.   The patient should be pro-
vided with a glass syringe,  with a long bulbous
extremity, and having filled it, should  introduce
it for about an inch with his right hand.  Then,
having  encircled  the glans penis with his left
forefinger and thumb, so as to compress the  ure-
thra against the syringe, and prevent any of the
    III.              92
fluid from  escaping, he  should push  down  the
piston with his right forefinger, letting the fluid
pass freely into the urethra.   The syringe should
now be withdrawn, but the orifice should still be
compressed, and the fluid be  retained for two or
three minutes; after  which, on removing  the
finger and thumb, it will be thrown out by the
elasticity of the urethra.   It  is always worth the
surgeon's while to see  that the injection is prop-
erly used."
   19. (c) In the second stage the diet  and regi-
men already advised should be continued.  The
patient  may drink soda-water, barley-water, lin-
seed  tea,  gum-water, and other mucilaginous
fluids, containing alkaline carbonates  and seda-
tives, and the bowels should  be kept freely open.
If much pain or chordee be complained of, the
following pills  may be taken night and morning,
and the mixture occasionally through the day :
  No. 372.  R Camphorse, 3j.; Potassse Nitratis, jjss.;
Extr.  Hyoscyami, y.; Mucilag. Acacia?, q. s.  Misce et
divide in Pilulas, xxxvj.  Capiat duas vel tres pro dosi.
  No. 373.  R Potassse Bicarbon., jjss.; Potassae Nitra-
tis, -jss.; Spirit. Athens Nitrici, jss.; Tinct. Hyoscyami,
3ij.; Mucilag. Acacise, Sjjss.; Syrupi Tolutani, 33s; Mist.
Camphorse ad fviij.  Misce. Sumantur CochL ij. vel iij.
ampla ter in die.
  No. 374  R  Liq. Ammonise  Acetatis, Sj.;  Spiritus
.(Etheris Nitrici, Sss.; Potass®  Nitratis, jjss.; Tinct.
Hyoscyami, jij.; Mucilag. Acacia, 5j.; Syrupi Althaea,
3vj. ;  .Mist.  Camphorse ad fviij.  Misce.  Capiat Cochl.
ij. vel iij. larga 4tia vel (itis horis.

   20. The  last of these  prescriptions will be
found serviceable in the most acute or inflamma-
tory cases, and when the urinary organs become
affected.   In these cases  a  number of  leeches
should be applied to the perinaeum, or above the
pubes, or near the groins.   In this  stage of the
disease injections should not be prescribed.  For
first attacks, and in young,  strong,  plethoric, or
irritable  subjects,  they may be  injurious.   Re-
frigerants, diluents, demulcents, alkalies, and sed-
atives, are then chiefly required.
   21. Dr.  Druitt advises that the bowels should
be opened by a dose of calomel at night, and some
castor-oil in the morning; and that a  grain or
half a grain of calomel, and one eighth of a grain
of tartar emetic, and ten grains of Dover's pow-
der, should be  given  every night while there is
much pain and chordee.   As soon as the patient
is free from fever, he should take copaiba or  cu-
bebs.  The former, in capsules, may  be given
before a  meal, as it  is then not likely to cause
eructations.  Mr.  Acton prescribes  copaiba and
cubebs in the following combinations :
  No. 375.  R Bals. Copaibae, yvj.; Magnesias Calcinat,
jjss. ; Extr. Hyoscyami,  383. ;  Pulv. Camphorse,  ?j. ;
Theriacae, *iij.;  Micae panis, ?jss.  Misce.  Fiat Elec-
tuarium.  Capiat Cochl. j. minimum ter in die.
  No. 376.   R Pulv. Cubebse, Jjss. ; Pals. Copaiba;, 5"ss.;
Extr.  Hyoscyami, jss.; Magnesias Calcin.,  -jss.  Pulv.
Camphorse,  5)ss.; Theriaca?, tj.  Misce.  Fiat Electua-
rium. Capiat Cochl. j. min. ter in die.

   22. Th"e last of these  is altered from Mr.  Ac-
ton's prescription, and the dose of camphor re-
duced one half.   Cubebs, when taken in very
large or frequent doses, generally diminishes the
discharge, and remarkably  relieves  the other
symptoms in a short time ;  but when employed
alone, the disorder often  returns after some time,
especially  if it  be relinquished, or the dose much
diminished.   Cubebs  should therefore  be  con-
joined with copaiba, or other substances, in mu-
cilaginous mixtures;  or the  tincture  of cubebs
may be substituted for the powder, as  in the fol-
lowing draught: 
1458
VENEREAL DISEASES—'
■Treatment of Gonorrhcea.
  No. 377.  R Copaibte, fllxv.; MuMlag. Acacia\ *jss. ;
Pulv. Cubebn', 'j. (vel Tiucturae Cubeba1, 5Jss.); Spirit.
-Etheris Nitrici,  ltlxxv.—Liquoris Potassse,  ITlxv.  Aquae
Mentha; Piperitte, et Mist. Camphorse, aa, 3V.  -Misce.
Fiat llaustus ter in die sumendus.
  23. d.  Several unpleasant complications  occa-
sionally appear in the course of this stage.  Pain-
ful erections and chordee are the most common.
They may be treated with tepid or cold applica-
tion, and by narcotics and refrigerants given in-
ternally.   Antimonials may be  prescribed with
small doses of camphor, nitre, and henbane  or
opium ; and a little extract of belladonna, or lint
wet with the tincture of belladonna, may be ap-
plied over the  course of the urethra at bed-time.
Hamorrhage from the urethra often affords relief.
If, however,  it  becomes  excessive,  it may  be
readily checked by  cold applications, and  by
pressure.   Inflammation of the  mucous  glands,
or in the cellular tissue external to the urethra,
may  be poulticed; and if abscesses  form, they
should be opened  early, or as soon as they ob-
struct the flow of urine.   Swellings of the glands
in the  groin are generally removed by rest, and
seldom require the application of leeches.
  24.  If  Epididymitis,  hernia humoralis,  or
swelled testicle, supervene, Mr. II.  Coote be-
lieves " that the best plan is to strap  the testicle
at once, after the fashion represented in the work
of Mr. Acton.   A layer of collodion over the
strapping is often useful.  The relief thus afford-
ed to the patient is surprising, and the swelling
will  often  subside to  one half  in twenty-four
hours.   The  application of cold, either by cold
lotions or by the careful use of pounded ice and
salt in a bladder, tends to relieve pain, subdue
the inflammation, and reduce the swelling. When
in consequence of pain this treatment cannot  be
carried out, we may fall back upon the practice
of leeching the testicles, and  of administering
emetics.   Nothing reduces inflammation of these
organs more  promptly than this, but  the treat-
ment is severe.  When induration remains after
the acute stage has passed, pressure is more serv-
iceable than frictions, whether of mercury or  of
iodine ; both may, however, be employed."  (H.
Coote, Report, <Src, p. 34.)  Since 1824, for the
cases respecting which I have been consulted, I
have ordered  an  emetic, afterward an aperient,
and the mixture (No. 374)  last prescribed; and,
two  or three  days afterward, full doses of the
iodide of potassium in the above alkaline mix-
ture  (No. 373).   Iodine is rarely of use when
employed externally in this disease.
  25. d.  In the third stage, or  when the acute
symptoms have subsided, the  injections advised
in the  first stage  may be  prescribed.  If these
fail, or if the  discharge returns, injections with
weak solutions of the sulphate or acetate of zinc
or of copper,  or of the bichloride of mercury,
and with the addition of vinum opii, mjiy be em-
ployed.   These solutions should vary  in strength
with the circumstances ofthe case ; but if either
of these  occasion  severe  pain,  their strength
ought to be much reduced.
  26. If the disease becomes chronic,  and passes
into gleet, a long-continued treatment is general-
ly required to remove  it, however judicious the
means may be.  The habits of the patient should
be strictly regular  and  temperate, and pills made
with Venice turpentine, or with  tar, or with co-
paiba and  liquorice powder, may be employed.
About thirty years ago I prescribed magnesia  in
the preparation  of pills with  these substances,
but they became so hard after a short time as to
be often passed  from  the  bowels  undissolved1.
If these fail, camphor,  with sulphate of iron, or
with sulphate of zinc, kino, or catechu, and small
doses of creasote, may be taken in the form of
pills ; or the tincture of the  muriate of iron, with
the tincture of quassia or  of calumba, may be
given in any suitable vehicle.   If micturition be
frequent or painful, or  if the  urine deposits  any
mucus, the preparations  of buchu, pareira,  and
uva ursi, are generally indicated.  In most of
these cases the cold salt-water douche, or local
bath,  sea-bathing, regular and  generous living,
suitable  tonics, and chalybeate mineral waters,
will be of essential service.   If the disease  still
remain obstinate, or if involuntary emissions oc-
cur, blisters to the perinseum, the introduction of
a bougie, or other means which  fall within the
province of the surgeon, may  be employed.
  27. e. The diet, regimen,  and beverages of the
patient during  acute, subacute, and chronic gon-
orrhoea,  should be  strictly enforced.   In   the
acute and subacute stages, constant repose on a
cool sofa or bed, and on a hair mattress; a diet
restricted to vegetable  or  farinaceous food in
very moderate quantity ; the careful avoidance of
active exercise, more  especially of exercise on
horseback,  and  of heating beverages.  The fluids
taken should be cooling and demulcent.   Weak
black tea, barley-water, weak veal soup, efferves-
cing magnesia-water, or  potash or soda-water,
&c, may be allowed.   In the chronic stage, or
state  of gleet, tar-water, spruce-beer, Dantzic
spruce, the  infusion or decoction  of the tops of
the spruce-fir,  camphor-water, with  nitre, &c,
may severally be taken.   They will tend to  pro-
mote  the effects of the medicines prescribed for
this state.
  [ Blennorrhagia.—Acute  inflammation  of  the
urethra from gonorrheal virus  is  usually com-
bated successfully by an  antiphlogistic regimen
and saline  cathartics,  followed, if necessary, by
injections of zinc, lead, or  sifver, as in  the  fol-
lowing formula:  $ Aq. Ros., 3*v.; Sulph. zinc;
Acet. plumb., aa, grs. viij.  The  patient, if  the
disease does not yield, should  take half an ounce
of the following electuary in the course of a day :
# Copaiba,  1 part;  cubebs, 2 parts ; ess. menth.
q. s., ft. electuary.   A bolus  of this, covered with
unleavened  bread, is easily swallowed.   About
four ounces is generally sufficient to effect a cure;
or, the copaiba  may be  given  combined with the
sirup  of Tolu and oil of spearmint, and given in
as large doses  as the stomach will bear.  As a
general rule, the antiphlogistic regimen, baths,
rest, and leeches  to the perinteum, will effect a
cure in the  course of one week ; and it is safer to
trust to these for that space of time, before com-
mencing with  the  indirect  anti-blennorrhagics,
copaiba, or  cubebs.  Injections should never be
resorted to  at  once; ii is safer to trust to  the
above  remedies for a reasonable time; if they
fail, then resort to the  above formula of zinc  and
lead, using  it from two to four times a day.  The
nitrate of silver injection, in  the proportion of one
grain  ofthe salt to six ounces of water, will also
answer a good  purpose.  If chordee supervene.
leeches should  be  applied to the perinaeum,  and
camphor and opium administered in the form of
pill, from two to six grains of the former, with
from  one half to one grain  of the  latter,  two or
three  times  a day.   Cold applications to the gen-
ital organs, with laudanum, also afford great re- 
VENEREAL DISEASES
lief; likewise mercurial ointment to the track of
the urethra.  Strict attention to hygiene is always
necessary.
  Blennorrhaa, or Gleet, is governed by the same
principles of treatment as blennorrhagia or acute
urethritis.   It is generally a very obstinate affec-
tion, and requires a persevering use of remedies.
Injections of sulphate of zinc, acetate of lead,
nitrate of silver, and cold water will be indicated,
but of a greater degree of strength ; alum, tan-
nin, and iodide of iron are also recommended as
injections ; blisters,  also, to the urethra.  The in-
jections should be of moderate strength at first,
and  the strength gradually increased.  Benja-
min Bell advises half an  ounce of sulphate  of
zinc to eight ounces of distilled water, using it
several times a day.  Vidal uses from 15 to 30
grains of alum to two ounces of distilled water.
A bougie, coated with an ointment of nitrate of
silver, one  grain to one drachm of lard, may be
used, or with mercurial ointment, or the  mercu-
rial cerate, or 1 part ungt. hydrarg., and  2 parts
extr. belladonna, or even the naked bougie may
often be used with  advantage.  The bougie, ac-
cording to  Vidal, should be large  and soft, and
introduced  three or four times a day, sometimes
for ten or twelve weeks together, and should not
be discontinued till the cure is complete.   If they
cause  an increase of irritation or  inflammation,
their use is to be discontinued.  Vidal remarks
that a  gleet which has resisted every kind  of
treatment occasionally disappears in an unknown
manner—that there are some cases which resist
every thing, even time, and which, after  having
been  symptomatic of a form of inflammation  of
the urethra, are found at length to be maintained
by strictures, disease of the prostate or bladder,
or are complicated with seminal emissions.  The
treatment then, of course, has to be modified ac-
cording to the complications ofthe case.  Great
caution should be used not to pass the bougie too
deeply into  the urethra, inasmuch as the disease
is usually seated near the  glans,  and confined
exclusively to that part.]
5—History of Syphilis.                 1459

   28*.  As to the long-agitated subject relative to
the early history of syphilis, it is quite unneces-
sary to enter farther than to notice a  few of the
authorities who have supported opposite opinions
regarding it.  Galesius (De Podagra et Morbo
Gallico, 4to, Bon., 1637);  Beckett (Philosoph.
Trans., No. 357, 365); Plenk (Beobachtungen,
o}c, ii.);  Hensler  (Geschichte der Lustseuche,
c\c, b. i., 1783); Klein (De Morb. vener. curat.
in India Orientali, Ham., 1795); Stoll (Protect.,
p. 94; Thierry, Richter (Chirurg. Biblioth., v.
i., p. 163);  and  many others, have  severally con-
tended, but with insufficient evidence,  for the ex-
istence of syphilis from remote antiquity, but in
a sporadic form, before the discovery of America,
and before its  occurrence in an epidemic form at
Naples in 1495.  De Blegney even believed that
it was known to Moses  ; F. Valesius (Ann., iv.,
p. 57), that it caused the baldness and ulcerations
of the  face ascribed by Tacitus  to  Tiberius ;
Lefevre (Hufeland, N. Ann., b. i., p. 309), that
it had existed  800  years before Columbus ;
Schenck (Observat, 1. vi., 217), that it had been
observed as far back as 1270 ; Alcazar (Hatter's
Biblioth. Med. Pract., ii., 197), that it was an an-
cient disease, and that it was epidemic in 1456 ;
Schaufus, that  it was  brought from  India into
Europe by the gipsies; Clavigero (Storia An-
tica, t. iv., 1781), that it was not imported from
America;  and Delius, that  it was an ancient
malady, but was sporadic, and became epidemic
by its complication with camp diseases at the end
ofthe 15th century.
   29.  The first author who contended  that syph-
ilis was a variety of leprosy was M. Cumanus, in
1495.   He considered  it identical  with the lep-
rosy of Campania, described in the 13th century
by Pa pi a of Lombardy.   A similar opinion was
entertained  by S. Aquilanus  in 1497, by Cam-
perio, Lange, Biondi, and Dodon^eus, early in
the 16th century; and was supported by Zacu-
tus  Lusitanus, Maynwaring, and Musitanus
in trie following century.
  30. That the distemper  was  brought from
America by the  followers  of Columbus was as-
serted by  several writers in the commencement
of and  early in  the 16th century,  especially by
N.  Poll,  L. Schjiauss, et U. Ab  Hutten, and
by many others. This  opinion as to its origin
was very  ably supported by  Astruc  and Gir-
tanner (Abh.  von der Lustseuche, Sj-c).   It was,
however,  denied by Sanchez (Abb.  Ueber  der
Ursprung Venussenche, cf-c, Bremen, 1775), who
argued that an indigenous malady could hardly
be brought to Europe  and there  become  epi-
demic; by Sarmicuto (loc. cit, i., p. 67); and
by Hensler (Geschichte der Lustseuche  die zu
Esde dis. 15. Jahrh. in Europa Ausbrach., Altona,
1783).  More recently Desruelles (Op. cit.) has
contended for the  antiquity of the disease, and
denied  the importation of  it from  America.
Desportes  (Hist,  de Malad.  de  St. Dominique,
t. ii., p. 61), Lagrange, Sloane, and  numerous
others, however, have shown that  a disease re-
sembling  syphilis was  prevalent  in Hispaniola
when visited by the Spaniards, and was brought
into Europe by them from 1493 to 1495. Astruc
states  that in the  Neapolitan, or  rather  in the
Spanish army, there were not a few of the sol-
diers  who, returning  from  the Indies, either  in
the first voyage with Columbus, in  the month of
March, 1493, or in the second with A. de Torrez,
in the beginning of 1494, or in the  third with P.
II. Syphilis — Siphilis, Sprengel and H. Mayo.
  Lues venerea, Auct.
  28. i.  History of.—Medical writings furnish
no precise or undoubted accounts of this dis-
temper until the appearance ofthe epidemic to-
wards the close ofthe 15th century in the south,
and soon afterward through all  of Europe.   In
that  and the following century, venereal erup-
tions occurred so commonly after  infection, not
only by sexual congress but also by contact, that
the disease was regarded as a contagious malady
affecting primarily and chiefly the skin.   At the
present  day, and for  a  long time past,  these
eruptions and the  other  affections which some-
times accompany or follow them are much less
frequent, and appear after a longer period from
the primary infection  than they did formerly.
This circumstance, as well as some other modifi-
cations  of the  characters of the distemper,  as
described by the earlier writers, may be referred
to the long transmission of the distemper by
contagion,  the  venereal  poison  having thereby
lost something of its original influence,  and to
its having, during many ages, been  almost exclu-
sively transmitted by the intercourse ofthe sexes,
and without general infection,  or not by  the
emanations or secretions from the  secondary af-
fections,  unless under peculiar  circumstances
hereafter to be noticed  ($ 109, et seq). 
1460                 VENEREAL DISEASES—History of Syphilis.
de Margarit, at the end ofthe same year, were
still infected with the venereal disease, or at least
had contracted it  in  Spain, after it  had been
brought by others into Europe.   And therefore
it is by no means strange that  many of the Nea-
politans should be infected with the same distem-
per, as they served under the same colours, and
conversed with the same females who followed
the camp.  Hence he concludes that the disease
was  communicated from the  Spaniards  to the
Neapolitans, from both to the  French, and from
all three to the other European nations, and to
most of the people of Asia and Africa ; though
he believes that, under the torrid zone, there are
some  countries where it seems to have been a
native  and  an endemial disease. (De Morbis
 Veneris,  vol. ii.,  4to, Paris,  1740, lib.  i.,  cap.
dec.)  Sanchez de Ribeiro, in 1765, contended
that syphilis originated in Europe, and assumed
the epidemic form in 1493.  He was  the first to
shake the belief in the American origin of the
malady, and was  followed by Hensler, who be-
lieved it to have been intimately connected, in
origin and  nature, with the leprosy of antiquity,
which he regarded as the precursor, in Western
Europe,  of syphilis at the end of the 15th cen-
tury.   Richter (Chirurg. Biblioth., b. i., p. 163),
however, contends that syphilis was an ancient
disease, and was imported into America by the
Spaniards.   But there is no sufficient evidence
of such  importation by  the Spaniards, whereas
evidence is furnished by Astruc and others that
a similar distemper was  prevalent in the West
Indies and America  among  the  natives when
first visited by Columbus, and that they treated
it with the same  medicines as were found most
successful  subsequently  by the  Spaniards and
other Europeans.  That this distemper existed
in America,  in  Western Africa,  and probably
also  in  other  intertropical countries, before the
discovery of America, appears to have been con-
clusively shown by numerous writers, although in
more or  less modified forms,  according to race,
modes of life, and numerous circumstances ; and
that it still exists in these forms, as a most preva-
lent and contagious distemper, in these countries,
cannot be doubted.   It was considered as being
not improbable that the milder states of the dis-
ease  prevalent in some of these countries, and in
Hispaniola, when first visited by  the  Spaniards,
assumed in the latter, as well  as in other Euro-
peans, a  much more severe character, especially
when they  became  associated with  scurvy,  or
with leprosy,  then so prevalent  in Europe,  or
with other  epidemic or endemic diseases,  or
when the distemper first infected different races
from those  in which it had first originated, using
different kinds of food, adopting different modes
of living, and observing very different social and
domestic habits, &c.  That the disease is modi-
fied by these causes, by climate and by treatment,
even at  the  present  day, cannot be  disputed ;
and hence, roost probably, it may have resulted
from those distempers, which arc denominated
syphiloid by several writers, which are character-
ized by the most prominent features of constitu-
tional syphilis, and which are different forms of
syphilitic cachexia, arising out of those  circum-
stances, in  connexion with differences of race,
with climate, habits of life, modes of communica-
tion, &c. (v 84, et seq.).
  31. In addition to these opinions as to the his-
tory of syphilis, another had been from an early
period entertained by  several writers, but had
received little attention until it was supported by
D. C.  G.  Gruner, who has inquired into  the
early history of syphilis with great learning and
candour; and has described the symptoms ofthe
disease, as it appeared in Italy in 1493 and 1494,
and the ways by which it was propagated.   From
his account, or rather, according to the authorities
he has adduced, it appears that syphilis was then
a much more acute, rapid, severe, and complicated
distemper than in modern times; and that it was
communicated in its several constitutional forms,
not only by sexual intercourse, but also by kissing,
by sleeping in the same bed, by contact, especially
with parts covered by eruptions, by shaving with
the same razor, by drinking from the  same ves-
sel, by inhaling the breath of the infected, by the
clothes, particularly woollen, of the diseased, and
even by contact of any part  of the body.  The
sudden appearance and rapid extension of  the
malady the medical men ofthe day were at a loss
to account  for.  As to the opinion that diseases
of the  genitals were at all times an occasional or
sporadic result of impure sexual connexion, Gru-
ner remarks, " Hoc quidem certum ac indubita-
tum est, homines nunquam sibi temperasse a ve-
nere vulgivaga, ideoque ab  historicis  stupenda
narrari exempla, quin sub finem seculi xv incre-
brescere vitia genitalium venereis similia, sed ea
fere leprosa.  Usee vero, nisi de verbis  disceptare
volumus, ut ferri quidem et  defendi possunt, ita
etiam corpora fuisse  apta ad recipiendam conla-
gionem affinem satis declarant.  Medici enim et
chirurgi horum temporum bene versati in cogni-
tione morborum cutaneorum, cum maxima? leprse,
tantum non omnes novitatem, morbi mirantur et
stupent, et similitudine quorundam symptomatum
opinantur earn esse lepra?  proximam, vel in earn
tandem transire ; leprosi vero Gallico morbo cor-
reptos cane pejus ac  angue fugiunt et procul
abesse jubent.  Ex hoc, ni omnis fallor, certissime
colligitur, foedum  morbum  non fuisse otnnino
eundem, sed paullo diversum  et a causa quadam
insolente productum.  Quam in venere imfura per
se latuisse vix affirmandum est."   (Op. at., xv.)
  32. Gruner contends that the opinion as  to
the introduction of syphilis in Europe from Amer-
ica cannot be sustained, inasmuch as it cannot
be shown that the distemper was in 1493 endemic
in America in the form in which it existed  in
Italy;  that, if the foul ulcers and buboes observed
in the  latter existed in the former country, they
should have been  manifest  in  those  aborigines
brought to Europe ; and that a malady imported
into Spain  by a few individuals from  America,
could not in the same year have been transmitted
to Italy and there so rapidly spread the devasta-
tion which  it was said to have produced.  He
therefore asserts that the evidences furnished by
Fulgosus,  Sabellicus, Nauclerus, Leo Afri-
canus, and  others respecting the expulsion ofthe
Moors  and  Jews from Spain in 1492, and in the
five preceding years, and  the fearful  distresses
and distempers  consequent upon this  expulsion
are sufficient to account for the appearance and
rapid  dissemination of  syphilis in Italy  and in
other  countries.   These writers state that  the
disease was brought from Africa into Spain, and
that, when  Ferdinand  expelled the Moors and
Jews from Spain, from 1487 to 1492, it assumed
a severe and epidemic  form, owing to  the dis-
tresses  experienced by  these emigrants.  It is
expressly stated by Nauclerus, " In itinere abe- 
VENEREAL DISEASES—History  of  Syphilis.
1461
untium Judaeorum triginta millia pestis absumsit.
Eodem  tempore  etiam  Marrani  (Moors) Roma?
ad  portam Appiam  morati  effecerunt, ut incon-
tinenter pestis  invaserit urbem, mortuique sunt
quam plurimi ex peste  et  contagione dictorum
Marranorum, de  quibus tota urbs impleta est."
Gruner therefore infers from these and other
authorities that the diseases to which the  genitals
were liable, owing either to impure connexion or
to leprosy or other causes, were developed into a
pestiferous  form  by the distresses and other cir-
cumstances  connected  with  the  expulsion and
emigration  ofthe Moors and Jews, that  the dis-
temper  in this  malignant form was disseminated
throughout  Italy—the  French army which  in-
vaded Italy  in  1493,  bringing it  with them on
their return to  France, and  that it spread rapidly
from thence and  from Italy  to other countries.*

  * As it is manifest, in  the present state of our knowl-
edge, that syphilis is caused by a specific poison or con-
tagious agent, originating, as far as we know, in the se-
cretions of the sexual organs, and generally communica-
tiug the disease by sexual intercourse, but sometimes also
by eon act under  different circumstances, and in different
stages ofthe malady, and even to the foetus; that syphilis
will not produce  gonorrhoea, although both diseases are
often associated ; and that gonorrhoea will not give rise
to syphilis, although like syphilis it is generally caused
by sexual intercourse, but capable of being propagated by
contact in other ways; so it follows that conclusions re-
specting the origin of the one disease cannot apply to that
of the other.   For being thus distinct, although sometimes
associated, and generally propagated in the same way, it
is very probable  that these distempers  may have origi-
nated in different epochs and in different circumstances.
Admitting that syphilis was brought into Italy in 1492 by
the Moors and Jews expelled from Sjmin, when  it was de-
veloped into  an epidemic and an  acute distemper either
by  the sufferings and other circumstances of these emi-
grants, or by  its being engrafted on or becoming associa-
ted with some other malady, as leprosy, camp fever, scur-
vy, &c, according to the evidence furnished by Gruner ;
or that syphilis was imported in the following year  into
Europe from  Hispaniola, where it had long existed as a
specific disease, although manifesting various  modifica-
tions in  its  primary and consecutive  phenomena both
there and still more remarkably in Europe, still there ap-
pears to  be no sufficient evidence that gonorrhoea, also a
specific disease, and known now as such, and existing
most frequently  unconnected with syphilis, either  first
appeared in connexion with this latter distemper, or ex-
isted previously to it.  It ia certain, however, that from
an  early period of the certain history of syphilis, or ear-
ly in the 16th  century, gonorrhoea was mentioned as a
frequent complication, or prominent symptom of syphilis.
It is very difficult to determine any thing conclusive as to
the origin of virulent or specific gonorrhoea, as most prob-
ably a puriform discharge was not an uncommon result
of impure connexion, or of sexual intercourse with un-
clean, leprous, or  otherwise diseased females in the early
and middle ages.  The descriptions of disease by most of
the writers of these ages, as well as of those of the 15th
and 10"th centuries,  are so vague as to give rise to grave
doubts as to their precise supplication, and although some
of the accounts given by authors  long  before the period
at which this distemper was developed in Italy seem to
apply to gonorrhoea, yet their accounts are not complete
in some respects, and fail in mentioning the association
of a copious  discharge, and of  certain other contingent
symptoms and consequences of the disease, although, oth-
er symptoms which are certainly characteristic of it are
fully stated.
  i.  The testimonies which have been  adduced as to the
existence of Syphilis in  Europe before the discovery of
America have been  considered as conclusive by ISeoket,
Hensler, Swediacr, 15. Bell, Desritelles, and altogeth-
er insufficient by Astruc and numerous writers  in the
16th  and 17th centuries.  I may  notice the  following
among the former: Guxielmus de Saliceto, in 1270,
states (in 1. i., cap. 42,  De Aposteinate in inguinibui.),
" Usee aegritudo  vocatur bubo  vel  dragoncella inguinis
vel apostema inguinis  *  * * * et aliquando cum accidit
homini in virg.i corruptio propter concubitum cum fceda
muliere,  aut ob aliam causam.  Itaque corruptio multi-
plicatur  et retinetur in  virgj, unde non potest natura
mundincarc virgam aut locum, primo  propter multam
plicaturam partium illarum et propter strictam viam il-
lius loci, unde red it et regurgitat materia ad  locum in-
guinum propter habilitatem loci illius  ad recipiendam
  33.  The question  still  remains unanswered as
to the origination ofthe syphilitic disease brought
 superfluitatem  quamlibet, et propter  affinitatem, quam
 habent hec loca ad virgam."—(Jap. 4S.  "De Pustulis
 albis vel rubris, et de Milio et de Scissuris, et de Corrup-
 tionibus vel hujusrnodi, quee fiunt in virgd vel circa prce-
 putium  propter coitum cum foetidd  muliere, aut cum
 meretrice, aut ab alid causa."
   Lanfranc, of .Milan, in 1209 (in Artis Complete Chi-
 rurg., tract, iii., doct. ii.,  cap. 11), asserts: " Sepc pro-
 venire apostema in inguine propter ulcera virgae et pe-
 dum, propterea quod locus  est descensus humorum  ad
 ilia  loca, et tunc non est  ita timendum, propterea quod
 venire tunc potest sine  multa corporis plenitudine, et
 absque eo quod decursus humorum maxime  ibt fiat"
 In tract, iii., doct. iii., cap. 11, De Ficv, et  Cancro, et Ul-
 cere in virga virili, he adds: " 1'icus est qusedam excres-
 centia, quae nascitur supra prseputium virgae, et aliquan-
 do super caput, qua? quidem aliquando est mollis, ut de
 phlegmatica generata materia; aliquando dura ut de Mel-
 ancholic^ ;  qua? si  corrumpatur, transit  in  cancrum.
 Cancer fit in virga, sicut in aliis diximus fieri membris:
 ulcera veniunt ex pustulis calidis virga? supervenientibus,
 qua? postea crepantur; vel ex acutis humoribus locum
 ulcerantibus; vel ex commissione cum fceda muliere, qua?
 cum aegro talem habente morbum de novo coierat."
   Bernard Gordon, in 1300, l'rofessor of Medicine at
 Montpelier, remarks (Lib. Med., part vii., cap. 5, De Pas-
 sionibus Virgce): Passiones virgae sunt multae, sicut sunt
 apostemata, ulcerationes,  cancri, inflatio, dolor, pruritus.
 Causa? sunt exteriores aut interiores.   Exteriores,_ sicut
 casus, percussio, et jacere cum muliere, cujus matrix  est
 immunda, plena sanie, aut virulentia, aut ventositate et
 similibus corruptis.  Si autem  causa fuerit  intrinseca,
 tunc sunt sicut humores corrupti, et mali descendentes ad
 virgam, et ad partes inferiores, inducentes pra?dictas pas-
 siones."
   John  of Gaddesden, in  1310  (Rosa Anglica, cap. de
 curd ulcerum virgce), states: " I'lcera virga? virilis con-
 tingunt  vel ex  coitu cum juvencul.i, vel  ex  coitu cum
 menstruate, vel ex retentione urina? et spermatis."
   Guido i>e Cacliaco, of Montpelier, in 1360 (Chirurg.
 Mag., tr. vi., doct. ii., cap.  7), has a chapter, "de Calefac-
 tione et Foetiditate in virg.i propter decubitum cum mu-
 liere ftetida."
   Vale8cus he Taranta, Professor of Montpelier in 1400
 (Phil., 1. vi., cap. C, De Ulceribus et Pustulis virga),  de-
 scribes these as follows : " Causa? possunt esse primitivae,
 aut  antecedentes, aut conjuncta?.   Primitive, ut est vul-
 nus, vel attritio, vel coitus cum fcetidj, vel immundii,  vel
 cancrosa muliere; alia causa potest esse portasse femora-
 lia nigra, foetida et immunda; alia causa potest esse ma-
 teria spermatica vel corrupts retenta inter caput virga? et
 prseputium, vel mali humores ibidem retenti, qui ibi re-
 tenti et  non evacuati corrumpunt locum, quern tangunt,
 vel  ulcerant."   And again towards the end : " Pustule
 virgse fiunt, si quis coeat cum fceminii habente ulcus in
 matrice, qua? contagio sitate sua  inficit virgam, et in ea
 facit ulcus."
   Petrus de Argelata, of Bologna, in 1470 (Chirurg., 1.
 ii., tr. xxx., cap. 3.  De Pustulis, qua  adveniunt virga
 propter conversationem cum f add muliere, qua alba sunt
 vel rubrev) writes :  " Ex materia venenosfi, que retinetur
 inter pra?putium et pellem virge causantur istae pustule
 tales per lmnc modum, quoniam ex retentione illius ma-
 terie, qua? remanet inter pellem et preputium, ex actione
 viri cum fced:i muliere, que non respirat putrefit; deinde
 ille locus denigratur et mortificatur substantia virge, que
 restaurationem non recipit, nisi corruptione illii  remota,
j et loco absterso."   And then after prescribing certain  de-
 tergent, styptic lotions, &c, for the cure of those pustules,
 he thus  goes on : " Ununi recordor vobis, quod antequam
 ista balnea dicta (or lotions) ex vino illo styptico fiant, fiat
 purgatio, aliter illis bubo superveniret in  inguine, quo-
 niam materia que venit  ad locum ilium retropellitur  a
 balneo isto (or rather lotion) et inveniens concavitatem
 inguinis illic moram facit; quare bubo generatur ad exi-
 turam pluries  deveniet.   Quare  purgationem universa-
 lem facias; et imperiti medici sperantes  indiscrete  vel
 incautehi non  faciunt purgationem, quare duplici modo
 lucrantur, quoniam de virg.i et bubone.  Iterum viri tales
 debentes materiam venientem ad  loeum resolvere, qua?-
 runt illud saniare ut aliquid lucrentur, et hoc non debet
 fieri a discreto homine et magistro."
   That  the above brief notices of ulcers on the penis and
 buboes in the groins refer to syphilis can hardly be cred-
 ited, unless consecutive  constitutional disease had also
 been described; but of  this latter no  evidence is fur-
 nished.  However, It may be stated by the abettors of the
 non-mercurial  t-eatment  that these eores were actually
 venereal or syphilitic, no secondary symptoms appearing,
 owing to the strictly local  or non-mercurial  treatment
 adopted for their cure.  Among the first writers who  de- 
1462                   VENEREAL DISEASES—History of Syphilis.
by the Moors and Jews from Spain into Italy.  It
has been, as stated above (v 30-32), acknowledged
scribed the venereal disease, which appeared at Naples in
1494 or 5, and became epidemic over Italy, and rapidly
spread throughout Europe, were  Maroellcs  Ci.masub,
KlOOLAUB LEONICENUS, and CORADINUS GrELINVS.   Their
works  on this disease appeared in 1496 and 1407, and
were followed by other productions in this latter year, in
14HS and in 1500, and in almost every successive year
down to  the middle of the 16th  century.   The writers
were chiefly Italians, who describe  the symptoms and
treatment of the disease, assert it to have been an un-
known malady previously to 1495, and speculate various-
ly respecting its prevalence and rapid extension.
  From these descriptions it is manifest that the distem-
per was virulently contagious ; that it was communicated
not only  by sexual intercouse, ulcers appearing  on  the
genitals, and followed rapidly by the most severe  consti-
tutional symptoms, &c, but  also  by  contact of any part
of the body of those infected,  and by fomites, &c.  Those
who are desirous of becoming acquainted with the early
history of this distemper—the most important chronic
malady which infects the human frame—will consult with
advantage the collection of early treatises on Lues Vene-
rea, formed by Aloysius Luisinus, under the  title Aph-
rodisiacus sive de Lue venerea, continens omnia qua-
cumque de hac re sunt ab omnibus Medicis conscripta, 2
vols, in fol., Lugd. Bat., 1728. The dates of the first  ap-
pearance  of these treatises are, however, not always given
fey Luisinus.   A Supplement to this  work has been add-
ed in historical order by C G. Gruneb, entitled Aphro-
disiacus sive de Lue venerea: ejus vestigia in Vcterum
Auctorum monimentis,  et  epios  A.  Luisinus  Omisit
Scriptores, fol., Jene, 1789;  and the following work, by
the same author, will be perused with some  interest: De
Morbo  Gallico Scriptores Medici et Historici, partim  in-
editi; accedunt Morbi Gallici Origines Maranica, Colle-
git, edidit, glossario et lndice Auxit.  8vo, Jene, 1793.
.Daniel Turner published an  abridgment  of the folio
volumes  of A. Luisinus, under the following title:  A
Summary ofthe Ancient Writers on the Venereal Disease,
extracted from, his two Tomes, revised by Boeehaave, with
Index of  those omitted.  Svo,  Lond., 1730.
  ii.  As the Identity of syphilis and gonorrhaa, formerly
contended for by some and denied  by others, is now satis-
factorily disproved, although in the present day most com-
monly  resulting from impure sexual intercourse, it fol-
lows that the evidence furnished respecting the period in
which syphilis first appeared in Europe cannot be viewed
us comprising  also the time  when gonorrhoea made its
first  appearance—or that the proofs  as to the historical
origination of the one could be extended to, or  be consid-
ered as conclusive of, the same origination of the other,
either aa  to time or to place.  In the earlier histories,
however,  of cases of syphilis,  gonorrhcea was often men-
tioned as  a prominent symptom.
  In the Statutes which Jane I., Queen of both the Sici-
lies, directed to be formed for the regulation of the public
stews, established at Avignon  in 1347, it is enacted (Stat.
iv.) as follows : " The Queen commands that, on  every
Saturday, the women in the house be singly examined by
the abbess and a surgeon appointed by the directors, and
if any of  them  has contracted any illness by their whor-
ing, that they be separated from the rest, and not suffered
to prostitute themselves, lest the youth who converse
should catch their distempers."  This statute may be
viewed as applicable  to  either venereal  disease,  or  to
neither; for it has been contended  that sexual intercourse
with a female  during the catamenia, or suffering under
Ieucorrhoea, with a leprous female, during the  Middle
Ages, or even in more recent times, when personal clean-
liness was not so much attended to as now, would produce
a sexual disease capable of propagation.  That the mala-
dy which the above statute was intended to  abate might
have been gonorrhceal is not improbable, although no suf-
ficient proof of its existence appears.
  Mr. Bbcket (Philosuph. Trans.,  No. 357, ann. 1715) has
endeavoured to prove  that  a venereal gonorrhcea was
known in England some ages before  1494, under the
names of Ardor, Arsura, Incendium, &e., and in English
of Brenning, or burning, and described as an inward heat
and excoriation of the urethra.  This affection is treated
of by John-of Gaddespen in hia Pract. Med. seu Rosa
Anglica, in a chapter,  " De Infectione ex Concubita cum
leproso vel leprosa;"  and he there states:  " Ilium, qui
concubuit cum muliere, cum qui coivit leprosus, puntu-
ras intra carnem et corium, hoe est inter balanum et pre-
putium, et aliquando calefactiones in toto corpore sen-
tire."  That this scalding might or might not arise from
the cause here stated is equally probable, but it cannot be
viewed as a proof of the existence of gonorrhoea, inasmuch
as no mention is made of its coexistence with a copious
muco-purulent discuajge.  That the time and the circum-
by many who have visited the West Indies and
inter-tropical  America, that a syphilitic disease
has prevailed  from time immemorial in these isl-
ands  and countries;  and writers  soon  after the
discovery of America mentioned the communica-
tion of it to the Spaniards, who carried it back
with  them  to  Europe.  Gruner states that  at
first he was inclined to believe this  to have been
the source  from which it  had  been introduced
into Europe ;  but, upon farther investigating the
history of the  distemper, he was induced to relin-
quish  this  opinion  in favour of the one he has
espoused ;  but as to  the question now  at  issue,
he does  not furnish  a satisfactory  reply farther
than that it was said  by a' few writers that the
malady  had  long  previously  been  introduced
among  the  Spanish  Moors  from  Africa,  or
brought  from Africa by them.  Now there can
be no  doubt that a syphilitic malady very similar
to, or  a slight modification only of the syphilis
of modern  times, was  an endemic or indigenous
disease  in Africa long before the expulsion  of
the Moors  from Spain, and most  probably for
many  ages previously; and  it is very  probable
that the disease  existing among both Moors and
Jews,  even to a slight extent, may have  been de-
veloped into a most prevalent, pestilential, or epi-
demic condition  by the circumstances connected
with the emigration, and with the military inva-
sion alluded to (y 32).  I may refer  the reader to
what will be  stated hereafter (y 84, et  scq.) re-
specting the  diseases very  closely  related  to
syphilis, or syphiloid  affections.   There  can  be
no doubt of these diseases having prevailed both
in Africa and America long before  the  close  of
the fifteenth century ;  and admitting that  they
had been introduced into Europe  by  the follow-
ers of Columbus, they most  probably had been
brought into Spain  by the Moors and Jews from
Africa long before the discovery  of America;
and, existing  among  them, had  been conveyed
into Italy on their expulsion from Spain, shortly
before the French invasion.*
stances of the origination of gonorrhcea are not without
some interest, will appear from the fact of this complaint
lieing viewed by many recent writers as in no respect dif-
ferent from leucorrhcea, or blennorrhagia, according to
modern nomenclature.  In Africa, as I was able to learn
from Moorish and other native physicians, gonorrhcea was
viewed as a distinct disease, although often complicated
with the  yaws or syphilitic affections and with leprosy,
and was viewed with syphilis, as possessing an antiquity
as great as that of leprosy (see  5 84, S5).
  Whether gonorrhcea made its  first appearance in Eu-
rope at the close of the 15th  century, or previously to
this period, admits not now of satisfactory proof; nor even
do we now know at what time it was first viewed as a va-
riety of the venereal disease, or at least intimately con-
nected with syphilis.  Astruc  remarks that all the phy-
sicians who lived in the close  of the 15th  and beginning
of the 16th centuries were unanimous in  their opinion
that the venereal disease was a new distemper; but they
entertained very different notions as to its origin.
  The earliest writers believed  the malady to have arisen
from the influence of the stars,  or certain conjunctions of
the planets ; others that it proceeded from the ^tate ofthe
seasons in connexion with fortuitous circumstances ; some
that it was an  offshoot of leprosy, or that  it  arose from
the connexion  of healthy with leprous persons; a few
that it was the result of unnatural or unclean sexual in-
tercourse, or of bestiality;  and  many that it was indigen-
ous or endemic among the natives of Africa and America;
but it does not  appear to what  they attributed the origin
of the disetist'  in these  countries.  (See the Cluster on
syphiloid  diseases, or affections closely allied to xyplnlis).
  [* It has long been the  practice, especially with Euro-
pean writers,  to  attribute the  origin of syphilis to the
American continent, and  that, too, in opposition to all
well-attested facts connected with its  true history.  The
first writers in  Europe who described the disease'say not
a word in regard to its transatlantic origin, but attribute 
VENEREAL  DISEASES—History op  Syphilis.                    1463
  34. But admitting that syphilitic diseases (y 32)
actually prevailed both in America  and in Africa
it either to a celestial influx, a malignant conjunction
of Saturn and Mars in the sign Scorpio, Divine venge-
ance, an earthquake, or a malignity of the air caused by
an overflow of tlie Tiber, &c.  Lord Bacon, following Fi-
obavanti, believed it to have been generated  by the use
of human flesh as food at the siege of Naples.   The first
writer who suggested its American  origin was  Leoniia.ri>
Soiim auss, a German physician who wrote in 1518, twen-
ty-five years after the disease first appeared in  Italy; and
he was followed by CLiuen van Hulten, Oviedo, and
others on the same side, so that in the space of fifty years
the American origin of syphilis was received very gener-
ally as a well-established fact in history.  They unite in
the statement that the disease wa3  imported into Europe
by the crews of Columbus on his  first or second return
home, in 1493 and 1496, "a belief," says Dr.  Good, who
seems to have investigated this point with great industry
and impartiality, " which seems to be altogether with-
out foundation ; for, at the period even of the first return
of this,  celebrated cincumnavigator,  in March, 1493, it
seems to have preceded his return by some weeks' time.
On his reaching Seville in the ensuing month of April, in
order to join the Spanish army, it had already  arisen, and
was spread over Auvergne, Lombardy, and various parts
of Italy; as in  the course of the summer months  it was
observed  in  Saxony,  Brandenburg,  Brunswick,  Meck-
lenburg, and especially Strasburg, as all  the German
writers concur in admitting ; and even at Cracow,  in Po-
la-ul, according to Strykowsky's  ' Chronicle of Lithua-
nia.'  While 1- bacastorio, who was an eye-witness ofthe
entire progress  of the disease, and  from his high medical
reputation, and residence almost on the spot of its first
appearance, more largely engaged  in the cure of it than
any physician of his day, asserts that it was even  ravag-
ing a considerable part of Asia and Africa, as well as of
Europe."  Not only this writer expresses his disbelief in
the disease  having been  imported from America  by the
crews of Columbus, but not a single writer who was an
eye-witness of the first outbreak of syphilis ascribed to it
an American origin ;  nor did Columbus, nor his brother,
who left such accurate narratives of his voyage, make
the least mention of such a disease having been discov-
ered among the natives, or prevailing among the crews of
their vessels.  Moreover, we have  the testimony of Ful-
gori that it prevailed in Upper Italy in  the  year l-l'ii ;
Of SABELLICO, INPE88URA, Delphint, and  Fulgoei that
it prevailed in Upper Italy in 1493;  and of Massa, Ca-
taneo, Pinetor, Bueouardi, and Capueoli, that syphilis
prevailed extensively at Home and  in  Italy in 1404.   Now
Christopher Columbus, on his first return  to Europe,
landed on the 4th of March, 1493.  The statement, there-
fore, of Oviedo, that this disease was carried  to Italy by
the army of Gonzalvo must fall to the ground, inasmuch
as this general arrived at Calabria  as  late as the month of
May, 1495.  Oviedo has always been the great authority
on this  point, but he was  charged and convicted  of the
grossest falsehoods, contradictions, and inaccuracies, by
his cotemporaries Feedinando Columbus, A. Herrera,
De la Casa, and others.  There is, indeed, not a shadow
of evidence that syphilis existed in America till the third
voyage of Columbus, in 1498, when it was probably  car-
riod to St. Domingo by his crews,  and five years after it
had prevailed extensively in Europe.   If any  thing more
be wanting  to  confirm the belief  that syphilis did not
even exist in the West Indies and on the continent of
America at  the period of their discovery by the  Span-
iards, it may he found in the following letter, from our
distinguished countryman, William H.  Pbescott, the
historian, to Dr. A. E. Hosack.
                           " Boston, Jan. 221,1814.
  " My dear Sir,—I have received your note of the last
week, inquiring whether in my researches relative to the
history of Mexico, I had met with any trace of the exist-
ence of  the venereal disease among  the aborigines pre-
vious to the coming of the Spaniards. * * * In a note in
the ' History of Ferdinand and Isabella,' vol. ii., p. 501,1
took occasion to express my own conviction that the ve-
nereal disease did not exist among the natives  of America
at the time of its discovery.   I had met with no allusion
to it in the narratives of Columbus  or his son Ferdinand,
or in any other record ofthe Spanish adventures.  I have
been led into a much wider range  of observation in pre-
paring the ' History of the Conquest of Mexico,'  but it
has served to confirm  my former  opinion, since I have
never met with  a notice of this disease, or of  any  which
resembles it.  The ancient chronicles speak of an Indian
epidemic, called the Matlazahuatl,  which swept off great
numbers of the nations both before and after the conques t,
and which seems to have had some  resemblance to  the
Yellow Fever.   They also notice the  introduction of the
■mall-pox  by a  black, who came  into the  country  the
for ages before  the discovery of Columbus,  it
does  not follow  that the  disease brought by his
followers from America was the cause of the epi-
demic syphilis of Italy and  other countries in
1493, 4, and 5.   Indeed this  inference  is  com-
pletely disproved by facts ; for, as Sprengel has
contended, syphilis, according to  the testimony
of most  reputable  authors, had  appeared  early
in 1493, and soon afterward extended to  most of
Europe, while, according  to  Oviedo, the  most
credible of all witnesses on the subject, the fleet
of Gonsalvo, wliich conveyed the Spanish sol-
diers to Italy, arrived in Messina on  the  26th of
May, 1495.   Thus the disease was existing two
years before  the arrival of the  Spaniards, and
spreading in the  army of Charles VIII. of France.
That the disease existed in Barcelona in 1494 or
5, appears  in a letter published by Thiene, from
Nicholaus Scyllatius, a physician  of Messina,
the editor  of an  edition of the " Rosa Angltca,"
in 1492, and  addressed to Ambrosius Roxatus,
physician to the Duke of Milan.   From  this let-
ter it appears that Scyllatius was in Barcelona
in 1494, that the distemper was spreading among
all ranks, and was  propagated by contact  only,
and that it was  universally believed to have pro-
ceeded from Provence, where  it  was named the
disease  of St. Ment.  Scyllatius thought it the
sahafathi of Avicenna ; but while he describes
its general characters,  he says  nothing, as may
year after the arrival of Cortez.  The  Spaniards would
certainly not have omitted to notice so terrible a disorder
as the venereal, had it been found among the natives;
especially as, considering their own licentious indulgence,
it must have fallen very heavily on themselves.   Their
uniform silence, therefore, is evidence so strong, that it
may be called positive rather than negative, and may be
considered as establishing  the fact that the disease was
not known in the Mexican  empire at the time of its dis-
covery.   Whether a disease so easily propagated among
adjacent  tribes, and which seems to be  circumscribed by
no parallel of latitude, could have existed in other parts
of the continent without finding its way into Mexico, is a
question  which your own knowledge of the subject will
enable you to determine better than I can.
                                " W. II. Trescott.
  " A. G. Hosack, Esq."
  The following extract from " Ferdinand and Isabella"
gives the paragraphs referred to above by Mr. Prescott :
  " While the colonial commerce failed to produce imme-
diately the splendid returns which were expected, it was
generally believed to have introduced a physical evil into
Europe, which, in  the language  of an  eminent  writer,
• more than counterbalanced all the benefits that resulted
from  the discovery of the New World.'  I allude to the
loathsome disease which Heaven has sent as the severest
scourge of licentious  intercourse between the sexes, and
which broke out with all the virulence of an epidemic in
almost every quarter of Europe, in a very short time after
the discovery of America.   Trie  coincidence of the two
events led to  the popular belief of their connexion with
each other, though it derived little support from any oth-
er circumstances.   The expedition of Charles the  Eighth
against Naples, which brought the Spaniards, soon after,
in immediate contact with  the various nations of Chris-
tendom, suggested a plausible medium for the rapid com-
munication ofthe disorder; and this theory of its origin
and transmission, gaining credit with time, which made it
more difficult to be refuted, has passed with little exam-
ination from the mouth of one historian to another to the
present day.
  " The extremely  brief interval which elapsed between
the return of Columbus and the simultaneous appearance
of the disorder at the most  distant parts of Europe, long
since suggested a reasonable distrust of the correctness of
the hypothesis; and an American, naturally desirous of
relieving his own country from so melancholy a reproach,
may feel  satisfaction  that the more searching and judi-
cious criticism of our own day has at length established
beyond a  doubt that the disease, far from originating in
the  New World, was never known there till  introduced
by Europeans."—(The X. Y. Journ. of MA. and the Col-
lateral Sciences.  Edited by S. Forest, M.D., vol. ii., New
York, 1844, p. 150.)] 
scription of Primary Syphilis.
1464           VENEREAL DISEASES—Dej

be expected from  the date  of his  letter, of an
American origin.
  34*. It is difficult if not impossible to determine
accurately either the place or the date of the first
appearance of syphilis  in Europe.   So rapidly
did it manifest itself in  one  place after another,
that it is impossible to determine  the place in
which it was first recognised.   Fulgosus  states
that it appeared in Italy as  early as 1492;  Pe-
TRONIUS,  C. ToRELLA,  HaSCHARD,  UlRICH DE
Hutten,  and Borgarutius, in 1493; John de
Vigo, Massa, Cateneus, Hock, Schmauss, Fal-
lopius, and many others, in  1494; Brasavolus,
in 1495  ;  Phrisius, Montesaurus,  Mainard,
Benivenius, and Montanus, in 1496 ; and Fra-
castorius as early as 1490.  It should not be
overlooked that these and other authors evidently
assigned  these dates as the  times when the dis-
ease  became known to them, or in the  places
where  they wrote, or they took the dates from
the testimony of others.   Wherever or whenev-
er it first appeared, it cannot be disputed that  it
was  speedily evinced in the chief cities of Eu-
rope.   That it was seen as early as 1490, accord-
ing to Fracastorius, or 1492, as  stated  by Ful-
gosus, may be inferred from the circumstance
of its having been mentioned in the Mansfield
Chronicle, in the Leising  Chronicle, the Leipsic
Annals, and the Zweifalt Annals, as being gen-
eral in Germany in the summer of 1493 ; " and
it  is even said to have prevailed  at least  four
years in  Misnia.   It was  common  in Auvergne
in 1493.   It was known in Paris in 1494,  and in
Augsburg in 1495."  It appeared  in Memmin-
gen, at Niirnberg, and in Edinburgh, in 1496; and
it spread  through Bohemia in 1499.   It has been
considered remarkable  that  the  Chronicles of
Barcelona, Valencia, Murcia,  Toledo,  Seville,
Burgos,  Guadalaxara,  Valladolid, Segovia,  and
other cities in Spain, have made no mention of
the period at which the disease first appeared,
and the same is true of the  cotemporaneous an-
nals of Portugal.   The opinion which I have ex-
pressed (§ 112), that this  distemper is identical
with the African   Yaws, which is indigenous
among the  negro  races,  that  it spread to the
Moors  and Jews in Northern  Africa, and  was
thence conveyed by them  into Spain and Portu-
gal ages  before it  spread into France and Italy,
and there became  epidemic, will account for the
first appearance of the distemper in the cities of
the Iberian peninsula not having been mentioned,
inasmuch as it had become  there a well-known
malady for ages before the end of the 15th cen-
tury.
  35. ii.  Description  of Primary Syphilitic
Ulcers.—These, usually  termed chancres, are
caused by the application  of the syphilitic virus,
to any part—mucous or cutaneous;  to the for-
mer when entire or otherwise,  to the latter also
when entire, but much more readily when wound-
ed or abraded.  Their common seat is the geni-
tals ; in men, most  frequently on the inner surface
of the prepuce, or between the prepuce and coro-
na glandis, and especially in the angle by the
side  of the fraenum.  " The time at which vene-
real sores appear is said to be from the third to
the tenth day after  infection; but it is more proba-
ble, as Ricord observes, that the syphilitic virus
operates  progressively from  the first moment of
its application, but that the ulcer is fully formed
by the fifth day, although it may not be perceived
till later."  (Druitt.)  The  average duration of a
syphilitic  ulcer produced by inoculation is, ac-
cording to Wallace, twenty-five days.
  36. Primary syphilitic ulcers present several
varieties,  which  have  been arranged by  Mr.
Henry  Lee  under the following heads :  1st.
The  indurated or Hunterian chancre—a slow,
torpid  ulcer,  encircled by  adhesive  inflamma-
tion ; 2d. The non-indurated, or pustulous, ulcer,
marked by early and free suppuration; 3d. The
phagedenic or ulcerative ; and, 4th. The slough-
ing ; 5th. To  these I may add, Urethral chancre.
  37. 1st. The indurated or Hunterian chancre
" is generally found on the common integument,
or on the glans penis.   It may  begin  either as a
pimple, or as a patch  of excoriation which heals
up, leaving the centre ulcerous."  When this ul-
cer is  produced by inoculation, in order to  ob-
serve accurately its progress, M. Ricord states,
" that the  puncture reddens during the first twen-
ty-four hours ; that in  the second and third days
it swells  slightly, and becomes  a pimple, sur-
rounded by a red areola; from the third to the
fourth day the cuticle is raised into a vesicle by
a turbid fluid, with a  black spot on its summit
caused by the dried blood of the puncture; from
the fourth to the fifth  day  the morbid fluid in-
creases, and becomes purulent, the vesicle becom-
ing  a  pustule with a depressed summit.  The
areola, which had increased, now begins to fade;
but the subjacent tissue becomes infiltrated  and
hardened with lymph."  After the sixth day, " if
the cuticle and the dried pus which adheres to  it
be removed, there is found an ulcer, resting on
a hardened base;  its depth equal to the whole
thickness  of the true  skin, its edges seeming as
if cleanly  cut out by  a punch—its surface cov-
ered with  a  grayish pultaceous  matter, and its
margin hard, elevated, and of a  reddish-brown or
violet colour.   The ulcer feels to the finger like a
little cup of cartilage set in the  flesh."
  38.  2d. The  suppurating  or  non-indurated
chancre has been divided into four stages.  It  is
first a small  itching pimple or pustule, and  dis-
plays when it bursts, secondly, a foul yellowish or
tawny sore, with slight swelling and redness, and
spreading circularly ;  it may or may not be cov-
ered at first  with a dirty brown scab.  " In the
third stage it throws out indolent fungous gran-
ulations (and in this stage is sometimes called the
raised ulcer ofthe prepuce), and is usually station-
ary for a little time, after it has ceased to ulcerate
and before it begins to heal.  In the fourth stage
it slowly heals; cicatrization being preceded by
a narrow  vascular  line.  If the ulcer be seated
near the framum, it is sure to perforate it."
  39. 3dly. Phagedanic chancres are very pain-
ful and rapid in their progress.   Their surface is
yellow, and dotted with red  streaks ; their shape
irregular,  their edges  undermined  or irregular,
and  the discharge from them profuse,  thin, and
sanious.   The surrounding margin  usually ap-
pears puffy or cedematous, generally  presenting
a low grade of vitality, but sometimes it is firm,
and vividly red.  These ulcers occasionally eat
deeply into the substance of the penis, or under-
mine the  skin extensively; but  they generally
spread much  more widely than deeply, and hence
they have  been called serpiginous.   Sometimes
these sores are more irritable than phagedenic,
being acutely painful,  discharging a  thin ichor,
having a  raised surface of yellowish  exudation,
but not spreading much although obstinately re-
fusing to heal. 
VENEREAL DISEASES—De
   40.  4th.  Sloughing chancres  are  most  fre-
quently  observed  in  the prepuce  and integu-
ments.   Other chancres, however, presenting the
simple  states  of inflammation  observed in the
second variety, may be changed into a gangren-
ous or sloughing state by local irritation, excess-
ive horse-exercise, by excessive debauchery, in-
toxication,  or  whatever depresses  or  exhausts
vital force.
   41.  5th.  Urethral Chancre.—The  secondary
syphilitic symptoms which were formerly attrib-
uted to gonorrhcea have been satisfactorily proved
by Ricord, but  very  long believed to proceed
from a chancre in the urethra, and the distinct
natures  ofthe two venereal diseases thereby de-
termined.   The existence of chancre in the ure-
thra may be inferred, if, with many ofthe symp-
toms of gonorrhcea, the discharge varies much,
sometimes being thin, scanty, and bloody, some-
times  thick and profuse; and  if there be one
painful and indurated spot, not far from the open-
ing ofthe urethra. But the existence of urethral
chancre can be certainly proved only by the ulcer
being visible at the orifice, or by inoculation with
the matter.
   42.  Syphilitic ulcers in the female may
assume the several states described above.  They
do not commonly cause  so  much distress  as in
the male, although there are many exceptions to
this rule ;  but they are always  slow in healing,
especially when the urine passes over or comes
in contact with  them.   When  they are seated
high in  the vagina, the symptoms  produced  by
them are very equivocal, the discharge not ma-
terially differing from  that  attending  other le-
sions ;  an examination by the  finger or by the
speculum being requisite.
   43. iii. The Diagnosis of primary Syphilis.
—Various affections, described under their ap-
priate  heads,  may be  mistaken for chancre.
These are,  1st. Gonorrhaa externa, or balanitis,
consisting of inflammation of the glans and in-
side of the prepuce, with profuse purulent dis-
charge  and excoriation  of the  cuticle.  It may
proceed  from gonorrhceal infection, or from neg-
lect of cleanliness, and the acrid  secretions of the
part, or the unhealthy secretions of the female,
especially in a person with a long prepuce; 2d.
Minute aphthous-looking points  surrounding the
glans;  3d.  Herpes praputialis;  4th.  Psoriasis
praputh; 5th. Chronic eczema,  which, however,
rarely affects the genitals, unless it be  present in
other parts ; 6th.  Simple excoriations, from fric-
tion or other non-specific causes.
   44.  It must, however, be admitted that the
characters«of primary syphilitic affections are not
sufficient to enable us to distinguish them with
certainty  from the above or similar  affections
arising from ordinary causes ; and that the sev-
eral varieties of primary syphilis  now described
afford us no sure ground for practical distinctions
between  each other.  The only  circumstance in
which  all writers, from Astruc to  the present
day, agree, is that ulcers of an obstinate nature,
attended or followed  by induration,  are  those
most likely  to be followed by constitutional dis-
ease.   That the indurated chancre alone is char-
acteristic of genuine syphilis, according to Hun-
ter, Car michael, and Evans, cannot now be cred-
ited, and would confine  syphilis  within very nar-
row primary limits; for the  genuine Hunterian
chancre  is now extremely rare.  Nevertheless,
Mr. Henry  Lee and Dr. Druitt, although they
cription of  Primary Syphilis.            1465

 divide primary syphilitic ulcers into four varieties
 (v 36), state that it seems almost certain that it is
 only after the Hunterian  variety that constitu-
 tional symptoms  are  to be dreaded, or preventive
 treatment  required;  and that  sores of the sup-
 purative, ulcerative, and sloughing varieties, and
 those attended by suppurating bubo, do not, as a
 general rule, affect the constitution.
   45. On  this fundamental subject, Dr. Colles,
 a most  experienced and  enlightened surgeon,
 makes the following  remarks :  " Although every
 surgeon must admit that  Mr.  Hunter's descrip-
 tion of a chancre is correct, and drawn from na-
 ture, still I believe few will confine this term, or
 that of primary venereal sore, to those ulcers only
 which answer to this description.   As the result
 of long, attentive, and anxious  observation, I
 should say that primary venereal ulcers present
 an almost  endless variety of character. 1 would
 define a primary venereal  ulcer to be  one which
 is remarkably slow in yielding to  ordinary, mild,
 local treatment;  but  which is curable by  mercu-
 ry, and which, if not  so  cured, is likely to be fol-
 lowed, in  two or three months, by  secondary
 symptoms, which again are also curable by mer-
 cury.  If,  then, there be, as I affirm there is,  an
 almost endless variety in  chancres, how can we
 decide on  the nature of primary ulcers, so  as to
 pronounce some to be syphilitic, and others  to be
 mere common sores, or  simple excoriations !   I
 reply, that we are to be guided in our decision
 by observing, first, that many of these  suspicious
 ulcerations cannot be referred to  any class  of
 common ulcers,  as they  strikingly differ  from
 them ; and, secondly, by attending to the  course
 which these  take, when not interfered with  by
 any stimulant or caustic application,  and when
 treated only  with some mild  ointment or cold
 water.   If, under these circumstances, we find
 that, after eight or ten days, such ulcers show  no
 disposition to heal, and if at the same  time there
 be a total absence of  any cause, such as defect in
 the general health, to account for this obstinate
 condition of the local disease, we  may then pro-
 nounce them to be syphilitic."   (Op. at, p. 75.)
   46. The constitutional effects of syphilitic in-
 fection are even still  more  variable and uncertain
 in their characters than the primary.  It is mani-
 fest that bubo has been considered by  many, and
 more especially by M. Boyer, of too great im-
 portance, for it is certainly not a diagnostic  of
 genuine syphilis, nor  is it a secondary symptom,
 but merely a local consequence  of the primary
 sore—the  effect of irritation, or ofthe  virus con-
 veyed to the  inguinal glands, by the absorbents
 from the local sore,  no constitutional affection
 often  supervening when  it suppurates  freely.
 When a patient has  a syphilitic sore which has
 not been destroyed within five days, he is liable
 afterward to  these effects which  will hereafter
 be  described  as secondary and tertiary syphilis.
 Yet, according to Mr. Henry Lee and Dr. Dru-
 itt, it seems almost certain that it is  chiefly aft-
 er the Hunterian variety that these effects are  to
 be dreaded, and their  preventive treatment is re-
 quired ; and that  the  suppurative, ulcerative, and
 sloughing varieties, and those attended with sup-
 purating buboes, do  not, as a  general rule, in-
 flict secondary disease.   A developed Hunterian
 chancre, or its cicatrix if hard or red, like the vac-
 cine vesicle, affects the  constitution, " so that  if
 it be cut out or destroyed, the wound will assume
 the same character, and require the same consti- 
1466
VENEREAL DISEASES—Secondary Syphilis.
tutional treatment, as if the malady had not been
interfered with."  It has also been recently shown
that repeated syphilitic infection begets a protec-
tion against fresh attacks ;  and that the produc-
tion of additional suppurating syphilitic sores not
only docs not confer any fresh liability to second-
ary symptoms, but seems to diminish that which
exists already.   Hence it has been proposed, as
will be shown in  the sequel,  to inoculate syphi-
litic and other persons with syphilitic matter, or
to syphihzc them—in order  to prevent  and to
cure this distemper—a subject which will be no-
ticed in the sequel.
  47.  The marked differences presented by the pri-
mary sores and the  secondary symptoms of syph-
ilis, not only soon after the epidemic appearance
of the distemper in Europe, but also during its
subsequent prevalence, and in  modern times, have
been variously explained.  Mr. Carmichael be-
lieved that there were several distinct species of
venereal poisons, each of which produced a spe-
cific primary sore and a specific train of second-
ary symptoms; that the  Hunterian chancre, for
example, was followed by an  excavated ulcer of
the tonsils, scaly eruptions on  the skin, nodes,
&c.  But the history of the malady,  the diversi-
fied symptoms which result from either form of
primary  sore, and various  other considerations,
warrant a belief only in one specific virus or pois-
on,  which  manifests itself both  primarily and
constitutionally in varied forms, according to the
circumstances of infection—to  the intensity of
the primary morbid action, to the tissue  with
which the virus is brought in  contact, and to the
temperament, habit of body,  diathesis, and sus-
ceptibility of the  person  infected.  Hence  arise
different modifications or even varieties of the
distemper, all resulting from one specific morbid
poison.   Thus they pass into  each other in every
phase or grade, without being originally or spe-
cifically distinct;  and hence the one  form or va-
riety may prevail in different countries and races,
and even in different ages, and under different
influences,  and yet give  rise to another variety
either as to form or intensity,  when it infects dif-
ferent races, diatheses, and constitutions.   Even
in the same country and  race, the circumstances
and habits  of the infected, especially mental and
physical distress, prolonged fatigue and exhaus-
tion, debauchery, frequent excesses and intoxica-
tion, neglect of cleanliness, &c, will occasion a
much more intense and intractable disease, than
in persons  differently  circumstanced.  It was
most probably owing to these influences that the
disease was so severe even in its primary symp-
toms among our troops during the campaigns in
Portugal and Spain, and so mild among the na-
tives   Owing probably to the difference in race,
it presented to my own observation in Africa dif-
ferent modifications or forms and grades of inten-
sity among the negroes, from those more usually
observed in the white race.  As to this topic, how-
ever, I would suggest a further, and more precise
and extended observation, than I was enabled to
make.   There can be no doubt  that in this coun-
try various forms of constitutional affection may
proceed from the same kind of primary sore.
  47*. III. Syphilitic Bubo.—Inflamed and en-
larged lymphatic glands, consequent upon  a ve-
nereal ulcer, arise from the virus contained in, or
secreted by this ulcer or chancre.   This affection
of the inguinal glands may arise from the irrita-
tion of, or absorption from, gonorrhceal inflamma-
tion of the uretha ;  but it is not so frequent, nor
so severe as when it is caused by chancre.  Syph-
ilitic bubo cannot be viewed as an indication  of
the existence, or even  of the commencement, of
the secondary or constitutional  disease; for the
affection of the glands may even, according to
the more recent occurrences of the disease, be the
means of preventing the constitutional contami-
nation.   This, however,  was not the case in the
earlier histories of the  distemper, and more espe-
cially after the epidemic prevalences of the dis-
ease in the end of the  15th, and during Ihe 16th
century —a.  The forms  and diagnosis of bubo
have been correctly and  succinctly given as  fol-
lows by Dr. Druitt : 1st. Bubo of the penis is an
inflammation of a lymphatic in  the penis, which
may be felt like  a  cord  under the integuments,
and which passes into abscess in some part of its
course.  2d.  Acute bubo in the groin generally
affects one gland, and  pursues the course  of an
acute abscess. The cellular tissue  surrounding
the gland is the usual seat of suppuration,  but
there may be also a small abscess in the centre
of the gland, caused by  the transmission of the
poisonous matter, and the pus of this latter is
alone capable of producing a chancre by inocula-
tion.   2d. Chronic or indolent bubo commonly af-
fects more than one gland.  It occurs in weak or
scrofulous habits, and especially in  persons in-
jured by the improper use of mercury.   The
glands  enlarge slowly, suppuration  is protract-
ed  and  imperfect, and  commences  at  several
points.   The skin is long in inflaming, and on be-
coming so a  large tract  assumes a dusky bluish
tint;  the matter  extends, and  at last  large por-
tions  of skin  perish by ulceration, leaving an ex-
tensive sore, that  may be months in healing.
  48. b. The diagnosis of syphilitic bubo requires
attention.  If one gland only, and that above Pou-
parfs ligament, be affected, it  is most probably
caused  by chancre  on the penis, provided  there
be or has been one.   " But  if many glands  are
swollen, and they are below the level  of Poupart's
ligament, the swelling is probably caused by some
irritation about the foot (or extremity). But the
only sure diagnosis of a syphilitic bubo is that, if
the matter taken from it be inoculated, it will pro-
duce  a chancre; or that the sore produced by
opening the bubo presents the elevated edges and
copper-coloured margin of a chancre." As  every
bubo  is attended by suppuration ofthe surround-
ing cellular tissue, the matter taken when first
opened may  not  cause chancre by  inoculation.
There is no certain proof of a bubo being syphi-
litic unless preceded by chancre, unless a  chan-
cre can be produced by inoculation  of the dis-
charge, or unless decided secondary symptoms
supervene.
  49. IV. Secondary Syphilis.—Constitutional
syphilis may occur from a fortnight  to three or
four months  after the primary symptoms.   The
usual time is five or six  or seven weeks.   Early
in the history of syphilis in Europe, the constitu-
tional  affection was much more early than the
shortest time now named, and was net unfrequent-
ly the first produced, owing to the readiness with
which the contagious principle was imparted and
imbibed.  Before the  appearance of secondary
symptoms, the constitution betrays  its infection
by a variety of premonitory symptoms—by  a dis-
pirited  and even wan expression, by want of ap-
petite and sleep ; by heaviness of the eyes, rheu-
matic pains, especially during the night, and pal- 
VENEREAL DISEASES—Secondary Syphilis.                   1467
lor and loss of flesh ; and, lastly, by a slight erup-
tive fever usually of an inflammatory type.   Upon
these, after a  short but variable period, the sec-
ondary symptoms supervene, sore throat general-
ly accompanying this fever or soon following it.
  50. The symptoms premonitory  of the  second-
ary or constitutional disease are  sufficient evi-
dence of the infection of the  body  by the primary
disease, although those alterations  usually termed
secondary are not yet developed. The dull, earthy
hue of the surface, the  loss of bodily health and
mental vigour ; the dryness of the hair, and loss of
its smoothness and glossiness, and the giddiness,
headache, uneasiness about  tlie neck, or supra-
orbital pain, usually on  one  side,  and when the
body  is recumbent, are among the earliest indi-
cations of this infection.  On these  supervene
pains about the joints ; lassitude of the limbs ;
enlargement ofthe posterior cervical glands ; loss
of the tone, fulness  and strength of the pulse;
more or less anaemia, and falling out of the hair.
The loss of hair indicates an inveterate  form of
disease, and is often attributed by patients to the
use of mercury ; but this mineral will not cause
alopecia, but syphilis will.   These symptoms, al-
though not  generally recognised as secondary,
are so nevertheless, and, if not arrested by treat-
ment, will soon be  followed by those which are
more generally described as  such.
   51. i. Syphilitic Eruptions.—The secondary
effects of syphilis are ultimately developed either
on the skin or mucous  membrane, especially of
the throat, or on both.—A.  The earliest of these
to appear is  an exanthematous or erythematous
eruption, which may be  either attended by fever,
as stated above (§ 49), or entirely independent of
fever.  This  eruption may  occur either during
the existence of the primary symptoms,  or a few
weeks after their disappearance.   It  sometimes
assumes the appearance of either measles or scar-
latina, and at its commencement  is usually of a
rose-colour, the surrounding skin  being of an un-
healthy or dusky hue.   The redness  disappears
on pressure, but returns immediately when press-
ure  is removed.  The  surface of the body may
be covered at once, but more  frequently in suc-
cession, by  this eruption, which soon  loses its
rosy  hue, and daily becomes more  and  more
dusky, until it assumes  a coppery and more per-
manent tint.   It is generally unattended by either
heat  or itching.  It generally fades away for a
while, and then reappears ;  and it may thus pro-
ceed, with interruptions, for two, six, or twelve
months, but after a year or two  it entirely dies
away.  In half the cases the  eruption remains un-
noticed, and it very often fades away without the
patient being  aware that it ever had any  exist-
ence ; but some time after another and  a deeper
eruption makes its appearance. This state of the
eruption may be mistaken for pityriasis, or this
latter for syphilis ; but the history of the case, the
appearance of the eruption,  the absence of itch-
ing, and the  impaired health of the patient, will
indicate its syphilitic nature.
   52. B. A more developed  form  of syphilitic
eruption may appear as papula, of various sizes,
or as psoriasis, in which the  skin is raised in cop-
per-coloured blotches, covered by scales of hyper-
trophied cuticle.  These eruptions are succeeded
merely by exfoliations of the  cuticle or thin super-
ficial scabs.   An aggravated state of the forego-
ing begins with an eruption of copper-coloured
blotches, which become covered with scales of en-
larged cuticle, and form  syphilitic lepra.   These
scales are succeeded by thin scabs, and these, on
falling off, leave shallow ulcers with copper-col-
oured edges.
  53.  C.  Vesicular eruptions, often assuming the
form  of rupia, may  occur, appearing at first as
large flattened bullae, filled with  serum,  passing
into a  purulent  state, and  finally drying into
thick scabs, under which the skin is ulcerated.
The ulcers spread under the scabs, and, owing to
the successive  additions of the dried matter  as
they extend, they become remarkably thick, coni-
cal,  and resemble limpet shells.   The  eruption
may be distinctly pustular, constituting syphilitic
ecthyma, the pustules being large and prominent,
leading to ulcers, with a copper-coloured base.
   54.  D.  Tubercular  eruptions,  broad,  reddish,
or copper-coloured, appear on the face, most fre-
quently at the alee of the nose, or on the cheeks.
They  suppurate  slowly, and are succeeded by
deep irregular ulcers, terminating in puckered
cicatrices.  This eruption, in Dr. Druitt's opin-
ion, more properly belongs to the class of tertiary
symptoms, in which  mercury is almost inadmis-
sible.   This eruption usually appears a very con-
siderable  time from the primary symptoms  in
persons of weak constitution, or who have been
broken down by  privation, dissipation,  or una-
vailing courses of mercury;  it is consequently
an unfavourable form of the disease.  " A patch
of this kind of unhealthy inflammation  is apt to
form on the tongue, and after a time an abscess
breaks, disclosing a ragged excavation, filled with
orange-coloured sloughs, and exuding a copious
fetid discharge.   If it occur on the palate, a probe
will detect bare  exfoliated bone, which rapidly
perishes,  and leaves a hideous chasm."
   55. E.  Mucous Tubercles, Condylomata—Tu-
bercule muqueux, Pustule Plate, consist of raised
patches of skin, with a red and moist surface, like
mucous membrane.  They exude a thin, acrid, and
offensive discharge.   They are most frequently
situated in the vicinity of the genitals, or in any
other place where two surfaces of skin  come in
contact,  presenting  an  excoriated  appearance.
They constitute  a peculiar  syphilitic eruption,
and are undoubtedly capable of producing consti-
tutional syphilis, generally with  a similar erup-
tion, in healthy  persons.  Indeed such a result
may follow the tubercular or even the  pustular
 forms of  secondary syphilis in certain favourable
circumstances.   (The several forms of syphilitic
eruption  are more fully described in the several
articles devoted to diseases of the  skin.)
   56. Venereal eruptions are not severally char-
acteristic of any  distinct form of syphilis, prima-
ry or constitutional.   Dr. Colles states, 1st.
 That he has not been able to trace back particular
 forms of  eruption, to particular forms of primary
 ulcer.  2d. He has  not unfrequently  observed
varieties  of eruption existing  together in  the
same person.   3d. After the removal ofthe first
eruption  by mercury or other means, the second
crop will often prove of a different kind ; and,
4th.  Any form of eruption may be converted, by
injudicious treatment, as  the  excessive use  of
mercury  in bad  habits, into one which  is  most
obstinate and severe.  This opinion agrees with
those of Hennen, Oesterlan, S. CoorER, Bacot,
and others.  Mr. Babington considers the varie-
ty of venereal eruptions to be so great as to baffle
description.  He, however, arranges the more
distinct  forms under the heads of Tubercles, 
1468
VENEREAL  DISEASES—Secondary Syphilis.
Lichens, Psoriasis and Lepra, and  Rupia.  The
most important practical point, which many writ-
ers connect with these distinctions into form of
eruption, is, that rupia and ecthyma are met with
in a very dangerous general depression of health,
requiring the greatest care.
   57. F. The diagnosis of secondary eruptions is
of great importance—is sometimes very easy, and
occasionally very difficult.  In all cases the pre-
vious history of the  patient  should be inquired
into.  It is not only necessary to ascertain wheth-
er or no a chancre has existed, but  also the time
when it  occurred, its situation, and  its character, i
If no chancre, but gonorrhcea only, in male or
female, preceded the eruptions, it should be  rec-
ollected  that chancre may have  escaped the pa-
tient's notice, or may have existed in the urethra
of the male, or in the vagina or cervix uteri.  In
these cases caution  and farther  observation  are
required.'  If sores are admitted, their characters,
especially as regards induration, are of import-
ance.*   A knowledge, likewise, of  the  existence
of suppurating bubo may be useful, for indurated
chancre  is rarely  attended by suppurating swell-
ing in the groin; and, lastly, the  existence of
any traces of indurated chancre or bubo ought to
be ascertained, the denial of the patient not  be-
ing sufficient.
   58. As  respects the eruption, M. Ricord  re-
marks that one of the most important characters
of it is a total absence of pruritus, whereas itch-
ing is a very frequent symptom ofthe other kinds
of eruption.  When, however, the syphilitic erup-
tion affects naturally pruriginous regions, as  the
anus, the genito-crural fold, there may be  consid-
erable itching, owing to  the  irritating nature of
the secretion.  Syphilitic eruptions are generally
apyretic and indolent, involving  in a short time
the whole  body, generally  by successive  instal-
ments.   They spread indiscriminately to all parts,
and do not affect  the face in preference to other
parts.   They emit no smell, unless there be an
exudation of fluid or suppuration.  " There is
nothing  specific in the  smell, nor in the  colour
mentioned by  Swediaur, nor the ham-like  hue
spoken of by Fallopius, which latter has been,
with reason, looked upon as an important sign,
and an absolute and constant character."  Sec-
ondary eruptions  generally present rounded  and
well-defined patches, the colour of which may be

  * Dr. M'C'ARTnr says, "In  123 cases of secondary
symptoms, indurated chancre had preceded the eruptions
118 times, and been recognised in the hospital, or the pa-
tient recollected having felt it.  In one case only the pa-
tient could recollect that a clap only had preceded the
condylomata which we observed on the patient; but this
clap was  attended, he told us, with a bloody discharge,
which occurred seven months previous to his admission
into hospital.  In 4 cases we were unable to obtain accu-
rate recollections on  the subject of induration.
  " The examination of these 123 cases clearly proved to
us, in consequence of the frequent unexpected situation
of the primary sore, the reason why we daily meet with
cases which give reason  to suppose that secondary symp-
toms may arise spontaneously.   In G cases the sore was
Beated in  the urethra, when inoculation enabled us to rec-
ognise it  three times; in other cases the disease, at first
concealed from view, ultimately appeared as a  urethral
chancre at the meatus.  I our times at the anus, once in
the nostril, once on  the chin, once on the lip.  Suppose
we take these 123 patients, and  compare those  primary
Bymptoms, for the purpose of attempting to discover some
one character which appears sufficiently often to enable
us to draw a deduction  from it, we find that in one ami
all the inguinal glands have been observed enlarged, but
suppuration took  place  only twice, and in these the bu-
boes had  a scrofulous appearance, and it was not possible
by inoculation  to obtain the specific pustule."  (Xote
from Acton's op. cit, p. 488.)
more or less deep in their centres.  They have
very little tendency  to  suppuration; and when
matter does form, it is generally small in quanti-
ty and  unhealthy  in character.   The eruptions
which do not suppurate, generally disappear in
time by resolution or desquamation.  The scales
in these cases are  less brilliant and thinner, dry
more quickly, and  more frequently furfuraceous
than  in non-specific affections,  and the  scales
sometimes fall off in  large shell-like pieces. The
crusts sometimes accumulate in successive layers,
as in rupia.  When, by the falling of the crust,
the ulceration  underneath becomes apparent, it
generally is rounded, its fundus grayish  and pul-
taceous, is surrounded by a darkish areola, with
a certain induration in the margins.  Phagedaena
of these  ulcerations is  rare;  but when it does
happen, it sometimes extends rapidly.   Seconda-
ry syphilitic ulcers are  preceded either  by some
eruption, as ecthyma, rupia, papulae, or tubercles;
they rarely follow  vesicles or psydraceous pus-
tules.   Ricord agrees with Hunter in consider-
ing the diagnosis of secondary symptoms as most
difficult; for " there is hardly  any disorder that
has more diseases resembling it  in all its forms
than the venereal disease."*
   59.  G. Secondary affections ofthe scalp—Alo-
pecia syphilitica—is  among the earliest constitu-
tional disorders consequent upon syphilis.  It
commences with a slight itching, tenderness or
soreness ofthe scalp, attended by rheumatic pains.
On examination, no trace of eruption can be de-
tected ;  but if the patient have  suffered within
four or eight weeks from chancre, or if any indu-
ration remain in its  situation, the tenderness of
the scalp will soon be followed by the loss of hair
and some one ofthe  affections ofthe skin, throat,
&c.   The alopecia  commences  very  gradually.
The hair at first becomes dry and crisp,  loses its
glossy  appearance,  breaks  readily, a brush or
comb causing great pain.  The hair is often seen
broken off close to the scalp, and  patches of bald-
ness, or approaching to it,  are found here  and
there.  At a more  advanced stage the hair comes
away with the bulbs in  considerable  quantity.
Pityriasis  now  becomes troublesome ;  and vari-
ous points of the scalp  assume a rosy hue ; the
rest  ofthe skin  generally having  a yellowish, un-
healthy appearance.  Slight febrile symptoms set
in, attended often with rose-coloured spots on the
abdomen.  The  patient now frequently complains
of rheumatic pains in the joints, with loss of ap-
petite  and debility.  The loss of hair  requires
immediate attention, especially when caused by
syphilis, as it may be very considerable in a short
time, and its growth very uncertain.   It should,
however, be  remarked  that if the hair  does not
fall out at the commencement,  it is not  very fre-
quently lost in the latter stages of constitutional
syphilis.
  60. At a more advanced stage,  a papular affec.
tion  of the scalp, commencing with little rose-

  [* For the best description of the siiphilie'a, or cin>M-
litic eruptions, the reader may consult  the American edi-
tion of Vidal "On  Venereal Liscases." with  colored
plates, translated  by  George C. Blackman, M.D., 8vo,
p. 409.   New York : Famuel s. and William Wood, l'f>4
in this, the ablest  work on this class of diseases hitherto
published, the different varieties, including the exanthe-
matous,papul'r, squamous, vesicular,  bullous, pustular,
and tubercular, are described at great length, and ac-
curately represented by coloured engraving-.   We feel
tempted to give a synopsis of these varieties, but the work
is so accessible, and so well known to the American pro-
fession, that it is unnecessary.] 
VENEREAL DISEASE
coloured elevations, attended  by itching, is ob-
served.   These  papula?, or lichens, increase in
number, slight pearly-white scales form on their
apices, which fall away and are  replaced by oth-
ers.   The hair is scurfy, and the papula? or ele-
vations, at first  the size of millet-seeds, become
large  and assume the form of lepra or psoriasis.
When the scales are removed, the skin looks like
a recently-blistered surface, and exudes a small
quantity of thin  pellucid fluid; or it is quite dry.
In  particular situations,  especially behind the
ears,  in the folds of the neck of stout persons, or
those inattentive to cleanliness, those places in-
stead of becoming scaly remain moist, the oozing
from  them excoriating the surrounding parts, and
developing mucous tubercle or condyloma.  As
the disease of the scalp advances  the papulae or
lichen pass into an impetiginous or an eczema-
tous state.  In still more advanced stages, ulcer-
ations of a very intractable character, forming
tertiary symptoms, form in the spots of impetigo
or eczema ; and tumours as large as horse-beans
form  in the scalp, at first unattended by pain or
redness   Fluctuation may be detected in them
after  some time, and when  punctured a thin, se-
rous,  straw-coloured fluid exudes.  If left alone
they  become painful and  red, ulcerate, exposure
of the bone ultimately following, and even necro-
sis, which are now chiefly seen in pathological
collections, and but rarely in practice in the pres-
ent day.
   61. H. Syphilitic Onychia.—The venereal af-
fections of the skin or scalp may be extended to
the nails.  In these cases the  matrix  suffers, and
the nail grows  thick  and nodulated, closely re-
sembling the changes which take place in it from
inveterate psoriasis.   There is a great similarity
between onychia and alopecia.   They both de-
pend  upon the constitutional infection interfering
with  the formation  or nutrition of these cuticular
appendages.
   62. ii. Syphilitic Affections of Mucous Sur-
faces.—A. Syphilitic  Affections of the Throat.—
a. The mildest  affection of this kind is a superfi-
cial excoriation of the mucous  membrane, most
frequently of the  tonsils, but not unfrequently
also of some other parts of the  fauces or mouth,
corresponding to psoriasis on the skin.  The af-
fected parts are slightly swollen and sore, after-
ward red and raw, or covered with a  whitish ex-
udation, or with a patch of thickened  epithelium.
If the disease proceed it will generally be follow-
ed by superficial ulceration.
   63. b. An excavated ulcer may follow the fore-
going, or may be first to come before the physi-
cian,  although  it may  have been a consecutive
lesion of the parts.  This  ulcer appears as if a
piece had been scooped  out  of the  tonsil.  Its
surface is foul  or  yellow, its edges raised and
ragged, and swollen.   It occasions much less in-
convenience than its appearance might indicate ;
and there is very little constitutional  disturbance
from  it, unless  it be attended by eruption.  As
the lesion advances, or swelling increases, the
patient's speech becomes guttural, and he often
complains of pain  shooting to  the ears, and of
partial deafness.
   64. c. Sloughing ulcer begins as a small aph-
thous spot which rapidly ulcerates, and is attend-
ed with great pain and fever.    " The surface of
the ulcer is covered with an ashy slough, and the
surrounding membrane is dark, livid, and swollen.
The lingual artery  may be opened  by the spread
IS—Tertiary Syphilis.                   1469

of the ulceration, and the  patient may die of
haemorrhage, unless the common carotid is tied."
(Druitt, p. 187.)  In some instances, especially
when mercury has been given in large quantities
for primary symptoms, the affection of the throat
comes on  notwithstanding, and assumes a  red
and sloughy appearance ; a piece of the tonsil
appears as if punched out, and the ulcers rapidly
extend in size and depth.
   65. The situation of the ulcerations, most  fre-
quently of the  excavated, is  commonly on  the
tonsils, on the sides of the tongue, on the upper
surface, or on the under surface close to the frae-
num.  Sometimes they are  met with on the dor-
sum of the tongue, here assuming  an elevated
character, like the condylomata around the anus.
They occasionally attack the palate, pharynx, and
more rarely in  the posterior  and lower part of
the pharynx, in which latter situation it occurred
in a patient many years  ago  under  my care, ul-
ceration also having  extended to the larynx  and
terminated fatally.   Ulcers  also form at the cor-
ners of the mouth, where they may form scabs,
or are liable  to bleed when the mouth  is fully
opened.
   66.  B. Syphilitic ulcerations of the nose  and
palate commence with inflammation and ulcera-
tion of the mucous membrane covering the parts,
similar to  those of the  throat.  The ulcerations
may proceed until they  denude the  periosteum,
and afterward produce exfoliation of the bones
and profuse fetid discharge, and ultimately  very
marked deformity.  Ulceration ofthe nose gener-
ally begins with ozaena, or with a sense of pain,
heat, dryness, and snuffling.  But the bones of
the  nose  may  become   otherwise  attacked, as
shown in the sequel (§ 75).
   67.  C.  Syphilitic ulceration of the larynx is
chiefly a consequence ofthe extension of ulcera-
tion from the palate or pharynx.  It  is character-
ized by tenderness, slight pain or uneasiness re^
 ferred to the larynx, by  huskiness of voice, fol-
lowed by a low whispering, or loss of voice ; by
 suffocative cough, and by expectoration of a san-
guineo-puriform matter.  There is great loss of
strength and flesh;  and  life is often terminated
by suffocation.
   68.  D. Secondary Affections of the Eyelids and
 Eyes.—Not only may inflammation of the eye be
consequent upon gonorrhaa (see art. Eyes, gon-
orrhaal inflammation of, § 56, et seq.), but erup-
tions  and  affections of the eyelids and of the
 eyes themselves, chiefly in the form  of iritis, may
appear in the course of secondary  or constitu-
tional syphilis.   These eruptions often appear on
 the external surface  and on the ciliary margins
 of the lids.   In some instances the corners of the
 eyelids have a cracked, scaly appearance, resem-
 bling a similar alteration  more frequently occur-
ring at the angles ofthe mouth, and, as in  this
 latter state, the eruption is connected with syph-
 ilitic affections of either  the skin or of the  mu-
 cous membrane, of the throat, &c, or of both ;
 and it may appear in any period of  the progress
 of these affections.   In some cases the conjunc-
 tiva is also either partially  or extensively impli-
 cated.  Syphilitic iritis is  not unfrequent;  and
 is fully considered in the article on the diseases
 ofthe Eye ($ 132, et  seq.), to which I must  refer
 the reader.
   69.  tii. Tertiary Syphilitic Diseases.—Cer-
 tain constitutional effects of syphilis, which more
 frequently  are  consecutive of several of those 
1470                   VENEREAL DISEASES—Tertiary Syphilis.
already mentioned, than  associated with them—
although such associations, especially in the ad-
vanced course of the latter, arc often observed—
have been classed as  tertiary symptoms of the
disease.   They may, however, occur after the re-
moval of the secondary forms of the distemper,
or independently of these, and at a remote period
frorn the  primary symptoms.  Under the  term
tertiary symptoms have been arranged nodes, in-
flammation of the periosteum, exostosis, caries of
the bones, tubercles of the  sub-cutaneous and sub-
mucous tissues, disease of the testes consequent
upon primary  or  secondary  syphilitic  disease.
These  affections were  generally  classed  with
those secondary symptoms already noticed.   John
Hunter  first distinguished them by designating
them the  " Symptoms of the second period of con-
stitutional syphilis," a designation which many
will agree with me in considering as more appro-
priate than that imposed on them by M.  Ricord.
   70. Though  tertiary symptoms generally de-
pend upon chancre, or, in rare cases, upon infec-
tion by a secondary  disease, they follow the pri-
mary symptoms after a much longer interval, and
they are seated in other and more  deeply-seated
structures than the secondary.  They affect chief-
ly the sub-mucous and sub-cutaneous cellular tis-
sue ; the structure of the bones; the fibrous struc-
tures, especially the periosteum ; the joints; the
testes, and lymphatic  system.  The syphilitic
poison may even  develop disease  of the  liver,
lungs, brain, and heart.  Tertiary affections can-
not be transmitted from parent to child—are not
hereditary ; but they are undoubtedly capable of
producing a scrofulous diathesis in the offspring.
   71. A. Course.—In the more usual course of
the disease, tertiary  symptoms do not supervene
until six, seven, or nine  months from the prima-
ry, and in some they may be delayed for several,
or even as many years.   Although these symp-
toms may be  separated with propriety from the
secondary, yet it will very frequently be difficult
to draw the line of demarcation between them.
They may be both so associated, or the one class
may pass so insensibly into the  other as not to
admit of an inference as to the predominance of
the one set of symptoms over the other.  In the
natural course of syphilis the tertiary form very
frequently thus appears  during the existence of
the secondary, in the same way as the latter may
come on during  that  of the primary.  Under
other circumstances, as  from treatment, careful
regimen, &c, the secondary symptoms may have
successfully disappeared and returned, and ulti-
mately the tertiary have supervened ;  and  even,
although in rare instances,  an indurated chancre
may have existed, and been apparently cured, yet,
after a very considerable lapse of time, tertiary
symptoms may appear generally from the influence
of causes hereafter to be  noticed (y 109, et seq.), at
first in a slight form, but with increasing severity,
notwithstanding the non-existence of secondary
symptoms between  the primary  and  tertiary.
During the course of tertiary affections, various
complications  majT be developed, not only by the
syphilitic poison, but also aided by treatment, by
pre-existing tendency to visceral  or  other dis-
eases ;  by the  causes,  influences, and circum-
stances to which the patient may  have been ex-
posed, and by climate, race, occupation, &c.
   72. B.  Syphilitic affections ofthe  testes are gen-
erally among the earliest of tertiary symptoms to
appear, and may occur  during the existence of
the secondary.  They may, however, supervene
in five or six months, or not until as many years,
from  the  primary infection.  They may appear
either alone, or attended by pains in the bones,
exostoses, or gummata ; but they are of rare oc-
currence in the present state of the distemper.
Astruc first, and Hunter, Sir A. Cooper and
Dupuytren, subsequently, made  the distinction
between diseased testicle consequent upon syph-
ilis and  that following  gonorrhoea.   Syphilitic
disease  of the testes  may commence in one and
extend to both, or it  may begin in both at 'once.
Excepting slight nocturnal pains in the loins in
some cases, the affection often reaches a consid-
erable height before  it  is  noticed.  When  the
patient's  attention is attracted by it, the testes
are found heavy,  hard,  and generally much in-
creased in size, although not always.   The dis-
ease  may run  its course without  much uneasi-
ness, and hence be neglected, and organic lesions
may supervene which cannot be removed.   The
erections, however, and the venereal desire  be-
come, on the full development of the disease, less
frequent,  and the  seminal discharge is diminish-
ed.   If the disease continue, or be neglected, the
testes decrease in size, and ultimately may be-
come atrophied, and  may even disappear nearly
or altogether.  These  changes  are extremely
slow, and may continue for several months or
even years before the organs are entirely lost. A
full description of them will be  found in the
works of M. Ricord  and Mr. Acton.
   73. C.  Small tumours are sometimes formed
in the scrotum, and are described as tubercles, or
gummata, either in connexion with disease of the
testes or  independently of it.   They occur  as a
tertiary symptom  in the deep layers ofthe scro-
tum, and sometimes  implicate the testes, or are
mistaken for affections  of these  organs.  They
never appear before the fifth or sixth month from
infection ; but they may occur after many years.
They mostly appear as small elastic tumours, and
feel as if they were filled with a gummy matter.
As they grow they become  painful, inflamed, and
the  skin  covering them softens and  ulcerates,
and a deep ulcer follows a copious puriform dis-
charge.   The edges of the  sore are undermined,
and the adjoining parts are involved in the  de-
struction.*
  [• Pee paper by JoriN Watson (in Xew Yerk Journal
of Medicine for Xovember, 1846), entitled " Further Ob-
servations on some of the more obscure and  remote ef-
fects of Syphilis ;" also, in same journal for July, 1843,
Dr. W. was one ofthe first, if not the .first, in this coun-
try to show  that the venereal disease in its  progress
through the system may affect the brain and its meninges,
the asophagus, the bronchial tubes, and the  testes; and
that it may simulate other diseases, as pulmonary phthi-
sis, and diseases of the digestive organs, liver, &c. Among
the cervical ganglia he shows that P may simulate stru-
mous aelenitis, and in the lower extremities elephantiasis,
while  it occasionally involves the re turn and prostate
gland.  He also offers some very original and interesting
remarks on " the rarity of secondary syphilis after sloughy
primary sores ;  on the frequent and  early occurrence of
superficial necrosis in connexion with nodes ; on the co-
existence of syphilis with other constitutional diseases;
and on mercurial cachexia, as liable to be mistaken for
the remote effects of syphilis."  With regard to the syph-
ilitic affection of the testicle, from various examinations,
Dr. Watson concludes that the primary seat of the affec-
tion is in the fibrous envelope forming the proper capsule
of _ the testis, which occasionally becomes enormously
thickened, while the proper tissue of the testis remains
healthy.  The tubuli seminiferi, with their continuous
vessels of the epididymis, were atrophied, pale, and im-
mersed in serous effusion.  In one case there was a de-
posit of a large yellow mass, irregular in shape, broadest
in front, and apparently connected  with the fibrous en- 
VENEREAL DISEASES—Syphilitic Cachexia.
1471
  74. D. Syphilitic disease of the periosteum and
bones generally  commences with  tenderness in
the situation ofthe more exposed and superficial
bones, especially in the bones of the nose, in the
tibia, ulna,  cranial  bones,  clavicles,  &c.   The
tenderness and  pain become aggravated in the
evening, last all night, but cease  altogether or
abate during the day.  The pain is followed by
oblong swellings or nodes, caused by the inflam-
mation of the periosteum, and by the  infiltration
of lymph and serum.  These swellings are ten-
der, and the skin  over them is  at first pale and
moveable.   They present to the touch a doughy
character, or an obscure sense of fluctuation.  Dr.
Druitt remarks that " if the disease  is arrested
at this  stage, it causes merely  a superficial de-
posit of rough porous bone, from the organiza-
tion of the lymph  effused ;  or else consolidation
of  the bone itself, through  deposition of fresh
osseous matter  into its cancelli.   If the disease
proceed one step farther, a quantity of glairy se-
rum is effused between the periosteum and bone,
producing an exquisitely painful fluctuating tu-
mour.  If it advance still  farther, the bone be-
comes carious ;  matter forms between it and the
periosteum; extensive exfoliations ensue ; the
patient suffers  severely from the pain and dis-
charge ;" and if the disease be  seated in the cra-
nium or os frontis—corona Veneris—death may
ensue from extension of disease to the dura ma-
ter, or from protrusion ofthe brain through the
eroded  apertures  in the skull.   Such extreme
cases are now very rare, but they were common
enough  many years ago, and when it was sup-
posed that mercury given in excess was the only
cure for the distemper.
   75. E. Disease  ofthe bones ofthe nose is often
among the  earliest of the tertiary symptoms, but
it  is of only occasional occurrence,  and some-
times not  until an advanced period.   The  nose
may become diseased, as stated above (§ 66), from
ulceration of the mucous membrane ; but the for-
mation of internal nodes on the  palate, vomer,
ethmoid, and bones  forming the bridge of the
nose, may cause these bones to be carious, and
probably the spongy structure of these bones may
contribute to this even so quickly as it is some-
times observed.   In rare cases these bones are
nearly destroyed before the nature ofthe disease
becomes apparent.  When caries of the os frontis
near the root of the nose takes place, the disease
may extend to the ethmoid bone, and produce the
worst effects.   The  existence  of a deep-seated
pain in the palate, and at or near  the root of the
nose, with  or without a fetid  discharge, should
always be viewed with suspicion, especially  if
either primary or  secondary symptoms  have ex-
isted at some previous period,  although very re-
mote, and apparently altogether removed. Ozaena
may proceed from scrofula, scurvy, or even from
chronic cephalic catarrh ; but in 99 cases out of
100 it is the result of syphilis in the circumstan-
ces just named.
   76. F. The joints are not frequently nor so
quickly affected as the bones.  Large  gummy
swellings sometimes, however, form around the
ankle, knee, and  elbow joints, owing to  vene-
real disease; and in rare cases even the joints
themselves.  In two instances I was consulted
velope ofthe testicle, and extending backward in the direc-
tion of the corpus Highmorianum.  This mass, by press-
ure, produced atrophy of the tubuli seminiferi.  For an
excellent account of syphilitic sarcocele, see also Vidal.]
where  nearly  all these  joints were  remarkably
swollen and diseased, consequently  upon other
serious syphilitic affections.   In a third—that of
a late  M.P.—amputation  of the  leg above the
knee had been performed by Mr. Dalrymple, of
Norwich, and the case subsequently  came under
my care.   The  small bones of the  extremities
may also be similarly affected.  In venereal dis-
eases of the joints it is  difficult to determine, as
I have not seen these cases terminate fatally, al-
though they doubtless  occasionally do, whether
the disease is entirely external to the joint itself,
or whether the  articulations or the  ends of the
bones are also implicated  by the disease.  That
the cartilages are sometimes eroded, and even
the ends of the bones or their epiphysis also are
affected, may be inferred not only from the  case
for which  amputation  was  performed, but  also
from what is  observed  to occur as  regards the
cartilages and bones of the  nose.   These local
syphilitic diseases:—of the bones, joints, &c.—are
generally attended by a slow or syphilitic hectic,
and with  the  several constitutional  phenomena
described hereafter as the syphilitic cachexia.
   77.  iv.  The  Syphilitic  Cachexia.—It  may
justly be asked, can syphilis so contaminate the
constitution as to give rise to dangerous  or even
fatal results of a different kind, or in addition to
those which have been described above  as sec-
ondary and tertiary 1  To this question I cannot
hesitate to answer in the affirmative.  These re-
sults do not often occur in the present day ; and
even the most severe  of the tertiary affections
noticed above, although sometimes  terminating
fatally, have not always  this issue.  In their most
unfavourable results, it is often difficult to say
how much may be imputed to  treatment.   But,
irrespective of the more severe  and dangerous of
the  affections already mentioned, states of the
system may be induced, attended by marked se-
verity  or  imminent danger, in which none of
these  affections had appeared, or, if they  have
appeared at some previous periods, they had been
removed by medical treatment or regimen.   This
dangerous state of constitution—this the most re-
mote or advanced ofthe effects ofthe syphilitic
poison—has not  been  overlooked by previous
writers, more especially by Dr. Colles  and M.
Ricord.
   78.  Syphilitic cachexia is generally a conse-
quence of a single constitutional contamination
(such  contamination not occurring twice), and is
favoured by the following circumstances :  1st, by
an originally weak or bad constitution, by scrof-
ula, scurvy, and a peculiar or vitiated diathesis,
previously to the venereal infection; 2d, by the
persistence of certain severe syphilitic symptoms ;
3d, by an ill-timed or batlly-managed treatment,
and by neglect of treatment; and, 4th, by causes
which tend to lower the vital powers  subsequent-
ly to infection—such causes, according to my ob-
servation,  being excessive  sexual indulgences,
masturbation, exposure  to cold and moisture, to
the continued influence  of malaria, or to noxious
exhalations, &c.
   79. The symptoms of syphilitic cachexia are not
always well defined ; for they may be associated
with certain of those already noticed, or they may
appear as the sequelae of some ofthe more severe
of them, or they occur at periods so remote from
them as to occasion grave doubts of their nature
and origin.  They may, however, be  stated to
consist chiefly of pallor, sallowness, and anaemia 
1472
VENEREAL DISEASES—Syphilis in Children.
of the surface, flabbiness of the flesh, emaciation,
debility of both body and mind, various anoma-
lous scorbutic or cutaneous appearances, hectic
or continued nervous fever, night exacerbations,
diarrhoea, sweats, aphonia, and ultimately death,
arising from some important internal organ ex-
periencing disorganization, to which it may, pre-
viously or subsequently to the venereal infection,
have become predisposed.  Thus the patient may
be cut off by extreme anaemia, by diarrhoea  ter-
minating in  ulceration of the intestines, by affec-
tions of the  lungs, &c.
  80.  Sometimes, after the patient has improved,
under treatment for various secondary or tertiary
symptoms, in  respect both of these symptoms,
and of flesh, strength, and appearance, he begins
to exhibit a much less favourable aspect.  He
appears sickly, loses flesh, presents a waxen hue,
complains of  loss of appetite and strength, of
want of sleep, and of night sweats.  If any erup-
tions  or other syphilitic  symptoms are  present,
they may disappear, and  yet the general consti-
tutional cachexia may long  remain, or even be-
come more  marked;  or, if the  local symptoms
continue, they may be slowly deteriorated.  Thus
tubercular eruptions, or pains in the joints and
bones, may continue in various grades of severity
for some years, while the constitution is slowly
wasted, anaemied and visibly contaminated.  In
some cases the local symptoms, in the course of
the general breaking down  ofthe frame,  are so
changed as hardly to be recognised as venereal—
various local or visceral changes, the consequence
chiefly of this cachexia, or of the  treatment, be-
ing developed, and masking the venereal affection
and its effects.  This formerly obtained more re-
markably when the treatment by mercury was
carried to excess.  There can be no doubt, how-
ever, that, even? independently of this, or  of any
other  treatment, the venereal cachexia  may ter-
minate fatally by calling latent tendencies  into
action, and by developing disease in vital or other
internal organs.  It may, however, be most man-
ifest  in all  its indications, even when the local
affections are comparatively slight; or,  although
they have been severe, after they have entirely or
almost altogether disappeared.  The local affec-
tions, as well as the constitutional contamination,
are often developed, hastened, delayed, or aggra-
vated  by a number of circumstances, influences,
and concurring or reinforcing causes (y  115, et
scq.),  to which the patient may have been ex-
posed subsequently to  the period of infection.
During  syphilitic hectic or cachexia, not  only
may the contingencies now alluded to appear,
but there are several others which may also su-
pervene ; namely, paralysis, epilepsy, hypochon-
driasis, melancholia, monomania, and even more
or  less general insanity.   These disorders ofthe
mind are, however, seldom met with even in the
advanced states of constitutional syphilis—the
intellect being generally but little, or not at all,
affected to the last.
   81. v. The diagnosis of constitutional syphilis
is often very  difficult, more especially when pa-
tients deny that they have had any primary symp-
toms, or even any suspicious intercourse, or  even
any sexual  intercourse  whatever.  These last
circumstances are, however, very rare, or  may
even be considered next to impossible.  But the
rare modes of communicating the distemper, in-
dependently of sexual  connexion—much more
common in former times than now—should not
be forgotten.  These modes  will be  noticed in
the sequel (y 110, et seq.).  If, however, copper-
coloured eruptions, sore  throat, loss of hair, en-
largement ofthe glands around the occiput, pains
in the  joints, periosteum or bones,  periosteal
nodes  on the long  and  superficial bones, with
night pains,  a faded, pallid,  or waxen and un-
healthy look, loss of flesh and strength, be com-
plained of;  and more especially if these  symp.
toms follow a somewhat similar succession, and
cannot be attributed to locality, diet, regimen, &c,
or to any recognised visceral disease, they may
be confidently referred to constitutional syphilis.
Where, however, neither the above  succession
of symptoms, nor many of them appear, the dif-
ficulty of diagnosis will  be much greater, espe-
cially if primary symptoms be not admitted; but,
if admitted,  there can be no doubt  of the na-
ture of the  disease, although a long period be-
tween the existence ofthe primary symptoms and
the appearance of those which are doubtfully sec-
ondary may have intervened.   It has been stated
above  that the period to which the supervention
of secondary and tertiary symptoms  upon the
primary may extend  may  be very long—may
even extend to several years ; but the exact term
to which this interval may be extended has not
been ascertained.  Its duration evidently depends
upon a variety  of causes and circumstances (v
115, et seq.).
   82.  vi. Syphilis  in Children.—Syphilis In-
fantum.—Hereditary syphilis differs so far from
the disease  as it occurs in adults, as to  induce
some writers to doubt its venereal origin.  It is
certainly the transmission of the constitutional
contamination or distemper to the fcetus,  during
utero-gestation, and not the infection ofthe foetus
during parturition.   The malady may exist at
birth, or may not appear for some days or even
weeks after birth.  It is indicated by copper-col-
oured spots on the cutaneous surface, especially
about  the arms, genitals, and mouth, which may
go on to ulceration.   There  are also a peculiar
shrill  or hoarse voice, excoriations and  ulcera-
tions,  or an  aphthous appearance at the corners
ofthe mouth, on the tongue, throat, and  palate.
In more advanced stages, emaciation and a senile
appearance of the countenance ; snuffling, or ob-
struction ofthe  nose, enlargement ofthe glands,
general cachexia, terminating in death, if the dis-
ease be not early detected and judiciously treated,
and even in such  favourable circumstances the
child may be carried off' by some severe compli-
cation.  In  most ofthe  cases of syphilis infan-
tum the mother has been stated to have infected
the foetus.  I believe, however, that the infection
has  not always  proceeded from the mother only.
Schenck adduces an instance (Observ. le xj., No.
21) ofthe infection ofthe fcetus from the father,
the mother being unaffected.  It must, however,
be admitted that it  is very difficult to prove the
mother to have been untainted by the distemper,
when  the father has  been affected.   Upon the
whole, it may be generally expected that the fatus
will manifest the  disease when the pregnant
mother is constitutionally affected ; and it is not
improbable  that the  child may be infected by
a constitutionally syphilitic  father, without the
mother having manifested any symptoms ofthe
constitutional or primary distemper.  Mauriceau,
however, has adduced instances of the child hav-
ing been free from syphilitic taint, although the
mother was affected; and I know cases of the 
  T
npmut:
VENEREAL DISEASES—Yaws described.
1473
 children being free fromJHphilitic taint although
 their  fathers were con^rtutionally affected ; but
 these children presented more or less ofthe scrof-
 ulous diathesis, or died in infancy.   " The child
 may be also  affected after birth, by a nurse suf-
 fering under syphilitic  ulceration  of the  nip-
 ple, or by its  mother under  the  same circum-
 stances, if the disease of her nipple has been de-
 rived from a strange child ; but no instance  is
 known  of a  child infecting its own mother, al-
 though it will immediately communicate the dis-
 ease to a strange  nurse."   The infection ofthe
 nurse is manifested by ulceration of the throat,
 identical with  that succeeding primary disease,
 by cutaneous eruptions, by the formations of ex-
 crescences about the pudenda, which are capable
 of affecting  her husband, in whom  the infection
 is likewise followed by constitutional symptoms.
 Hunter believed that secondary symptoms could
 no longer infect;  but this  opinion is disproved
 by many very  experienced writers,  and by  sev-
 eral  instances which have come  under my  own
 observation.  There can be no doubt that during
 the 16th and 17th centuries, the communication
 ofthe distemper, and even in more recent times,
 by secondary symptoms was  remarkably frequent.
 This circumstance shows the intimate connexion,
 if not the identity, of syphilis with yaws, sibbens,
 and some other diseases, which, in this and many
 other characters, differ in no respects from syph-
 ilis, as will be shown in the  sequel.
    83. Dr. Rizzi, of Milan, has recorded the re-
 sults  of his extensive experience of congenital
 syphilis, and has  confirmed  the  remarks of Dr.
 Colles.   According to Dr. Rizzi, if a woman
 contracts syphilitic ulcerations of the breast by
 sucking an infected infant, mucous tubercles fre-
 quently appear  on the vulva  and  about the anus.
 The syphilis, although secondary, is transmissi-
 ble by contact, so that an innocent woman may
 communicate the distemper to her husband.  Of
 this fact the physician should be fully aware.  Of
 100 persons with  chancres  on the breast  from
 impure lactation, or in the mouth or throat from
 contact with an infected infant, 34 had tubercles
 ofthe vulva, 19 syphilitic angina, 2 iritis,  14 tu-
 bercles of the vulva and angina simultaneously,
 5  tubercles of the  vulva and  others disseminated
 over different parts of the body, 6 tubercles of
 the vulva, angina, tubercles of the skin, and iritis,
 and 19 no secondary symptoms.   In nurses, as
 well as in men infected by them, Dr. Rizzi found
 tubercles  the most  common form  of secondary
 symptoms, and  angina often superadded.   Dis-
 charges, vegetations, and exostoses  were rare,
 and buboes, when they occurred, consisted only
 of swelling and tension of the sub-maxillary or
 axillary glands.   (Ranking's Abstract, &c,  vol.
 v., p.  250.)

 V. Varieties or Modifications  of Syphilis—
   Syphiloid Diseases.
 i.  Syphilis ^Ethiopica.—Syphilis vel Lues Mthi-
   opica—Syphilis   Africana— Yaws—Sibbens—
   Sivvens.—Pian, Epian, Fr.—Frambasia.
   84.  This distemper has existed in Africa, cer-
 tainly,  for ages before the epidemic outbreak of
 syphilis in  Europe at the end ofthe  15th centu-
 ry  ; and, if not identical with, is at least a form
 or   modification  of, the  disease  which existed
in  the West Indian islands when they were dis-
covered by Columbus, and which was consider-
ed   as  intimately resembling, if  not the same
    III.              93
 as, the  epidemic  syphilis of the  15th  and 16th
 centuries.
   85. The African syphilis, or the yaws, as com-
 monly termed, in all respects more closely re-
 sembles the earlier manifestations of syphilis in
 Europe than the modern occurrences of this dis-
 temper.  Indeed the few cases of yaws wliich I
 saw in Africa  in 1817 agreed with the early ac-
 counts of syphilis so prevalent in Europe  in the
 15th and 16th centuries ; not only as respected
 the character  and severity of the  distemper, but
 also as regarded the modes of its communication
 and the treatment  of it found most beneficial.
 That  the yaws in Africa  is identical  with  the
 yaws or pian of the West Indies, is also undoubt-
 ed ; and it  is most probable that the identity ex-
 isted before the discovery of America.  The de-
 scriptions of the  disease, as observed in Africa
 and in the West Indies, agree as closely as  the
 descriptions of any specific disease  furnished by
 different writers, whether as occurring in negroes
 or in mulattoes.  It  is very rarely observed in
 white persons  in modern times, as it is especially
 dreaded, and hence avoided by them.  That it is
 also the same  disease as the sibbens or sivvens
 formerly seen  in the west of Scotland, is admit-
 ted by those who  have seen both maladies.   Dr.
 Thomson remarks that he possesses the notes of
 an old physician in Jamaica, who visited a part
 of Scotland where  the sibbens was prevalent;
 that these notes were made without any regard
 to theory;  and that his observations confirm the
 identity of yaws and sibbens.  (Edin. Med. and
 Surg. Journ.,  vol. xv., p.  321, and vol.' xviii.,
 p. 31.)
   86.  This complaint is usually preceded by se-
 vere pains  in  the limbs, often resembling  those
 of rheumatism, which are most severe around the
 joints.  The pains are attended by languor and
 debility, and often continue for several days with-
 out  any other appearance  of  disease.   These
 symptoms are generally precursory, and are suc-
 ceeded by more or less fever, sometimes preceded
 by slight rigors.  In many cases, however, the
 fever is  so slight as hardly  to be noticed.   Gen-
 erally the patient complains of headache, loss of
 appetite, and pains of the back and loins, which
 are exacerbated towards evening.  These symp-
 toms are continued for  several days, and are fol-
 lowed  by an eruption of pustules, more or less
 numerous, in various parts of the body, but  es-
 pecially upon the face, neck, groins, pudenda, and
 around the anus, vulva, &c.   The  eruption  of
 these pustules  is not completed over the  whole
 body at one time, nor do they appear in any reg-
 ular succession on the different parts; but while
 one crop is  falling off, another is making its ap-
 pearance in other  places.  Every fresh eruption
 of pustules is preceded by a slight  febrile parox-
 ysm.   The  pustules are  filled with an opaque
 whitish fluid :  they are, at their first appearance,
 not so  large as  the head of a small pin ; but they
 grow larger gradually, until they attain the size
 of a sixpence or even of a shilling.  When the
 pustules burst, a thick viscid matter is discharged,
 which forms a foul and dense crust or scab upon
 the surface.  The  number and size of the pus-
 tules is proportioned  to the degree  of eruptive
 fever.  When  the febrile symptoms are slight,
there are few pustules, but  they are  mostly of a
larger size than when the complaint is more vio-
lent.  From the larger pustules red fungous ex-
crescences frequently arise of various magnitudes, 
1474                  VENEREAL DISEASES—Yaws, Sibbens, etc
from the size of a pea to that of a large mulberry,
which fruit, owing to their rough, granulated sur-
faces, they somewhat  resemble.   These  fungi,
though they rise considerably above the surface
ofthe skin, have but a small degree of sensibili-
ty.   They never suppurate kindly, but gradually
discharge a sordid  glutinous  matter, forming an
ugly scab round the edges of the  excrescence,
and covering the upper parts of it, when  much
elevated, with white sloughs.   When these erup-
tions appear  upon any part of the body covered
with hair, the  colour  of the hair  is gradually
changed from black to white.   At the commence-
ment of the disease, when there is any doubt of
the nature of the complaint, the natives open one
of the pustules and  drop  upon it  a little  of the
juice ofthe capsicum :  if it be ofthe yaws spe-
cies, little or no pain is excited.
  87. The eruption is more elevated and broader,
and  more numerous in the face, groins,  axilla,
verge of the anus,  and labia majora, than in any
other part of the body.   The crops of yaws are
various.  In some there is only one copious erup-
tion, of a healthy nature, with well-defined edges ;
it continues  on the skin for a long  time, the pa-
tient enjoying his usual health.  This is the most
favourable form, and in the robust and well-fed
is  terminated in seven  or nine months.  More
frequently small watery yaws appear, and recede
in  a month or'so.   The patients lose flesh ; be-
come cachectic, and dropsical;  but in these a
nourishing diet will often, in a month or two, in-
duce a return of the eruption in a more copious
and larger form ; and several crops of such erup-
tions  may successively appear.  When the dis-
ease attacks the throat, the soft parts are always
lost.  If there be any tendency in the constitution
to  hereditary or visceral disease, it is generally
excited into action, especially upon the disappear-
ance of the  eruption ;  and caries of the bones,
disease ofthe joints, dropsy, &c, supervene.  In
the successive eruptions of yaws there is often
one ulcer which does not heal, but becomes  larger
than the rest, and if neglected is apt to produce
caries of the  adjoining bones.   Nocturnal  pains,
swellings of the periosteum, ulcers of the pha-
rynx, &c, generally  attend the advanced course
of the distemper; and are accompanied by chronic
hectic, and  general  cachexia.  If the  infection
takes place in the mouth or lips, ulcerations ap-
pear in these parts, and extend to the fauces, pal-
ate—the bones of the palate and those of the nose
becoming implicated.
  88. The duration of the period elapsing from
exposure to  contagion to the commencement of
the eruptive or febrile symptoms varied in several
cases, accurately observed by Dr. Thomson, from
seven to ten weeks.  In some cases in which he
had recourse to inoculation, the eruption appeared
in seven weeks.  The duration of the disease after
the appearance  of the eruption varies from some
months to several  years.   It depends upon the
complete eruption  of the  pustules.  When the
eruption  is  slight, the pustules being few and
small, the hectic cachexia and complications su-
perinduced prolong the distemper, and ultimately
occasion  death, the  eruption  having long pre-
viously disappeared.
  89. ii. Sibbens or Sivvens.—This form of syph-
ilis was formerly seen in the  southwest of Scot-
land, especially in the counties of Ayr, Galloway,
and Dumfries, but  is now entirely extinct.   The
descriptions  given of it by Adams, Hall, Gil-
christ, Hope, Barry, and others, show that this
is the same disease as the yaws, and the syphilis
epidemic in  the  16th century.   Indeed, yaws,
sibbens, and  other forms of syphilis about to be
noticed, are merely modifications ofthe same spe-
cific distemper, owing to local circumstances, man-
ner and habits of living, &c.; these forms being
in no respect different, as to their modes of com-
munication, from the malady of the  15th century.
The syphilis ofthe present day is that form which
has become most sensibly modified in the  course
of ages, but which, under circumstances of neg-
lect, unwholesome living, want of cleanliness, &c,
will in most  cases assume as virulent and infec-
tious a character as was displayed by it when first
disseminated throughout Europe.
  90. Sibbens shows itself, according to  the mode
of infection,  in  modified states, especially at its
commencement.  Like yaws and other  forms of
syphilis about to be noticed, it was communicated
by  sexual intercourse, by mercury, by the com-
mon use of the  same utensils, of the same bed-
clothes, especially when blankets only were slept
in,  and by want of cleanliness, and by two or
more sleeping in the same bed, as not unusual
in former and even in recent times.  In infants
at the breast, and in children, the distemper ap-
peared first in the throat and  mouth, with inflam-
mation of the velum palati and adjoining parts,
followed by a whitish eschar, or a superficial red
ulcer.  At the same time white spots, eschars,
and small elevations of a pearly or milky  colour
occurred on the  insides of the cheeks, lips, &c,
and in  these situations, excrescences,  or small
fleshy  growths,  resembling a raspberry,  which
became covered  with a scab,  were afterward de-
veloped.   These excrescences were diagnostic of
the malady.   This  state, when neglected,  or oc-
curring in cachectic or debilitated subjects, was
followed by destructive ulceration and extension
of the mischief to the pharynx, larynx, &c, with
loss of the velum palati and affection of the bones
of the nose, face, &c.
  91. In others, after pains in the joints, bones,
and febrile symptoms of varied duration, the dis-
ease appeared in the skin, under somewhat dif- ,
ferent aspects.  The whole surface of the body
was often spotted with a coppery or dusky-red
eruption.  In many clusters  of pustules  broke
out, followed by successive  desquamations,  or
scabby eruptions of the scalp, forehead, insides
of the  thighs, accompanied by little hard  tuber-
cles in the skin.  In some tumours resembling
furuncles were seen in various  parts,  and gave
rise to ulcers which perforated the integuments.
These ulcers were  supposed  to  be  produced by
the  virulent  matter of the disease having come
in contact with the  surface, as when the disease
had been caught by sleeping with  the  infected,
or in the same foul  blankets as had been used by
an  infected   person.   Ultimately  soft, spongy,
raspberry-like tumours (hence  the  name  fram-
basia, sibbens, sivvens) broke  forth in various
parts of the body.   Affections of the bones were
not observed by some ; but Bell and others men-
tion nodes and caries.   The affections of the gen-
itals, when not occurring primarily, owing to the
contagion affecting  the surface of the body, some-
times appeared  consecutively.   Different cases
presented somewhat different appearances, mani-
festly owing  to the parts primarily infected  and
affected, and  to the progress the distemper had
made when arrested by treatment.   The disease 
VENEREAL DISEASES-
!—Varieties of Syphilis.
1475
was often fatal in children and infants in whom
it had made progress before  submitted to treat-
ment.
  92. iii. Pian or Epian is the term usually ap-
plied to yaws, as observed and described by phy-
sicians who have practised in the French West
India Islands, and although manifestly the same
disease  as yaws, and as syphilis  at its  earliest
appearance in Europe, presents a few differences
in the character of the eruption, especially, ac-
cording to the descriptions of these physicians.
The  patient experiences slight  fever, with pains
in the limbs and bones, and  small red spots on
different parts of the body.   He loses flesh, and
the skin becomes scaly.  The intensity of these
symptoms slowly decreases,  but the eruption is
developed, and assumes  three  aspects.  The first,
or large pians, sometimes become as  large as the
hand, from  which fungous excrescences shoot,
and a thick sanious  matter exudes.   The small
pians are much less  in  size and more numerous
than the former ; their  excrescences are redder
and less fungous.  The red pians are larger than
the latter, but less than the former, of a flesh
colour, and are developed slowly and successive-
ly ; but  are accompanied and followed by more
serious symptoms than  those of the other two
varieties, particularly those of the first, which is
the mildest.
   93. One of the ulcers of pian generally becomes
larger than the others, forming a deep ulcer of a
bad character, without  fungi, discharging much
sanious  matter.  It  is  aggravated by  the usual
dressings, and is called the mother pian, as a sim-
ilar large ulcer in yaws  is called the  mother yaw.
It is dangerous to dry  it up before  the  general
infection is fully manifested.  In this variety, as
in yaws, if a patient has an ulcer on any part of
his body before the  infection of pians, the  first
pustules are developed upon it, and the ulcer often
becomes the mother pian.  This variety of syph-
ilis, if allowed to proceed, is followed by farther
alterations.   These  consist  chiefly,  1st.  Of ex-
crescences on the soles of the feet and palms of
the hand, which are tender at first, or before they
break, but which, when they break,  discharge  a
purulent matter ; 2d. Of thickenings of the skin
ofthe soles  ofthe  feet and  palms ofthe hand.
These are red, painful, tender, and hardened, but
without exudation;  3d. Of wandering jeains in
the bones, ofthe tumefaction  ofthe spongy bones
and of the extremities ofthe long bones, attended
by caries, softening,  exostosis, &c.   This state
ofthe  disease, called bone-evil,  is often attended
by the formation of numerous ulcers, by affection
ofthe bones ofthe  face, ofthe palate, &c. ; the
patient often being reduced  to a horrible state.
The  chief difference between  yaws, pian, and
syphilis, in its aggravated state  of secondary dis-
ease, is in the fungiform aspect of the ulcers in
yaws and pian : but this state of the eruption in
these affections (Frambasia) is probably to be
imputed to the peculiarity of the skin  and habit
of body ofthe negro, in whom this distemper was
observed by those who  have described it.  The
following accounts ofthe occurrence of syphilis
as local  epidemics are  interesting, inasmuch as
they exactly agree with  the descriptions given of
syphilis in the 15th and 16th centuries.
   94. iv. Disease of St. Paul's Bay (Canada),
Le Mai de Chicot—prevailed between  the years
1776 and 1780, not only in this locality, but also
in some other parts of Canada.  It was described
by Dr. Bowman, who was  ordered by  the  gov-
ernor to investigate the distemper.  In children
most  frequently  the disease  commenced  with
aphthous pustules on the lips, tongue, and inside
of the mouth.   These advanced rapidly, and the
tongue, palate, &c., were sometimes nearly de-
stroyed by them.   The whitish puriform matter
exuded from them communicated the disease to
others.  Older patients complained of pains of
the bones, and of  slight febrile exacerbations,
until  eruptions, followed by ulcers, appeared on
the skin, and in the mouth and throat, when the
pains abated.   These ulcers, according to  their
situation,  which depended upon the contact of
the virus,  were followed, in many instances, by
cervical, axillary, or inguinal buboes  At a  more
advanced  stage the body became covered  with
pruriginous tetters, which  soon disappeared.
The bones of the nose, palate, cranium, pelvis,
and extremities  were  ultimately  attacked  by
nodes and caries.  The frame appeared altogether
contaminated, all  the functions disordered; and
many sunk in a  state  of extreme wretchedness,
especially  children, the weak,  and  neglected.
Robust persons withstood the successive compli-
cations of the  distemper for many years.
  95. The inhabitants ofthe parts where the dis-
ease appeared stated that it was introduced and
extended by sexual intercourse, by contact, and
by  foul clothing.   It spared no  one  exposed to
infection,  but was  most virulent  in  children.
Swediaur, admitting the imperfections  of the
description given of the distemper by  Dr. Bow-
man, considered that it agreed with the  earliest
accounts of syphilis in the 15th and 16th centu-
ries.   It is also manifestly  the same malady as
that which was epidemic in 1800, and in follow-
ing years until 1809, in districts  of Schcrlicvo,
Gronemico, Fiume,  4-c.
  96.  v. The  Syphilis of  Scherlievo, or the
epidemic which received this name from its  prev-
alence in  this locality.   MM. Percy  and  Lau-
rent state that, in this district and those adjoin-
ing it, the commission appointed to inquire into
the nature of the  distemper  found more  than
13,000 persons infected by it, out of a population
of 38,000.  It  reappeared, or became  epidemic
again, in 1808 and 1809, where it seemed to have
been perpetuated  by the filth of the lower orders,
whose damp cabins were shared with  their do-
mestic animals.  The disease usually commenced
with lassitude ofthe limbs and pains in the bones,
which increased  during the night.  The  voice
became hoarse, deglutition difficult, and  the ve-
lum palati, uvula, the tongue, and pharynx, red
and aphthous.  Soon after the aphthae  burst and
discharged an  ichorous matter, which eroded the
adjoining  parts.  Ulcers afterward were formed,
which extended into each other, creating  sores
of various dimensions, but always rounded,  of an
ashy  colour, and  with hard or raised  and  dark
red edges.   These  ulcers were seated  chiefly in
the tonsils, uvula,  velum  palati, tongue,  and
cheeks, and were  followed by caries of the bones
of the face and nose, and the  discharge  of foul,
fetid pus.  The voice was more and more changed,
and at last lost, from ulceration extending to the
larynx. The exostoses and nodes in rare cases
vanished along with the pains, as soon as a pus-
tular eruption  was evolved on the skin.
  97. In many cases, after the pains in  the bones
a pustular eruption appeared  on the  surface,
which M.  Boue states  to  have  been announced 
1476
VENEREAL DISEASES—Syphilis, Diagnosis  of.
by itching, which disappeared when  the erup-
tion  was fully out.   The pustules were of a cop-
pery colour, round,  and of various extent;  and
appeared  most frequently on the forehead  and
hairy scalp, on the inner surface ofthe thighs and
extremities, and around the anus and genitals.
In some cases an acrid ichor exuded from them,
which excoriated the skin ; in others the discharge
dried and formed  scabs.  The disease often re-
mained stationary in this state for a  long time.
After the scabs had fallen off" the skin retained
marks of a coppery hue, which were removed with
difficulty.*
  98. The disease appeared in some cases with
various-sized blotches of a coppery colour, in the
centres of which ulcers were formed, from which
a matter was  exuded which fomed scabs similar
to those  which  covered the  pustules.   These
blotches were surrounded by a  coppery areola.
It was  remarked that the female genitals were
more frequently  affected than the male.   Dr.
Cambieri, among  an immense number of cases,
found only one of gonorrhoea, which complicated
the distemper.  The ulcers which often eroded
the scrotum were consequent upon the  general
infection.   Buboes in the groins, or enlargements
of other lymphatic  glands, were seldom seen.
The  modes of communicating the malady were
the same as those which will appear in  the sequel
(v 109, et seq.).
  99. VI. Diagnosis of Syphilis.—This is often
very difficult;  for although the distemper has gen-
erally presented a modified  and milder character
in modern times,  nevertheless cases  sometimes
occur which,  owing to  neglect, to  constitution
and  habit of body, to treatment  and mariner of
living, are as virulent  as many  of those which
were described by writers in the 16th century,
or of those which  have  been termed syphiloid
diseases.  It will have been remarked,  from what
I have  stated  above, that I consider these latter
as identical with the early  manifestations  of
syphilis in Europe ; the differences  actually ob-
served being only  such as arise from the manner
of infection—from the exudation from the cuta-
neous  and other parts, during the constitutional
disease, having infected these parts in persons
with whom these  exudations had come  in con-
tact, and from differences of race and other cir-
cumstances (v 109, et seq.).  That the disease as-
sumes  a different character as respects the dif-
ferent races, may be expected  in as far as the in-
teguments are concerned ; for, owing to the struc-
ture  and vital  condition and functions ofthe skin,
and to the asthenic diathesis of the dark-skinned
races, and more particularly of the negro, syphilis
attacks these structures with greater severity than
in the white  race—although  even in  this there
are often exceptions—and assumes in the former
the characters described under the head Yaws and
other  Syphiloid Distempers.    As regards  the
treatment, that found most  beneficial in the  one
is also  most beneficial in all the  others.  I have
seen small-pox in the negro in Africa, and yaws
in the  same race ; and the difference of the  for-
  * J. 1\ostius (Medicina Imlonni). 4u>, Lugd. Bat., 1718)
describes the " Amboyna Pox" in terms which are equal-
ly applicable to yaws, sibbens, and other varieties of syph-
ilis, and states that the disease is indigenous to Amboyna,
ths Moluccas, and other Eastern islands.  He says that it
i-i identical with constitutional syphilis, but  differs from
it in being most  frequently communicated otherwise than
by sexual intercourse.  He states that the remedies em-
ployed for its cure are preparations of mercury, of anti-
mony, sarsaparilla, guaiacum, China root, &c.
mer malady in the negro from  that observed in
the white race is as great as that ofthe latter dis-
ease is from  secondary syphilis  in the white.
The causes, efficient and concurring, are the same
in character;  the treatment is also the same;
and  this being  admitted as  respects  yaws, the
inference must  necessarily extend  to the  other
modifications of the distemper belonging to this
category.
   100.  The diagnosis of constitutional syphilis,
as it occurs in the present day in the white race,
and after the virus has passed through many gen-
erations, is often very difficult,  even when  aided
by the history of the case; and this difficulty is
increased by the different tissues and parts which
are secondarily affected, either singly or conjoint-
ly.   Mr. Holmes  Coote has classed the  second-
ary effects of syphilis as follows, and  to  these I
may add the tertiary :
   101.  i. Secondary Symptoms or Effects.—
1. Cutaneous  eruption.—a. Erythema; b. Scaly
eruption ; c. Papular eruption ;  d. Pustular erup-
tions ; e.  Tubercular eruptions.  2. Mucous tu-
bercles, or condylomata.  3.  Ulcerations between
the toes, Rhagades digitoria.  4.  Superficial ul-
cerations of.—a. The meatus auditorius externus;
b. The navel; c. The nose ;  d.  The lips and the
angles of the mouth.  5. Syphilitic affections of
the tongue.—a.  Excoriations of its surface; b.
Ulcerations, fissures,  &c.; c. Induration of its
substance.  6.  Ulceration  of the gums.  7. Ul-
ceration of the  tonsils.—Soft and,  hard  palate.
Excoriations of these parts  without ulceration.
8. Ulceration of the pharynx.  9.  Ulceration ex-
tending to the rima glottidis.   10. Affections  ofthe
eye and appendages.—a. Ulceration of the eye-
lids ; b. Iritis;  c. Sclerotis.  11.  Ulceration of
the roots ofthe nails.   12.  Alopecia, or baldness.
13.  Ulceration of the rectum and large  intestines.
Syphilitic dysentery.
   102.  ii. Tertiary  Effects.—1.  Tubercles or
gummata.—a. Ofthe skin and cellular tissue ; b.
Of those parts passing into  phagedaenic  ulcera-
tion ; c. Of muscular and fibrous structures.  2.
Inflammation of the periosteum.  3.  Inflammation
and  enlargement of joints.  4.  Diseases of the
testes.—a.  Inflammation and enlargement of one
or both testicles ;  b. Atrophy or other structural
lesion  of the  testes.   5. Inflammation of bone
and its effects.—a. Pains in the  bones ; b. Exos-
toses ; c. Caries.   6. Inflammation and structural
change ofthe eyes, eyelids, or lachrymal apparatus.
7. Phagedanic ulceration of the scalp.—a. With-
out  disease of  the  pericranium  and subjacent
bones;  b. With disease of these parts.   8.  Pha-
gedanic ulceration of the pharynx.—a. Extending
to the larynx, cartilages, trachea, &c. ;  b. extend-
ing upward to the bones of the nose,  face, and
palate ; c. extending to and causing caries ofthe
cervical vertebrae.  9. General syphilitic cachexia.
—a. Without any prominent visceral disease ; b.
With  prominent disease of  the viscus,  as the
lungs, &c. ; c. With paralysis ;  d. With dropsy,
&c.
  103.  It is not to be expected that the  lesions
belonging to the first or the second of these classes
of constitutional disease will appear singly.  On
the contrary, they are generally associated in va-
rious forms or  groups ; affections  of the  skin
being often complicated with those of the throat,
tongue, gums, &c.   Affections of the joints may
be conjoined with inflammation ofthe periosteum
and  bones, and  with  phagedaenic  ulcerations. 
VENEREAL DISEASES—Syphilis, Prognosis of.
1477
Even various tertiary lesions maybe accompanied
with one or more of those which are secondary ;
or, more correctly, certain secondary affections,
such as those of the skin and throat, may per-
sist, although one or more tertiary alterations are
fully developed.  Thus,  in a case which I saw
with Sir B. C. Brodie, there were ulcerations of
the throat, pharynx, larynx, nodes, pains in the
bones, &c, consequent upon syphilitic eruptions
and cutaneous ulcerations, which still remained,
the pharyngeal ulcerations implicating the cervical
vertebrae.  The disease in this case was preceded
by suppurating buboes.  In another case, which
I attended  with the late Mr. Copland Hutch-
ison, there were  extensive ulcerations of the
skin ; nodes, caries of the bones  of the nose and
palate,  inflammation  of both  eyes and eyelids,
remarkable enlargement of the knee and elbow-
joints,  phagedaenic ulceration  of the scalp, and
general cachexia.   In other cases, in addition to
affections  of the  bones and joints, there  were
phagedaenic ulcerations  ofthe pharynx, with in-
flammation and necrosis ofthe palate and nose,
enlargement of the bodies  of  the testicles, and
large ulcerating tubercles ofthe integuments.
   104.  The diagnosis of syphilis depends chiefly
upon the  history of the case, especially as  re-
spects the existence of primary symptoms, of bu-
boes, and exposure to infection by direct or indi-
rect  contact,  more especially by sexual  inter-
course, suckling, &c.   (See the Causes, § 109,
et seq.).  The  eruptions in the secondary stage
will generally indicate the nature of the malady;
but even all that has been stated above (<J 57, 81)
on this subject may not be sufficient for this pur-
pose, if other particulars be not sufficiently con-
sidered.  The  colour of syphilitic eruptions, al-
though generally yellowish or coppery, especially
before they ulcerate, may be of a brighter hue if
febrile action be present.  In rare cases the pus-
tular eruptions may very closely resemble  the
eruption  of small-pox;  but  a few  days  will
disclose the differences.  These eruptions and
their rapid enlargement and ulceration in the early
history of the distemper were very common, and
hence the name of great-pox, very commonly given
to them.   Mr. H. Coote very  correctly remarks
that syphilitic eruptions do not always preserve
the same type in the same individual.    The  scaly
and tubercular, or the scaly, papular, and pustular,
may be combined in the same case ; and a  scaly
eruption may exist on the trunk and a pustular on
the scalp.   A scaly eruption often becomes tuber-
cular as  the  constitutional  cachexia  advances.
Scaly and papular eruptions are often coexistent,
both terminating in desquamation, leaving copper-
coloured  stains.   Large tubercles of the integu-
ment pass  into deep, excavated, or phagedaenic
ulcers,  and may be attended by  the usual forms
of rupia.   Syphilitic scaly eruptions are general^
ly circular, and more strictly resemble lepra than
psoriasis.   The eruption on the trunk is  often
different  from that on  the extremities;  on  the
 former it is more generally erythematous, papular,
scaly, and pustular; on the latter it is often tuber-
cular, passing into large and deep ulcers with el-
evated  edges, especially on the lower extremities.
Rupia, however, may equally affect all parts.
   105. Syphilitic erythema usually precedes oth-
er eruptions, but it may continue in the form of
dull red or coppery patches, or coexist with other
eruptions.  The most common eruption is syphi-
litic lepra, the scales of which are dark, and differ
widely from the silvery scales of lepra vulgaris.
This eruption  may extend over the whole body,
causing the hair to fall off, and affecting the palms
ofthe hands and soles ofthe feet.  It spreads into
mucous outlets and canals, into the nasal, buccal,
anal, vaginal, and others, where it causes ulcers,
fissures, tubercular elevations, excoriations, dis-
charges, &c.   Lepra syphilitica often attacks and
excoriates the scrotum, and is frequently attended
or followed by  foul ulcers between the toes, mu-
cous  tubercles about  the arms, in the axillae,
groins, or where  the transpiration ofthe surface
is allowed to accumulate.  The elevation of the
scales of lepra into copper-coloured tubercles  is
always,  according to Mr.  H. Coote, associated
with impairment  ofthe general health, and is an
indication, during a mercurial course,  that the
medicine is acting injuriously, that the treatment
should  be changed,  or at  least that the patient
should be allowed a more generous diet, and  a
moderate amount of stimuli.  The cicatrices from
syphilitic sores,  it  may be remarked, are often
characteristic, being usually rounded, depressed,
of a dull white hue, and irregular on the surface.
   106.  The tertiary effects of syphilis may gener-
ally be recognised with greater certainty than the
secondary.  The history of the case, the antece-
dent symptoms and lesions, however remote, and
the nature of these as inferred from their charac-
ters and succession, are to be taken into account.
But there are hardly any of the lesions which are
termed tertiary that may not be inferred to be one
ofthe more  remote effects of constitutional syph-
ilis, when viewed and considered with reference
merely to its own characters and  relations.  The
mere  enumeration (§ 101, et seq.) of these effects
sufficiently indicates their nature; and are equally
the results of neglected or injudiciously treated
syphilis, as  observed in the present day, and of
the African yaws  as  observed  by myself and
others.
   107.  VII. The prognosis of  syphilis mani-
festly depends  upon  so many circumstances as to
be stated with much difficulty, and even with un-
certainty.   It depends not only upon the progress
the distemper has made, and upon the effects ob-
served, but also upon the health and constitution
ofthe patient previously to infection, and at the
time of his eoming under treatment.   Nor should
the mode of infection, and the course it has pur-
sued, and its recurrences when the distemper has
become  constitutionally chronic, be overlooked.
If the patient  be  young, in previous good health,
be not  exposed  to fatigue, cold, or  anxiety of
mind, and not given to excesses of any kind,  a
favourable opinion may be given  both in the pri-
mary and secondary stages ofthe distemper.  But
if his health, strength,  and constitution be mani-
festly impaired ;  if he be  dissipated, exposed to
fatigue,  and irregular in his habits ;  and more es-
pecially if the secondary effects be severe, be
complicated, have been rapidly developed, or have
reappeared after courses of mercury, or after other
 judiciously employed  means, an  unfavourable or
at least  a guarded diagnosis should be given, the
danger  of the  case fully admitted,  and due pre-
cautions for the guidance of the  patient fully
stated.   In most cases ulcerations ofthe pharynx,
owing to their disposition to extend to important
adjoining parts, or to become phagedaenic, should
be viewed unfavourably, more especially in the
circumstances just mentioned.  The severer kinds
of secondary effects  should also be much dreaded 
1478               VENEREAL  DISEASES—Syphilis, Causes, etc, of.
in infants;  and they are always most difficult to
remove in patients of all ages when they are pro-
duced by the now infrequent modes of infection
(y 110, et scq.) which commonly prevailed in the
16th century, or by the discharges or exudations
of secondary sores, either directly or indirectly
coming in contact with the  naked cutaneous or
mucous surfaces.
   108. The tertiaiy effects of syphilis are always
attended  by more or less present or  prospective
danger.   But the imminence of the  one, or the
amount ofthe other, will depend upon the extent
of lesion already produced, upon its complications
and constitutional relations and effects, upon the
history of the case, and upon the effects of ap-
propriate treatment.  When pharyngeal ulcera-
tion  has become phagedaenic, or has extended to
the larynx, to the bones of the face, and to the
eyes, the patient is in great danger; and this is
more extreme  if the cervical vertebrae become
implicated.   The same prognosis may be given
if, with general  and increasing cachexia, pulmo-
nary, paralytic,  or dropsical disease supervene,
after obstinate, prolonged, or even rapid course
ofthe distemper ; although in some of these cases
life may be prolonged for a considerable time un-
der favourable circumstances, and suitable  regi-
men and treatment.  In this far-advanced  cate-
gory of morbid  results an opinion  of the issue
will  be based upon experience of the effects of
the most influential medicines, upon the local and
constitutional associations of each case, upon the
previous and existing  circumstances of the pa-
tient, upon the history of the malady,  and upon
the  various influences which have modified  its
course.   In respect ofthe tertiary effects of syph-
ilis,  I may state  that an opinion respecting them
should always be given with caution and reserva-
tion ; even although circumstances may not war-
rant that opinion to be unfavourable.
   109. VIII. The efficient Cause of  Syphilis,
and the Causes aiding its  operation.—The
former has  been very  generally  recognised, and
its effects admitted; but all the  modes and cir-
cumstances of its application and operation have
not been sufficiently shown and considered.  The
latter have been cither overlooked or imperfectly
estimated, especially as  regards  the  successive
changes, promoted and brought  to maturity, as
manifested in the secondary and tertiary results
ofthe poison.  The causation of syphilis has been
studied merely  from what has been  observed in
modern times, and from the common way of prop-
agating the distemper at the present day.   But
the  more general way by which this infection was
produced soon  after its introduction into Europe,
and during  its epidemic prevalence, has been al-
together overlooked ; although, under the circum-
stances  existing in these ages,  it may be still
propagated in the same ways, and its effects pre-
sent as severe a character, and the same  features
as those which  distinguished it in former times ;
and which still  distinguish it in  that form ofthe
distemper  which  prevails in Africa, and which
prevailed there from immemorial ages before it
was introduced into Spain.
   110.  The contagion of syphilis at the present
 day, and for many years past,  has  arisen from
 sexual intercourse, either the male or the female
being the  subject of the primary disease.  In
 these cases  the infection is produced  by the vi-
 rus, poison, or  morbid secretion of the  primary
 sore.  This mode is generally admitted, and is
now, with very few exceptions, especially in Eu-
rope, the common mode, no other being acknowl-
edged by many, the exceptions being altogether
io-norcd.   But I have  had sufficient reason to
conclude that whenever  a secondary  venereal
ulceration, seated on the integuments, or in the
mouth and throat, produces a  secretion or dis-
charge which comes in contact with a mucous
surface, or with an abrasion ofthe cutaneous sur-
face, or  is even allowed to remain in contact with
an unabraded surface,  infection  is liable to take
place, and that this liability exists both in chil-
dren and in adults.  The communicability of sec-
ondary  syphilis, especially when the sores have
proceeded to secrete or produce a fluid exudation,
was  a well-recognised fact in former times, and
has been witnessed by myself during the course
of my experience in several instances.   It was a
recognised fact by Dr. Colles ;  and  although
Hunter believed that secondary symptoms could
no longer infect, Mr. Babington remarks, when
commenting  on this belief, that  " the facts (that
they do infect) are so well established, that it is
more easy to  question the principle than to doubt
the facts."
   111.  Judging from what I have  seen in sever-
al countries  and climates, and  in children and
adults in this country, I conclude that the mor-
bid secretion from secondary sores, if allowed to
remain  in contact with the more susceptible sur-
faces or parts of a healthy person, will infect that
person,  provided that he be predisposed to, or sus-
ceptible of, the infection ; and that the local con-
tamination, at first confined to, and more particu-
larly and severely  affecting, the tissues first in-
fected, will become general, and  will  the more
readily  and  severely, by means of the secretion
from the ulcers or  sores produced in the course
of the distemper, infect those to whom this se-
cretion  is either directly or  indirectly applied.
This  mode  of communicating the malady was
often observed in all the varieties  of it described
above as syphiloid diseases,  and in the  usual
manifestations of the  malady, from the end of
the  15th until the close of the 17th  centu-
ry, or even later.   The extensive prevalence of
syphilis during these centuries, although imput-
ed  by many, and probably not without reason,
first to a leprous  diathesis,  and afterward to a
scorbutic diathesis, or to a complication of syph-
ilis with  leprous  or with scorbutic symptoms,
may be more correctly accounted for by the facts
of the  secondary, or early constitutional effects
ofthe malady having become thus virulently con-
tagious, both by this mode of communication, and
by its successive propagation  in this manner.
   112.  If we note the habits ofthe lower classes
in those ages, the ready infection and the severity
of syphilis  are easily  explained.  As  observed
in the present day, with  respect to yaws in ne-
groes, the contagion was produced by the  secre-
tion from the sores on the cutaneous surface, by
mediate or  immediate  contact,  much  more fre-
quently than by sexual  intercourse.  In the low-
er classes in Europe, in the 15th, 16th, and 17th
centuries, the circumstances favouring this mode
of communicating  the  malady were much more
remarkable than in the negro, with whom the dis-
ease most probably originated; for among this
race its antiquity appears to have been  the great-
est, and by this race the  distemper was commu-
nicated to the Moors and Jews in the north of
Africa, and by them conveyed into the  south of 
                    VENEREAL DISEASES-

Spain, where it existed long before the expulsion
of them from the Iberian  peninsula.*   The low-
er classes in Europe during the centuries of the
earlier prevalence of syphilis were remarkable for
their neglect of cleanliness, for their use of wool-
len night and day clothes next to the skin ;  for
the habit of two, three, or more sleeping in the
same bed, often in  a  state of nudity ; for drink-
ing and eating out  of the same vessels ;  and for
these  and other social conditions favouring the
communication of the disease,  in its secondary
stage, independently of sexual intercourse.
   113. With the progress of civilization, and with
the knowledge acquired ofthe communication  of
the distemper by these means, the infection of it
otherwise than by sexual intercourse became less
frequent;  and the  virus more  generally having
to pass through the absorbent system, when the
genitals were the seats of primary infection, was
either arrested in the course of its constitutional
contamination, or rendered more mild, and slower
in producing its successive specific effects, than
when infection was produced by the virulent se-
cretions from secondary sores  applied to parts
which more  readily  admitted  of constitutional
contamination.  The successive propagation  of
the  distemper in this latter mode, and generally
without the intermediate interruption and amel-
ioration resulting from the action of the virus  on
absorbent glands, without the production of bu-
boes, manifestly rendered the malady more rapid
and more severe, and was the chief cause of the
early  prevalence of syphilis being  in some re-
spects different from what is observed of it at the
present day, but in every respect similar to the
varieties mentioned above (v 84, et seq.); many
ofthe influences producing these varieties actu-
ally having existed at the time of, and for ages
after, the introduction of syphilis  into Europe.
   114. As  observation rendered  persons aware
ofthe habits and circumstances causing and fa-
vouring infection, more  especially in  the higher
classes of society, these habits were reformed or
refrained from.  Persons no longer drank out  of
the same glass or cup, or slept  in a strange bed,
without due precaution ;  and much of the man-
ners of modern times originated either in precau-
tions  against infection, or in  evincing a confi-
dence that no precaution was required.   But in
whatever manner the infection may be produced,
whether by primary sores on the  genitals, where
the  morbid  secretion was favourably placed  to
operate its effects, or by the secretions from sec-
ondary sores or ulcers in the cutaneous or in the
mucous  surface, under circumstances favouring
their operation  and consequent contamination—
now occurring  very rarely, in former ages very
frequently—there are a variety of causes or in-
fluences which aid the efficient  or exciting cause
  * Dr. Winteuhottom (An Account of the Xat.ive Afri-
cans, see vol. ii., p. 148) remarks that "the yaws is not
mentioned by authors as a disease which occurs in Egypt,
though, from the frequent communication of that country
with those parts of Africa in which the disease is endem-
ical, we might be led to expect that it would be imported.
There is reason, however, to suppose that the yaws does
actually appear there, though mistaken for the venereal
disease."   He proceeds to remark that a Copt, who pro-
fessed to cure the venereal disease in its advanced states,
prescribed " two coffee-cups of flax oil  to be taken every
morning fasting," directing no regimen farther than to
keep the patient warm.   The pustules and other erup-
tions he covered with a red earth common in some parts
of Egypt.   They gradually became dry, and left no mark.
At the end of three months a cure  was effected.  It is
farther stated that those persons who have been affected
and fully cured have no fear of a second infection.
■Syphilis, Causes, etc., of.                1479

—the syphilitic poison—in developing, hastening,
or in aggravating its constitutional or contamin-
ating effects.  These are so diversified and yet so
influential, whether acting simply or in combina-
tion, as to require a brief but particular notice;
and  are first predisposing, and next concurring
and determining.*
   115. A. The chief predisposing causes of syph-
ilitic infection  are infancy, childhood, and early
age ;  delicacy of constitution,  original or  ac-
quired ; debility  or temporary exhaustion ;  de-
bauchery, fatigue, and irregularities of any kind ;
and the neglect of all those habits and social ob-
servances which constitute modern civilization.
The  precautions observed in  several cities and
places against the propagation ofthe distemper
manifestly tend not only to render it less frequent,
but also more mild, than in other countries where
no precautions  are instituted, especially among
those who  more commonly are infected by, and
who communicate the malady.  But the predis-
position, however produced, or in whatever form
it may exist, favours  not  only the primary infec-
tion  and effects, but also the  development of the
secondary or constitutional disease, and the ter-
tiary results, if the morbid procession be not  ar-
rested by treatment; and, according to the amount
of predisposition, will  be the rapidity with which
the morbid effects are produced.  Doubtless cases
are not unfrequent which  evince no particular
predisposing cause of the infection, or of the  ra-
pidity or severity of the results ; but these may
be imputed  to a diathesis, or some unascertained
cause favouring the operation ofthe poison, or to
susceptibility of infection and contamination  in-
herent in some constitutions.
  [* M. Vidal has clearly proved that secondary accidents
are transmissible, and the same doctrine is supported by
the following British and American authorities : Sir Ast-
ley Cooper, Lectures on Surgery, by Ttrrel, Am. ed., p.
497; Mr. Liston, Elements of Surgery, by Dr. Gross, p.
205 ; Mr. Colles, On Venereal, p. 203; Mr. Wallace,
On Venereal, p. 335; Mr. Hey, Med.  Chir. Trans., vol.
vii., 1830, p. 511; Jesse Foot, On Venereal, p. 402 ; H.
Mayo, On Syphilis, p. 122, 123; Sir B. Brodie, Lecture
in London Lancet, Feb., 1844, p. G7T;  Mr. Babington,
Notes to Hunter, Am. ed., p. 321;  Mr. Lawrence. Lec-
tures on Surgery, London Med.  Gazette, March, 1S30, p.
806, S07 ; Mr. Porter, Lectures on Syphilis, Dublin Med.
Press, Feb. 17th, 1847, p. 99 ;  Mr. Whitehead, Illustra-
tions of transmitted Siixjhilis;  Samuel A. Lane, Lectures
on Syphilis, London Lancet, May 28th, 1842, p. 294; Mr.
Bacot, On Syphilis, p. 252; Mr. Caemiohael, Clin. Lec-
tures on Vener. Diseases, p. 51; Langston Parker, Mod-
ern Treatment of Syphilitic Diseases, 2d ed., p. 169 ; Mr.
Egan, On Syphilitic Diseases,  p. 293, 294; Eusmus Wil-
son, On Syphilis, p. 36; George M'Lellan,  Princ. and
Prac. of Surgery, p. 250, 251;  Dr. Nelligan, Dub. Quar.
Journal of Medicine, Feb., 1853, p. 119 ; Dr. Campbell,
Xorth. Journal of Med., 1844;  or Cormack's Journal,
Sept., 1844, p. 773; JortN P.. Cormack, London and Ed.
Monthly Journal of Medical Science, Sept., 1844. p. 773 ;
Evanson and Maunsell, On  Diseases of Children, Am.
ed., p. 350 ; Jas. Stewart,  On Diseases of Children,  4th
ed., p. 468; Dr. Watson, United States Med. and Surg.
Journal, vol. ii., p. 103 ; Dr.  H. D. Bulkley, On Syphilis
in Infants, New York Journal of Medicine and Surgery,
Oct., 1840; Geo. C. Placeman,  Amer. ed. of Vidal  On
Venereal Diseases, p. 55.  This question is very ably and
successfully argued by Vidal in opposition to Kicoed,
who very inconsistently admits the infection of the nurse ,
by the child and the contagiousness of the mucous tuber-
cle in the adult—in other words, physiological inocula-
tion, while he denies the fact of experimental inocula-
tion.  M.  Malgaigne has very  happily, in few words,
characterized this author as follows :
  " M. Ricord, possessed of a theatre of observation vast
as could be wished, began by  rejecting the observations
of others ; then, adopting a certain theory, he disregards
those of his pupiU made under his own eyes, in his own
service; and finally, I must say it, he takes no heed of
his own when they conflict with his  own preconceived
views."—L' Union Medicale, Aug. 30, 1S51.] 
1480                VENEREAL DISEASES—Syphilis, Causes, etc., of.
   116. That all persons who have not been pre-
 viously constitutionally infected are liable to syph-
 ilis, provided that the virus is applied in sufficient
 quantity, or is allowed to remain in contact with
 a part upon which it is capable of acting, may be
 inferred ;  but there is reason to conclude, from
 what has been observed in persons previously in-
 fected, that a second  constitutional infection of
 syphilis rarely or never takes place, and that such
 an occurrence is merely the return, or the re-de-
 velopment, in  a state of active manifestation, of
 the disease, which had been lurking in a latent
 state in the body, and which various influences
 had reproduced independently of any second lo-
 cal  infection.   While,  therefore, all  previously
 uncontaminated are liable to syphilis, those who
 have been thus diseased are  not liable to a second
 constitutional  infection, provided that they have
 been completely cured; but they are liable to  a
 return in an aggravated form ofthe secondary or
 tertiary disease, if it  have  not  been  completely
 eradicated, especially if they are exposed to the
 causes about to be noticed (y 117, 118); or, in
 other  words, that constitutional  syphilis, when
 cured, renders  the body unsusceptible of a sec-
 ond constitutional infection.*
   117. B.  Several  causes favour, 1st, the devel-
 opment ofthe constitutional disease from  the lo-
 cal infection or primary sores; and, 2d, the ag-
 gravation  and local manifestations of the syphi-
 litic contamination, when it is not completely re-
 moved, but remains lurking in a more or less la-
 tent form, in the body.  The  most remarkable feat-
 ures of constitutional syphilis are the severe and
 even dangerous developments sometimes assumed
 by it after it has  remained for several, or even
 for many, years latent in the frame.  These cases
 present two difficulties—first, to estimate the in-
 fluence ofthe poison in affecting the vital cohesion
 and conditions of the tissues in  so permanent  a
 manner as to render them liable to ulterior changes
 and disorganization after very  remote periods;
   [* We are by no means convinced that syphilis can
 only occur once in the same individual.  No fact is better
 established than that a person may have repeated attacks
 of the disease, especially of the milder forms.  Syphilis,
 like other diseases,  occurs under various forms and in
 various degrees of severity.   The virus may only induce
 a chancre, which is readily cured, leaving the constitu-
 tion perfectly sound; or it may'produce caries, necrosis,
 various visceral aff. ctions, and profound cachexia, from
 which it is very doubtful whether a patient ever entirely
 recovers.  If, under the latter  circumstances, a person
 exposed to new infection has a new bubo or chancre, the
 advocates  of the  unicity of syphilis  maintain that it is
 only a relapse, and not the result of the recent inocula-
 tion.  Statistics are wanting on this subject, but it is
 stated by  M. Vidal that M. Bouley, physician of the
 Lourcine in Paris, produced a second syphilitic infection
 in a woman labouring under genuine tertiary symptoms
 by inoculation.  The obstacles in the way of settling this
 question conclusively are, the difficulty of finding  cases
 so complete that we may know that the syphilitic diathe-
 sis is exhausted, that it has produced all it can produce ;
 and, 2dly. to collect under one head a sufficient number
 of cases to form statistics, the  result of which may be con-
 sidered a pathological law of real value.  When  we con-
 sider the varying durations of syphilis, its  modifications
 in different constitutions, the suppression of many of its
. manifestations by treatment, its relapses  from  various
 causes, &c, we shall perceive at  once the difficulty, if not
 impossibility, of establishing any such law.  In cases of
 typhoid fever, variola, rubeola,  pertussis, &c, no great
 difficulty exists,  inasmuch as they are acute diseases,
 continuing but for a short period, and most persons are
 liable to repeated exposures.  At any rate, this question
 cannot be settled till it is ascertained what is the duration
 of the primary, secondary, and tertiary stages of syphilis,
 how long it takes to expend its fnll force, and, indeed,
 whether confirmed  syphilis  is  ever perfectly curable,
 which is denied by some of the ablest syphilographers.
 See Vidal, Am. ed., p. 290.]
and, second, to recognise the effects of constitu-
tional remedies upon  these vital conditions and
consecutive changes, and to determine how much
of these effects may be imputed to the operation
ofthe means employed, and to the efforts of na-
ture, or ofthe vital resistance opposed to succes-
sive changes.   It is impossible for these difficul-
ties to be overcome without a satisfactory knowl-
edge  of  the various  circumstances which thus
tend to develop the constitutional infection, and
to aggravate this infection into dangerous local
disease.
   118. Observation satisfactorily and extensively
conducted  will demonstrate that all depressing
influences  acting upon the body after infection
has been produced will favour the supervention
of the secondary upon the  primary disease;  and
will even more remarkably develop the latent con-
stitutional taint  or contamination, wherever it
exists, into active disease and disorganization.
Among  these aiding and determining  causes
may be mentioned anxiety of mind, and  fears of
the consequences of infection ;  fatigue, debauch-
ery, drunkenness, venereal excesses, unwhole-
some and  insufficient food ; want of sleep  and
sufficient repose;  excessive exertion, exposure
to extreme ranges of temperature;  moist states
of the atmosphere ; and exposure to  malaria in
any form, more especially miasmatous exhalations
in hot countries.   While these causes aid the con-
stitutional  infection in  accelerating the  changes
resulting in local disorganization, they also coun-
teract  the  vital resistance  opposed  to these re-
sults, and throw down the barrier which  the vital
force raises for the protection ofthe organization.
   119. C. Infection of the  Fatus by one or both
Parents.—Congenital syphilis, or the direct trans-
mission of syphilis to  the unborn fcetus, is a sub-
ject of considerable interest.   That the syphilitic
taint is more frequently in  the father than in the
mother appears manifest;  but it is not so evident
that the  disease is conveyed directly from the
father by means of the seminal fluid to the ovum,
for the father may first infect the mother, the dis-
ease being afterward communicated by her to the
foetus. Secondary syphilis, however, being a con-
stitutional  taint,  like  other constitutional taints,
it may be transmitted  to the offspring from either
parent, in  a more or less modified form.  There
can be no doubt, also, that secondary syphilis may
be communicated to married women by their hus-
bands  without pregnancy  having taken place;
or even to  them or to  any one else by close con-
tact, independently  of sexual intercourse, when
the circumstances stated above (y 112) favour the
infection.
  120. Dr. Porter mentions the case of a lady
who had become pregnant three months before the
father's first contraction of syphilis, and whose
foetus died within a week  from birth  of unmis-
takable lues.  The circulation of the mother had
therefore been poisoned at a considerable time
subsequently to impregnation, although the father
had never a sore  capable of furnishing a drop of
matter, and the mother never a  symptom of any
description, until an eruption appeared  a few days
before  her  delivery.    Dr. Porter believes " that
the semen  of a diseased man deposited in the va-
gina of a healthy woman, by being absorbed, may
contaminate that woman withoutthe necessary oc-
currence of a chancre  or any open sore secreting
matter in either  the man or the woman."   Mr.
Holmes  Coote very  correctly remarks (and hia 
VENEREAL DISEASES—Syphilis, Causes, etc., of.
1481
remarks bear out my own observations in a variety
of cases) that " when the mother has once been
infected with the syphilitic poison it becomes ex-
tremely difficult, if not  impossible, to say when
the taint will become extinct.   The immediate ef-
fect, as regards the foetus, is to cause its death  in
utero.   As the  poison becomes less virulent, the
child is born with  the disease, and perishes  in a
few days or weeks.  Then comes a class of cases
in which the characteristic eruptions break out
some weeks or even months after birth ; but the
exact limits of these periods  have not been, and
perhaps cannot be,  accurately ascertained.   In
Illustration of these  remarks, I refer to the two
following cases. In the first a respectable woman
is infected by her husband. She is delivered con-
secutively of three dead children.   At the expira-
tion of thirteen years she gives birth to a living
child, which is covered by the usual eruptions
shortly afterward.   In the second, a fine healthy-
looking young woman is infected by her husband
a few weeks after  marriage.  She is delivered of
a dead child ; after which she does not again be-
come pregnant.  But, eight years having passed,
she suffers in her own person from the original
taint."  (Op. cit., p.  129.)
   121.  While I was physician to the Infirmary
for Children, cases  illustrative of the above re-
marks,  as well as of the following statements,
were occasionally  brought under my observation.
1st. That an infected mother  may not commu-
nicate the disease  to her infant.  2d. That an in-
fected mother is very liable to transmit the dis-
temper to the foetus or infant.  3d. That the moth-
er has been infected several,  or even for many
years, has  given birth to one or more dead  chil-
dren, and has  had at  last a living child, which
soon after birth presented the syphilitic cachexia,
with anaemia, copper-coloured lepra, and ulcera-
tions ofthe nose, mouth, anus, or genitals.   4th.
The mother has had syphihs  communicated  to
her by her husband; and the disease has disap-
peared,  but she has  been delivered of dead  chil-
dren ; and after a number of years from the  in-
fection  by her husband, the  distemper has ap-
peared  in the throat and bones of the palate, or
in other parts.  5th. The mother has  been the
subject of syphilitic eruptions, &c, has been ap-
parently cured; but after many years has had a
return  of secondary symptoms, and  been preg-
nant, either in  the interval or at a later period.
The child when born, has been, and has continued
in good health for several months or years, but
has presented secondary symptoms subsequently.
6th. A woman  has been the subject of secondary
syphilis—of syphilitic  eruptions,  &c, and has
communicated the distemper to the child given to
her to nurse.   7th.  Secondary syphilis in a child
has been communicated to  another child  with
which it has slept, the severer forms of secondary
disease  resulting.   8th. Secondary syphilis in a
child has been by it communicated to its nurse,
who has soon afterward experienced the charac-
teristic  syphilitic eruptions, sore throat, alopecia,
and other  still more severe  affections.  9th. A
healthy woman has suckled, even for a few times,
a syphilitic infant, and  the secondary disease has
been communicated  to this woman by this infant;
she afterward  has suckled her own infant and
given it the distemper.
   122.  These  statements have been fully  con-
firmed by my experience at the institution men-
tioned above, and in private as well as in gratu-
itous practice, during a number of years, and will
readily be  admitted  by other experienced phy-
sicians.   Indeed, they  are fully confirmed by the
writings  of Dr.  Colles, Mr. H. Coote,  and by
nearly all the old writers on syphilis.  Dr. Colles
remarks that the child may be infected after birth
by a nurse suffering syphilitic ulceration of the
nipple, or by its mother under the same circum-
stances, if the disease of her nipple has been de-
rived from a strange child ;  but that no instance
is known of a  child infecting its own mother,
although  it will immediately communicate the
malady to a strange nurse.  The infection of the
nurse by a diseased infant manifests itself by syph-
ilitic  affections  which  cannot  be distinguished
from that succeeding primary disease—by ulcer-
ations of the throat, &c, by  cutaneous eruptions,
and by the formation of moist excrescences about
the pudenda, which  are capable of infecting her
husband, in whom they are  likewise followed by
constitutional effects.   In him the ulceration of
the throat has not the same venereal character;
it is superficial, and its  surface is covered  with
patches of whitisl) lymph.   Dr. Colles believes
that the disease may be further imparted  to other
members ofthe  family by contact, the use ofthe
same utensils, &c, for it is  remarkable, he adds,
that its contagious property increases as it ex-
tends farther from its source.  Its symptoms, he
states, bear an  exact resemblance to each other
in different individuals ;  and in this third remove
from  the source of contagion, it is permanently
fixed  in the parts it first seizes, and is of a much
milder nature.   If we compare the histories of
the manifestations  of  syphilis in different ages,
as furnished us by the most trustworthy writers
down to Oesterlen, Wallace, and to still more
recent authors, we are compelled to conclude that
syphilis is one  specific malady, that it presents
various modifications  resulting from modes of
infection, race, treatment, and other influences;
all its varieties  being  traceable  to one stock or
source.
   123. D. Inferences.—As the result of obser-
vation and research, I  conclude, 1st. That syph-
ilis,  in  the various forms  and  modifications it
has presented in different ages  and localities, is
derived from, and hence originally identical with,
the indigenous yaws ofthe native Africans.   2d.
That this identity or derivation is proved by the
characters of both forms of  disease, by modes of
infection  or contamination,  by the  susceptibility
and unsusceptibility of both, as shown by  inoc-
ulation,* and by the  same treatment being appro-
priate to both.   3d.  That the indigenous African
or Ethiopic syphilis was communicated to the
Moors and Jews in the  north of Africa, and thence
conveyed into Spain, and probably also into France
and the north of Italy, even before the discovery
of America.  4th.  That the distemper was far-
ther diffused and rendered epidemic or pestilential
by the  expulsion of the Moors  and Jews  from
Spain by Ferdinand, towards the end ofthe 15th
century, and by the distresses consequent  upon
this act;  the miseries  and the horrible  sufferings
resulting from  it, as well as the diseases  diffused
by it, being recorded by contemporary  writers.
5th. That this  occurrence shortly preceding the
  * The yaws are inoculated at an  early age in  many
places in  Africa, in order to prevent subsequent  infec-
tion ;  and syphilization is now practised in some places
in Europe  to prevent infection,  as well as to produce  a
permanent cure of constitutional syphilis (see syphiliza-
tion in the sequel). 
silis, History of  its Treatment.
1482          VENEREAL DISEASES— Syp*

invasion of Italy by Charles VIII. of France, by
augmenting the sufferings and distresses of the
inhabitants, increased the spread ofthe malady,
and rendered it at the same time more virulent,
acute, and fatal.  6th.  That the diffusion, severi-
ty, and the infectious character ofthe malady were
promoted by the distresses then prevalent in those
countries, and for many years afterward, by the
prevalence of a leprous, or of a scorbutic diathesis
in many, and by the habits  and social conditions
of communities in those ages and countries.  7th.
That there is sufficient evidence to conclude that
the disease existed as now  stated, and  had been
propagated extensively, before the  connate mal-
ady, the yaws, or pian, or epian, which  was said
to have existed in  America when discovered by
Columbus, could have been conveyed by his fol-
lowers  into Europe.   8th.  That the manifesta-
tions of the distemper, usually described as vari-
eties of it—as yaws, epian, or as syphiloid dis-
eases, or as pseudo-syphilis  ;* the chief of which
are noticed above (y 84, et seq.), are merely modi-
fications of the malady  resulting from modes or
sources of infection, race, social  conditions and
habits, food and regimen, neglect of cleanliness,
treatment, &c.,as already insisted  upon (y 111,
et scq.).   9th.  That whatever lowers  the  vital
forces ofthe economy, and more especially a com-
bination of causes producing this effect, will favour
the infection of syphilis, the development of the
constitutional  contamination,  and the  outbreak
ofthe distemperwhen it lurks in the body.  10th.
That the parent tainted by syphilis will often, but
not always, communicate the  disease in a more
or less severe constitutional form, with marked lo-
cal affections, to the fcetus—with a severity often
sufficient to destroy the life of the foetus, either
previously to or soon after parturition ;  and that,
in many cases where the venereal taint has not
been congenital, scrofulous diathesis or more man-
ifest tubercular disease will result.   (See y 82,
et scq.)  11th.  That many ofthe circumstances
and social habits which have been shown above
to have favoured the dissemination and severity
of syphilis for ages, after it was introduced into
Europe, now no longer exist, excepting in limited
localities; but when they have  existed in more
modern times, the distemper has presented  a se-
verity, and other characteristics displayed  by it
in former ages.  12th.  That there is reason to
believe  that the disease existed  in China  from
time immemorial, or at least ages before the pe-
riod at which it became  epidemic in Europe ; but
the extent, or the  form, of its  prevalence in that
country at the present day I have not the means
of knowing.*   13th. That inoculation,  as prac-

  * Sydenham believed the yaws to be the same disease
as syphilis.  The writer of the article " fyp'eiv," in the
" Encyel'ipidie Methodique," has classed it, the yaws, and
venereal disease as the same maladies.  " Epian. Nom
que les naturels de Sajnte-Dominique donnoient i la ve-
role, qu'on croit avoir et '■ endemique dans cette ile.  Quel-
ques-uns ont cru que cVtoit un caractere de maladie plus
grave et plus facheux encore que  la verole;  mais il est
actuellement prouv^-, que e'est la meme maladie que les
Franeois ont appell.- mal de Naples, et les Italiens mal
Franiois, chacun  s'empressant  de dtsavoucr I'origine
d'un mal aussi honteux, et accusant ses voisins d'en avoir
propag ■ la contagion."  (Tome vii., p. 2.)
  t My relative, Mr. Pottinger, who passed  some time
in China, informed me that syphilis appeared to be a dis-
ease of great antiquity in that country, and that the pri-
mary sores caught by Europeans from ( hinese females
generally assumed a phagedaenic or sloughing character.
The constitutional affection rarely occurred.  He states,
in answer to my inquiries, that the disease appeared in-
digenous to the country; that secondary symptoms are
tised for ages on children by the negroes on the
Gold Coast, for the prevention of yaws, and as
lately had  recourse to on the Continent against
syphilis (see Syphilization, y 155, et scq), may be
expected to lead to some important results.
  123.*  IX. Treatment.—i.  History of.—It
would appear, from the earliest writings respect-
ing the  discovery  of America, that  the disease
existing  in Hispaniola, when  discovered by the
Spaniards, was  a variety of syphilis, if not the
same distemper, or the same as the yaws existing
at the same time, and for centuries previously, in
Africa (see y 84, et seq.);  that this disease  was
treated successfully by the natives of Hispaniola
by the decoction of guaiacum ; and consequently
that guaiacum was employed by the Spaniards
who had there contracted the  disease.  We ac-
cordingly find many of the early writers on syph-
ilis, especially  from the commencement to  the
middle  of the  16th  century—as  De Hutten,
Delgado, Ferro, Poll, Zene, Gallls. Michel,
Ryff,  Boncossus,  Huschardus,  &c.—recom-
mend guaiacum for its cure.  Although a very few
writers mention, towards the close of this centu-
ry, mercury as a remedy for syphilis, yet it was
not until the  middle of the 17lh century (1649)
that Bonnjonnier asserted that this malady could
be cured by mercury alone.   Some years  after-
ward, Mendez (1668) and Von Hammon (1674)
proposed the question, whether or no mercury
should be preferred to guaiacum in the treatment
of syphilis 1   Since then, and especially from the
commencement of the 18th century until the be-
ginning  ofthe 19th century, mercury has been
the almost universal remedy for this distemper;
and corrosive sublimate was .the most employed
preparation of it; more than one hundred writers
(117) during the 18th century alone recommend-
ing it.   Cieza and Blancard prescribed sarsapa-
rilla ;  the former stating that this medicine was
adopted by the native Peruvians  for the cure of
syphilis, as it prevailed among them ;  and numer-
ous Spanish and Portuguese writers in the 16th
and 17th centuries employed it, in conjunction
with guaiacum  and sassafras ; this combination
being very generally resorted to as a part of the
treatment of syphilitic cachexia down to the pres-
ent day.
  124. Early in the 18th century, Willoughby
(Salivation shown to be of no use or efficacy in the
cure ofthe Venereal Disease, 4to,. Lond.,  1723)
contended  against the practice of salivation, then
so generally adopted;  and in 1779, Cockburn
affirmed that all venereal ulcers will heal under a
local treatment merely, and that mercury should
be resorted to only when constitutional symptoms
appear.   Early in the present century several ar-
my  surgeons, probably instructed by their observ-
ations in Spain and Portugal, where the prac-
tice followed before the general introduction of
mercury  still lingered, proclaimed  the treatment
of syphilis without mercury ; and from 1820 to
1830, experiments were made  in the hospitals of
Sweden—a country where scientific  progress is
always in advance—and in Hamburg, on the non-
mercurial treatment of this  distemper.   In  the

not more frequent among Europeans in China than  else-
where ; that the phagedenic form of chancre was very
common, but the round indurated  ulcer was often met
with, and was extremely obstinate; that as the  phoge-
dienic sore progressed towards a cure, much hardness ap-
peared about its edges; and that it was then necessary to
make the gums slightly tender in order to heal it up com-
pletely. 
VENEREAL DISEASES—Syphilis, Treatment of  Primary.            1483
present day there can be no doubt of the success
of this treatment in the majority of cases ;  and
that  the worst states  of the  disease—the most
prolonged and most dangerous forms—have been
those for which mercury had been most  abund-
antly employed at an  early stage, and the most
copious salivation produced and continued for the
longest periods.
   125.  In  the summer of 1825 the iodide of po-
tassium was first prescribed by me for the cure
of secondary and tertiary syphilis, and the pre-
scriptions were then prepared by Mr. Morson, the
well-known  operative  chemist,  who  also, about
the same time, prepared for me  an iodide of sul-
phur, in order to employ it in similar cases; but
I soon relinquished the internal use of the latter
for the former, as being, even in small doses, too
irritating to the digestive mucous surface.   In
the following year I had recourse, in the case of
E. L., Esq., M.P., to  the use  of iodine.  This
case, the nature and history of which was well
known to Mr. C. Beevor, of Upper Harley Street,
had  been treated  unsuccessfully by mercury in
every conceivable form and combination;  and
when it came under my care I viewed the severe
symptoms, which were seated chiefly in the large
joints,  as  the result of the combined effects of
syphilis and mercury.   Iodine was had recourse
to successfully in this  case.   The correspond-
ence between this gentleman  and  myself re-
specting the treatment during his absence from
London is  still preserved by me in proof of the
early and successful employment of iodine and its
preparations for secondary and  tertiary syphilis.
   126.  Since 1825 I have prescribed these prep-
arations whenever I have been consulted in cases
of this nature ; but in some, and in certain stages
and  states of the disease, they have failed, as in
two  instances which lately came before me, and
which I remitted to the care of Mr. H. Lee, for
the employment of his plan of mercurial fumiga-
tion.  Most ofthe severe and dangerous cases of
syphilis which I have  had an opportunity of wit-
nessing have been  reduced to  this  state by an
excessive or an improper use of mercury ; and it
has  been more especially in those cases that the
use  of iodine, especially the iodide of potassium,
has been most successful.  The worst symptoms,
which have been too frequently ascribed  to local
manifestations of syphilis, especially affections of
the  periosteum, bones, &c, have  been  demon-
strated to me to have been the results of excessive
doses of calomel alone, very commonly given in
hot countries, during the early part ofthe present
century, for the cure of fevers.   At one period it
was attempted to bring the system under the in-
fluence  of mercury in  these maladies,  but the
practice very generally failed ;  and  in some of
these cases, in which recovery took place, disease
ofthe periosteum was the result.*

   * The following interesting case illustrates this fact:
it occurred more recently than the period above referred
to.  Some years ago a gentleman trading to  the west
coast of Africa was attacked by fever, and was treated by
calomel given in scruple doses every three or four hours.
He recovered from the fever, and returned to  England.
I was called to see him soon afterward, and found him
completely hemiplegic, with two large  swellings  of the
pericranium.  Having heard the account of his case, that
he had never any venereal symptom, primary or second-
ary,  that he had taken an excessive quantity of calomel
during the attack of fever, I inferred that a tumour of the
dura  mater, as well as of the pericranium, had resulted
from the calomel, and now pressed upon the brain.  The
iodide of potassium was therefore prescribed, and he rap-
idly  recovered the use of his side,  the paralysis disap-
  127. ii. Treatment of Primary Syphilis.—
A. The intensions of cure in this stage of syphilis
are, 1st. /To destroy the poisonous ulcer and heal
the part as soon as possible ; and, 2d. To prevent
the contamination ofthe constitution.   Theirs*
intension  is best accomplished by touching the
sore  with nitric  acid, nitrate  of silver, or any
other escharotic.  The penis may  afterward be
wrapped in a rag dipped in warm water.  An ape-
rient may also be given, and rest and low diet en-
joined.   If the sore have lasted above a week, it
may still  be expedient to  destroy it;  but there
will  not be the  security against constitutional
contamination which  an earlier recourse to these
means might afford.  When, however, the chan-
cre consists of a well-marked indurated lump, or
when the penis is swollen and inflamed, the pa-
tient  feverish,  or when there is swelling  or ten-
derness in the groin, then the above local treat-
ment is  no longer applicable; and mild liquid
applications, consisting of the black wash, lotions
containing tannin or catechu, or of other substan-
ces capable of decomposing the contaminating se-
cretions, may be prescribed to the affected parts.
If there be  much irritation, the penis should be
enveloped in a poultice, or in a fomentation of
boiled chamomile flowers and poppy heads, and
the patient kept  in bed.  If induration exist, an
ointment  with calomel may be applied.   " After-
ward, during the indolent and granulating stages,
the sores  may  be treated with any astringent lo-
tion, and be touched occasionally with nitrate of
silver or sulphate of copper."  (Druitt.)
   128. B. The prevention of the constitutional con-
tamination of syphilis was formerly attempted by
a recourse  to  mercury contemporaneously with
the treatment of the primary sores, the belief be-
ing general that where this  object was not attain-
ed by means of this substance, the disease would
infallibly  proceed from bad to worse.   Had, how-
ever, the  malady been  studied with a due refer-
ence to its origin and to its  treatment, during the
earlier periods of its history, as well as to the
treatment ofthe connate malady, of which I have
contended that it is merely an extension and mod-
ification,  a different method of cure would have
been instituted; and a recourse to mercury would
have been either reserved or entered upon in such
a  manner, and with  such precautions, as would
have secured  successful results.  The modern
opinion, however, is, that every case of primary
syphilis  may  be treated without mercury;  that
the too profuse administration of it may render
the disease infinitely worse ; that there are many
cases which do not admit of it at all; but that in
the  right cases the moderate and judicious use
of mercury removes the existing symptoms, and
renders the patient far less liable to a relapse.
   129. Mercury is either  not required  or not
admissible  under the following circumstances:
 " When the primary sore has been destroyed, or
has healed within seven days from its commence-
ment ; when it is much inflamed, irritable,  slough-
ing, or phagedaenic;  when the patient is feverish
and irritable ; when a bubo is present;  when the
health or constitution has  suffered from  attacks
of syphilis or the use of mercury ; when mercury

pearing with the subsidence of the pericranial tumours.
He has continued in good health up to this time.
  While this was passing through the press I was called
to a lady similarly affected to the above case, after the
prolonged use of mercury for hepatic disease.  The iodide
of potassium has already been very beneficial to her, but
sufficient time is not yet elapsed to show the full results. 
1484
VENEREAL DISEASES—Syphilis, Treatment of  Primary.
is known to cause rapid salivation, or to occasion
loss of flesh,  sore throat, night sweats, or  mer-
curial erethism ; and when scrofulous disease is
manifestly pronounced, or when tubercular con-
sumption is  fully developed.  If there  be  none
of these  contra-indications, and  more especially
if the sore  be indurated, mercury may be given,
not because  absolutely necessary to a cure, but
because it has been proved by experience to has-
ten the cure of the primary, and to lessen the
chance of secondary symptoms."  (Druitt.)
   130. But,  as Mr. H. Coote has justly stated,
" every form  of primary syphilitic disease may be
followed by constitutional  affections, the nature
and the duration of which no one can predicate,"
whether the  treatment be mercurial  or non-mer-
curial.   The want of fixed  opinions  as to the
treatment ofthe disease, displays itself in all the
countries of Europe; and although it-causes  much
uncertainty and distrust ofthe use  of remedies,
the injurious recourse to the excessive use of
mercury, so common in former times, is no longer
adopted.   The most important question, howev-
er, is the frequency of constitutional disease after
primary  syphilis, when treated with, or without
mercury;  for the primary affection  is, in by far
the greatest  number of cases, an evil of compar-
atively  little magnitude.   Secondary  syphilis,
when once established, is a disease  of which no
one  can  foretel the  termination.   Its various
phases, their succession and complication, are al-
most beyond the reach of our knowledge, and
often out ofthe sphere of treatment.  Dr. Hen-
 nen  treated  105 cases of primary sores without
mercury ; secondary symptoms followed in eleven
instances,  and all these were cured without mer-
cury, excepting one obstinate case.   In the report
 ofthe Army Medical Department, from December,
 1816, to December, 1818,  1863  cases of primary
 chancre were cured without mercury out of 1940
 cases, ninety-six  having had  secondary symp-
 toms ; the average time required for their cure
 being twenty-one days when bubo did not exist,
 and forty-five days when bubo was present.  The
 average time for the cure of secondary symptoms
 without mercury was from twenty-eight to forty-
 five  days.    In the above  period, 2827 cases  of
 primary affection  were  treated  with mercury;
 secondary symptoms occurred in fifty-one of them.
 The  average time for the cure of primary  symp-
 toms without bubo was thirty-three days; with
 bubo, fifty days;  and for  the cure  of secondary
 symptoms, forty-five days.  Of thirty-two cases
 treated by Mr. Green without mercury, buboes
 occurred in  sixteen  cases, six  only suppurated,
 and  constitutional  disease, preceded by  febrile
 symptoms, followed in nine cases.
    131.  From these data it will be seen that the
 balance of advantages is not much in  favour of
 mercury ;  and yet there are  a  few cases  which
 cannot be cured, or  at least not so soon or cer-
 tainly cured, without this mineral, when used in a
  judicious manner.  The opinions of some of the
 ablest recent writers as to the use of mercury for
 primary syphilis appear to accord with those of
 H. Lee, Druitt, and Acton ; and upon the whole,
 with the  results  of my own experience,  which
 agrees also with the following remarks by Mr.
 Holmes Coote : " I  am far,"  he  states,  " from
 undervaluing mercury as a remedy in syphilis;  on
 the contrary, it is the most certain and powerful
 remedy we possess;  but it requires to be admin-
 istered with caution.  The best method of secur-
ing a patient against the invasion of secondary
symptoms is by destroying the primary sore, when
small and manageable,  by  caustic ;  next, by
healing  the  primary sore when that measure is
impracticable as quickly as possible without det-
riment to the  patient's health.  If we  salivate a
patient in whom a  small superficial  sore is  run-
ning its usual brief course of two or three weeks,
we positively do the man an injury.  But if in-
duration should occur, either in the base of the
sore as in the indurated chancre, or in the cicatrix,
a course of mercury, judiciously administered, is
invaluable."   The rules which should  guide the
treatment of  chancres, are, 1st. To destroy,  as
rapidly  as possible, the  syphilitic virus, by ap-
plying  the  nitrate of silver, the strong nitric
acid, or  the  acid  nitrate  of  mercury, or  the
Vienna paste, to the sore when it is small, and
spreading, but without induration ; 2d. For sores
which  are  not  indurated,  spread  feebly,  and
show signs  of incipient granulation, the adminis-
tration  of mercury is injurious, as retarding the
healing  process, and not protecting the patient
from secondary symptoms  ; 3d. When indura-
tion  exists  in the  slightest degree in or around
the sore ; when the chancre continues to  spread
quickly, or  when, after seven days, it  shows no
disposition  to heal,  then mercury is  required;
4th.  Mercury is either inadmissible, or not re-
quired, or even dangerous, for phagedaenic and
sloughing chancres, and in  the  other circum-
stances  above noticed (y 129);  5th. The longer
a syphilitic sore continues unhealed and secreting
the contaminating  matter, the greater the risk of
constitutional infection ;  6th. The  more robust
the constitution, and the more perfect the general
health, the  risk of  secondary symptoms from pri-
mary sores  appears diminished ; but this  vital
 resistance to contamination should not prevent
 the early cure of chancre, more especially when
 it is indurated, nor prevent a recourse to mercury
 if the sore has been neglected or of long contin-
 uance.
    132.   Having determined, after due considera-
 tion, to have recourse to mercury, the selection
 of the preparation and mode of exhibiting it re-
 quire some attention.  The preparations which
 are most suited to the primary disease, when there
 is no bubo, are the hydrargyrum cum creta and
 calomel, and  in some cases the pilula hydrarg.
 chloridi composita.  The other preparations of
 mercury, especially the mercurial ointments and
 the bichloride, are more beneficial in other states
 of the distemper.   The dose, and frequency of
 exhibiting the hydrarg. cum creta or calomel, re-
 quire no remarks.   They should be regulated ac-
 cording to the state ofthe patient, and their effects
 upon the bowels.   Calomel generally requires to
 be conjoined with  small doses of opium, or with
 the pilula saponis  composita, but in  this  latter
 combination the dose of calomel should be much
 increased.  The object is to produce a slight sore-
 ness and sponginess of the gums, with a very
 slight salivation when indurated chancre exists,
 and to continue it for four or five weeks, preferring
 in the latter case the longer period.  The dose of
 the medicine should be regulated according  to its
 effects.   During this course the regimen of the
 patient  should in part depend upon his state of
 health when commencing it.  He should live reg-
: ularly, but not too  low.  If he be in ill health in
 other respects, the treatment, and regimen, and
 diet suited  to his state should be prescribed.  In 
•
               VENEREAL  DISEASES—Syi

general, excesses  in  food  and wine should be
avoided, and whatever is calculated to disorder
his digestive and  biliary organs.  The clothing
should be warm; and fatigue, cold, wet, the morn-
ing and night air, ought to be carefully avoided.
If, notwithstanding this attention to health, and to
the prevention of disorder,  any ofthe indications
described, when treating ofthe injurious effects of
mercury, make their appearance, the means rec-
ommended for their removal, in the articles Ery-
thism. Mercurial, and Poisons (y  562, et seq),
should be employed.
   [In  regard to the use  of mercury in the treat-
ment of syphilitic diseases, the editor, from a long
course of dispensary, hospital, and general prac-
tice, has  arrived  at the following  conclusions :
 1st. That venereal affections of every description
are  curable without mercury, and especially all
secondary and tertiary forms of the  disease ; 2d.
That the accumulated experience on  this point
ought  to suffice to banish  this mineral from the
 treatment of this class of diseases, except perhaps
in some rare cases, when there is hepatic derange-
 ment and torpor of the liver, when it may be ad-
 vantageously given as  an  alterative,  in  small
 doses  ; 3d.  Mercury has no power to prevent sec-
 ondary symptoms when  given  in  the primary
 stages ;  4th. This mineral, if given freely, will in-
 duce,  and in  all cases increase the tendency to
 ulceration of the  mucous  surfaces, especially of
 the mouth, fauces, palate, and throat, and  also
 cause  affections ofthe bones very similar to those
 caused by syphilis.  The diseases produced by it
 have very generally been confounded with those
 produced by the venereal poison ; 5th. The symp-
 toms following mercurial treatment  are more se-
 vere and difficult to remove than those following
 primary sores not treated with mercury ;  and,
 when  relapses do occur in the secondary  stage,
 they are far more readily removed in those  cases
 where no mercury has  been given;  6th.  Mer-
 cury, when given incautiously,  or  in too  large
 quantities,  especially in syphilitic diseases, tends
 to undermine the constitution, to predispose to
 and aggravate  constitutional  affections,  to  in-
 crease general irritability, to  induce  inflamma-
 tion and ulceration in and destroy the  mucous
 textures, to promote morbid absorption and re-
 moval of the fatty, fibrinous, and  osseous sub-
 stances of the system, and to induce synovial, al-
 buminous,  and  serous accumulations  in the re-
 spective cavities lined with the membranes pro-
 ducing such secretions; though, given in moderate
 doses, and  with proper care, it may tend to re-
 move such  accumulations  ; 7th.  The extent and
 injury to the  soft and bony parts of the system,
 produced by mercury, are more to be dreaded than
 any primary or  secondary effects of venereal
 poison ;  8th. Mercury is not, therefore, a specific
 against any form of syphilitic disease or virus, and
 is not essential to its cure;  thousands having been
 easily, effectually, and permanently cured of every
 form and in every stage of the venereal disease
 without having taken a particle of mercury;  9th.
 Mercury should especially be avoided in slough-
ing sores ofthe penis and other parts, attended
 with high inflammation and tumefaction of the
parts affected, attended with fever, &c]
   133. C. Gangrenous chancre, when it occurs in
strong, sanguine, plethoric, or healthy persons, is
usually the result of excessive inflammatory ac-
tion, and requires large  vascular depletions, free
pinging, and afterward opium conjoined with sa-
hilis, Treatment of Primary.           1485

lines, antimonials, &c.  Locally, poppy fomenta-
tions, poultices with balsam of Peru, or with tur-
pentine, after the nitric acid  lotion, will  detach
the  sloughs.   If the  ulcer which remains  is
healthy, and heals, there is no need of mercury ;
but if it ulcerates, independently of the state of
the general health, or if secondary symptoms ap-
pear, mercurials should be directed.   Sloughing,
gangrene, and phagedana of venereal sores are,
however, most frequently consequences of an ex-
hausted or broken-down constitution, from in-
temperance or other causes.   In such cases, the
application  of opiate and  camphorated lotions  to
the sore, of strong nitric  acid, if it spread ; and
opium and camphor, or ammonia, the fixed alka-
lies and tonics taken internally, aided  by a gener-
ous diet, beef tea, wine, &c, are indispensable.
   134.  D. Phymosis is sometimes caused either
by balanitis, or by one or more ulcers under the
prepuce.  In these  cases there is more or less
discharge.  A chancre is often detected by local
hardness and tenderness.   If the prepuce  be
elongated, and cannot be retracted, circumcision
may be  advisable;  but generally it will be suffi-
cient to split the prepuce so  as to enable the parts
underneath to receive due attention, and the treat-
ment which the character and progress of ulcera-
tion  may  require.  The  fraenum is  not  unfre-
quently perforated by a chancre ;  and it then re-
quires to be divided.   In  the circumstances now
stated, the duration  of the chancre, and the con-
finement ofthe secretion under the prepuce, in-
creases  the risk  of constitutional contamination,
and requires, unless in very recent cases, a re-
course  to  mercury.   A chancre in the  urethra
requires astringent injections, preferably such as
contain the bichloride of mercury, and a  course
of this mineral if not contra-indicated  by the state
ofthe patient.
   135. iii.  The  non-mercurial treatment of
primary syphilis may be  adopted in the  circum-
stances above stated  (y  131, 132),  or even  in
 others where it may be considered prudent or ad-
 visable to have recourse to means which will im-
 prove the general health, and enable the constitu-
 tion to resist the invasion of the poisonous virus.
 If there be debility or impairment of the  digest-
ive and assimilating functions, tonics, the chaly-
beates ; the preparations of cinchona, or of sarsa-
parilla, or of guaiacum ;  cod-liver  oil, simple or
medicated ; the compound decoction  of sarsapa-
rilla, with  or without  iodide  of potassium and
 liquor potassa?, will be found the most deserving
 of confidence, especially  if prescribed appropri-
ately to the circumstances of the case, and if the
patient  live regularly, and avoid  intemperance
of all kinds, and all causes of vital  exhaustion
(y H8).
   136.  iv. Treatment of Bubo.—Mr. H. Coote
states that he knows of no  relation between the
occurrence of bubo and the frequency of seconda-
ry syphilis ; and he believes the idea that  a copi-
ous suppuration from  the  groin  eliminates the
venereal poison to be unfounded.  ' -When swell-
ing ofthe glands occurs in conjunction with pri-
mary syphilis, or is supposed  to depend upon the
syphilitic poison, mercurial  frictions are directed
upon the thighs, that the mineral may pass through
the enlarged parts."   In  more chronic enlarge-
ments the swelling may be covered by a  plaster
of the unguentum hydrargyri, or of the unguen-
tum ammoniaci  cum hydrargyro.  " Leeches are
not often required to an inflamed bubo, but they 
hilis, Treatment of Secondary.
I486          VENEREAL DISEASES—Sypi

may sometimes be applied with advantage." The
existence  of suppuration should not suggest an
early recourse to the lancet, as absorption often
takes place after the skin has become red or even
thin.  Absorption ofthe matter from suppurating
buboes does not add, in Mr. H. Coote's opinion,
to the patient's danger of secondary syphilis.  An
opening, when required in a suppurating bubo,
should always be made in the long axis of the
thigh.   If any burrowing of matter occur, partic-
ularly in scrofulous persons, who are most liable
to buboes, tonics, with a restorative and digest-
ible nourishing diet, are required.
  137. The treatment  advised  by Dr.  Druitt
and Mr. H.  Lee for bubo is very different from
that now stated.   The former writer remarks that
the first indication is  to produce  resolution of
acute bubo—" by rest, aperient and saline reme-
dies, low  diet, leeches  and  fomentations.  The
applications to the chancres must be soothing, and
mercury, if being administered, should be at once
given up.   As soon as the tenderness is relieved,
pressure by means of a compress and bandage, or
by placing a weight on the part as the patient lies
in bed, is useful.  Even if matter does form, and
does not seem inclined to come to the surface, the
iodine paint, cold lotions, aperients, tonics, and
pressure will sometimes cause it to be absorbed.
But if it increases, and the skin becomes inflamed
and shining, a puncture should be made, and the
case be treated as any other acute abscess." The
chief circumstance deserving notice in this quota-
tion is the abandonment of mercury if it have been
already  prescribed.   My observation in former
days has induced me to  agree with Mr. H. Coote
in a recourse to mercurial inunctions  on the
thighs, as they produce " a complete effect upon
the constitution, and may be used with advantage
in cases of chronic bubo, combined or not with
primary disease."   Suppurating buboes, or solid
inguinal swellings, will often disappear under this
treatment, which, to be effectual, he advises to be
done in the  following way : " The patient, sitting
before the fire, should  rub  on the skin  at the
inner part of the thighs a drachm of the  strong
mercurial ointment every night, or every night
and morning.  He should slip on a pair of draw-
ers and go into bed, that the absorption of all that
which stains the skin may go on.  The patient
should not be allowed to wash the part except at
intervals, to prevent the skin from being chafed."
The introduction of a drachm or two of mercurial
ointment into the axillae when in bed will gener-
ally produce the mercurial action when it is  re-
quired in other circumstances.
  138. In cases of indolent bubo the indication is
to improve  the  general health, by sarsaparilla,
tonics, and the other means advised above (y 135)
For these, change  of air, sea-voyaging, removal
to a warm and dry locality, and digestible food,
are the most beneficial means of cure.   The local
use of iodine is sometimes of service both in these
and in the chronic enlargements ofthe inguinal
glands, but it is  not so beneficial as the internal
use ofthe preparations  of this substance, which,
when used  internally,  should be combined with
either the liquor potassae, or with either of the
carbonates of potash, and be prescribed with other
suitable medicines.  If sinuses form, or if slough-
ing or phagedana occur, or if the ulcers become
irritable or much inflamed, the means suitable to
the case,  both internal and external, should be
employed.
  139. v.  Treatment of constitutional Syph-
ILis.—A.  Of secondary Affections.—It has been
contended by some recent writers and stated above
(y 46), that the  simple  and phagedaenic  sores
are rarely followed by  constitutional  syphilis,
whereas the indurated chancre rarely if ever fails
to be  succeeded by the secondary disease.  Mr.
H. Coote  disputes these positions, and concludes
that secondary  symptoms  in  large  proportion
ensue after every  variety of simple  and non-
indurated  chancre.  After primary phagedaena,
too, secondary symptoms may be dreaded, and no
lapse  of time seems to render the patient's  con-
stitution free, the secondary disease partaking of
the character ofthe primary sore.   "If a person
were to have a well-marked phagedaenic  ulcer, I
would not guarantee his not suffering phagedaenic
ulceration  of the  throat after an interval of ten
years, or even more."  Mr. Coote adds,  that no
one who  has  primary syphilis in any or in its
slightest form can be safely guaranteed from the
occurrence of constitutional disease; but if six
months elapse after the  healing of the primary
sore, the patient remaining well, the chances are
greatly in his  favour that he will escape any fur-
ther disease.  An  exception, however, must be
made in the case of primary phagedaena.
   140. It is often necessary to disabuse  the pa-
tient's mind of the belief that the syphilitic pois-
on may be destroyed by some specific which will
enable him to revert to his former habits.   All,
however, that can be done is to combat the dis-
ease as it appears, and to point out those modes
of living which may prevent, although they can-
not procure complete security from, the constitu-
tional infection, or certainly remove the contam-
ination when it has already been produced. Much
depends upon the patient himself, in respect of
the amount of protection which may be afforded
him.  For anxiety of mind, gloomy ideas, and all
irregularities and excesses, and the other  concur-
ring causes mentioned above (y 115-118),  will
perpetuate the constitutional contamination, and
develop its local  manifestations, and  induce a
state  of syphilitic cachexia.
  141. If venereal eruptions, sore throat, &c, be
ushered in, as they often are, by febrile or inflam-
matory symptoms, aperients, salines, and  anti-
monial diaphoretics will be of service.  The  diet
should be restricted, the  patient confined to the
house, and the warm bath often resorted to.
" When the febrile state  has vanished, if the pa-
tient has never taken a course of mercury—or if
he have been subjected to an imperfect course of
it for the  primary symptoms—and his, constitu-
tion is sound, he may take mercury as  already
directed.   If under its use  the strength and gen-
eral appearance are improved, so much the  bet-
ter ; but if the patient gets thinner, weaker, and
haggard, and suffers from chills  and feverishness,
or if his ulcers become irritable and phagedaenic,
it must be given up. The mercurial vapour bath,
or the corrosive sublimate in very small doses, and
not carried to the extent of affecting the  mouth,
will often be of great service when the full course
of the mineral is inapplicable."   (Druitt, Op.
cit., p. 189.)   The  numerous authorities in fa-
vour ofthe bichloride,* and my own experience
  *  l'r. Dzondi, Professor at Halle,  prescribes the bi-
chloride as follows : R. Hydrarg. hichloridi. gr. xij.; solve
In aquae distillatje q. s. et adde micte panis, et sacchari
albi, iifi, q. s. ut fiant pilula? cc,  sing. gr. j.  The pills are
to be rolled in powdered ( anella bark;  and on the first
day four pills are to he taken (one fifth of a  grain); on 
VENEREAL DISEASES—Syphilis, Treatment  of Secondary.
1487
of its  effects, have  rendered  me  partial to the
adoption  of it, in preference  to other prepara-
tions, when a recourse to mercury should be had.
  142.  The iodide of potassium is often of great
service, especially when a recourse to mercury is
considered inexpedient or improper (y  129);  or
after mercurial  remedies have been prescribed
without a satisfactory  result,  or when they ap-
pear to have been injurious.   It is  in these latter
circumstances, and especially where  a protracted
course, or a too  liberal exhibition of this mineral
has  been directed without avail, that the prepara-
tions of iodine, especially the iodide of potassium,
in due solution and combination, according  to
my observation, have been most beneficial.
  143.  The preparations of sarsaparilla, especial-
ly the compound decoction, are  always produc-
tive  of great benefit.   They may  be prescribed
either subsequently to a course  of mercury or
of iodine ; or the bichloride of mercury, or the
iodide of potassium may be taken with the  com-
pound decoction of sarzae, or  with the fluid ex-
tract or  sirup.   In  some  states  of  secondary
syphilis, the muriate or the  nitrate  of ammonia
may be taken in tonic and aromatic  infusions, in
as large doses as will not offend the stomach ; or
the  nitro-muriatic acids may  be tried, either in
weak dilutions or in the infusions just mentioned.
But in  most cases of secondary syphilis, charac-
terized by much debility and loss  of flesh, or by
anaemia, few means  are  so generally useful as a
prolonged course ofthe  bichloride  of mercury in
the  tincture, or  compound tincture of cinchona,
in the proportion of half a grain or a grain to the
ounce of the tincture, a drachm or a drachm and
a half being taken twice or thrice daily in a  little
water, according to the circumstances ofthe  case.
When the throat, palate, or other parts ofthe mu-
cous surfaces are much affected, this combination,
or the bichloride ia the sirup or fluid extract  of
sarzae, aided by gargles containing the bichloride,
or by mercurial fumigation, is very frequently  ef-
ficacious.
   144.  In cases of indurated chancre  of consid-
erable duration, in most cases of secondary syph-
ilis,  and  generally in tertiary  syphilis, analyses
of the blood demonstrate a great diminution  of
red  corpuscles, an increased  amount of albumen,
the  fibrin not being  materially altered  in quanti-
ty.   These results should not  be overlooked, as
they indicate the propriety of caution in the ex-
hibition of mercury, and of selecting the mode of
exhibiting it now advised;  or of adopting the
preparations of iodine, and especially the iodide
of iron, prescribing it in the sirup of sarsaparilla.
   145.  During  the  treatment of  constitutional
syphilis, it should always be kept in recollection
that whatever depresses the vital  force  or im-
pairs the general health favours the development
of the syphilitic contamination and its external

the second day none; on the third day six pills; on  the
fourth none; on the fifth eight pills; on the sixth  none;
on the seventh day ten pills, and so on, until the twenty-
seventh day, when thirty pills are to be taken (li grain).
The  treatment is then complete, but in some instances of
severe secondary symptoms they are to be* carried even
farther.   The pills may be taken on a full meal.  Sarsa-
parilla is also to be taken during the course, or even aft-
erward.   Also animal food ia to be reduced to one half
the usual quantity, and pork and  bacon avoided.  The
cold  night and morning air, and cold and wet are to be
shunned.  I have been consulted by patients for whom
this treatment has been adopted,  but the cases have been
too few to admit of an opinion respecting it.   It is  mere-
ly a modification of the well-known treatment advised by
Van  Swietkn.
or local manifestations ; and that, if the remedies
resorted to produce these effects  upon the con-
stitutional energies, they will very probably prove
more injurious than beneficial.  Hence the rem-
edies should be so combined, exhibited, and alter-
nated ;  and so aided by a regulated diet, and by a
healthy, temperate, or warm and dry atmosphere,
as to  promote  the constitutional  powers;  im-
provement in the healthy appearance ofthe pa-
tient generally indicating the success ofthe med-
icine employed.
  146.  B. The local tn^atment of secondary syph-
ilis consists chiefly of warm,  vapour, or sulphur
baths, for the  eruptions ; of the application of lo-
tions of corrosive sublimate, or ointments con-
taining the unguentum hydrarg. nitratis, or the
unguent, hydr. praecipitati albi, especially when
the eruptions are severe, or are leprous or tuber-
cular.  If itching or irritation be experienced, lo-
tions or frequent sponging the parts with a sat-
urated  solution  of the  biborate of soda  in  any
emollient fluid will generally be of much service.
Dr. Druitt states that " for the common excori-
ated  sore throat any soothing detergent gargle
will do.  When there are ulcers, it  is advisable
to use gargles of corrosive sublimate ; and when
the ulcers are indolent they may be touched with
the linimentum aeruginis.  Mercurial fumigation
is also  occasionally of benefit.  It is effected by
putting a scruple of red sulphuret, or ofthe com-
mon black oxyde, or twice the quantity of mercu-
ry with chalk, on a heated iron, in a proper ap-
paratus, and inhaling the vapour;  a  heated pen-
ny-piece  in a tea-cup will answer the purpose.*

  *  Mr.  Henry Lee has given (Transact  of Med. Chir.
Society of London, vol. xxxix., p. 339)  the following di-
rections as to the use of mercurial fumigations :
  L' I- inding from experience that it was the light-coloured
oxyde alone which volatilized, and produced its effects
upon the patient's constitution, and having reason to be-
lieve that the light colour depended upon the presence of
calomel, I performed a series of experiments with calomel
alone, or mixed in a certain proportion with the gray ox-
yde.  The general result of these experiments has been to
satisfy me that, for the purposes of mercurial fumigation,
five or ten grains of calomel alone is, in ordinary cases,
quite sufficient; and that when the gray oxyde is used,
the admixture  of a few  grains of calomel  will facilitate
its sublimation  and insure its medicinal action.
  " Upon making comparative trials with  calomel alone
and combined with steam, it was found  to  act more cer-
tainly and with greater regularity in the latter case.
  " The plan which I have adopted is very simple.  Two
small lamps are procured in which the methylated spirit
(much cheaper than spirits of wine) is used; over the first
lamp is a thin metallic plate, upon which the ten grains
of calomel are  placed; over the  second lamp is a small
cup of hot water.   A small cane-hottomed chair is placed
over the lamps, and the patient sits upon it.  He is then
enveloped, chair and all, in a blanket;  at the expiration
of a quarter of an hour or twenty minutes he rolls him-
self up in the blanket and goes to bed.
  "For  patients to whom it  may not be  convenient to
procure the spirit lamps, the mode of proceeding may be
varied as follows : The patient is directed to heat a thick
tile in the fire;  this is then put into a night-stool, and a
gallipot full of warm water placed upon one corner of it.
The calomel powder is then sprinkled over the rest of the
tile, and the patient sits over it, being enveloped, as be-
fore, in a blanket.  This  mode of applying the vapour is
very convenient in cases of affections, either primary or
secondary, of the generative organs.  It is  not necessary
in either case that the patient should breathe the mercu-
rial fumes.  It is remarkable how soon the patients' sys-
tems are brought under the influence of the mercury by
this simple means,  and, according to my experience, how
effectually it acts in cases both of primary and secondary
syphilip.  Its great advantage, however, consists in the
very little constitutional disturbance produced, and in the
avoidance of those symptoms of irritation and  debility,
both  mental and physical, which  the prolonged internal
use of mercury is so apt to occasion.  The  mercurial ac-
tion, when the medicine is introduced through the skin,
may be continued for nearly any length of time that may 
1488                VENEREAL DISEASES—Treatment  of Tertiary.
When a foul ulcer is seated in the velum, or roof
of the mouth, or pharynx, or alae nasi, an attempt
may be made to check its ravages, by destroying
its  surface and edges with  acid nitrate of mercu-
ry."  (Op. at., p.  190.)  The ulcerations at the
roots of the nails, or between the toes, are cured
by  the  internal administration of mercury, and
the application of  a solution of nitrate  of silver,
from four to ten grains to  the ounce of distilled
water.  When the hair falls off the  scalp, the
hair should  be kept short, and  the dilute  oint-
ments just mentioned applied, or the means re-
sorted to which are advised in the article on the
Hair (v 32, et scq.).
   147.  Mr. II. Coote remarks that the common
warm bath effects  but little in comparison with
the Turkish  bath, which is admirably suited for
the chronic stages of secondary syphilitic erup-
tions,*  and which may now be procured in Lon-
don.   Extremes, or even alternations, of temper-
ature should be avoided; and the  regimen  and
diet should be regulated according to the habit of
body, the usual modes of living, and the pecul-
iarities  ofthe case, avoiding too great abstinence
on  the  one hand, and too full living on the oth-
er ;  moderation in all things being always ob-
served.
  148.  vi. The  Treatment of Tertiary Syphi-
lis.—In this state of constitutional contamina-
tion, mercury, if exhibited  at all, should be pre-
scribed with great caution, and it ought  not to be
given if it have been previously resorted to, ei-
ther in  prolonged courses, in large quantity, or in
such a manner as to occasion copious salivation,
or any  of the more unpleasant effects described
in the article Poisons (y 562, et seq.).  But if the
patient have  not had recourse to  this mineral in
any form, if none ofthe more severe tertiary af-
fections exist, the bichloride  of mercury may be
prescribed in full  and increasing doses in the
compound decoction  of sarsaparilla upon  a full
meal, or as advised by Van Swieten, or mercu-
rial fumigations may be resorted to.   But  if a
manifest improvement in health, and in  the  local
affection, in a  reasonably sufficient time be not
observed, or if there be any  aggravation  of symp-
he necessary, and may be repeated as often as may be
convenient without injuring the patient's constitution.
  " The smallxuiantity of calomel  which it is requisite to
use at each fumigation is probably one reason why mer-
cury in this form may be used with such comparative im-
punity."
  * Mr. Coote describes this bath as follows: " The clothes
having been removed, and a suitable bathing-dress sup-
plied, the bather is conducted into a heated apartment,
where he is allowed to sit and accustom himself to the
increase  of temperature.  During  this time the body be-
comes covered with a tolerably  profuse perspiration.
Next he is conducted to another apartment, where there
is a higher degree of heat (115° F.), and the atmosphere
is charged with watery vapour.   There he reclines on a
heated marble slab, and undergoes a slow process of sham-
pooing.  The quantity of cuticle that peels off surprises
one  who has not witnessed  the process, but the skin is
left  in a cleaner state than perhaps it had been in for
years.  After the movements of the limbs have been test-
ed in a variety of ways the bather is conducted to a re-
cess, in which is  a fountain with hot  and cold water,
where he may apply soap and hot water as his taste dic-
tates, or have the process performed by an attendant.
A feeling of languor, not by any means unpleasant, su-
pervenes, which renders a short  period of repose on a
couch agreeable.   This process removes a large quantity
of cuticle from the integument, causes the blood to circu-
late through the minute capillaries, and brings into activ-
ity the sudoriparous and sebaceous glands. We may, I
presume, infer  that without the proper performance of
these functions the skin is not in a healthy state; and
that any morbid condition, such as lepra or lichen, would
be materially benefited by rousing them into activity."
(Op. cit, p. 108.)
toms from this treatment, the iodide of potassium
should be substituted, and given in doses of three
grains thrice daily, increasing them to live grains
conjoined with the liquor potassa?, or with  cither
of the  carbonates.   In cases  where  mercurials
have been freely employed, and especially where
there is reason to infer that the affection of the
periosteum or bones  has been caused or aggra-
vated by these medicines, or where there is  doubt
whether or no any ofthe tertiary affections have
been caused as much by mercury as by the dis-
temper, the decided use ofthe iodides ofthe fixed
alkalies is generally the most beneficial.  In  cases
manifesting more or less ansemia (see y 143,144),
the  courses of iodides, and still more those of
mercury, should be followed by a course of the
iodide of iron taken in sirup of sarsaparilla.
   149.  If the  periosteum or bones be diseased,
still greater caution in  having  recourse to mer-
cury is  required, although in strong constitutions,
and where mercury has not been previously given,
full  doses of calomel and opium, or of these with
camphor, will  often  initiate the treatment  with
benefit, and they may  be continued or modified as
long as they  continue of service, and afterward
the iodide may be prescribed, increasing the doses
until success result from  it.   I have  generally
prescribed this  medicine in  the following combi-
nations :
  No. 3T8.  R Potasii Iodidi, 3j. ad 3ij. ; Liquoris  Po-
tassae, rij. (vel  lotassae  Bicarb., 3ij.); Tinct. Aurautii
(vel  t.'ascarillae), jvi. ; Extr. fluidi  Sarza, =jss.;  Infttsi
Gentiana? (Jomp.  ad Jviij.  M.  Fiat  Mist, "cujus  capiat
cochl. ij. vel iij. larga, ter in die in aquae cyatho amplo.
   150.  It will generally be of service to take the
iodide in weak solutions, even when it is pre-
scribed  in the largest doses.   If it relax the bow-
els,  a few  drops of tinctura opii, or a little  tinc-
tura camph. comp. may be  added to each dose;
or the iodide and the alkalies may be taken in the
compound decoction  of sarsaparilla, to  which a
tonic or aromatic tincture, or an opiate, may be
added, according to circumstances.   When this
remedy succeeds in removing the venereal affec-
tion, it should be continued for some weeks after-
ward, gradually diminishing the  dose.  In some
cases it causes irritation ofthe mucous surface
of th6 throat, nostrils, and eyes, with a copious
defluxion, or pains at  the region of the stomach,
or irregular febrile symptoms.   These disorders
are observed especially when the iodide has  been
given in too large doses, or uncombined with the
carbonate  or  solution of potash.   When taken
thus uncombined,  the acid  in the  stomach de-
composes the iodide, and the free iodine irritates
the mucous surfaces.
   151.  In cases of ulceration  ofthe pharynx, or
larynx,  or  of disease  of the bones, of the palate
or nose, mercurial fumigations may be first tried,
if mercury has  not been already employed  ; but
care should be  had not  to allow it  to affect the
mouth.   Sarsaparilla,  with a cautious use of the
iodide of potassium and  sedatives;  the  applica-
tion  of a strong solution ofthe  nitrate of silver,
or of the bichloride of mercury to the  ulcerated
surface, ancj of terebinthinate embrocations to the
throat externally, are  often  beneficial.   Gargles
containing either the bichloride or the  iodine,
neither  of these substances being in such quanti-
ty as to occasion  much irritation of the throat,
may also be tried.   In all these the utmost atten-
tion  and  care  are required.  When tubercula-
ted or other eruptions assume the characters of
open sores or ulcers, the simple or compound 
VENEREAL DISEASES—Syphilis treated by Inoculation.            1489
 tincture  of iodine will be  most  advantageously
 applied to them, in modes and in degrees of dilu-
 tion varying with their appearances.
    152. When nodes are formed, the pain and
 consequences which often result require  iodine,
 alkalies,  sarsaparilla, and opiates, with light, nu-
 tritious diet, residence in a warm and dry air, and
 blisters over the affected parts.  The blisters often
 should be  repeated, in order to prevent,  by the
 external  discharge, the inflammation from extend-
 ing  to, or  disorganizing the  osseous  structure.
 If mercury have not been employed, the blistered
 surface may be  dressed with strong  mercurial
 ointment, and either with opium or morphia ; and
 the diet  and  regimen duly regulated, with strict
 reference to the  several peculiarities of the case,
 to the extent to which the general contamination
 and cachexia may have advanced, and to the state
 ofthe local affections.
    153. vii. Syphilis in Infants  and Children.
 —The treatment should be directed not  merely
 to the infant or child, when the state  of either
 admits of any hope from treatment, but more es-
 pecially to  the parents.   For these as well as for
 the  child,  a mercurial course, if not previously
 had recourse to, should be prescribed ; and in the
 majority  of cases, the bichloride of mercury, ex-
 hibited as above (y 141), or combined with either
 of the  tinctures of cinchona, will be found the
 most efficacious.   Subsequently  the iodide of
 potassium or iodide of iron,  and the preparations
 of sarsaparilla  may be employed, according  to
 the peculiarities  of the case, more especially  if
 anaemia be very manifest.   It  has been recom-
 mended for children to rub ten grains of mercu-
 rial ointment, daily, into the axilla or soles ofthe
 feet, or to administer half a grain or a  grain of
 hydrargyrum cum  creta  every night  until the
 symptoms disappear.   But the disease is not so
 completely  eradicated by these means as by a ju-
 dicious exhibition and management ofthe bichlo-
 ride, especially when followed by the means just
 named, varying the dose, and the vehicle in which
 it is prescribed, with the age and circumstances
 ofthe case.
   154.  X.  Syphilization, or the inoculation of
 syphilis, has recently attracted attention not only
 as a  cure, but as a prevention of any future oc-
 currence  of the  distemper.— i.  History.—M.
 Auzias Turenne  first  proposed  this  startling
 mode of  treating and of preventing syphilis in
 1850, by  bringing it before the French Academy
 of Medicine.  This young physician commenced,
 about 1844,  a series of experiments with the view
 of testing John Hunter's doctrine of the non-
 communicability of syphilis to the lower animals.
 After many experiments and some failures, he
 succeeded in  producing in monkeys, inoculated
 with chancre-matter, a true chancre, and the dis-
 ease thus  communicated to them was transferred
 to rabbits, cats, and horses.   " The malady was
 again returned by inoculation from these to the
 human species, the first trials in this regard hav-
 ing been made by Dr. Robert Weltz, of Wiirtz-
 burg, on his own person.  On four separate oc-
 casions Dr.  Weltz  succeeded in  producing an
 unmistakable  chancre on his own person, by in-
 oculation  from animals, and this  was acknowl-
 edged even  by Ricord."
   155. This discovery, as  stated  by Dr. Rad-
cliffe, issued in one more surprising still, upon
which the process of syphilization is founded,
namely, the  strange  and curative  change ofthe
    III.              94
 disease when the inoculations are often repeat-
 ed in the same individual.  Experimenting upon
 apes, it was found that the artificial ulcers  regu-
 larly diminished in size and virulency, in propor-
 tion as the inoculations were multiplied, until at
 length the virus ceased to take effect.   The sys-
 tem seemed to become protected, as in ordinary
 inoculation  and vaccination, and a state or di-
 athesis was produced in  which the body was no
 longer capable of being affected by syphilis ; and
 the process by which this is accomplished is that
 to which  the name syphilization belongs.  This
 result, also, is all the more  surprising  because
 reiterated inoculations were evidently essential to
 it, for only once inoculated  and then left to them-
 selves, the poor apes speedily perished with all
 the signs of the syphilitic  cachexia.   Having
 satisfied  himself of the  reality of these  results,
 M. Auzias Turenne  then  proceeded to inquire
 whether  man was capable  of syphilization.  He
 had many ardent followers, who eagerly submit-
 ted to the experiment, and who shortly seemed
 to furnish evidence in the affirmative.*
    156. This pretension excited great oppolition,
 particularly in the Academie  de Medecine.  In
 other quarters, however, the impression was more
 favourable.  At Turin, M. Casimiro Sperino, the
 chief surgeon in  the  Syphilicoma, or  Syphilitic
 Hospital  of that city, at  once took up  the new
 views, and put them to the test on a large  scale.
 He was  favourably inclined towards  them, he
 tells us,  for several reasons.   He  had observed
 that severe inguinal buboes are more apt to fol-
 low small and insignificant chancres, which heal
 in a few days, than  those  which are large and
 obstinate ; that the constitutional symptoms held
 an  almost inverse relation to the severity and
 continuance ofthe local disease ;  and that he had
 known many prostitutes,  whose constitutions had
 never been sensibly affected, who had had chan-
 chres for years, either constantly open, or closed
 only to open again immediately.  He had repeat-
 edly satisfied himself that foul buboes were  more
 prone to heal in those cases in which their syph-
 ilitic character had been tested, after  Ricord's
 plan, by inoculations on the surrounding skin.
   157. The subjects of M. Sperino's experiments
 were fifty-two hospital patients, all prostitutes,
 and all suffering  from aggravated forms of pri-
 mary or secondary syphilis.  The virus was taken
 from the person syphilized, or from a comrade—
 from the  first, if possible—and  always  from  a
 growing ulcer.  The inoculations were repeated
 once or twice  a week in three or four distinct
 places, usually in the abdomen.  The time re-
 quired for the establishment ofthe artificial chan-
 cres was from two to three days.   The effects of
 the  second inoculations  were  less serious  than
 the  first; of the  third, than the  second; of the
 fourth, than the third, and so on until  the virus
 ceased to  produce any effect whatever ; contem-
 poraneously with which epoch, all former ulcers
 had healed, and buboes, recent nodular enlarge-
 ment of bones, and cutaneous stains or blotches,

  * In Dr. Winterbottom's work on the native Africans
 already referred to, it is stated, on the authority of Mr.
 ICdwards, the author of the  " History of the West In-
 dies," that  the natives ofthe  Gold Coast of Africa give
 their children the yaws by inoculation, and that they per-
 form the operation by making an  incision  in the  thigh
and inserting some of the matter from the sores of the
yaws. By this means the infants or children have the
disease slightly, and recover  speedily; whereas, by be-
coming  infected at a later time  of life, it is much  more
severe, and  "gets into the bone." (Vol. ii., p. 156.) 
1490           VENEREAL DISEASES—Syphilis treated by Inoculation.
had either disappeared, or were in rapid process
of disappearance.  The virus, also, which made
no impression at this time, was found to  retain
all its virulence when tried upon an unprotected
person.
   158. Since this time M. Sperino has shortened
the intervals between the several inoculations,
and has  increased the number of punctures in
each operation to twelve, sixteen, or twenty, and
with the  effect (he tells us) of expediting the pro-
cess, and of ensuring a slighter form of artificial
chancre.   He has also  subjected  his syphilized
patients to a course of bathing in the sulphureous
waters of Acqui, which waters are notorious for
their power of bringing out secondary symptoms
in the subjects  of  syphilis,  and he  has  found
them to  resist this test as well as  that of inocu-
lation.
   159. Such are the main particulars  of these
fifty-two cases,  as gathered  from M. Sperino's
communication to the Academy of Medicine and
Surgery  at Turin.  No other treatment was em-
ployed.   They are said to have been without ex-
ception of an aggravated character, and without
any spontaneous tendency to  heal. For a month
before the institution ofthe experiments they had
been  purposely  left without  any treatment, and
during this period they had retrograded.
   160. An account of Dr. Sperino's proceedings
was given  by Dr. Radcliffe (in  Ranking's Ab-
stract of the Medical Sciences, vol. xvi., p. 333),
and M. Turenne's  experiments were noticed by
Dr. De Meric (Lancet, July,  1853, p. 203) before
Dr. Sperino's work had appeared.  The subject
has been very recently brought before the profes-
sion in  an able  article on syphilization  in  the
" British and Foreign Medico- Chirurgical Re-
view" (No. xxxvii., p. 410), in which  the  subse-
quent experience of Dr.  Sperino in Turin, of
Professor Boeck in Christiana, of Dr. Daniel-
sen in Bergen, and of Dr. Carlsson in  Stock-
holm,  during  several years,  has been  given.
These enlightened men,  professors  and  physi-
cians to  hospitals in cities where medical science
is in its  highest state of rational cultivation, in-
stead of declaiming against the doctrine promul-
gated by M. A. Turenne, have been engaged in
a series  of careful experiments and observations
to determine its truth or its fallacy.  Experiment
and careful  observation can alone  decide this
question, which is one ofthe  greatest importance
in practical medicine.
   161. Dr. Sperino's observations were confirm-
ed by similar results  obtained by Dr. Gamberini
at Bologna, and by Dr. Gulligo at Florence.   In
 1853, Dr. Sperino  published a detailed account
of ninety-six cases of syphilization.   Of these
ninety-six cases, fifty-three weTe of primary syph-
ilis, and forty-three of the constitutional disease.
Fifty ofthe cases of primary  syphilis were cured,
two failed, and one was not treated by syphiliza-
tion alone.   "Ofthe forty-three  cases of consti-
tutional  affection,  twenty-six  were  treated  by
syphilization alone, and seventeen by this method,
in conjunction with mercury  or iodine.  Twenty-
five of the twenty-six in the first category are
said to have been cured.   In only two cases of
the primary disease did any constitutional symp-
toms appear, and these symptoms rapidly  yielded
under a continuance  of the  syphilization.  No
relapse  has yet taken place in any case.   Many
of these cases were of very severe character, and
were such as were not likely  to have healed spon-
taneously ; while the numerous inoculations that
were  required produced no serious effects, ex-
cept in one or two instances a slight tendency to
form phagedaenic sores."
  162. Dr. Boeck, of Christiana, in  1853, pub-
lished, in the seventh volume of the Norwegian
Medical Journal, the results of a few experiments
he had then made on syphilization.   Since then
he has closely investigated the subject, and has
extended the practice to  infants at the breast.
The same plan of treatment has also been pur-
sued by  Dr. Danielsen in the hospital  at Ber-
gen.  When the writer of the review above re-
ferred to (y 160) revisited this hospital in July,
1856, he  was assured by this physician " that he
fully coincided with the views of Dr. Boeck, and
that the results obtained in Bergen  by syphiliza-
tion were as successful as those recorded by the
latter at Christiana."   The  reputation,  talents,
and high position of those physicians in Norway
are unquestionable.
  163. Dr. Boeck states that all the cases which
he  treated by syphilization  laboured under con-
stitutional syphilis, in its  most varied stages and
forms.   Some of those  cases had previously un-
dergone  every mode of treatment  that  science
could devise, while others had had  no treatment
at all.  He thought it of great importance to col-
lect observations from both classes  of cases.   If
syphilization is  not had recourse to till all other
remedies have been tried, it is difficult to form a
correct estimate of its  powers ; for under such
circumstances, as Dr. Boeck justly remarks, we
can hardly know what symptoms belong to syph-
ilis, and what to the medicines administered; and
particularly to mercury.  He states  that cases
which have  undergone a mercurial  treatment,
persons  of an inflammatory  diathesis, habitual
spirit drinkers, and weakly constitutions, should
not be subjected to this treatment. In these cases
the artificial chancres may take on a malignant
action.   " The bowels  should be regulated, and
the digestive organs brought into good order;
but it is  not  necessary to  enforce any strict rule
of diet.  In  the hospitals of Bergen  and Chris-
tiana the ordinary full diet was always allowed."
Dr. Sperino and Dr. Boeck mention the readi-
ness with which patients  submitted to, and even
sought for, the  mode of cure which they had
seen  so  successful with their fellow-sufferers.
   164.  ii. Modes of  Inoculation.—M. A. Tu-
renne at first  kept  up  a succession of single
chancres; while Sperino  made  three  or four
separate inoculations at once, and repeated these
two or three times in the  week.  After having in
this way reached twenty-four or thirty inocula-
tions in  all, he found that the chancres last pro-
duced were  exceedingly  small, and he then di-
minished the intervals, and made more  inocula-
tions at each sitting.  He found  that the first
chancres were deeper, larger, and more inflamed
than those which succeeded them; and that by
diminishing the  intervals and increasing the num-
ber of inoculations the earliest chancres visibly
diminished, and were less painful  and inflamed.
After a  large number of inoculations which did
not appear successful, he returned to his former
plan  of  inoculating for six to ten  chancres at  a
sitting.  " While these chancres are progressing,
it is not  advisable to inoculate afresh, nor should
this be done until the former chancres arc devel-
oped.  Should the chancres be developed too free-
ly  and threaten  active inflammation, or to extend 
VENEREAL DISEASES—Sypf
as phagedaenic sores, he checks their progress by
inoculating afresh at shorter intervals."
   165. The practice of Dr. Boeck  differs little
from that of Sperino.   He  inoculates for two
chancres only every six days, because he found
from experience that it required about five days
to produce induration in a chancre, although he
does not consider this latter circumstance  abso-
lutely essential.   He subsequently shortened his
intervals to three days, and increased the inocu-
lations to eight or ten. Less time is thus required
to produce immunity; but Dr. Boeck is distrust-
ful of pushing cases too rapidly through their
course of syphilization.  With regard to the parts
of the  body selected by these  physicians for in-
oculation, Sperino preferred the lower regions of
the abdomen, Dr. Boeck the arms and thighs,
   166.  The conclusions drawn by Dr. Boeck
from the eighty-four cases of syphilization, which
he has treated up to March, 1856, are: 1st, that
in all cases, without exception, immunity to the
venereal virus is obtained, sooner or later, by in-
oculation of the poison ; 2d, that the symptoms
of syphilis present at the commencement of syph-
ilization  disappear during the employment of this
mode of treatment ; 3d, that the general health
does not suffer in the least from syphilization;
on the contrary, if the patient has been in weak
health before inoculation, he most materially im-
proves in strength and  appearance during the
process.   These  propositions  are  conceded as
undoubted facts by Dr. Boeck's colleagues, by
Dr. Sperino, by M. A. Turenne, by Danielsen,
by Dr. Carlsson, and by Dr. Stenberg of Stock-
holm.
   167.  The time required  to  produce  immunity
from syphilis by syphilization depends upon the
various strength  of the virus, upon the rapidity
or otherwise with which the inoculations succeed
each other, upon the number ofthe chancres pro-
duced, and upon the idiosyncrasy of the patient.
Dr. Boeck states that "the  attaining to immunity
depends  upon the length ofthe intervals between
each inoculation—the  more frequent the inocu-
lation the more rapidly does it ensue.  If there
were  sufficient virus to be obtained, we might,
if we chose, inoculate every  day;  but if, as is
generally the rule,  we keep to obtaining the vi-
rus from the most recent inoculation, we cannot
easily  do this.   From  my own experience,  I
would  say that the matter obtained in a pustule
of only one day's growth is generally capable of
being inoculated;  but I have also seen that pus-
tules of three days' growth produced no effect;
while  three days later, the  matter taken from
them was decidedly contagious."   (P.  196).
   168. Granting that immunity is really pro-
duced from  the disease, the question follows, Is
it merely from the existing disease, or from any
subsequent  infection"!  and if from subsequent
infection, is the immunity, produced for a  time
only, becoming impaired gradually, and ultimate-
ly lost after an indefinite time ; or is it continued
through life, a diathesis being imparted by it, ren-
dering the frame insusceptible of the syphilitic
infection!*  That the immunity is  at least for a
  [* "I am much inclined to believe," says Dr. Boeck,
" that this is really the case, but to prove it is  not so
easy; for, according to my views, this question cannot
be determined by artificial inoculation.  I have not con-
sidered myself justified in putting those healed by syph-
ilization to the proof of inoculation after some time had
elapsed since the cure, as I thought it possible that such
inoculation might produce constitutional  symptoms, as I
fiiLis treated  by Inoculation.           1491

time, is shown by the fact of the last inoculation
having failed to take effect, however virulent the
matter employed.   Dr. Boeck is of opinion that
persons who have reached  perfect immunity to
inoculation in the course  of syphilization are in-
sured against contracting syphilis  for all the rest
of their lives ; but the lapse of time since the first
employment of this practice admits not of any
conclusive evidence of the fact.
   169. Of forty-two cases of constitutional  syph-
ilis, where no mercury had been previously used,
not one had  exhibited any relapse up to the com-
mencement  of 1856, and many of these had been
for three years or more  without  requiring any
treatment whatsoever.   Of the twenty-one cases
recorded in  Dr. Boeck's first work, six had been
treated without mercury, and in all these syphili-
zation dispersed the symptoms, which have  never
returned.  The average duration ofthe treatment
in these six cases was six months  and two days,
the average  number of chancres were 322.   In
a second class  of cases,  in which the constitu-
tional  symptoms were chiefly confined to the skin
and mucous membranes, but which had all  taken
more or less mercury,  the average duration  of
treatment was  six months and twenty-four days,
the average number of chancres being 432  ; two
thirds  of the number being, however, very small
and transient.   In the third category of cases, in
which the constitutional disease was very invet-
erate,  all of which had been subjected to mer-
curial  treatment,  some repeatedly, the average
duration  of treatment  was  seven months and
twenty-four days, the average of chancres 570.
   170. The  increase in both ofthe last categories
of cases in  the number of chancres, and in the
length of time  required to complete the cure, is
ascribed by  Dr. Boeck  to the previous adminis-
tration of mercury.   It is, however, probable, as
he  observes, that another  circumstance may have
retarded the cure, viz., that  the syphilitic virus
may have undergone a material change during
the many years it had  been resident in the sys-
tem.   The more inveterate, and especially the tu-
berculo-serpiginous forms, were found to be ex-
tremely rebellious to treatment, and some of them
were not cured when immunity was reached.  It
was necessary then to have recourse to iodine,
upon the exhibition of which all symptoms rap-
idly disappeared, though previous to syphilization
both mercury and iodine had proved inefficacious.
   171. Dr. Boeck suspects that in those very ob-
stinate cases a  union ofthe syphilitic with mer-
curial  poison has taken place.   In  most instances
this union seems to be dissolved by syphilization,
and then iodine, which had before been ineffectu-
al against the united poisons, acts readily on the
mercury, and eradicates it from the system.  Dur-
ing the two years elapsed from the publication of
his first work, he had treated sixty-three cases by
syphilization, and of these thirty-six  had  never
taken  mercury.   In the twenty-seven cases, for
which mercury had  been given, he  invariably
found  the cure  more difficult, and  in some cases
impossible  without the aid  of iodine.  Where

believe that syphilization destroys the syphilitic poison in
the system.  Ricord's dogma, that an individual can
only once in his life be affected with constitutional syph-
ilis, may perhaps be erroneous, and the patient might
then be in the position of a  previously healthy  person
newly inoculated with syphilis. I have,  therefore, always
abstained from testing by inoculation those who had not
previously teen Seated with  mercury."—Med. Chirurg.
Review, Apr., 1857, p. 321, Am. ed] 
!492             VENEREAL  DISEASES—Bibliography and References.
mercury has not been  employed, he is decidedly
in favour of syphilization, for, as far as can be as-
certained from the forty-two cases of this  char-
acter thus treated, no relapse had occurred up to
the present period.   A great objection to syphi-
lization is the length of time  required for its com-
plete performance.   In the  Christiana hospital,
the  average duration  of the  mercurial  cure is
three months and a half,  while syphilization av-
erages a full half year.   If, however, the latter be
not liable to relapse—at least in non-mercurial-
ized cases—it is preferable,  even if it required a
much longer period.    It is doubtful whether it is
possible to  syphilize, so as to  cure permanently,
by matter taken from one source alone ; for Dr.
Boeck met with cases  where complete immunity
existed to the matter taken from one  source ; but
upon obtaining fresh  virus  from  other persons,
the inoculation succeeded perfectly again.   How-
ever, he has been able, in some instances, to ef-
fect a complete and permanent cure with matteT
from one source alone.
   172.  I have given this account of syphilization,
as it is hardly known in this  country.   It is man-
ifest that it could not  be  rationally submitted to,
but  as a  cure  of the distemper, and not by a
healthy person to prevent the  infection of it.   If,
however, it be  found to be by farther experience,
not only a  permanent  cure, but also a permanent
preventive, it will establish- for itself a reputation
not possessed by any other means ;  for none be-
sides, however judiciously administered, has been
found constantly and permanently curative—has
proved a remedy under all circumstances, and for
the future  duration of  life in all cases.
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p. 18. — Flamand, Journal Complem. du Diet,  des Sci.
Med., t. v.,  p. 134.—.M Rayer, Theoretical and Practical
Treatise on  1 iseases of the Skin, Eng. Ed., 8vo.   Lond.,
1835,  p. 1147.  (Syph. of Bay of St. Paul's.)
  iii.  SvrniLizATiox. — Diday, in  Gazette Medicale de
Paris, July  10th,  1S52.  (Suphilization.)—V. de Meric, in
Lancet, July, 1S53, p. 233.—C. B. Radcliffe. in Half-year-
ly Abstract ofthe Medical Sciences, &c, vol. xvi., p. 333.
— IF. Boeck. Syphilizationen, Svo.   Christiana,  1854__
Also, Die Syphilization  bei  Kindern, 8vo.  Christiana,
1850.—Anon., in  British and Foreign Mcdico-Chirurgical
Review, &c. No. xxxviii., April,  1857, page 410.   The
writer of this review has observed this practice in the
hospitals in  ( hristiana and Bergen.
  [Amer.  Bibliog. and  Refer.—John W. Francis, an
Inaugural Dissertation on Mercury, embracing its  Medi-
cal  History, Curative Action, and Abuse in certain Dis-
eases.   N. York,  1811; also, an P'ssay on the same sub-
ject in Amer. Med. and Phil. Register for April, 1813, and
April, 1S14.  In this essay Dr. F. condemns the practice
of giving large  quantities of mercury  for the cure of
syphilis, and especially the practice of inducing saliva-
tion  at that time generally  supposed necessary for the
cure of the disease, and advocates  the use of small doses
of corrosive  sublimate in connexion with the free employ-
ment of a decoction  of guaiac and sarsaparilla, drunk
warm.  The advantages which he  claims for this mercu-
rial preparation overall others are that, if judiciously ad-
ministered,  it is particularly mild and safe in  its opera-
tion, will admit of a more extensive use in all the various
forms of the disease, and subject the patient to fewer in-
conveniences ; that  it readily enters the  circulation, and
soonest arrests the progress of the complaint by eliminat-
ing the morbid matter from the system; that it super-
sedes the necessity of salivation by its action on all the
secretions, and especiaUy those of  the skin and kidneys;
that it is the only preparation to be depended on in those
peculiar habits of body so susceptible to salivation by ev-
ery other form of mercury now in use; and, lastly, that
in its ultimate effects on the constitution it is attended
comparatively with no injury.   Dr.  F. recommends it to
be given in  doses of one  eighth of a grain twice a day in
pill, after the following formula: R Oxymuriat. Hydrarg.,
Muriat. Ammon., fifi, gr.  xv.; Aqua} destillat.  -jss.;
Panis q. s., ft pil. cxx.  To children he recommends it to
be given in a state of solution, two  grains to one ounce of
brandy, of which three or four drops may be given in
sweetened water to a child of one year, and repeated three
times a day; and to a child of two or three years old, six
or eight drops three times a day, increasing the dose after
two or three days to ten or twelve  drops.  This mode of
treating syphilitic affections was introduced into the New
York Hospital in 1811, and about the same time  into the
New  York Alms - house  and City  Dispensary, and, ac-
cording to Dr. I-'rancis, with  marked success compared
with  former modes of treatment.   He  advises that the
medicine should  be continued  two or three weeks after
the disappearance ofthe disease, in order more effectually
to accomplish a radical cure.   The decoction of guaiac
and sarsaparilla  are to be  prepared by boiling an  ounce
of each in three pints of water to two pints, of which the
whole is to be drunk  warm in  the course of twenty-four
hours.  See also  in  this connexion M'Neven's Account
of the Rob of Laffacteur, In New York Medical and Phil.
Journal, vol. iii.. p.  28.  —S. A.  Cartwright, Essay on
Syphilis, Am. Med. Recorder, vol. viii.—D. M. Reese, Am.
edition of Cooper's Surgical Dictionary.   N. York, 1833.
—John Le Conte, an  Essay on the Origin of Syphilis, in
New York Journal  of Med. and the Collateral Sciences,
vol. xi., p. 5».— IFm. //. Prescott, on the American Origin
of Syphilis, in  Ibid.,  vol. ii., p. 150; also, "History of
Ferdinand and Isabella," vol. ii., p.  504; also, "History
of the Conquest of Mexico."—Washington Irving,  Histo-
ry of Columbus ; also, New York  Journal of Med., vol.
ii., p. 153.—Humboldt, Nouvelle Espagne, torn, i., p. 333;
and iv., p. 162, 2d ed.—Samuel Forry, New York Journ.
of Med., &c, vol. ii.,  p. ISO, on the Origin of Syphilis.—
A. J. I.. .Tovrdan.  Historical and Critical Observations
on Syphilis, translated from the French, by it. La Roche, 
VERTIGO—Description  of.                               1495
 M.D.  I'hila., 8vo, 1823.   (Dr. J. proves beyond a doubt
 that the venereal disease was not derived from America.)
 —X. It. Chesebrongh, Summary of Observations on Syph-
 ilis in Infants, New York Journal of Med. and Collateral
 Sciences, vol. L, N.S., p. 184. — George M'Clellan, Princ.
, and Pract. of Surg., edited by his son, J. H. B. M'Clellan.
 Phila., Svo, 184s.—John  Watson, Observations  on some
 of the more Obscure and Remote Effects of Syphilis, in
 New York Journal of Med. for July, 1S43, and November,
 1845, vols. i. and v.; also, U. S. Med. and Surg.  Journal,
 1835. — Henril M. Gray,  Review of Ricord's "Practical
 Treatise on Venereal Diseases, or  Critical and Experi-
 mental Researches on Inoculation applied to the  study of
 these Affections," &c, in Ibid., vol. x., p. 78. —A. Sid-
 ney Doane, Am. edition of " The Study of Medicine," by
 John Mason Good, 2 vols., 8vo.  N. York, 1835. —John
 Thompson, on the Treatment of Syphilis without Mercu-
 ry, Am. Med.  Recorder, vol. i., p. 405.— J. C. Rousseau,
 Sketches on Venereal Complaints, Am. Medical Recorder,
 vol. iii., p. 171, and Philadelphia Medical Museum.—G.
 Buck, Select Hospital Reports, " Venereal Diseases and I
 their Sequela?," in New York Journ. of Med., vol. iii., p.
 360. — H.  D. Bulkley, on Syphilis in Infants, in N. York |
 Quar. Journal of Med. and Surgery, vol. iii., p. 239.   A ]
 most elaborate and able essay on the subject of Infantile
 Syphilis, illustrated by the history of 35 cases of the dis-
 ease ; also, Am.  edition of Cazenave and Schedel  on  the
 Skin. New York, 8vo, 1848.— M. Devergie, on the simple
 Antiphlogistic Method of treating Syphilis.  See Amer.
 Journal of Medical Science, vol. xviii.,  N.S., p. 498, and
 vol. xix., p. 230. — F.  W. Oppenheim, on the Treatment
 of the Venereal Disease without Mercury, or an Account
 of the Non-mercurial Remedies  recommended for its
 Cure, &c., in Ibid., vol. xix., p. 454.—Gouverneur Emer-
 »)«,  Review of Pract. Researches relative to the Treatment
 of Syphilis; a Work founded upon Observations collected
 in the Service and under the Eye of M. Cullerier, chief
 surgeon of the HOpital des Veneriens, by Lucas  Cham-
 pionniere, in Ibid., vol. xxi, N. S., p. 155; also, of Colles's
 Practical Observations on the Vener. Disease and on the
 Use  of Mercury, in Ibid., vol. xx., p. 407.—Analysis and
 Translation of J. Burder on Syphiloid Diseases,  in Amer.
 Medical  Recorder, vol. ii., p. 555. — Thomas Ileicson, on
 Venereal  Opthalmiae, in Ibid., vol. viiL, p. 35G; on Syphi-
 litic  llcers, in Ibid., p. 647.—J. R. Lucas, on Syphilis, in
 a Letter to Dr. PJberle, in Ibid., vol. v., p. 704. — Thomas
 Harris, on the Mercurial Treatment of Syphilis, in Ibid.,
 vol. ix., p. 3)6.—O. R. Bacheler, Mercury as  employed by
 Hindoo Physicians, in Boston Med. and Surgical Journal,
 vol. xxxi., p. 318.—Charles H. Stedman, Report of Cases
 in the United States Marine Hospital, Chelsea (" Primary
 Syphilis," says Dr. S., "has for the last six years been
 treated on the antiphlogistic plan ; with a very few excep-
 tions, mercury has seldom been made use of, and the cure
 has been easily effected in all cases where the patient has
 submitted to the necessary restrictions in diet and regi-
 men"), Ibid., vol. xv., p.  245. —Prof. Sigmund, on the
 Duration of the Incubation of Syphilis, in Brit, and For.
 Medico-Chirurg. Review, No. xxxvii., January, 1857, Am.
 edition, p. 205;  also, on the Cure and Relapse  of Syph-
 ilis, Ibid., January, 1858, p. 201.—Notice of H. Labatt's
 Observations on  Venereal Diseases, Ibid., July, 1853, p.
 13\  American edition___Thomas Harris, on the  Mercu-
 rial Treatment of Syphilis, in North Amer. Med. and Surg.
 Journal, Nov., 1-25. (Dr. Harris states that he had not
 used mercury in the treatment of any forms of this  dis-
 ease for the last six years, during which time he attended
 164 cases  of venereal.  He treated it by bleeding and
 purging, the warm bath once a week, and the " decoction
 of the woods.l'   Secondary symptoms rarely appeared ;
 in two cases of the latter, nitric acid and the above de-
 coction were entirely successful.  Twenty-three other sec-
 ondary cases, which had been treated  with  mercury by
 other practitioners,  were effectually cured  without it.
 The  local treatment consisted in poultices and cooling lo-
 tions, if there was much inflammation; afterward  the
 black wash, a strong solution of blue vitriol and the ni-
 trate of silver, where a stronger caustic was indicated.)—
 John Bell, a Treatise  on Baths; including Cold, Sea,
 Warm, Hot, Vapour, Gas, and Mud Baths, A:c., 12mo, p.
 653.  Phil., 1S5 i. (Dr. Bell gives a very favourable ac-
 count of the influence of the  Vapour Bath in Syphilitic
 Eruptions and Ulcers, also of sulphurous fumigations;
 he also gives a  history of mercurial fumigations, and
 baths of corrosive sublimate for the cure of venereal af-
 fections, which the reader may consult with advantage.) —
 See also " Lectures on the Theory and Practice of Physic,
 by John Bell and William Stokes," 2 vols.  8vo.   Phil.,
 1845.  (Dr. Bell  advocates the non-mercurial treatment,
 and says, p. 567, " I can speak confidently, after positive
 experience, of the success attending the use of iodine in
 tincture, and  ofthe iodide of potassium, with  the com-
 pound sirup and decoction of sarsaparilla in cases of ve-
 nereal disease, both ofthe tonsils, and mouth, and tuber-
 cular ulcerations, after mercury had been prescribed by
those who preceded me in vain.")—Grover Coe, " Concen-
trated Organic Medicines ;  being  a Practical Exposition
of the Therapeutic Properties and Clinical Employment
of the combined proximate  medicinal Constituents of In-
digenous and Foreign Plants," &c, Svo, p. 431.   N. Y.,
1S53.   Of the indigenous  plants  recommended for the
cure of  syphilitic affections, the  most important are:
Smilocin, the active, neutral principle of the Snalax offi-
cinalis, in doses of two grains three times a day; the con-
centrated Tincture of Smilax  sarsaparilla, in  doses of
fifteen  drops ;  Menispermin, derived from the Meni-
spermum Canadense, in doses of from two to five grains,
three  times a day, especially for  the train of symptoms
termed  Mercurio-syphilitic; Xanthoxylin, derived from
Xanthoxylum fraxineum,  in doses of from two to  four
grains, including the Oil and  concentrated  Tincture of
Xanthoxylum, in doses of  from two to five  drops each;
Hydrastin, from Hydrastis  Canadensis, in gleet and gon-
orrhcea  in doses of one or two  grains three times a day;
Irisin, from Iris versicolor; Corydalin, from Corydalis
formosa;  Stillingin, from  StilUngia sylvatica;  Phytola-
cin, from  Phytolacca decandria;  Rumin. from Rumex
crispus; Alnuin, from Alnus rubra. Swamp Alder;
Podophyllin, from Podophyllum peltatum, May-apple;
Chimaphillin, from  Chimaphilla  umbellata; Anipelop-
sin, from Ampelopsis quiivjuefolia; Macrotin, from Ma-
crotys racemosa.  The  actual  value of the above rem-
edies, in the various forms of syphilis, is to be determined
by farther observations and more extended experience.
There is good  reason,  however,  to believe that among
them will be found some of the most valuable alteratives
in the Materia  Medica, and good  substitutes for the for-
eign sarsaparilla, guajac, mezereum, &c]

VERTIGO.—Svx.—Vertigo (from  verto, I turn
   round);  Tceptorpoepi},  oKorupa.   Vertige,  Fr. ;
   der  Schwindel,  Germ.   Giddiness, dizziness,
   swimming in the head.
   Classif.—IV.  Class, III.  Order (Author).
   1.  Defin.—A  transitory erroneous perception,
or  a  sense of general whirling or turning round,
with  difficulty of standing, or  a feeling of impend-
ing sinking or falling.
   2.  Vertigo has been  noticed by Hippocrates,
Galen, Aret^eus, and other  ancient  writers;
and by these, as well  as  by modern writers, it
has been viewed  chiefly as a symptom of many
diseases, and in some,  but in much rarer  cases,
as  the chief or  only  apparent  disorder.   That
it is as much a primary affection, on some occa-
sions,  as headache, or several other  disorders,
may be admitted,  although it may be shown, if
the pathogeny ofthe affection be duly considered,
that it is commonly owing to previous disorder of
the organic nervous influence endowing the brain,
or  to the state of the capillary circulation in this
organ, or not  improbably  to  both in various de-
grees.   In the great majority of cases, however,
it is merely a symptom, either of a very early, or
of a more or less advanced stage of some maiady,
very often of some  disease which has  not fully
declared itself, or which  still remains latent  or
imperfectly developed,  or  of  extreme  debility, or
of protracted indigestion, &c.
   3.  I. Description.—Vertigo occurs as an  il-
lusion, or  a transitory erroneous perception of
objects, although quiescent, in a  state of more or
less rapid motion, usually in that of gyration or
whirling round ;  but also  not unfrequently with
either  a  descending or ascending movement, or
with a sense of sinking.   In the more extreme
cases, or when caused by ebriety, these sensations
are often present in a greater  or  less degree,
although the eyes at the time are quite shut.  In
some instances the objects which thus appear in
motion are  also  changed  in colour—are  either
variegated  or obscured.   Vertigo  may  be  ex-
perienced only when assuming the erect posture,
as  in cases of fever, extreme  debility, &c. ; but it
may also be felt while  recumbent in bed, objects
presenting not only a rotatory, but also an ascend- 
)escription of.
1496                            VERTIGO—E

ing motion, with a feeling of sinking, and some-
times also with noises in the ears.  In this latter
form it should be viewed as a most serious symp-
tom, especially when occurring in  malignant or
pestilential maladies, or when these are prevalent,
or in the course of organic  disease of the brain.
In many instances, vertigo precedes, or is follow-
ed by, severe paroxysms of retchings or of vom-
itings.  This  sequence  is  commonly  observed
in pestilential cholera, in sea-sickness, in  fits of
drunkenness,  after ingestion of the sedative or
depressing and irritating poisons, and especially
after the improper or inordinate use of tobacco.
In all cases of vertigo, walking or even standing
is difficult  or  impossible;  and,  from a dread of
falling, objects are laid hold of for support.   Ver-
tigo may be only temporary and quickly evanes-
cent, or it may continue for a considerable time.
It is more  rarely  continued or prolonged.   It is
often evanescent, but marked, when it occurs as
a prelude of syncope, or of fully-developed disease
of the brain, as epilepsy, paralysis, or apoplexy.
It often precedes  amentia and other states of in-
sanity.   Swift was very subject to vertigo at dif-
ferent periods of his life, and more especially be-
fore the loss of his powerful mental faculties.  It
is more  prolonged or continued when it  is  a
symptom of either active or passive congestion
ofthe cerebral vessels, or of anaemia ofthe brain,
or of the vascular system generally.   When ver-
tigo occurs as  a severe or acute paroxysm, it may
gradually pass into the epileptic state; the ex-
treme giddiness, after several occurrences of the
seizure, being attended by  a  temporary loss of
consciousness, and ultimately by convulsions and
all the phenomena of a complete epileptic attack.
  4. The more continued or prolonged states of
vertigo are generally referable  to the following
pathological conditions :  1st, to determination of
blood to the brain ; 2d, to congestion of blood in
the cerebral vessels, owing to impeded return of
blood or  retarded circulation through the  heart;
3d, to lesions of the cerebral arteries, and soften-
ing of the structure of the brain ; 4th, to general
or local, momentary or prolonged anaemia, or in-
sufficient supply  or circulation of blood  in the
brain.   In  these  states, however, one or other
of the primary changes already assigned as char-
acterizing the more  evanescent states of the af-
fection (^ 3) are also present.   In either of these
forms, or owing  to  either of their  pathological
states, vertigo may manifest certain grades, either
of which only may be complained of, or all of
which utay supervene  in succession, either very
slowly and imperceptibly, or more or less rapidly.
These states  or grades are usually  described as,
1st, confusion, unsteadiness, or indistinctness of
perception ; 2d, dizziness or fear of falling ; 3d,
giddiness, with incapacity of progression ;  and,
4th, swimming in the head, or complete vertigo,
with an incapability of standing.
   5. i.  The occasional exciting  causes of vertigo
are very different, or even  opposite in different
cases.   Whatever determines  the  blood  inordi-
nately to the brain, as long and intense thought
and reflection; or prevents and impedes the return
of  blood from this quarter, as  cinctures of the
neck, &c. ; and whatever promotes a rapid return
of  blood from the  brain, as suddenly assuming
the erect from the recumbent posture, long ab-
stinence, inanition ; and. in short,  whatever oc-
casions too great fulness on the one hand, or too
great a deficiency of blood in the  brain  on the
other, will, in weak,  susceptible, or predisposed
persons, give rise to this state of morbid percep-
tion.
  6. Vertigo is most frequent in persons of ad-
vanced . age,  in hysterical  females,  in persons
who are bald, especially on exposure  to cold, or
in cold seasons and in variable weather; in those
liable to  haemorrhoids, epistaxis, or other hemor-
rhages, especially when these are suppressed, and
in crowded and close apartments;  in females dur-
ing prolonged lactation ;  in  persons addicted to
excessive sexual intercourse, or to the  vice of
masturbation ;  and in those who indulge in  too
much sleep, or who lie too long in bed, or who
live irregularly as to diet and regimen.
  7. The more common  causes  of vertigo  are
obviously those which produce  the diseases of
which vertigo is a more or less prominent symp-
tom ; while those occurrences of it which assume
more of a primary or idiopathic  form, are refer-
able entirely to whatever occasions the patholog-
ical  states of which  it  is a chief manifestation.
Thus, if it be  imputed to vascular determination
to, or congestion of blood in the brain, the numer-
ous remote and efficient causes of these conditions
should be ascertained, as  indicating the only ob-
vious means of removing the affection.   If it be
chronic,  protracted, or of frequent recurrence, the
temperature of the scalp, the state of the arterial
and venous circulation in the neck, temples, &c,
the circulation through the heart;  the functions
ofthe stomach, bowels, and kidneys, &c, sever-
ally require examination, especially with reference
to excessive or to deficient fulness of blood in the
vessels  of the brain.   The  causes of these very
opposite conditions are generally manifest on due
investigation ; but these conditions are commonly
"attended by others of not less importance, name-
ly, by excited or by  depressed  vital power—by
the latter especially.   This association  of disor-
dered circulation with depressed vital  power ob-
tains in most cases of this affection, whether pro-
tracted  or evanescent; and  in  febrile diseases
the blood is also more  or  less altered, although
not in a manifest degree at an  early stage of these
diseases. The impairment or depression of vital
power is especially evinced by the organic nerv-
ous system, through the media of the  several or-
gans which this system endows, and more partic-
ularly of the digestive, assimilating, and genera-
tive organs.   Impairment ofthe  former, and  ex-
haustion from abuse ofthe latter, are among  the
most efficient sources of this affection, in its more
chronic forms.  When  it proceeds from this last
source, the disorder is often most protracted and
most difficult to cure, for the cause generally con-
tinues ;  and it not unfrequently assumes a recur-
rent or  periodic form,  and even ultimately,  but
gradually, passes into fully-developed epilepsy, or
the worst forms of hysteria.  Of these  results I
have seen several instances in both sexes, in  tho
course of my practice.
  8. ii.  The chief states and associations of ver-
tigo may be enumerated as follows, with reference
to their  causes :  1st. Vertigo nervosa:  nervous,
hysterical, epileptical, or hypochondriacal vertigo.
2d. Vertigo  traumatica, from  injury, concussion,
&.c, of  the brain.   3d.  Vertigo  plethorica, from
determination  of blood to, or inflammation or
active congestion of, the brain.  4th. Vertigo toxi-
cata, from  poisons, especially sedative and  nar-
cotic poisons,  and from  poisonous fish,  meats,
&c.   (See art. Poisons.)   5th.  Vertigo  febrilis, 
VERTIGO—Treatment  of.                             1497
in the invasion and progress of most fevers, espe-
cially when the organic nervous force is depress-
ed,  and  the  blood contaminated.  6th.  Vertigo
gastrica  vel Stomachica, from gastro-bilious dis-
order ; such  disorder, however, often being,  as
well as the vertigo, merely symptomatic of dis-
ease ofthe brain.   7th. Vertigo exsanguinea, from
an  insufficient supply of blood to  the brain,  or
from general anaemia, or unequal distribution  of
blood.   8th.  Vertigo cardmca, from disease ofthe
heart impeding the return of blood from the brain.
9th. Vertigo  arthritica,  from  misplaced or retro-
cedent  gout.  10th.  Vertigo  rheumatica,  from
rheumatism ofthe membranes ofthe brain, or of
the  pericranium.  11th. Vertigo accidentahs  vel
fugax, from  various odours or smells, especially
in certain idiosyncrasies, or from various causes,
often of an indefinite or not very manifest na-
ture.
   9. iii.  The Diagnosis and  morbid Relations of
 Vertigo.—The nature ofthe affection is generally
manifest from the account given by the patient
of his sensations.  It may, however, in the more
sudden attacks, be mistaken for a slight seizure of
either apoplexy or epilepsy.   From both these it
may be readily distinguished by the loss of con-
sciousness, which does  not occur  in  vertigo.
When fits of vertigo are likely to  pass into epi-
lepsy,  a momentary  loss of recollection  or con-
sciousness then  generally  characterizes them.
The difficulty in the diagnosis respects chiefly  the
pathological  condition of which vertigo is a chief
or related manifestation—as regards the states of
organic nervous  or vital power, and  of vascular
action or congestion in the brain—as to the affec-
tion being a  precursor of a febrile or exanthe-
matous disease, or a symptom  of  disordered  di-
gestive function, or of misplaced gout, or of most
serious disease, or of structural lesion ofthe nerv-
ous masses within the cranium.   This, the most
important diagnosis of vertigo, entirely depends
upon the peculiarities of individual cases ;  upon
the age and previous diseases ofthe patient; upon
the recognised and presumed causes ofthe affec-
tion ; upon the states of organic, nervous, or con-
stitutional power, and of local and general vas-
cular action ;  and upon the phenomena observed,
and the symptoms ascertained, during the disor-
der.  It  must be apparent  from  this that  the
knowledge, acumen, and experience ofthe physi-
cian will be called into requisition  in most cases
of vertigo ; and his success in their treatment will
altogether depend upon  the pathological infer-
ences he may form.
   10. There are other circumstances  than the
above to which attention should be  directed ; and
among these the  probable existing morbid states
causing this  affection at different periods of life
may be  noticed.  If* the  disorder occurs  soon
after, or even several years  after,  puberty—and
if the patient be thin, pallid,  or anaemied, and be
incapable of directing his eyes firmly on the per-
son addressing him, impaired nervous power, very
probably occasioned by masturbation, may be  in-
ferred.   If the affection occur in mature or ad-
vanced age, although it may proceed from disorder
ofthe  digestive organs, it may, as well as such
disorder, be much more likely a prominent symp-
tom of disordered circulation in the brain, caused
either  by atheromatous,  fatty,  ossific, or other
changes  in the coats ofthe arteries, or by disease
of the  heart,  of  its  valves, or  even  by  organic
lesion ofthe  intimate structure, or by more mani-
fest alterations of the brain, either consequent
upon one or other of these morbid conditions of
the vessels, or taking place independently of them.
I have seen cases where this affection has been
produced by these several lesions, by scrofulous,
tubercular, cancerous, or other formations in the
membranes or substance ofthe brain, and by im-
peded return of blood from the  head.   In  a re-
markable case of colloid  cancer of the mamma,
under my care a few years ago, that was seen by
Dr. Ramsbotham and Mr. Fergusson, the cancer-
ous disease ultimately  invaded  the  brain,  occa-
sioning, for a considerable period, constant ver-
tigo, and ultimately general paralysis and coma.
The connexion, also, of vertigo with the gouty
diathesis, and the occurrence  of it as  a form of
misplaced gout, should not be overlooked when it
affects persons of mature or advanced age, espe-
cially when the exact nature of this affection is
clinically  investigated.   The connexion of this
affection, also, with cachectic states of the system,
with imperfect excretion and depuration of the
blood,  and with  disordered function or organic
lesions of  the kidneys,  but still more intimately
with organic lesions of the heart, its orifices, or
of its valves, demands due consideration.  Several
instances of chronic vertigo have come before me
which had been referred to cerebral disease, but
which, upon auscultation of the heart, were found
to depend upon impeded return.of blood from the
head, owing to interrupted circulation through the
heart.
   11. II. The prognosis of vertigo should be al-
ways given with caution, and often with much
reservation.  In  some  cases,  especially  in early
or middle  age, when the affection is slight, and
depends chiefly on disorder of the digestive or-
gans, or the organic nervous system, a favourable
opinion may generally be given, unless there be
reasons to infer that it is a precursor of fever of
an exanthematous or any other  form ;  and  then
the result will entirely  depend upon the consec-
utive disease.   Whenever the  affection occurs
suddenly or in fits, then its passage into fully-
developed  epilepsy  should be dreaded, however
 judicious the treatment may be, more especially
if there be any reason  to  infer  that it is caused
by masturbation, or by  excessive venereal indul-
gences.  Of this causation and  transition of ver-
tigo, many cases have come under my observation,
not only in early and middle, but also in far-ad-
vanced age.  In  this last period of life, as well as
in middle and mature age, vertigo, in  any of its
grades, should always be dreaded and  viewed as
a precursor of a more serious or dangerous attack.
In these cases the symptoms connected with the
organs contained within  the cranium  should be
carefully observed,  especially the several senses ;
the temperature of the scalp,  the state of the
pulse in the  carotids;  the action, rhythm, and
sounds of  the heart, and the  appearance of the
veins of the head  and  neck, and an opinion  be
given  conformably with the evidence  furnished
by these sources, the juvantia and laedentia being
also taken  into due consideration.
   12. III.  The treatment should be based upon
the inferences arrived  at as to  the causes and
pathological states of vertigo.—(a) If the causes
inferred be such  as reduce organic, nervous, or
constitutional  power, and  if they are  of such a
nature as are likely to convert the disorder into
either hysterical  or epileptical seizures, as certain
ofthe causes above noticed (§ 6, etseq.), a restor- 
1498
VOICE  AND SPEECH—Affections  of, described.
ative, antispasmodic, or tonic treatment, such as
the preparation of valerian, asafoetida, zinc, &c,
cod-liver oil, oxyde of silver, &c., ought to be pre-
scribed ;  and if there be  any indications at the
same time of local or general anaemia, chalybeates,
either alone or in addition to these means, are also
required.   In cases of this description, as well as
in those indicating a tendency to assume either
an hysterical or epileptic character, I have found
the tincture of sumbul,  either alone or conjoined
with other medi'cines of a tonic  or antispasmodic
nature, of great service in several cases.   In these,
also, I have prescribed the cotyledon umbilicus, but
not with so marked benefit as I expected, although
it also was sometimes very beneficial.
   13. (b)  In persons who are liable to vertigo from
prolonged or profound thought and reflection (§ 5),
and especially if the scalp be hot, and vascular de-
termination to the brain, as evinced by the action
of the carotids, be excessive, cooling applications
to the brain, local depletions, internal and extern-
al derivations, purgatives, a regulated diet, and,
above all, the avoidance of  the cause, change of
air, of scene, and of habits, travelling, voyaging,
&c, and  relaxing amusements, or agreeable and
slight  occupations merely,  are  the  means upon
which the chief reliance should be placed.
   14. (c) In persons of a full habit of body, in
those who live luxuriously, or even  moderately,
and who  take  little exercise, the temperature of
the scalp, the pulsation of the  carotids, or the
action or sound of the  heart, indicating local or
general plethora, or impeded return of blood from
the head, the occurrence of vertigo  should be
viewed in a very serious manner, and local deple-
tions, derivations, both external and internal, pur-
gatives, setons, or issues, spare diet, and regular
exercise in the open air, are generally beneficial.
Other means in addition to these may be resorted
to ; but they must be left to the judgment ofthe
physician, who will prescribe them appropriately
to  the  features characterizing  individual cases.
Emetics,  the application of cold,to the head, the
restoration of suppressed  haemorrhages, bleeding
from the nostrils, and venaesection, were the chief
means recommended by Aret^eus for vertigo, and
they are indicated in the circumstances just now
mentioned ;  but emetics  should follow, not pre-
cede, the other means when  cerebral or general
vascular plethora is present.
   15.  (d) In cachectic habits of body, in cases
manifestly depending upon disorder of the digest-
ive organs,  and  when the  temperature of the
scalp, and the local and general states  of the cir-
culation and of vascular action, present no contra-
indication of  the propriety of the  practice, the
treatment of vertigo may be  initiated  by the ex-
hibition of an emetic.   When this affection  is
indicative of the commencement of fever, or of
one of the exanthemata, and is attended by lassi-
tude, pains in the back or limbs, or by chills or
shivering, this practice  is  then also productive of
benefit;  but  ipecacuanha or sulphate of zinc
should be preferred  to antimony as an emetic;
or, if this last be prescribed, it will  be advanta-
geously conjoined with  a warm, aromatic, or anti-
spasmodic  medicine, such as Cayenne, ginger,
&c ; but it ought not to be repeated oftener than
once.   Vertigo in the gouty diathesis requires, in
the first instance, cholagogue purgatives, followed
 by alkalies, magnesia, sulphur, and other vascu-
 laTdepurants, which increase the functions of the
 kidneys, skin, and digestive mucous surface.  In
all cases of vertigo unconnected with the invasion
of either of the forms of fever,  the previous hab-
its, modes of living, and disorders of the patient
should be  ascertained, and a more  or less com-
plete change of these habits be insisted upon, as
far as his age and other circumstances may ren-
der the change advisable.
  Biblioo. and Refer.— Aretceus, Curat. Chronic, 1. L,
c. 3. (Emetics for.)—Galenus, de loc. Affect., 1.  iii., c. 8.
(Distinguishes the Idiopathic and Symptomatic.)—Ori-
basins, Synopsis, 1. viii., c.  5. —  Ccelius Aurelianus,
Morb. Chron., 1.  c. 2.—Paulus  JEejinela, 1. iii., c. 12.
(Sternutatories.)—Avicenna, Canon, 1. iii., Fen.  i., Tr. 5,
cap. 1. — Batlonius,  Comment,  in Libr. Theophrasti de
Vertigine, Opera, vol. i., p. 2S)1, et consil. vol. iii.. No. 1,
24, 52, 101.— Willis,  Opera, t. ii.,  p. 185.—G. Fontamis,
Terras gravissimorum capitis affectuum, 4to. Lion, 165T.
—De Fugtrolcs, De  Bensuum  affectibus, t. ii., c. 5.—Ro-
land, Curat. Empyr. et  Hist. Cent., ii., c. 26, 66,  67.
(Purgatives.) — Robillard, Ergo Vertigine Arteriotomia.
Paris, 1621.— Wapfur, Observat.,  p.  230.  (Caused by To;-
nia.)—Zeicutus Lusitanus, Prax. Admir., 1. i., Ohser. 38.
Prax. Hist., 1. vii.,  Obs. 20. — T. Mayerne,  Praxis, &c,
p. 59. (CalamusAromaticusadvised.)—Bontt, Sepulcliret.,
1. i., s. xi., Obs. i., 2, 4. (Lesions ofthe Brain.)—Obs. 9.
(Hydatids in the Brain.)—Boerhaave, De Morbis Nervo-
rum, p. 576.—Riedlin, Lin. Med., 1700, p. 1160. (Hysteri-
cal.)—Boerhaave, Prselect. Acad, de Morb. Nervor. Cur.
v. Eems, 8vo.  Lipsiae, 1762, p.  476. — F. Hoffman,  De
Vertigine, Opera, t. iii., Obs. 8, p. 226.—J. C. Ilamsjieck,
Biga Remediorum Fra»tantissimorum, &c  Basil, 1745,
p. 739.  (Cajeput Oil recommended.)—Fontana, Opusculi
Scientifici Firenz., 1785, p. 180. (Hydatids in the Btain.)
—M. Stoll,  Praelectione.", t. i., p. 382. (Caused by Mas-
turbation.)— Vogel,  Precis de la Med. Pratique, t. i., p.
174.—Bang, in Acta Reg. Soc. Med. Havn., t. i., p. 2S0,
et t. ii., p. 47. (Seton in the  Xape.)—Hanoi, in Ibid., t.
iv., p. 113 (Guaiacum for Arthritis), p. 261 (caused by
Colo). — Bellini, De Morbis Capitis, p. 681. — M. Stoll,
Praelectiones, i., p. 333. (Intense study, Manustupratio.)
—E. Darwin, Zoonomia, &c, vol. i., p. 231, et seq.—Horn,
Archiv. fiir Pract. Medecin., b. vi., p. 116. (Camphor ad-
vised for.)—Sumeire, in  Journ. de Medecine,  t. lxi., p.
G71.— Winders, in Ibid., t. lvi., p. 115. (Advises Asafoe-
tida.)—Fieliz, in Richter, Chirurg. Biblioth., b. vi., p.
721. (The Willow Bark for.)—M. llerz, Yersuch iiber den
Pchwindel,  8vo.  Berlin,  1791.—Parry, in PMin. Med.
Comment., vol. xiii., p. 245.—L. B. Borsieri, Instit. Med.
Pract., vol.  iii., cap. ix., { 294.—Musgrave, De Arthritide
Anomala, c. 14. (Misplaced Gout.)—J. P. Frank, De Cu-
rand. Horn. Morbis., 1. v.,  p.  259  (caused  by  seminal
Emissions), et Opnscula  Posthuma, 1824, p. 237.—IFtT-
ner, Apologie des Brownschen Systems, b. ii. (Stimulants
advised.)—Rudolphi,  Bemerkungen, t. i., p. 26. (Hyda-
tids.)—Horn, Archiv. fiir Pract. Medecin., b. vi., p. 116.
(Camphor advised for.)—Joerdens,  in Hufeland Journ.
des Pract. Arzneyk, b. iv., p. 531.  (Mentha Piperita in
Asthenic Vertigo.) — Conradi,  in Hufeland, Journ. der
Pract. Arzneywissenschaft, b. vi., p.  469.  (Searificalio
nucha? et verticis.)—J. Frank, Prnxeos Medicse Unlverwe
Praecepta, v. i., par. ii., § i., p. 537.  (Seminis jactvra.)—
J. Midler, Physiology, Baly's edition, vol. ii., p. 1179.—
R. Hull, Essays on  Determination of Blood to the Head,
Svo.  Norwich, 1842.  Essay  1st, On Vertigo.  Ken. in
Brit, and I-'or. Med. Review,  vol. xvii., p. 201.—M. H.
Romben; Lehrbuch des  Nervenkrankheiten des Men-
schen, 8vo.   Berlin, 1S43.  Transl.  for Sydenham Socie-
ty, 8vo.   Lond., 1S53.

   VOICE AND  SPEECH—Disorders  of.—1.
Voice and speech are functions by means of which
the human species claims  and maintains an  as-
cendency  over  all  animated"  nature.   The more
perfect animals,  including the winged creation,
possess the power of emitting vocal sounds, which
admit of such changes in power, modulation, and
character  as convey intimations to individuals of
their own genus or species of danger, of pleasure,
of sources of nourishment, of desire, and  even of
affection.   The practised ear can  recognise, in
nearly all  animals which emit  sounds, variations
in cadence, character, and power, which are known
by the same species  as  announcements  of the
presence of objects of prey  and subsistence, of
sources  of danger, of the loss of offspring or ob-
jects  of affection, and of danger, suffering, or
distress.   And it is by no means improbable that 
VOICE AND SPEECH—Affections of, described.                1499
the sounds  characteristic of individual species,
even of the  lowest capable of emitting them, are
so modulated as to convey to one another  the
various instincts and suggestions which seasons,
localities, and external circumstances  and influ-
ences may  excite ; the  sounds thus modulated
becoming  known, as regards each  species, as a
distinct, but  limited  language, although unknown,
unless in its more manifest and prominent char-
acters, to man.
  2. The sounds produced by the organs, so won-
derfully and beautifully provided for them, in the
human species, are the chief means of develop-
ing the  mental faculties, of exercising dominion
over the rest of the animal creation, and of ac-
quiring and of exerting power over those requiring
guidance or governance.   The sounds produced
by the human organs of vocalization and articula-
tion are the manifestations furnished to the species
of tho finest sentiments, ofthe deepest as well as
the highest states of feeling, ofthe most profound
and abstract results of thought, and the  wisest
and best revelations of mental reflection and of
human reason.  But considered philosophically,
they are studies rather for the physiologist than
for the pathologist.  To the  latter, however, the
more strictly philosophical consideration  of hu-
man sounds, as manifested in the modulated voice
and in speech, becomes a necessary introduction
to an intimate knowledge of the several modes in
which both voice and  speech are disordered, or
more or less impeded, or even  lost.   For these
preliminary sources of knowledge  the reader is
referred to the recent writings of Muller, Car-
penter, Todd, Bowmann, Bishop,  and Willis,
which are in the hands of most medical men.
   3. Vocal sounds  and articulate speech or lan-
guage are two distinct functions ;  and although
the latter proceeds from the former, an additional
apparatus is required  for its  production.  The
instrument of vocal sound, the  larynx, is distinct
and appropriate  to this purpose, and is calculated
by its mechanism to produce the several  grades
and modulations of voice ; but, although thus in-
dependent, the vocal sounds  cannot be modified
into articulate  speech, or even into  a near ap-
proach to articulation, without the aid  of the oral
cavity, more especially  of the  tongue.   Hence
there may be vocal sound without speech;  but
this latter cannot be produced without the  for-
mer ; and hence both may be separately or even
conjointly disordered, or even lost.  But, although
speech may be altogether lost, a vocal sound can
hardly be quite lost while  respiration is performed,
unless in complete  syncope, catalepsy, apoplexy,
in the coma of  fever, and in other occasions of
loss of sensibility and consciousness ; for even in
these states, unless in profound syncope and cata-
lepsy, a simple or low respiratory sound may still
be emitted.
   4.  I. Voice is produced, according to Mr. Bish-
op, by the conformation  of the vocal  apparatus,
which combines the  properties of a stretched
chord, a membranous  pipe with a  column of air
vibrating in it, and  a reed, and is the perfect type,
of which these instruments are only imperfect
adaptations.  Dr. Carpenter  states  "that the
sound is the result of the vibrations of the vocal
ligaments,  which  take  place  according  to the
same laws with those  of metallic or other  elastic
tono-ues ;  and that the  pitch of the notes is chiefly
governed by the tension of these laminae."   How-
ever the various tones,  modulations, &c, of the
voice may be  explained, or referred  severally to
the especial or combined movements and actions
of the different parts constituting the vocal appa-
ratus by physiological writers, it must be manifest
that a healthy condition of the vocal chords and
ligaments, of the cartilages, of the muscles which
move them, and of all  the parts both above and
below the larynx, as well as ofthe larynx itself,
and  the mucous membrane covering it  and its
vicinity, and even  of  the velum palati  also, is
necessary to the production of the human  voice
in its natural and perfect state ;  and consequently
that this function,  capable of the  utmost perfec-
tion, of the greatest range in power and modula-
tion, and of astonishing improvement as  regards
these, by  careful and  scientific cultivation, de-
pends upon a perfect condition of their several
parts, disorder or structural lesion of any one of
them affecting the voice in a more or less remark-
able manner.
I. Aphonia.—Loss  of Voice.—Syn.—'Aefruvia
   (from a priv. and §uvq, voice). Aphonia, Vogel,
   Sagar, Cullen.   Dysphonia,  Good.   Raucedo
  paralytica, Darwin.  Pcrte de la Voix, Fr.   Die
   Stimmlosigheit, Aphonic, Germ.
   Classif.—IV. Class, II. Order. (See Preface.)
   5. Definit.—More or less  impairment or com-
plete loss  of the power of emitting vocal sound,
owing either to functional disorder or to structural
lesion.
   6. The voice may be impaired in every degree
from the slightest catarrhal form to the most com-
plete loss from organic change.   The impairment
or loss  may be either  temporary or permanent.
The slightest as well as the less permanent apho-
nia often proceeds  from functional disorder,  espe-
cially from extreme nervousness, fright, fear, and
hysteria;  but  it also is.frequently caused by ca-
tarrhal  congestion  of the mucous membrane of
the  larynx  and of the subjacent  cellular tissue,
and by  temporary  impediment to  the movements
of the vocal chords from  this cause, or from in-
flammation  and its results implicating for a time
any of the parts of the vocal apparatus.  In the
more strictly nervous states of aphonia there is no
manifest lesion of structure, the nerves supplying
the laryngeal muscles and chords having become
for a time incapable of conveying the dictates of
volition to  these  parts, unless volition be most
energetically exerted.
   7. A. Functional  aphonia occurs chiefly in
delicate, nervous, or hysterical females, and  much
more rarely in  similarly constituted  males.  In
the  former sex it is most frequent about and sub-
sequent to  the period of puberty, and during the
catamenial  epoch of life;  in the latter chiefly be-
fore the period of puberty, and only in very rare
cases, and when occasioned by fear or fright, and
it is then of short  duration only.
   8. Hysterical aphonia may be viewed as one
of the  forms  of functional  paralysis, which not
unfrequently complicates disorder of the female
organs, such  disorder  being generally either not
otherwise  manifested, or latent, or masked by
some other affection.  In most cases it is easy to
distinguish the hysterical from all  other  forms
of aphonia ; other allied symptoms, the previous
history of the  case, the state  of the uterine func-
tions, the moral affections, impressions, and sen-
timents, which may have preceded the loss, &c,
generally indicating its nature.  It should not be
overlooked  that, in hysterical females, more espe-
cially in those most subject to uterine or sexual 
1500
VOICE AND  SPEECH—Affections  of,  described.
irritation, aphonia is sometimes feigned.   In rare
instances, also, it  may be difficult  to  determine
whether or no it is hysterical or owing to struc-
tural disease in or near to the base of the brain ;
and this difficulty is increased, 1st, by the ab-
sence of other hysterical symptoms ; and, 2d, by
the presence of other states of cerebral paralysis,
the catamenial functions or organs having been
previously disordered.  I  was recently called in
consultation  to a  delicate, nervous female, aged
18, who had  menstruated irregularly and scanti-
ly, and  was  seized with incomplete hemiplegia
and complete loss of voice—the muscles of the
face not being affected.  In this case it was dif-
ficult, at first, to  determine whether the aphonia
was hysterical 01 owing  to some  lesion within
the cranium, causing also the hemiplegic affec-
tion.  Then  history and progress, however, gen-
erally elucidate the nature of these cases.
  9. B. Structural aphonia is caused, firstly,
by changes implicating one oi more of the parts
composing, or in  the immediate vicinity of, the
vocal  apparatus;  and, secondly,  by  lesions at the
origin or in the course  of the nerves distributed
to the laryngeal muscles and vocal  chords.  The
slighter or more incomplete forms of aphonia are
those of a catarrhal nature, arising  from  more or
less congestion and tumefaction of the  mucous
and sub-mucous tissues ofthe larnyx and adjoin-
ing parts.   Severer cases  of aphonia are often
occasioned by serous infiltration into the sub-
mucous  tissue, with or without  inflammation of
the mucous  membrane of the larnyx and of its
vicinity, in the direction either  of  the fauces or
of the trachea, or of both.   This serous infiltra-
tion may be slight, and continue only during the
catarrhal attack, or it may be so very considera-
ble as to nearly suppress the voice altogether and
cause suffocation, as observed in adema of the
glottis and epiglottis.  Aphonia from  this and.
other  affections of the  vocal  apparatus  is fully
considered in the articles Larynx and Trachea,
where the lesions which affect the voice  are de-
scribed,  and  the  treatment appropriate to each
pointed out.   The voice may also  be affected in
different degrees by inflammatory affections ofthe
fauces, pharynx, and tonsils, by  tumours in these
situations, or by morbid growths  pressing upon or
implicating the larynx or trachea, by aneurisms,
and most frequently by chronic laryngitis  and its
consequences, especially thickening, ulceration,
&c, arising either primarily or  consecutively of
acute  laryngitis, or of tubercular disease of the
lungs, or of  syphilitic infection.  All these are
fully discussed in  the articles now referred to ;
but in all the voice is affected rather than the pow-
er of articulation,  which is perfect  as far as the
production of vocal sound admits ;  for the affec-
tions ofthe larnyx in such cases are rarely asso-
ciated with any interruption to the movements of
the tongue and ofthe parietes ofthe oral cavity,
by means of which articulation or speech is per-
formed.
  10.  IT. Defectcs  Loquelje.—Syn.—Alalia,
    Frank.   Loquela Abolita, Auct. Var.   Mu-
    titas, Sauvages, Macbride, &c.  Sprachlosig-
    kcit, Stummheit, Germ.  Loss  of Speech.
  11.  Voice,  as stated above, is  produced by the
larynx, its modulations into musical  sounds being
effected by means  of this organ aided by the epi-
glottis and adjoining parts.   Speech is the modi-
fication  ofthe voice, or sounds emitted by the la-
rynx, by the organs or parts intervening between
i it and the os  externum.   It is obvious  that, to
 produce articulate sounds,  forming language, the
 movements ofthe tongue, fauces,  and connected
 parts must be complete ;  and that these should be
 in a Healthy condition to render articulation per-
 fect.  The tones ofthe voice, and articulate speech,
 cannot be produced in childhood, when the sense
 of hearing is completely lost in early infancy, or in
 the fcetal state ;  and as  long as the sense  oi hear-
 ing continues lost, dumbness is the result; for the
 sense required to modify and adjust vocal sounds
 does  not exist.*   Voice, especially in its  healthy
 and cultivated states, and in its modulations into
 music, is capable of expressing the several emo-
 tions of mind, in a more remarkable  degree and
 manner than  articulate speech;  but speech or
 language has  a much greater, more  varied, and
 more  extensive power of addressing, informing,
 and enriching the intellect, of furnishing definite
 ideas of objects, properties, actions, &c,  and of
 conveying the results of reflection and of rational
 deductions.   The vocal organ, aided by the move-
 ments  of the  tongue and parts composing the
 oral cavity, is  adapted for, and in health is capa-
 ble of, forming a number of simple sounds, which
 are readily combined into groups forming words.
 Dr. Carpenter justly remarks, that the number
 of combinations which  can be thus produced is
 so inexhaustible that every language has its own
 peculiar series, no difficulty being found in form-
 ing new ones  to  express  new ideas.   There is
 much diversity in different languages, even with
 regard to the use of the simplest of these com-
 binations ;  some  of them  are more easy of for-
 mation  than others, and these accordingly enter
 into the composition of all languages ;  while, of
 the more difficult ones, some are employed in one
 language, some in  another;  no  one  language
 possessing them all, or using them to any co-or-
 dinate extent.
   12. The  mechanism  producing  vocal  sounds
 being complicated, and actuated in its individual
 parts and in its combined movements by volition,
 and by the states of vital force, as  influenced by
 health, constitution, and disease, and adjusted by
 the sense of hearing, it  necessarily follows that
 the faculty of speech, in whatever language, will
 be  modified, altered, interrupted, impeded,  and
 even altogether lost, in numerous modes, so as
 not  only to furnish most  important  indications
 of disease ofthe slightest as well as ofthe most
 dangerous nature.  The articulate sounds which
 have become familiar to  the  ear  are  often re-
 membered' as long as the appearance of the per-
 son by whom they were furnished ; and the per-
 _ * The nicest modifications and adjustments of the ac-
tions of the muscles of the larynx, and of the several
parts of the fauces and oral cavity, are requisite to tho
production  of determinate tones, accents, and speech;
and these actions are ordinarily adjusted and modified by
the sense of hearing.  Hence a fine or educated ear in
music is of great advantage in singing and in the pronun-
ciation of languages. This adjustment, being learned in
the first instance under the guidance ofthe sounds actu-
ally produced and heard, is subsequently effected volun-
tarily, in accordance with the mental conception—or in.
ward sensation—of the tone or sound uttered, which con-
ception  cannot be formed unless the sense of hearing has
previously brought similar tones to the mind.   Hence it
ia that persons who are born, or become, quite deaf before
articulate speech is  formed or attempted, are also dumb.
They have  no malformation, no paralysis of any part of
the organs  of voice and speech; but they cannot utter
distinct musical tones or articulate speech, because  they
have  not the guiding conception or sensation of the na-
ture and character of these sounds, fumieihed by the ecnsQ
of hearing. 
VOICE AND SPEECH—Affections of, described.
1501
son, even after many years, is often  recognised
by his voice and speech before he is seen.  De-
bility weakens the  articulating  power, or the
strength of articulate sound; but disease may
alter it  more  remarkably, different maladies af-
fecting it in various ways.  When the voice is
altered,  or lost by disease, the speech is then
necessarily similarly circumstanced,  as  already
stated (<) 5, et seq.).  But  speech is more espe-
cially affected as a precursor, or as a symptom,
of apoplexy and paralysis ;  and, when so affect-
ed, it indicates the most serious  results at a pe-
riod which, although indefinite, may generally be
viewed  as comparatively short.   In cases where
speech is altogether lost, especially at an advanced
age, or  is so  nearly lost as hardly to be  under-
stood, or when the  sounds are mostly inarticu-
late, if no apoplectic or paralytic seizure have
preceded or accompanied this loss, then either
of these seizures may be expected before  a long
time elapse, unless the time be deferred by treat-
ment, and diet, and regimen ;  and more frequent-
ly, notwithstanding these  means of prevention.
(See arts. Apoplexy and Paralysis.)
   13. Loss of speech, whether  complete  or in-
complete, is generally to be imputed to structural
disease, wounds, or fractures, implicating either
parts within the  cranium, or the nerves in their
course to the organs of articulation. Cases of loss
of  speech, consequent upon  apoplexy, or asso-
ciated with other paralytic states, are very  fre-
quent, and are by no means rare as a precursor
of  a  dangerous  apoplectic or paralytic  attack.
When thus present, as the only apparent ailment,
the result is not the less to be dreaded.  In sev-
eral cases, for which I have been consulted in the
course of my practice, speech was so completely
lost, that no articulate sound  was produced, the
simple vowel-sounds a and o being only emitted,
and yet none of the organic, or of the cerebro-
spinal functions,  and none of the senses, evinced
any disorder.   In all these, an apoplectic, hemi-
plegic, or more general paralytic seizure super-
vened generally in a few weeks or months, owing
to the development of latent pre-existing organic
lesion.  Whenever, therefore, the faculty of speech
becomes impaired, or is lost by persons who had
previously possessed  this faculty in  a healthy
state, more especially if this change occur in ma-
ture, middle, or advanced age, it should be viewed
as  a form of local or partial  paralysis, which is
generally followed, at no very remote period, by
a very dangerous form of apoplectic, or of more
general paralytic seizure.
   14. III. Impediments of   Speech — Hesita-
tions   of Speech—Stammering—Stuttering.
—This affection  is  generally functional,  or of a
nervous nature, and may present several forms.
These are usually observed in childhood and in
early life; while incomplete or complete  loss of
speech,  briefly considered above (§ 13, et seq.), is
the consequence  of structural lesion or of injury,
and is a form of paralysis of a most  dangerous
nature.   Hesitations in articulating sounds, or a
momentary impediment in uttering certain words
or  letters, or  a stammering, or repetition of cer-
tain consonants, are generally observed from in-
fancy or childhood, but they may increase or di-
minish, or even disappear as age advances. They
may continue during a long life, or they may oc-
cur only occasionally.  In this latter case they
are induced  or aggravated by fear, anxiety, and
various mental emotions   They cannot be mis-
taken for impairment or loss  of the previously
healthy power of articulation, which, as stated
above (§ 13), proceeds  from slowly-formed or-
ganic lesions implicating the origins or course of
the glosso-pharyngeal nerves ;  and which occurs
under different  circumstances, and is  attended
and  followed by very different phenomena  and
consequences.
   15. The muscles employed  in the production
of definite vocal  sounds  and of articulate speech,
being  actuated  by  volition conveyed from the
brain to these muscles  by means of the nerves
proceeding from the former to the latter, it nec-
essarily follows  that both voice and speech de-
pend on the capability  of the brain to generate
or exert volition, and of the nerves to convey this
act to the muscles.  Thus speech, as  well as
voice, requires for its perfection a due exertion,
and  a healthy transmission of volition, by means
of the nerves, to the apparatus destined for its
production ; and, if volition be feebly exerted, or
imperfectly transmitted  to the muscles concern-
ed in articulation, various imperfections of these
functions will result.  But the  complete, perform-
ance of both voice and speech depends also upon
the healthy functions of the lungs and respirato-
ry passages, these  functions being modulations
of expiration by means of the larynx, tongue,
fauces, oral cavity, and lips.
   16.  Thus it is apparent, as  remarked by Mr.
Bishop, that " the  mechanism provided  for the
production of speech comprehends  a  large  as-
semblage of organs.   The most simple vocal
sounds require the combined action ofthe lungs,
windpipe, larynx, and respiratory muscles;  and
for articulate language, an  additional set of or-
gans must be called into play, namely, the pha-
rynx, hard and soft palates, uvula, tongue, teeth,
lips, and nostrils."
   17. It is justly observed by Dr.  Carpenter
that, " great as  is  the  number of muscles em-
ployed in the production of definite vocal sounds,
the number is much greater for those of articu-
late language ; and the varieties of combination
which we are continually forming unconsciously
to ourselves, would not be suspected, without  a
minute analysis of the  separate actions.   Thus,
when we utter  the explosive  sounds (explosive
consonants), we check the passage of air through
the posterior nares, in the very act of articulating
the letter; and yet this important movement com-
monly passes unobserved.   We must regard the
power  of forming the several articulate sounds
and their simple combination, as so far resulting
from intuition,  that it  can in general be  more
readily acquired by early practice than other ac-
tions of the same complexity; but we find that,
among different races of men, there exist tenden-
cies to the production of different sounds, which,
though doubtless influenced in great degree by
early habit (since we find that children, when first
learning to speak,  form their  habits of vocaliza-
tion in great degree in  accordance with the ex-
amples amid which they are placed), are certain-
ly also dependent in part upon congenital consti-
tution, as  we often see in  the  case of children
among ourselves, who grow up with certain pe-
culiarities of pronunciation, not thus derived from
imitation, of which they do not seem able to di-
vest themselves."
   18. I must refer the  reader to Mr. Bishop for
a nttice of mechanical  contrivances for the pro-
duction of vocal  sounds  ; but these can never suf- 
1502
VOICE AND SPEECH—.
-Affections  of, described.
ficiently illustrate the intonations of voice or the
production of articulate speech, or even satisfac-
torily show what it is that constitutes the essen-
tial character or distinction between  the vowels,
and on what part  of the mechanism of the voice
the vowel-sounds depend.  These sounds, as well
as those of the consonants, are formed by so
slight changes in the relative position ofthe sev-
eral  parts of the complex organs of voice  and
speech, varying in accent and intonation so re-
markably with the language, &c, as hardly to
admit  of any estimate.   Mr. Bishop observes
that, " in the application of the theory of vowel-
sounds to the mechanism of the human voice
and  speech,  there are  two hypotheses which
would equally  satisfy  the conditions  for their
production  artificially.    The first is,  that  the
glottis produces the primary, and the air in the
pharynx, mouth,  and nostrils, the secondary or
vowel-quality  pulsations.  The  second is, that
the glottis produces  the primary, and the mem-
branes of the pharynx, mouth, and nostrils pro-
duce the secondary pulsations of the air."   Dr.
Thomas Young observes, in respect of the first
of these, that the " reflection of the  sound from
the various parts  ofthe  cavity ofthe mouth  and
nostrils, mixing at various intervals with the por-
tions of vibrations directly proceeding from the
larynx, must, according to the temporary form of
the parts, variously affect the laws of the  motion
ofthe air in such vibration."
   19.  As to the second view,  Mr.  Bishop re-
marks, that  " we know by  experience that the
breath passing through the glottis is  thrown into
a certain state of vibration, and reaches the cav-
ity of the mouth, which is already so disposed as
to present a proper extent of its own membranes
to the action ofthe breath.  By these means the
membranes  are also made to vibrate, and these
latter vibrations, coexisting with the original vi-
brations of the glottis, may generate the vocal
sounds."  Now the chief objections which may
be offered to this view are, that the  surfaces of
parts, over which the vibrations of air from the
glottis pass, are not membranous or are not mem-
branes capable of vibration, but are surfaces con-
stantly changing  their configurations by means
of the muscles by which they and the subjacent
parts are actuated, the vibrations of air thrown
out by the glottis being modified or changed by
the alteration in the configuration of these sur-
faces—ofthe surfaces of those parts between the
glottis and the external  features—so as  to pro-
duce the different vowel-sounds, and to pass from
one  simple  vowel-sound  to another.  Without
attempting to proceed farther in the considera-
tion of the other simple sounds, or of the physi-
ology of voice and speech, my limits oblige me
briefly to notice the  more practical part  of this
subject.
   20. Very  great ignorance, some mischief,  and
no little discredit to  medical science, have been
displayed by the energetic proceedings of some
surgeons who have either written upon stammer-
ing and stuttering, or who have  officiously med-
dled with, and injuriously operated upon, certain
parts which  are jn no way implicated in the  dis-
order under consideration.  It has been supposed
by these meddlers, with surpassing  profundity,
that these  momentary  or temporary affections
arise  r'rom  some  lesion  of the  muscles of the
tongue, or of the fraenum linguae, or of the vflum
palati, or ofthe uvula, or even ofthe tonsils, each
acting on his own peculiar inspiration—with a
success properly exposed by Mr. Bishop, and suf-
ficiently manifested to my own observation.   It
must  be very demonstrative  of the progress of
surgical science to see one  surgeon " dividing
the muscles of the tongue at its root, cutting at
the same time through the Iinguales, the genio-
hyo-glossi, and  stylo-glossi muscles, with their
blood-vessels and nerves ; or  cutting  a trans-
verse  wedge-shaped slice out of the dorsum of
the tongue!" Or  another surgeon extirpating
the tonsils, which may affect the  pitch and the
quality of the voice, but which can have nothing
to do with  stammering!  Or  a  third  surgeon
cutting  off the uvula, which is unconcerned in
articulation!   Now  these pleasant  operations
have all been done, and may be done again and
again, under  the seductive and perfectly safe (?)
influence of chloroform, but what are the results?
Let the victims articulate the answer, if they can
intelligibly—for  I have seen  some of them who
found this very difficult.  For, as I have already
noticed in another place, both the uvula and the
tonsils perform functions necessary to the perfec-
tion of both voice and speech  ; and if these be re-
moved, the pharynx and glottis are insufficiently
lubricated, and are liable to experience, in conse-
quence, more or less irritation, often passing into
chronic inflammatory action,  as have been  dem-
onstrated  by  cases which have come under my
observation, and in which these parts had been
extirpated.   In other cases, where these effects
have not appeared, or where the speech has been
without huskiness, or any lesion of distinct artic-
ulation, the voice has been so much injured as to
prevent attempts to sing.
  21. There  are several  conditions which  com-
bine to produce stammering,  each being more or
less concerned in the  morbid  effect.  The first is
imperfect  vocalization, or an  insufficient expira-
tion, owing generally to an imperfect respiration
or to  the  lungs  having been  nearly emptied of
their due quantity of air at the  moment of artic-
ulation ; the second is an insufficient force of vo-
lition, by which the act of articulation is attempt-
ed ; the third is, generally owing to the foregoing,
a want of synchronous and appropriate action of
one or more  of the parts concerned in the pro-
duction of voice and  speech ; and^fourth, an ir-
regular or spasmodic  action of some ofthe mus-
cles engaged in  articulation.   This last state is
generally, also, a consequence of attempts at ar-
ticulation  being  made either without  sufficient
force of volition, or without due vocalization, or
during an insufficient expiration from defect of
air.   It follows  from  the  above that the chief
source of stammering is to  be referred to the
nervous centres—more especially to the seats of
volition and emotion, and to  the functional con-
dition of the medulla oblongata.
  22.  Dr. Carpenter has justly  remarked the
analogy between  stammering  and chorea, the
former being sometimes  one of the modes in
which the disordered  condition of the nervous
system in chorea manifests itself.   " The slight-
est disturbance  of the feelings is sufficient in
most  stammerers to induce  a complete pertur-
bation of the vocal powers;  the very fear that
stammering will occur,  particularly under cir-
cumstances which render it peculiarly annoying,
is often sufficient to bring it on in  a predisposed
subject; and the tendency to consensual imita-
tion sometimes occasions stammering in individ- 
VOICE AND SPEECH—Affections  of, described.
1503
uals (especially children) who never show the
slightest tendency to it  except when they  wit-
ness the difficulty in others."
  23. That  one or more of the four conditions
which I  have  stated to be chiefly concerned in
the production  of  stammering  actually exists,
will appear from  what  is  observed as to the
manner in which timidity, fear,  and anxiety af-
fect these conditions, and, by thus affecting them,
produce  in many persons either stammering or
stuttering; although they are not subject to these
disorders of articulation  in other circumstances.
On this topic Mr. Bishop very correctly remarks:
" The emotions which arise in a person  when he
is about to address an  audience are  often so
overpowering that the voice loses its natural vol-
ume, becomes tremulous, and sometimes inaudi-
ble, the  respiratory  functions are irregular, the
flow  of  ideas is impeded, and  the  articulating
organs  perform their office so imperfectly, that
he who is  generally ready and fluent in conver-
sation hesitates, stammers, and cannot utter a
single connected sentence.  Now if persons, who
at other times have a perfect voluntary control
over  the organs of voice  and speech,  partially
lose it under the circumstances just mentioned, a
fortiori those who have at all times an imperfect
control  over  their articulation  will, in similar
states of feeling, find their powers paralyzed, and
their speech more than usually defective^'
   24. But it is chiefly in childhood and  boyhood,
when the sensibility and the emotional  suscepti-
bility are greatest—while the due co-ordination
of those movements ofthe parts which contribute
to correct articulation  is either being formed, or
is in the course of development, or only recently
perfected—that stammering either commences or
is chiefly manifested.  At these ages, and more
especially in those children in whom the faculty
of speech is slowly developed, or appears only at
a later period than usual, the emotions  are most
likely to disturb the force of volition, and, with
this disturbance, the normal exercise of the in-
tellectual, the respiratory, the vocal, and the ar-
 ticulating functions.
   25. Whatever may be the cause or nature of
the changes in the brain  corresponding to the
several emotions, they are propagated to the me-
dulla oblongata, and influence the action of the
respiratory  and the motor  nerves of  the  face,
throat, and tongue, as well as other nerves, and
through them the muscles  they supply.  The
emotions may  thus occasion irregular actions
of the  parts  concerned  in  articulation:  1st, by
causing a momentary spasm or closure  of the
glottis,  and thereby arresting  all vocal sound;
2d, by causing irregular  action, or by closing the
isthmus of the  fauces and  obstructing the pro-
nunciation  of letters and syllables which begin
with guttural letters; 3d,  by the  irregular  or
spasmodic motion of the tongue, the dorsum of
this  organ  being  carried backward, or brought
into contact with the palate, thereby affecting the
lingua-dentals, lingua-palatals, and lingua-palato-
nasals,  and syllables or  words commencing with
these letters; and, 4th,  by  closing the lips and
posterior nares, by  affecting the pronunciation
of the labials, and even  also of all the  other let-
ters.   An  acute and experienced observer may
readily  detect the particular cause of obstruction
—whether the glottis, fauces, the dorsum or tip
ofthe tongue, or lips.
   26. IV.  The treatment of stammering must
be based upon the result of observation as to the
seat of difficulty, or obstruction in the organs of
articulation.  Dr. Arnott proposes that all the
words should be connected by a vocal intonation,
in such a manner that there shall never be an en-
tire stoppage ofthe breath.  But the difficulty is
often  at the  commencement of a word or sen-
tence, especially when the glottis is spasmodical-
ly or irregularly affected ; and, as Muller con-
tends, this plan cannot do all that is required, as
the impediment often occurs  in the  middle of
words, although it may afford some benefit. The
most important remedial means is that much in-
sisted  upon by  Dr. Carpenter, and this is to
study carefully the mechanism ofthe articulation
of the difficult letters, and to practice their pro-
nunciation repeatedly, slowly, and  analytically.
"The patient would at first do well to practice
sentences from which the  explosive consonants
are omitted; his chief difficulty, arising from the
spasmodic  suspension of the expiratory move-
ment,  being thus  avoided.   Having  mastered
these, he  may pass on to others, in which the
difficult letters  are sparingly  introduced ;  and
may finally accustom  himself to the  use of ordi-
nary  language.   One of the chief  points to be
aimed at is to make the patient feel that he has
command over his  muscles of articulation ;  and
this is best done by gradually leading him from
what he finds he can  do, to that which he fears
he cannot."  (Op. at, p. 771.)
   27.  The  circumstance of stammerers being
often able to sing their words better than to
speak  them has been explained by the supposi-
tion that, in  singing,  the glottis is kept open, so
that therejs less liability to its spasmodic action;
but, in  singing, the velum palati, and  the other
parts concerned  in articulation, are also much
less liable to irregular or spasmodic  action, they
being  brought less into  action than in articula-
tion.   The difference may, however, as Dr. Car-
penter supposes, be  due to the direction of the
attention rather to the muscles ofthe larynx than
to those ofthe mouth.  One ofthe most obvious
and important objects in the treatment of stam-
mering is  the prevention of any emotional dis-
turbance during the act of speech; "and this re-
quires the exercise of the voluntary powers over
the direction of the  thoughts, in the following
modes: 1st.  To reduce mental emotion, by a dai-
ly, hourly habit of abstracting the mind from the
subject of stammering, both while speaking and
at  other times; 2d.  To avoid exciting mental
emotion by attempting unnecessarily to read or
speak, when the individual is conscious that he
shall not be able to  perform these actions without
great distress ; 3d.  To elude mental emotion, by
taking  advantage of any little artifice to escape
from stammering, so  long  as the artifice contin-
ues to be a successful one."  Having mastered*
the articulation ofthe difficult letters, and ofthe
words containing them, and having  thus avoided
or overcome mental emotion,  the patient should
practice reading and speaking aloud, slowly, and
with due enunciation and intonation, and with a
full and free respiration, never allowing the lungs
to become too far exhausted of air.   Due atten-
tion should also be paid to the digestive and ex-
creting functions, and to the improvement ofthe
organic nervous force and of the mental pow-
ers, by air, exercise, medical treatment, and diet.
Frequent declamation,  and reading or reciting
aloud such passages as interest the mental emo- 
1504               VOICE AND  SPEECH—Bibliography and Referenc es.
  tions, should be practiced as  soon as the patient
  has acquired a complete command over his artic-
  ulation  and over  the difficulties  which mental
  emotions have occasioned him.
    [Did our limits permit, it would be interesting
  to trace the history ofthe treatment of stammer-
  ing,  in  this country, from  the empirical modes
  adopted by teachers down to the  still more em-
  pirical practice  of various surgeons, who, follow-
  ing in the footsteps of Dieffenbach, severed the
  muscles at the root of the  tongue, removed a V-
  shaped portion  from its substance, or excised the
  tonsils and uvula, mistaking the temporary relief
  produced by the strong mental impression caused
  by the operation for a permanent cure ; and this,
  too, when it is well known  that a severe tooth-
  ache, rheumatic affections ofthe jaws or face, tic-
  doloreaux, ulcers on the tongue or  inside of the
  lips,  and other casualties, will cause a temporary
  cessation  of  stammering.   The  late Dr.  C.  C.
  Yates,  of New York, was the first to hit upon a
  philosophical and successful method of treatment.
  This was  imparted to the governess in his family,
  Mrs. Leigh, who,  in connexion with him, estab-
  lished an  institution for the treatment  of such
  cases, which was carried on for many years with
  very remarkable success.  Pupils flocked to them
  from every part of the Union, and were in  most
  cases speedily cured.   Other teachers, instructed
  by them, established other  schools in  different
  parts of the United States, and were equally suc-
  cessful  in  effecting  speedy  cures.  The  result
  which followed was what might  have been an-
  ticipated ; the cures obtained were so numerous
  and wonderful, and attended  with so much profit
  to the teachers, that multitudes of otljer persons
  soon set up to  cure impediments  of speech who
  were totally unqualified, and  the system soon" fell
  into  disrepute.   At present  very little is  heard
  of the system,  and it  would  seem to have  been
  generally  abandoned.   Dr. Yate&'s method may
  be found  fully and very ably  described by Dr. E.
  Warren, of Boston, in vol. xxi. of the Am. Jour.
  Med Sciences, p. 75.   One thing is certain, that,
  although  apparent cures are  easily made by this
  system, and appear perfect for  the time, there is
  great danger of a relapse unless confirmed by long
  habit.   In a few cases they  will remain perma-
  nent, but in a majority, unless the course is per-
  sisted in, the difficulty returns.  Whatever meth-
  od is employed for the relief of this affection, in
  a majority of cases no permanent  advantage will
  be gained  unless resolutely persevered in for one
  or two years.]

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 quens, seu Dissert, de Loquela, Svo.   Amster., 1702.__
 J. Wallis, De Loquela, seu  Sonorum Formatione, Svo.
 Leyd., 1727.—D. Dodart,  Memoires sur les Causes  de la
 Voix de 1'Homme et ses  differents Sons, dans  Mem. de
 l'Acad. des Sciences de Paris, Ann , 1700, p. 244.—A.
 Bergen,  De Palbutientibus Dissert, l-'r., 1756.—A. Fir-
 rein, De la Formation de la Voix de l' Homme, dans Mem.
 de l'Acad. des Sciences de Paris, Ann., 1744, p. 409.—R.
 O.Vogi 1, De I.aryngo Humano et Vocis P'ormatione, 4to.
 Erf., 1747.—De Hat n, Opuscul.  Ined., p. 1, n. 18.—Steel,
 Prosodia Kationalis, 8vo.  Lond., 1779, p. 49.—/. Watson,
 Instruction for the Deaf and Dumb, &c.;  Hints for the
 Correction of Impediments in Speech, &c, Svo.  Lond.,
 1S09.—S. H. Dutroihit, P^ssai sur une Nouvelle Theorie
 de la Voix, avec  1' P xpose des divers  Systemes qui ont
 paru jusqu'o ce Jour sur cet} Objet, 4to.  Paris, 1S06.—
 T. Sheridan et R. G. Loebel, Ueber die Declamation, 8vo.
 Leipzic, 1793.—.4. Portal, in  Mem. de la SocKte  Med.
 d' 1 mulation, t. i., p. 80;  et in Mem. de la Nature  et le
 Traitement de plusieurs  Maladies, t. ii., n. 8. — F. L.
 liovble,  in Journ. Gener. de Medecine, t. xxix., p. 137,
 1807. (The  Semiology of Speech.) —T. Young, Natural
 Philosophy, vol. ii., p. 55'J. — /. Thelwall, a  Letter to
 Henry  Cline, ICsq., on Imperfect Developments of the
 Faculties. Mental and Moral, &c.; and on the Treatment
 of Impediments of Speech, 8vo.  London,  1810, Rev. in
 Edin. Med. and Surg. Journ., vol. vi., p. 489.  (Contains
 very just Views of the Causes of Stammering.)— W. Kern-
 pelen, Le Mechanieme de la Parole, suivi de la Descrip-
 tion d'une Machine parlante, Svo.  Vienne, 1791, i. jig.
 —/. B. Bouilland, in Archives G6n6r. de Med., t. viii., p.
 25, 1825; l'p:xperience, t. iv.,  1839.—/?. Shuttess, Das
 iStammeln und Stottem, Svo.  Zur., 1830.—A. M. Rapp,
 Versuch einer Phys. der Sprache, 8vo,  2 vols. Svo.   1836.
 —F. A. Longet, Recherches Experim. sur  les  Fonctions
 des Nerfs et des Muscles du Larynx, et sur 1'Influence du
 N'erf accessoire de Willis dans la Phonation, 8vo.  Paris,
 1844; et in Anat.  Phys. du Syst. Nerveux, t. ii.—Coli/m-
 bat, Du B> gaiement et de tous les autres Vices de la Pa-
 role,  trait s par  de Nouvelles  Methodes,  2d ed., 8vo.
 Paris, 1831.—L. A. Legond, Hygiene  du Chanteur, &c,
 Svo.  Paris, 1845.—C. Bell, in Philos. Trans., 1832, p. 311.
 —Miiller, Physiology, lib. iv.—R. D., in Diet, de Med., 2d
 ed., art. Voix—Pathologic—Willis, in Transactions ofthe
 Cambridge Philosoph. Society, vol. iv.—Bacc. Med., On
 Stammering and  its Treatment, 8vo.   Oxon.,  1850.—/.
 Hunt, a Treatise on the Cure of Stammering, &c. Lond.,
 1856.—/. Bishop, on the Physiology ofthe Human Voice,
 in Philos. Transact, 1S46.—On Articulate Sounds; and
 on the Causes and Cure of Impediments of Speech, Svo.
 Lond., 1857 (an able awl scientific treatise); also on the
 Construction of Hearing and Speaking Instruments, Svo.
 Lond., 1832. Pee also article Voice, in Cyclopaedia of Anat-
 omy and Physiology, vol. iv.—W. B. Carpenter, Princi-
 ples of Human Physiology, with their chief Application
 to Psychology, Pathology, &c, 5th edition, Svo.  London,
 1855, § 815, p. 765, et see/.
   [Amer.  Bin. and Ref.—/. IF. Draper, Human Physi-
 ology, Statical and Dynamical; or, the Conditions and
 Course ofthe Life of Man, Svo, p. 64 '.   N. York, 1S56.—
 Samuel Jackson, The Principles of Medicine, founded on 
VOMITING AND  RETCHING—Pathology and Treatment of.           1505
 the Structure  and Functions of the Animal Organism, i
 Svo, p.  030.   Phil., 1832;  also, Amer. Journ. Med. Sci-
 ences, Pub., 1S^.», p. 272.  (  ase of total loss of language,
 vocal and written,  temporarily produced  by  cerebral
 congestion, and uaattended with any other functional
 disorder.   .Speech was immediately restored by copious
 bbeding, going to establish the doctrine of a specific in-
 tellectual organ for language.)—Robley Duwjliaon, Hu-
 man  Physiology, with 36S illustrations, 2 vols. 8vo, p.
 651, 694.   (This work contains one of the most able and
 elaborate articles on  the voice in the English language.)
 —Isaac Parish, Quarterly Summary of the Transactions
 of the College of Physicians of Philadelphia, Nov. and
 Dec., 1S41, and  Jan., 1342.—Daniel Oliver, First Lines
 of Physiology, 8vo, p. 520.   Boston, 1835.—/. R. S. Jack-
 son, on  the .Modification of the Voice and Respiration in
 Pleural Effusion, in  Amer. Journ. Med. Science, N. S.,
 vol. ii., p.  16.  —T. F. W. Lane, Amer. Translation of  a
 Treatise upon the Diseases and Hygiene of the Organs of
 the Voice,  by  Colombat de  l'lzere, 12mo, p. 220.  Bos-
 ton, 1845.—Edward Warren, Remarks on Stammering, in
 Amer. Journ.  Med. Science, vol. xxi., N. S., 1S37, p. 70.
 (A very philosophical and judicious essay, containing the
 substance of all that is known on,the subject of curing im-
 pediments  of speech.)—Dr. Serre, on the Cure of Stam-
 mering, in Ibid., April, 1S46, vol. it, N. S., p. 5:12.   See
 also vol. vi., N. S., for Dr. Abercrombie's views on the
 management of such cases. (The views of Dr. M-Cormac,
 of Dublin, who published a small volume on tlie subject
 in 1S2S, were obtained from Dr. Yates, while Dr. M'C. was
 on a visit to this country, and are substantially those of
 the former.)—lohn Webster, Cases of Aphonia, depending
 on an Affection of the Head, in Ibid., vol. xii., O. S., p.
 221.—Marshall Hall, on Stammering, in Ibid., vol. viii.,
 O. S., p. 220.—Baron Cuvier, Mechanism of the Human
 Voice during singing, in Ibid., vol. ix., p. 191.—Mxdam
 Boivin, Case of Idiotism and Aphonia, produced by Fright,
 in Ibid., vol. vi., p. 220;  Cases of Intermittent Aphonia,
 in Ibid., p. iii.—Horace Green, Cases of Aphonia, &c,
 successfully treated by Nitrate of Silver, in N. York Journ.
 Med., Jan., 1846, p. 16 ; also vol. iv., p. 251. — Isaac E.
 Taylor, ( ases  of Aphonia treated by Applications of Ni-
 trate of Silver, in Ibid., vol. iv., p. 348.—Aphonia suc-
 cessfully treated by Croton Oil, externally  applied, in
 Ibid., vol.  ii., p. 126. — C. A. Lee,  Clinical Lecture on
 Aphonia, Buffalo Med. and Surg. Journ., 1847. — James
 Rush, The Philosophy ofthe Human Voice, 2d ed.,  Svo.
 Phil., 1S33.]

 VOMITING AND RETCHING. — Synon. —
   'Epsala, Hipp.   Vomitus, Vomitio,  Vomitium,
   Vomitum,  Evomitio, Emcsis vomitio, Vomituri-
   tio, Emesia, Auct. Var.   Hyperemesia, Swe-
   diaur.  Palmus vomitus, Young.   Emcsis Vo-
   mitus, Good. Erbrechen, Germ.  Vomissemenl,
   Fr.  Vomito, Ital. and Span.  Puking, Spewing.
   —Retching.— Vomendi conamen  inane, Sub-
   versio stomachi;  Dysemesia, Mgntudo  ventri-
   culi—Ayant envie de vomir, Fr.   Sich Worgen,
   Germ.
   Classif. — Pathology — Symptomatology
      and  Therapeutics.*   (See  Preface.)

   * The mechanism of vomiting has been a subject of dis-
 cussion with both physiologists and pathologists.   Three
 principal opinions have been entertained on this subject.
 Magendie  was of opinion that the stomach was passive
 in the act, and that the contraction of the diaphragm and
 abdominal muscles on that organ is the sole cause of the
 phenomenon.   " This view was adopted by Kiciierand,
 Rostan, and Piedagnel; while Marquats, Maingaui.t,
 Portal, Tantini, Graves, Stokes, and Hall have em-
 braced more or less contrary opinions."   Maingaclt at-
 tributed vomiting exclusively to a gradual anti-peristaltic
 movement and contraction of the stomach.  Portal con-
 cluded that this act takes place during expiration, conse-
 quently during relaxation of the diaphragm.  That vom-
 iting may take  place without the action of the diaphragm
 is shown by a case observed by Drs. Stokes and Craves,
 where vomiting was a principal symptom, but the stom-
 ach was  found situated above the diaphragm.  In a case
 recorded by M. Define (Bullet de l'Acad. Boy. de Med.,
 1844), in which the abdominal parietes having been acci-
 dentally  laid open in the human subject, and the stomach
 having wholly protruded itself, it was seen to contract it-
 self forcibly and repeatedly, until, by its own efforts, it
 had expelled all its contents except gases.  The relaxa-
 tion of the cardiac sphincter is essential to the act of vom-
iting, for its fibres can resist, by their contraction, the
combined force of the expulsor muscles.  The retchings
or fruitless  efforts at vomiting are owing to the contrac-
     III.             95
    1.  Definit.—The rejection  of the contents of
 the stomach, with  or without retchings, generally
 symptomatic  of visceral or of  constitutional dis-
 eases, but sometimes occurring independently of
 these, or of any serious derangement: Retching
 is an ineffectual effort to reject  the contents of the
 stomach, or painful contractile efforts, either before
 the stomach is  evacuated, or afterward, and when
 the stomach is empty.
    2.  Vomitings and retchings are subjects of
 great interest:  1st, as symptoms of disease ;  2d,
 as a therapeutical  indication ; and, 3d, as a prom-
 inent manifestation, if not a primary or idiopath-
 ic state, of serious disorder.   The first of these
 is considered in the article on  Symptomatology
 (§ 130, et seq.), as well as in the history  of the
 several forms of disease ;  the second is partially
 noticed under the  head of Therapeutics  (§  40,
 43, and 56), and in the eighth class, and the third
 order of Therapeutical Agents.   Before, there-
 fore,  I proceed  briefly to consider vomiting as a
 chief and prominent affection, requiring  to be
 palliated  or allayed, I  shall notice the  circum-
 stances which appear mainly to require the arti-
 ficial production of vomiting.
    3.  I. Vomiting  as a therapeutical indica-
 tion  and  Agent has not, in the  article just now
 referred to, owing to the scope  and object of that
 article, been  considered so fully as its import-
 ance  demands.   It is  more especially required
 when  poisonous or  injurious  substances  have
 been taken into the stomach ; or when the stom-
 ach is overloaded by food or drink to a hurtful
 amount, more particularly when either or both
 threaten to occasion apoplexy,  or any other seiz-
 ure, or when these attacks actually result from
 these causes.   In  all such cases the selection of
 the emetic should  be suitable  to the  cause and
 nature  of the evil  produced, and always  be so
 energetic as to  produce a rapid and full effect.

 tions of the cardiac sphincter.  Vomiting, like other ef-
 forts at expulsion  of the contents of  the natural cavities,
 is performed by the muscles of expiration, and while the
 diaphragm is relaxed  and pressed up upon the lungs by
 the action of the abdominal muscles.
   The immediate causes, or the physiological pathology
 of vomiting, may  be  stated under the following heads:
 1st. The contact of irritating, poisonous, or unwholesome
 substances irritate the ganglial nerves supplying the vil-
 lous coat of the stomach, and affect  the cceliac ganglion
 and adjoining plexus.  The morbid  impression or irrita-
 tion is conveyed to the roots ofthe spinal nerves and cord
 by the ramifications of the ganglial nerves to these parts,
 and is reflected thence, by the motor  nerves of expira-
 tion, to the abdominal muscles, by what I termed a " re-
 flex sympathy," and  Dr. Marshall Hall  long  subse-
 quently designated a " reflex function."  2d. Irritations,
 &c., affecting other parts of the body (as stated § 18, et
 seq.), are propagated by the splanchnic ganglia and plex-
 uses to the stomach,  and through  them to  the  spinal
 cord, and are reflected in a similar  manner, by the mo-
 tor nerves chiefly of expiration, to the abdominal and ex-
 piratory  muscles.   The vomiting which thus occurs I
 have denominated from reflex  sympathy, because it is
 only occasional or  contingent, and not bo constant or nec-
 essary an effect a3 to  warrant the appellation of a func-
 tion.  3d. Impressions made on the senses,  or  violent
 emotions, may, through the medium of the pneumo-gas-
 tric nerves, affect the ganglial centres, and either through
 these latter affect also, in the way above stated, the spinal
 cord and motor nerves, &c, or be more directly propa-
 gated to  both the splanchnic and spinal nerves.  4th.
 Sea-sickness and vomiting cannot be referred to either of
 the above categories.   They proceed  from an impression
 of an irritating or  depressing character—the latter more
 particularly—made primarily on the semilunar and other
 splanchnic ganglia and plexuses, and propagated on the
 one hand to the ganglial nerves of the stomach, and  on
 the other to the ramifications of these nerves to the spinal
 nerves  and cord, thereby occasioning contractions of the
stomach simultaneously with contractions of the muscles
supplied by the motor expiratory nerves. 
1506          VOMITING  AND  RETCHING-

  4. a. Diseases of the respiratory passages, es-
pecially those attended by spasm, by suffocation,
difficulty of breathing, by difficult expectoration,
&c, are generally much benefited by a suitable
emetic and free vomiting. Croup, hooping-cough,
asthmatic seizures, spasm of the larynx, and lar-
yngitis, congestion of the lungs, bronchitis, and
bronchial catarrh, are severally relieved by emet-
ics.  In most of these, ipecacuanha, in  a full
dose, is the best  emetic; but when there is fever
or inflammatory action, the potassio-tartrate of
antimony may be given, but if it fail of produc-
ing vomiting in  a short time, a full dose of ipe-
cacuanha should be exhibited.   The sulphate of
zinc and ipecacuanha, conjoined with capsicum
or other warm spices, are most useful when vom-
iting is indicated during states of vital depression
or exhaustion ; and in cases of poisoning by sed-
atives, narcotics, &c.
  5. b. The invasion of fevers, continued or exan-
thematous, is often most satisfactorily treated by
an active emetic ; and, as well as in affections of
the respiratory passages and organs,  the good
effect is enhanced by the free promotion of vom-
iting, and by exhibiting warm diluents, especially
the warm infusion of chamomile flowers, or de-
mulcents.  Agues and other periodic fevers, es-
pecially remittent, gastric, and bilious fevers, are
also much benefited by initiating the treatment
by an active  emetic,  and by promoting its effects
by these means.  Antiperiodic and febrifuge rem-
edies,  and  chologogue purgatives, exert  a more
certain effect when  they  are preceded by free
vomiting, artificially  produced.
  6. c. Various disorders of the digestive canal are
most beneficially treated by procuring free vomit-
ing at  the commencement of the disorder or of
the treatment.   The  several forms of Cynanche
or Angina, especially when they embarrass respi-
ration  or deglutition, often  require a recourse to
emetics.  In the more  malignant  states of Cy-
nanche, or those characterizing Scarlet fever, the
sulphate of zinc, or ipecacuanha, conjoined with
capsicum  or  other spices, and promoted by the
decoction of senega, and by tonics, stimulants,
camphor, ammonia, &c, should be preferred to
others.
  7. d. Some forms of indigestion, or those arising
from accumulations  of mucous sordes, or crudi-
ties, and torpid states of the biliary formations,
as indicated  by a foul or loaded tongue, and by
morbid appearances of the evacuations, are often
the most successfully treated by commencing with
an ipecacuanha emetic.  All forms of dysentery,
inflammatory or sthenic, adynamic or asthenic,
acute or chronic, endemic or epidemic,  simple or
complicated,  hepatic or scorbutic,  derive benefit
from free and copious vomiting, especially when
produced and promoted by means suited to the
peculiarities of individual cases.  Ipecacuanha is,
however, the emetic  which is most generally ap-
plicable to dysenteric affections; and next to it
the sulphate of zinc.   After a free effect has been
procured by means of ipecacuanha, this medicine,
so valuable in dysenteries and chronic diarrha-as,
may be continued subsequently, in as large doses
as the  stomach may tolerate, but preferably in the
form of pill, combined with appropriate remedies
—narcotics, aromatics, tonics, &c.
  8. c.  Hypochondriasis and melancholia are some-
times relieved for a time by an energetic emetic,
judiciously selected and exhibited.   But it ought,
in order to be of service, to be followed by medi-
- Pathology and  Treatment  of.

i cines calculated to promote the secretions and
 excretions, and to impart tone and energy to the
 organic nervous system and to the organs which
 it actuates, by exercise, change  of air and  local-
 ity, and by travelling and occupations whioh both
 employ and interest the mind.
   9.  II. Vomiting and Retching as prominent
 Affections,  or States or Symptoms of  Dis-
 ease.—Retching or vomiting may be the most
 remarkable and distressing symptoms, owing, 1st.
 To injurious or poisonous ingesta; 2d. To severe
 constitutional  disease, as at the invasion,  or  in
 the course, of severe exanthematous or continued
 fevers, or of pestilential maladies ; 3d. To severe
 functional disorder or irritation,  or structural dis-
 ease of the stomach itself; and, 4th. To sympathy
 with disease or irritation in some allied or more
 or less distant organ.  The presence of either
 vomiting  or retching, or of both, necessarily in-
 duces the physician to inquire, 1st. As to the ex-
 citing causes, manifest or presumed ; and, 2dly.
 As to  the pathological states to which either  or
 both may be referred.
   10. A.  When a physician is called to a person
 who has previously enjoyed good health, or who
 has not complained in such a manner as to indi-
 cate a  liability to an attack of vomiting or retch-
 ing,  then he should  suspect  the nature of the
 ingesta as having produced it, and inquire  as  to
 the food or drink,  or other matters which the pa-
 tient may have taken; and the matters ejected
 from the stomach should all be  preserved for
 future  examination, if circumstances should arise
 to require such examination.  Where neither food
 nor  drink is the  cause, then poisonous matters
 taken voluntarily or accidentally, or given by oth-
 ers, ought to be suspected,  and  be carefully and
 artfully ascertained, and the matters rejected from
 the  stomach carefully preserved and examined
 by a competent person.  If poisonous substances
 have been taken  or given, or are  manifested by
 the character ofthe vomiting, by the allied symp-
 toms, or by the state of the vomited matters,  or
 by their presence  in these matters, the antidotes
 and  other means  of  treatment described with
 reference to the individual poisons (see that arti-
 cle) will be required.
   11. B. When the vomitings  or retchings are
 not caused by the  ingesta, their pathological rela-
 tions must then receive the necessary attention.
 In infants and children, as well also in adults,
 these affections may  proceed  from hot seasons,
 owing  to bilious or gastric disorder; from a bilio-
 gastric, continued, or  remittent  fever;  from the
 invasion of exanthematous fevers, especially scar-
 let fever and small-pox, and in  the former class
 of patients more  frequently than in the latter;
 from disease of the brain or  of its  membranes.
 They may be the invasion of the usual forms  of
 cholera, or of gastro-bilious disorder, during sum-
 mer  and  autumn  ; or the  very prominent and
 urgent  symptoms of pestilential cholera; or,  in
 warm climates, of hsmagastric  or yellow fever.
 In these climates, also, they may usher in remit-
 tent  or other fevers  and maladies ;  and in  all
 these, although most severe  and  even dangerous,
 as well as the most prominent, manifestations  of
 disease, they are  very far from being the disease
 itself, or even the  greatest part of it.
   12. C. Severe functional disorder, local or con-
 stitutional, will occasion vomitings or retchings,
 as that following dissipation or drunkenness (y  5),
 and  that occurring at the commencement of the 
VOMITING AND RETCHES
 fevers, and pestilential maladies already noticed ;
 but the most distressing attacks of retching and
 vomiting are often caused by the motions of ves-
 sels at sea, and by organic lesions ofthe stomach it-
 self  Of the former a more particular notice will
 be taken in the sequel under the head of Sea-sick-
 ness, or vomiting and retching during voyaging by
 sea; and  as to the latter causes, viz., inflamma-
 tion and structural changes ofthe Stomach (y 22-
 95), the symptoms now being  considered, when
 arising from these lesions, are duly noticed at that
 place.   To what I have there stated, and to  the
 article on the pathology of the Digestive Canal
 (v 37-43), I must refer the reader.  But there
 are other remarks which may be adduced at this
 place calculated farther to elucidate the history of
 vomiting.
   13. i. Vomiting and Retching from  Organ-
 ic Lesions seated in, or implicating the Stomach.
 —These lesions have been described at the places
 now referred  to ; and, among  these, ulcerative
 perforation of the stomach, either commencing in
 this viscus or extending  to it from  structural
 changes in adjoining parts, has occupied a con-
 spicuous rank.   These perforations may give rise,
 owing to  previous agglutination or adhesion  of
 the opposite serous surfaces, to communications,
 1st. Between the stomach and the substance and
 vessels  and ducts of the liver, owing most fre-
 quently to abscess in the latter viscus ;  2d. Be-
 tween the stomach and the pleural  cavities and
 lungs;  3d.  Between the stomach and  pericar-
 dium ; 4th. Between the stomach and vena  ca-
 va ;  5th. Between this organ  and portal  vein;
 6th. Between the  stomach and external  surface
 of the abdomen ;  7th. Between this viscus and
 the gall-bladder ;  8th. Between the stomach, gall-
 bladder, and duodenum ; 9th. Between the stom-
 ach and duodenum ;   10th. Between the stomach
 and some part of the  small intestines ;  11th. Be-
 tween the stomach and the colon ; 12th. Between
 the stomach and peritoneal cavity.  Other fistu-
 lous communications between parts of the digest-
 ive canal and other viscera are  met with  on rare
 occasions, and  are occasionally  attended by vom-
 iting ; but they are noticed in  their appropriate
 places.  Of the several kinds of perforated com-
 munications between the stomach  and other vis-
 cera now enumerated, theirs* is most commonly
 the result of abscess in the liver; although it may
 arise otherwise in rare instances, as in  a case
 which came under my care where the perforation
 of the stomach extended far into the substance of
 the liver.  The second is also most frequently the
 result of an abscess  opening into the stomach.
 The third, fourth, fifth, and sixth, almost in all
 cases, are  referable to perforating ulceration, can-
 cerous or simple,  commencing  in the stomach.
 The seventh and eighth forms of fistulous com-
 munication arc most  commonly caused by large
 gall-stones in the gall-bladder.  The  ninth, tenth,
 and eleventh most frequently proceed from can-
 cerous or  simple ulceration commencing in the
 stomach or pylorus.  The last of these lesions are
 caused chiefly  by the absence of adhesion of the
 opposite peritoneal surfaces, which adhesion takes
 place in  the others, although it is weaker,  or more
 readily separated, in  the cancerous or malignant,
 than in the simple forms of ulceration.  Of these
 forms of fistulous communications between the
 stomach and other viscera, gastro-colic fistula is
probably the most frequent.   This  form has been
ably described  by Drs. Brinton and Murchison,
tfG—from Organic Lesions.              1507

 and references have been given by them to inter-
 esting cases, published in medical journals, and
 to preparations contained in the principal patho-
 logical collections.
   14.  ii. Vomiting  from Gastro-Intestinal
 Fistula.—The vomiting caused by an abscess in
 the  liver, or by abscess  from  diseased vertebrae,
 opening into the stomach, or by a communication
 with purulent collections in the pleura or lungs, or
 in any other situation, may be recognised by the
 history of the  case, and  by the purulent charac-
 ters of the rejected matters.  When  occasioned
 by cancerous ulceration or growths, the vomitings,
 with the antecedent and attendant symptoms, are
 described at the places  above referred  to.  But
 when  perforation of the  stomach, either from
 these lesions, or from other ulcerative processes,
 takes place,  then the vomitings frequently  as-
 sume distinctive characters, which indicate the na-
 ture ofthe mischief.  In cases of gastro-cohc fis-
 tula the matters vomited very frequently indicate,
 or at least render probable, the existence of lesion
 from either cancerous or simple ulceration.   In a
 very able memoir on this subject, Dr. Murchison
 has  adduced 33 cases, of which 21 were caused
 by cancer, and 9 or 10  from  simple  ulceration.
 As to these he remarks, " that the proportion of
 cases resulting from cancer is more than double
 that from simple ulceration ; and, as simple ulcer
 of the stomach is about five times as common as
 cancer, Dr. Brinton was  not far wrong  when he
 conjectured ' that its proportion in the malignant
 disease is at least thrice (and probably six to ten
 times) as great as  in the ulcer.'   This  accounts
 for the  fact that some pathologists, as Rokitan-
 sky  and Bock, speak of it as a  result of cancer
 of the stomach, but make no mention of it under
 the head of simple  ulcer."  Had Dr. Murchison
 consulted what I have stated on this  subject in
 the article Stomach, and in the chapter on "  Ul-
 ceration and Perforation ofthe Stomach," he would
 not  have asserted  that pathologists "make  no
 mention of it (gastro-colic fistula) under  the head
 of simple ulcer."  This may be  true as respects
 the foreign pathologists whom  he has referred to ;
 but if he will turn to p. 1008 of the third vol. of
 this  work he  will find, among other remarks per-
 tinent to this subject, the following : " The ulcer-
 ation may be cicatrized,  as shown in  the  article
 just now referred to (y 39), or it  may proceed on-
 ward after adhesions have been  formed  between
 the opposite portions ofthe peritoneal membrane,
 and  thus the ulceration may proceed not only to
 perforation of the stomach, but also to perforation
 of a  contiguous portion ofthe  digestive canal, as
 the colon, or to more or less ulceration  and per-
 foration of another organ ;" and I proceed to far-
 ther illustrate the subject, and, in the following
 paragraphs, to  describe the commencement and
 course of ulceration and perforation of the stom-
 ach, the several varieties they present, and the
 symptoms which they occasion.
  15. This greater rarity of gastro-colic fistula,
 as a sequela of simple ulcer, may, according to
 Dr. Murchison, "depend on three causes: viz.,
 the fact  that simple ulcer is much more rarely
 met  with in that part of the stomach nearest the
 colon—the great curvature (in 5 only of ~20
 cases); and that there is a greater tendency in
 cancer to contract adhesion to neighbouring parts
 before perforation ;  while, at the same time, the
 cementing matter is of a less permanent quality
 than the lymph thrown out in the vicinity of a 
1508          VOMITING AND RETCHING—from Sympathetic Irritation.
simple ulcer."  The absolute frequency of gastro-
colic fistula, as a sequela of cancer of the stomach,
can only be  approximated.   Dietrich observed
this lesion  in 6 out of 160 cases, or in 375 per
cent.; Dr.  Brinton  in  11 out of 507  cases col-
lected by him, or in 2-17 per cent.  That the ul-
ceration generally commences in the stomach, I
have shown in the places above referred to ; but I
have admitted that it  may originate in the colon
or other parts, and extend by perforation  into the
stomach.   The cases recorded by Dr. Murchison
fully illustrate this inference.  He remarks that,
" Out of the thirty-three cases, there is every rea-
son to believe that the disease commenced in the
stomach in twenty-six;  in four cases there are
are not sufficient data for forming an opinion on
the point;  and in three only does the disease ap-
pear to have  been most advanced in the colon aft-
er death."   In  cases where tubercular disease
or abscess  finds its way into the stomach or into
both stomach and colon, as in vesy rare instances,
when this  result has occurred from disease of the
kidney or the gall-bladder, the course of the alter-
ation is manifest.
   16. iii.  The diagnosis of gastro-intestinal, or
gastro-colic fistula, depends chiefly on the charac-
ters of the matters thrown oft' the stomach.  The
topic is partly discussed, especially as respects the
antecedent and many of the existing symptoms,
in the articles referred to above;  but those phe-
nomena which indicate the presence  of this fis-
tula have not been so fully described.  Vomiting
is always  present, although it sometimes recurs
only at intervals.  It is often preceded, and at-
 tended, by fetid  eructations, or by bilious,  dark,
or grumous  matters in the ejected fluids.  When
there is a  free communication between the stom-
 ach and intestine, the vomited matters generally
 are  more or  less faecal.  But where the  fistula is
 long or circuitous, vomiting of faecal matters may
 not, or only  occasionally, be observed. Dr. Mur-
 chison remarks that out of nineteen  cases  in
 which the history was clear, faecal vomiting was
 observed  in eleven, and fetid—perhaps faecal—
 in three;  and  he draws the following conclu-
 sions: "1.  Faecal vomiting is probably present
 in all cases in which  the  opening (except this
 be very minute) is situated in the fundus, or great
 curvature, of the stomach, and may also be pres-
 ent when the disease is in the pylorus.   2.  In
 all cases in  which food is vomited the opening is
 at or near the pylorus, so as to preclude the pas-
 sage of food."   In cases of cancer of the pylorus
 or duodenum, vomiting may be less after the for-
 mation ofthe fistula than before, as the food in
 the former case  may pass into the intestine, into
 which the fistula opens.
    17. Where gastro-intestinal or colic fistula ex-
 ists  there may be present eructations with a faecal
 odour, as  well as faecal vomitings ; or there may
 be only fetid eructations.  Next to faecal vomit-
 ing, the presence of undigested food in the  stools
 is an important indication  of gastro-intestinal
 fistula.  I have  long supposed  that at least some
 of the cases of lientery, among the many which
 came before me at the Infirmary for Children,
 were actually instances of this form of fistula.
 As the disease advances, as it usually does, to a
 fatal issue in the course of several days (although
 it is sometimes prolonged to some weeks or even
 months, with intervals of partial ease),  diarrhoea
 with undigested matters in the stools soon after
 th?y had been taken, or an occasional recurrence
of costiveness, emaciation, anaemia, general ca-
chexia, or yellowness  of the body, as described
in the articles already  referred to, are commonly
observed.
  18. III. Vomiting and Retching from Sym-
pathetic  Irritation.—Irritability of the stom-
ach, so great as to be attended by vomiting or
retching, on receiving  all, or most kinds of food
or drink into the stomach, is often occasioned by
vascular erythism, inflammation, or organic alter-
ations of an adjoining, or even of a distant organ
or part.  The vascular excitement of, and deter-
mination of blood to the uterus during pregnancy,
and the death of the  fcetus in utero in  the ad-
vanced  months of gestation, are often productive
of vomitings or retchings;  and organic and in-
flammatory  diseases of the uterine organs fre-
quently occasion the same symptoms, especially
in delicate and susceptible females, or when those
diseases are of an acute or severe kind.  As  may
be  readily inferred, inflammations and  organic
lesions of any of the  allied or adjoining viscera
very often are productive of vomiting, the reject-
ed  matters consisting, as in the preceding  dis-
eases, chiefly of the ingesta, and of watery, ropy,
and mucous fluids, sometimes coloured with  bile,
unless when congestion, inflammation, or abscess
may give rise to the discharge of blood or puru-
lent matter from the stomach, or from adjoining
parts,  communicating with the  stomach.  En-
largements, morbid growths, or other lesions, in
the liver, spleen, pancreas, mesentery, omentum ;
disease of the diaphragm, or of the gall-bladder
and ducts; misplaced, or suppressed, or retro-
cedent  gout; suppression of urine, or retention
of this excretion, verminous diseases, &c, sev-
erally occasion vomitings when  they reach an
advanced stage of development.
   19.  In some serious organic  diseases of the
brain, vomitings sometimes occur, and occasion,
in both children and adults, in the latter especial-
ly, much difficulty in determining the true cause
and morbid  relations of this  symptom, which,
however, may be readily ascertained in most in-
stances from the history of the case, and by esti-
mating the succession and grouping  of the ac-
companying phenomena.   Diseases of the stom-
ach itself, especially of the pylorus, duodenum,
and of the intestines, particularly of the small,
 of the liver  and  gall-bladder—more  especially
 when the concave surface ofthe liver is much af-
 fected—and ofthe kidneys, are frequently attend-
 ed by vomiting; and when gall-stones irritate the
 gall-bladder or ducts, or are passing along the
 latter, the vomitings and pain  are then very dis-
 tressing.   The irritation of calculi in the kidneys,
 or in  their pelves, or when calculi arc passing
 along the ureters, produces the same distressing
 symptoms;  but the most urgent and dangerous
 vomitings occur in obstructions  of the bowels,
 especially of the small intestines, from internal
 or external strangulation, from intus-susceptions,
 from inflammations, or from various mechanical
 or structural causes  of intestinal obstruction, as
 shown in various places  (see arts. Colic and
 Ileus, Concretions,  Biliary  and Intestinal,
 &c), more particularly when the vomitings are at-
 tended by fetid eructations, and when the vomited
 matters present a fetid or faecal odour, or a more
.unmistakable  faecal character.   In all cases of
 obstruction, and irritation of any ofthe ducts and
 canals within the abdomen, especially when the
 obstruction  is caused mechanically or by a solid 
VOMITING AND RETCHING—from Sea-Sickness.
1509
body, the sympathetic occurrence of vomiting is
generally very urgent and distressing, although
often presenting intervals of comparative ease.
In all cases of vomiting and retching, the history
ofthe case should be ascertained as  fully as pos-
sible.
  20. Besides these more strictly local diseases,
which are  attended  by vomitings  and retchings,
there are  several  constitutional  maladies, espe-
cially those adverted to above (y 18, 19), in which
these symptoms are of a most prominent charac-
ter, and proceed from contamination  of the blood,
acting both on the frame generally and upon the
stomach and its allied viscera in particular.   No
doubt that in all these maladies, whether the chol-
eric and haemagastric pestilences, or the contam-
ination  occasioning  malignant puerperal fevers,
or that arising  from poisoned wounds, inocula-
tion, &c, the morbid impression is primarily and
energetically made upon the organic  nervous sys-
tem, the retching and vomiting  often following
closely upon it; but nevertheless, this impression
being made,  the alteration produced in the blood
aids it,  and promotes both by increasing the de-
pression of the organic nervous force, and by ir-
ritating the  stomach and adjoining parts, there-
by rendering the vomitings of a more  serious,
dangerous, or obstinate character, as evinced in
these maladies.
   21. IV.  Vomiting and retching from sea-
sickness  are common to all persons soon  after
they feel the motions of vessels on the sea, if they
have not acquired an immunity from this suffer-
ing  by habit.
   22. i. Description.—In some, vomiting is pre-
ceded by a prolonged nausea, with extreme pros-
tration, faintness, vertigo, and apathy.  In others,
vomiting takes place more  or less quickly, after
nausea is first felt;  and in many the nausea and
distressing retchings, with headache, vertigo, and
prostration, continue or return at shorter or longer
intervals after the stomach  has been completely
evacuated, but only if the motion of the vessel
continues.  When the retchings  continue or re-
turn after free  vomiting, a ropy, mucous  fluid,
mixed with more or less bile, is  evacuated, ow-
ing to  the emulgent operation of the retchings
on the liver, gall-bladder, and ducts, thereby pro-
ducing a favourable influence on certain diseases
noticed hereafter (y  25).
   23. The severity  and duration  of sea-sickness
depend much upon the susceptibility ofthe indi-
vidual,  and the extent of motion to which  he is
subjected;  and, although generally all  persons
 arc  liable to sea-sickness on first going to sea, yet
 its severity and continuance are  great in propor-
 tion to weakness and delicacy  of  constitution.
 Usually, however, the sickness either subsides or
ceases altogether in a few days ;  and in previous-
 ly healthy persons  it is  followed by a  good or
craving appetite, and a return of health, although
the cause ofthe suffering may continue.   Many
persons who, from  frequent or prolonged voya-
ging, have become  exempt from sea-sickness, at
 least while at sea, experience a recurrence  of it
when they return to  sea, after having passed  a
considerable time on land; but it is usually of
short duration,  or slight in  these persons.  Sea-
sickness occurring  during a short passage, as in
crossing the Channel, immediately ceases with
the  stillness of the  vessel, or on landing, vertigo
only remaining for a time.   Some delicate per-
sons, who are very susceptible  of  sea-sickness,
are also liable to nausea and vomiting from the
motion of a  carriage,  especially while they re-
main inside, but escape from the sickness when
they ride outside.
  24. ii. Prognosis. — Sea-sickness, although
mentally and physically most depressing, and al-
though both  vomitings and retchings are  most
severe, is generally unattended by danger, and it
very rarely terminates  fatally.   When this event
takes place, it is more the consequence of the
continued nausea, and ofthe loathing of all kinds
of ingesta, owing to their inducing retchings, and
of the resulting inanition, exhaustion and fatal
sinking,  than of any alteration of  structure, or
contingent lesion, produced by the severity ofthe
retchings.  In all cases where this  species of
sufferings is prolonged  by severe weather, and
susceptibility or peculiarity of constitution, more
or less  debility, exhaustion, inanition, anaemia,
and loss  of flesh are observed ; but  generally, as
soon as  the  cause ceases, or  even  considerably
subsides, as on  the  occurrence of fair weather
after storms, or on landing, these effects soon dis-
appear, and are often followed  by restored health,
or even  by an improved state of health, owing to
the circumstance noticed above (y 22).
   25. iii. The nature of sea-sickness has been
a subject of frequent discussion.  The brain, the
heart, and the cerebro-spinal nervous system gen-
erally, have been severally referred to  as the seat
of this distressing disorder.  That these are more
or less affected during its continuance—that the
brain and nervous  system are impaired  in voli-
tion and in the  vigorous  discharge of all their
functions, mental and  physical, cannot be doubt-
ed ; and that the heart acts feebly, although some-
times rapidly,but without tone or vigour, is equal-
ly manifest, until the retchings and vomitings oc-
casion more  or  less reaction, accompanied with
perspiration, which varies  with the  severity of
the sickness  and the constitution ofthe  patient.
But the affection of these—of the cerebro-spinal
nervous  system  and  ofthe vascular and muscular
systems, with the organs and parts more imme-
diately concerned in the act of retching—is the
necessary result of the effect produced by the mo-
tion of the vessel upon the semilunar and  allied
ganglia,  and  the viscera they endow with the or-
ganic nervous force.   This effect continues until
retching and vomiting supervene and occasion
more or less reaction, according to the constitu-
tional powers of the sufferer.   That the primary
influence ofthe vessel's motion on the semilunar
and allied ganglia is depressing may  be  inferred
from the distressing sense of sinking referred to
the epigastric region, and from the general phys-
ical and  mental prostration preceding the retch-
ings.  That  vomiting  and retching, each varying
in grade and character, follow very powerful de-
pressing influences, is shown by the effects of
most sedative and exhausting agents—whether
poisonous, morbid, or infectious—which act more
especially or immediately  on  organs  or surfaces
endowed by the organic nervous force.  It may,
therefore, be  inferred  that the vital  depression
produced by the vessel's motion is the  chief cause
ofthe sickness and vomiting,  the irritation caus-
ed by matters contained in the stomach during
this depression  merely aiding in developing the
retching and vomiting, this act and the  evacua-
tion ofthe stomach  affording  a slight temporary
relief, the depression and  sickness  etill continu-
ing more or less, or for a period,  according to 
1510       VOMITING AND RETCHING—fr
om  Exhaustion, Fermentation, etc
the continuance  of the cause, and to the consti-
tution and predisposition of the sufferer.
  26. iv.  The remedial influence of  sea-sick-
nf.ss is sometimes remarkable in several diseases,
more especially when the sickness is attended by
free vomiting, the appetite returning afterward,
and when the patient does not suffer inordinately,
or when the suffering is not long continued.  In
severe hooping-cough, especially in persons near
or past puberty, and  even in infants and children,
sea-sickness is often of marked advantage.  In
this complaint the patient, sufficiently  protected
from  exposure or weather, may be  placed in a
rowing or sailing boat, when much  swell of the
sea is observed, and carried out to  sea, until
vomiting takes place, when a return  to  land may
be directed.   In other cases  and circumstances,
a short voyage in sailing vessels furnishing the
requisite  accommodations, may be  taken with
benefit.   A  similar  advantage  may accrue  in
cases of tubercular consumption, as I  have shown
in that article (y 420); in haemoptysis;  in spas-
modic asthma; in chronic bronchitis; probably in
some cases of chronic diarrhaza and of dysentery,
when suitable accommodations are afforded, and
in torpid states of the liver, &c.  In  these cases,
the influence of nausea in lowering  vascular ac-
tion and removing spasm, and the action of retch-
ing and vomiting in  emulging the biliary appara-
tus (y 21), and in evacuating mucous accumula-
tions  in the bronchi, are of essential service. By
this action, also, congestions of the lungs and liv-
er are removed, or are aided in their removal, and
a healthy  secretion  of bile  promoted—circum-
stances of great importance in several pulmona-
ry, biliary, hypochondriacal, gastric, and intestin-
al diseases.
  27. V.  The  retchings and yomitings  which
may be  viewed  as  idiopathic  or primary, and
which are not  necessarily connected  with in-
flammation or structural  disease of the stomach
and allied viscera, although they  ultimately, by
persistence in their  cause, become thus associa-
ted, are those which  take place  in the  morning,
and which either recur frequently or habitually,
and which the  patient generally removes for the
time  with a glass  of brandy, or of brandy and
water, or of some other favourite liquor.  In these
cases, morning sickness is the result of exhaus-
tion from  previous  over-stimulation, and for  a
time is  merely functional, but sooner or later it
becomes more  and more structural.   The  same
form  of sickness often follows  in the  morning
heavy suppers, either with or without excessive
drinking.   The circumstance of a person  com-
plaining of  sickness or  vomiting habitually  or
frequently in the morning, and  more especially
if he have recourse to spirits to remove it, before
any food can be taken, is most positive evidence
of such person being an  incurable drunkard, al-
though  he may  never have  been intoxicated.*
  *  The following cases will illustrate this :  A young
man in a large wine-merchant'a house, and having free
access to extensive  wine vaults, was seized, after habit-
ual sickness and vomiting in the morning, with most vio-
lent pain in all the smaller joints, and especially in the
wrists and ankles.  He came under  my care, when he
confessed that siekness and vomiting every morning upon
getting out of bed had continued for three or four years ;
that it was instantly cured by a glass of brandy, but that
he could take  little or no breakfast.  As soon as he re-
turned to business in the morning, he continued drinking
at intervals sherry or port wine, or brandy, as either came
in his way, and he thus took from two to three bottles of
wine, besides brandy, every  day, unless Sunday, when
his supply was not so liberal, lie recovered hU health,
The form of disorder may be considered as allied
to vomiting from sea-sickness (y 21, el scq), the
most idiopathic form of vomiting.
  28.  When  the functions of the stomach are
exhausted by  the excessive excitements of intox-
ication, or by  the irritation of indigestible or un-
wholesome food, and  more  especially by the in-
gestion of substances which readily  enter  into
the acetous, the lactic, or the vinous  fermenta-
tions, when received in the  weak and exhausted
stomach,  then pain, vomiting, or eructations are
produced  by the  gaseous products, by the acidity,
and by the various irritating matters and combi-
nations resulting from the fermenting substances,
which, if  they fail in undergoing these processes
during the imperfect digestion, experience putre-
factive changes, and occasion the same, or even
more serious  and more obstinate disease.
  29.  When the digestive processes are impaired
or exhausted, owing to general debility (sec that
article, y  15, et seq.), or to inordinate muscular or
mental exertions, or to local or constitutional dis-
ease, the  articles of food most prone  to undergo
fermentation,  as  bulky vegetables, raw fruits, fer-
mented bread and  liquors, &c, produce an in-
crease of disorder, by the fermentation which en-
sues, and  the  frequent repetition of such disorder
at last passes into more serious disease, which is
characterized  by recurrences of retching and vom-
iting, and by  gastrodynia, whenever such disease
is aggravated by the ingestion, or commixture of
fermentative  substances.  The connexion of fer-
mentation in  the stomach with  indigestion  and
vomiting, has been  well discussed by Dr. Turn-
bull, and although the doctrine of fermentation
has been  pushed too far by him, there can be no
doubt  ofthe importance of giving due consider-
ation to changes of this nature, which certainly
take place in  the digestive  canal, when the na-
ture,  the  quantity,  and the admixture of indi-
gestible,  saccharine, and  putrescent  substances
are taken into the stomach  during functional or
structural lesions of the digestive organs.  Per-
sons addicted to the excessive use of intoxicating
relinquished this habit, and he has for very many years
been sober  and temperate.  He never evinced any symp-
tom of disease of the stomach or liver, and he is the only
instance I  can recollect of a complete reformation from
drunkenness.
  A cook in my family was always sick and retching in
the morning, and could take no breakfast   Her princi-
pal meal was supper;  soon after which she retired into
her own room, and nothing was known of her until she
had partly  recovered from her sickness and resumed her
morning duties. P'pon hearing this I became alarmed
at the probable  consequences of her  after-supper indul-
gence, and  means were devised to prevent her apartment
from being  fastened on the inside, and then she was there
found drunk. These cases are not of unfrequent occur-
rence ; but  in some instances vomiting is only occasion-
ally present, chiefly in the morning—a chronic diarrhoea,
sometimes  passing  to a  fatal dysentery, with diseased
liver, taking its place.
  Several cases  of  very young persons, mostly females,
who have died from the excessive use of spirituous liquors
have been brought under my notice.  These were charac-
terized by  habitual sickness and retchings  in the morn-
ing, which  were allayed by the accustomed stimulus or
by strong tea, but followed, after a longer or shorter pe-
riod, by enlarged  and fatty  liver;  or by  emaciation,
chronic diarrhoea or dysentery,  with ulcerated bowels;
or_ by  the  most  violent pains in the extremities,  of a
mixed neuralgic and gouty or rheumatic cliararter, ter-
minating in several of the cases before the age of twenty.
In one fatal case, at the age of IT, the growth was re-
markably stunted owing to this  vice, all the others who
had commenced  it at an early age being very much under
Bize.   In this instance the fatty liver filled almost the
whole abdomen, and descended deep into the pelvi5, and
produced an abdominal enlargement as great as the foil
period of pregnancy. 
VOMITING AND RETCHING—from Sarcina.—Treatment of.         1511
 liquors experience more or less fermentation in
 the stomach after the excitement caused by these
 liquors has  subsided;  and the products of the
 fermentation, acting on the exhausted organ, fre-
 quently produce  that amount of irritation which
 is manifested by nausea, retchings, vomitings, and
 gastrodynia, and which the  drunkard relieves by
 a recourse to the accustomed stimulus.
   30. VI. Vomiting attended by the discharge
 of the Sarcina Ventriculi.—In 1842 Profess-
 or Goodsir described this remarkable production,
 and since that time many cases of this kind have
 occurred, most of which have been either observed
 or referred to by Dr. Turnbull, of Liverpool.  I
 have not observed  more than three instances of
 this production in  the substances vomited since
 attention was  first directed to it, and these oc-
 curred  in cases of organic  disease of the  stom-
 ach, in which the  fermentative  and putrefactive
 processes appeared to have been readily produced.
 The writer just mentioned has noticed thirty cases
 of sarcina ventriculi recorded by various authors,
 and has himself observed six.  Of these eighteen
 had terminated fatally.  He arranges these cases
 in four groups: " 1. Cases in  which ulcers or
 cicatrices arising from them, or some other non-
 malignant disease of the stomach, obstructed the
 pyloric orifice.  2. Cases of cancerous disease
 contracting the pylorus. 3.  Cases in which there
 was no disease ofthe stomach itself, but displace-
 ment or some other condition obstructing the py-
 lorus.  4. Cases in which the disorder may have
 been functional, recovery having taken place more
 or less  perfectly."  The analysis of these cases
 furnishes the following: the disease is more com-
 mon in males than in females, in the proportion
 of twenty-four to ten, and between the ages of
 thirty and fifty.  Ofthe three cases which I saw
 two occurred  in confirmed  drunkards between
 forty and fifty-five years of age.  In all the cases
 vomiting was the prominent symptom ; flatulent
 distention, offensive eructatiSns, pain in the stom-
 ach, costiveness, emaciation, and anaemia being
 also present.  According to Dr. Turnbull,  the
 sensation of" something  alive in the stomach"
 was also experienced, but this was not remarked
 in  any  of the  cases for which I was consulted.
 Dr. B. Jones found the urine alkaline, and this
 excretion has, in some instances, contained oxa-
 late of lime  and sugar.
   31. VII. Treatment.—i. Treatment of Symp-
 tomatic Vomiting  and Retching.—It is mani-
 fest that the treatment of retching and vomiting
 can only be  successfully accomplished by a strict
 examination of the history of each case, and of
 its causes, extrinsic and intrinsic;  and by ascer-
 taining the particular category of causes to which
 each individual case should be referred ; whether
 the vomiting has been occasioned, 1st, by the in-
 gestion  of an injurious or poisonous substance
 (see Poisons) ; 2d, or by the invasion or acces-
 sion of a febrile, exanthematous, or pestilential
 malady ; 3d, or by disease of the stomach  or
 bowels, or of some adjoining organ or part; 4th,
 or by sympathy with the  irritation or structural
 lesion of a  more remote  organ; 5th,  or lastly,
 by the abuse of intoxicating or stimulating liq-
 uors.
  32.  A. If the vomiting be caused by poisonous
 ingesta, it is obvious that the means  advised  in
 such cases in the article now referred to are  re-
quired, conformably with the  evidence obtained
as to the nature ofthe poisonous substance which
 has been taken.  To this extensive subject I can
 add nothing to what I have adduced in the arti-
 cle Poisons.
   33.  B  If there appear any reason to ascribe
 the vomiting to the invasion of an exanthematous,
 infectious, or pestilential malady, especially when
 any such is prevalent or  epidemic in  the same
 locality, or when the vomiting is associated with
 shivering or any of the other symptoms of the
 invasion of any of these maladies, then the treat-
 ment advised for the accession of such malady
 ought to be adopted.   (See the treatment recom-
 mended on  the accession  of the Choleric, and
 H^emagastric Pestilences, of Scarlet Fever,
 Small-pox, 4"c)
   34.  It should, however, be recollected that the
 vomitings accompanying marked vital depression,
 especially those occurring in, or characterizing
 pestilential  and malignant maladies, and in ani-
 mal or fish  poisons, and in  contaminated states
 of the blood, admit not of being  cured, or even
 mitigated,  by depressing  or sedative  remedies,
 whether narcotic or anodyne, unless exhibited in
 small doses, and  conjoined with stimulants, aro-
 matics, and cordials.  Opium, morphia, and their
 preparations, hydrocyanic acid, chloroform, and
 hydrochloric ether, will produce little benefit un-
 less they be given in  the manner now stated.
 In these  cases, opium and  hydrochloric ether,
 when  judiciously combined  with  other means,
 will sometimes be of service; but the hot spices,
 warm stimulants, and cordials, prescribed in large
 doses, according to the malignancy of the case,
 will be found the most efficacious.  Thus large
 quantities of capsicum, brandy, and of other pow-
 erful stimulants, have been retained by the stom-
 ach in malignant and pestilential maladies, while
 sedatives  and narcotics have been instantly re-
 jected by it; and even the  spirits of turpentine
 have been retained, both in these maladies and in
 the last stage of low fevers, as well as in similar
 states  of disease, especially  when the  blood is
 contaminated and vital depression is extreme.  I
 have  seen these  effects in  numerous  instances
 since  1817, when I  first employed these sub-
 stances in the haemagastric  pestilence  or yellow
 fever.   In all these diseases the usual means of
 allaying vomiting had failed, and  increased the
 vital depression, the sense of sinking and mental
 apathy, and  therewith the vomiting; which symp-
 toms generally terminated in a fatal pumping up,
 or rejection ofthe contents ofthe stomach, with-
 out retchings, but often with singultus, when sed-
 atives and narcotics were employed.
   35.  C.  It is obvious that  the vomitings and
 retchings caused by  inflammatory and organic
 lesions ofthe stomach and allied viscera can be
 allayed only by means which will  remove or al-
 leviate the  disease of which the vomitings are
 merely a symptom.  In the less severe of these
 a temporary aid may be obtained  from the use
 of hydrocyanic acid, from opiates given with ole-
 aginous demulcents and nitrate of potash, or the
 muriate of  ammonia  in very small  doses, and
 from external derivatives.  But creasote and the
 more heating substances, often of service in the
 opposite states of vomiting, are seldom of service
 in these.  In cases of intestinal disease the re-
 marks  now  made are equally  applicable; and
 where  strangulation  or obstruction from  any
cause  exist in, or otherwise implicate, the intes-
tinal canal, the removal of it is essential to the
removal of the vomiting.  (See arts. Colic and 
1512

Ileus, Concretions, Biliary  and Intestinal,
Digestive Canal, Stomach and Intestines, In-
flammation and Organic Lesions, &c.)
  36. D.  The retchings or vomitings caused by
irritation,  inflammation, and  organic lesions of
distant organs  require careful  examination and
discrimination; and  although these sympathetic
vomitings are often allayed, especially by demul-
cents conjoined with  refrigerants and sedatives,
or with hydrocyanic  acid, or  creasote, opiates,
&c, yet the treatment should be mainly directed
to the particular disease, or structural lesion, of
which vomiting is a distressing  symptom, wheth-
er it be seated in the brain, in  the kidneys, ute-
rus, or other part.   When the irritating cause is
a calculus, or concretion in the gall-ducts or blad-
der, or in  the urinary apparatus, the means ad-
vised for these, under their  respective heads, and
warm anodyne fomentations, tepid or warm baths,
are those  which are  most appropriate, although
these may be conjoined, or alternated, with those
which are most serviceable in allaying the vom-
iting (y 34).  Creasote is often of much benefit,
when the stomach itself and its allied viscera are
free from  inflammatory and organic disease, and
when the retchings are purely sympathetic ; but
it soon fails as  a palliative  when the primary cr
chief disease has not received  due attention, or
when it  remains  unsubdued.  Moreover,  crea-
sote, when given in too large or frequent  doses,
is  apt to increase inflammatory action  when  it
exists, especially if it be of a sthenic or plegmon-
ous character.  When the  vomiting is attended
by manifest asthenia, or vital depression  or ex-
haustion,  creasote, as well as  stimulants,  aro-
matics, and cordials,  are frequently very  bene-
ficial.
  37. E.  The vomitings. Sec, attending pregnan-
cy, especially in the earlier months of this proc-
ess, will often  be  palliated or prevented by the
above means—by the combination ofthe alkaline
or earthy carbons with infusions of columbo, cas-
carilla, and with tinctures ofthe same tonics, and
with the addition of hydrocyanic acid, or small
doses of opium, or of chlorodyne. In this class of
cases fermentation often accompanies the sym-
pathetic irritability of the stomach, and develops
this latter state into the act of retching or vomit-
ing.   In the more obstinate and severe cases, or
when these means prove inefficacious, then crea-
sote in pill or in mixture, combined, according to
circumstances, with opiates, alkalies, &c, should
be prescribed.
   38. ii. Treatment of Sea-sickness.—This  is
a very hopeless subject, yet it is nevertheless one
which should not be abandoned, for with care and
judgment sea-sickness may be more  or less al-
leviated and its duration  abridged.  The usual
means employed for it are seldom of service and
often tend to prolong the  nausea, without ulti-
mately preventing the vomiting.  It is generally
preferable, when  the sufferer is youno- or even
moderately strong, to partake  of such" food and
drink as he may prefer, thereby to prevent inef-
fective retchings; and when free vomiting is ac-
complished, to  take small and frequent doses of
a suitable  anodyne, in small quantities of fluid.
Substances of large bulk,  or even in  moderate
quantity,  or gaseous fluids, by  distending or fill-
ing the stomach, generally bring back the retch-
ing and vomiting.  During the nausea, or even
after it is moderated, the stomach is quite inca-
pable of digesting alimentary substances ;  there-
HING—Treatment of.

fore their presence in the stomach acts only as
an irritant of the  weak and susceptible organ,
and in a short time brings back the sickness and
vomiting.   Having,  therefore, promoted a  free
evacuation of the  stomach,  in the way now ad-
vised, small doses, often repeated, of cither hy-
drocyanic acid, or tincture of opium, or chloro-
dyne, or  of chloroform, or of hydrochloric ether,
may be given in small quantities of a demulcent
mixture,  which may be made agreeable by the
addition of a few  drops of an aromatic cordial.
Creasote has been recommended, but its odour is
disagreeable  to many persons;  but,  when pre-
scribed for sea-sickness  either in the form of pill,
or in a demulcent  mixture, it should be given in
small doses, or not exceeding half a minim for a
dose,  which  may  be repeated according  to its
operation.   The demulcent and  anodyne medi-
cines may be given in  any of the mint waters,
especially when the patient is distressed by flat-
ulence and eructations, and any cordial or aro-
matic may be added if sinking at the epigastrium
or vital depression be experienced.
   39.  Females and delicate persons, subject to
sea-sickness, should retire to their cabins imme-
diately on  embarking, if the voyage be likely to
be longer than a few hours, or to continue during
the night.   Unless the  sufferer  be weak, or ex-
tremely depressed by the sickness, retchings, and
vomitings, it is generally preferable for him to
keep up  and struggle against his enemy, as he
will be the more likely to  overcome ultimately,
and to shorten the duration  ofthe attack.   If he
have  any  return  of appetite after vomiting, it
should be indulged in great  moderation, the food
being  the  most  digestible within his  reach; if
sickness  and vomiting recur, they will generally
be of short duration, and be followed by a return
of appetite, which, if prudently indulged, will be
generally followed by health.  This plan is to be
preferred if a long voyage, or one beyond three
or four days  be anticipated ;  for by that time, or
not much longer, the evil will cure itself.   It is
only for  the  more severe cases, or in short voy-
ages,  or for delicate females and weak persons,
that the medical treatment advised above  (y 38)
is either much required, or particularly appro-
priate.
  40.  iii.  Treatment of Retchings and Vom-
itings caused by Drunkenness and by  Fer-
menting  Ingesta. — The  drunkard  generally
knows well how to remove  the  morning effects
of his  previous indulgence,  and  he  finds the re-
currence to his accustomed liquor, or to one still
more  energetic, to be the most efficacious reme-
dy.  But he counts not the ultimate  cost, viz.,
according to the nature of the liquor indulged in,
organic disease  of the  stomach, pylorus, liver,
&c.;  or chronic diarrhoea, or dysentery, delirium
tremens, &c, often complicated with the forego-
ing.   Safer remedies for retchings and  vomitings
consequent upon Drunkenness are the aerated
waters, the compound  decoction of aloes with
cinnamon water, creasote in pills or in mucilag-
inous mixtures, and the  means advised in the ar-
ticle^Tiow mentioned (y  15,  el seq.).   When the
vomitings  are of daily recurrence,  it is evident
that the  only permament cure is to subject the
patient to  such restraint as may be legally per-
mitted, seeing that he is incapable of restraining
himself.  This is, however, one of those forms of
moral  degradation against which the laws have
no provision, and for which  medical aid is rarebj
VOMITING  AND RETC 
VOMITING AND  RETCHING—Treatment of.
1513
of any avail, especially as regards prevention or
permament cure—
     " Hie cum hominibus, non cum Diis agitur."
  41. Vomitings caused by excessive fermentation
in the stomach  are generally allayed by medi-
cines which either arrest or neutralize the proc-
ess,  or develop the vital force  ofthe organ, or al-
lay excessive irritability of it, or which  operate
in more than one of these modes.  The sulphite
of 6oda, the alkaline  carbonates, the  carbonates
of magnesia or  of lime, calcined magnesia, the
citrate of magnesia, the sub-nitrate of bismuth,
the biborate of soda, are severally of use in these
cases,  especially when prescribed in conjunction
with tonics, stimulants, and anodynes, and some-
times with narcotics.  As the fermentation and
the vomitings are generally attended by impaired
organic nervous force, as well as by irritation of
the  digestive mucous surface, tonics  and stimu-
lants arc required for the former morbid condi-
tion, while anodynes, especially hydrocyanic acid,
or small doses of opium, or of opiate preparations,
or of the lupulus, or  of hyoscyamus,  are appro-
priate for the latter.   In many instances, in ad-
dition to  a frequent recourse to certain of the
above, in varying combinations, other  substances
which are calculated to remove  irritation and to
check fermentation, and at the same time to pro-
mote a healthy secretion from the stomach, liver,
and duodenum, may be given from time to time.
Of  these  the most beneficial are  Hydrargyrum
cum creta, the pilula hydrargyri,  and calomel, and
these, according to circumstances, may be given
in full doses with  opium, creasote, the prepara-
tions of hop, &c.   Small doses ofthe nitrate of
potash, or ofthe hydrochlorate of ammonia, given
with hydrochloric ether, in mint water, &c, are
also beneficial in these cases.
   42.  In all cases of retching and vomiting, refer-
able either to the abuse of intoxicating liquors, or
to extreme dyspepsia attended by  vomitings, or to
gastric fermentation, or to  pregnancy, attention
should not be directed  alone  to  the morbid con-
dition of the stomach, for the  vomitings or retch-
ings will not be permanently removed, or they
will be liable to recur after a time, if the biliary
and gastro-intestinal secretions and excretions be
not duly promoted.  In all  such  cases, therefore,
having palliated the vomitings, a moderate ac-
tion should be  kept up on  the bilio-intestinal
functions;  and the means which I have most fre-
quently employed have  been  the  hydrarg. cum
creta,  or blue pill, or Plummer's pill with soap
taken  at bed-time, once or twice  in the week, and
the  following draught early on  alternate morn-
ings, or every morning, or at  bed-time :
  No. 379. R Botassae Bicarb., gr. xij. adxviij.; Ammo-
niae  Carbonatis, gr. vj.; Tinct. Pennse Comp.; Tinct.
Cardamom. Comp., ia, ?.i. ; Infusi Sennse  Comp., ?ss. ;
Infttsi Gentiana Comp. ad Jjsa. Misce, et sit Haustus.
   To  this  draught may be added, according to
the  peculiarities of the case, a dose either of hy-
drocyanic acid or ofthe extract of taraxacum.
   43.  iv.  Vomitings attended  by the  rejec-
tion of the sarcina ventriculi  are generally
the  result of protracted indigestion, attended ei-
ther with fermentation or with  organic  disease,
malignant or otherwise, ofthe  stomach or pylorus
(y 80, et seq.).   In the majority of these cases the
means already advised may first be employed, and
if these fail, as they often will  in this form  of
complaint, other more energetic medicines should
be prescribed, generally in efficient combinations,
viz., camphor, creasote, and small doses of opium,
made into pills, with any  suitable powder,  and
with either common tar (pix liquida) or the  bal-
sam of Peru.  These  having been  taken for a
time, the exhibition of tonics with alkalies, or al-
kaline carbonates and hydrocyanic  acid ;  or of
the sulphites, or the pyroxilic spirit, or limevva-
ter, or the chlorides, may be tried, conjoined with
preparations of either cinchona or cascarilla bark,
or with an infusion or decoction of cedar or pome-
granate bark.*
   44.  v.  Diet in Cases liable to Vomitings,
&c.— Vomitings, when palliated or removed,  pre-
sent the  greatest difficulties as to the selection
of alimentary substances.  As a general rule, all
such as are liable to readily undergo any of the
fermentative processes should be  avoided.   But
most alimentary substances undergo one or  oth-
er of these processes,  whether of an acid, or of
a  putrefactive, or of a saccharine nature, when
mixed with the morbid secretion of the stomach,
and when the organic nervous  force of this or-
gan is  much impaired.  Still there  are  aliments
which  are much less prone to undergo these
changes  than others, although much  depends
upon the  peculiar  idiosyncrasy of  the patient.
Frequently the food which the  patient most de-
sires in these  cases, or for which  he feels a rel-
ish, will be found the most easily digested or re-
tained.  Substances which readily undergo fer-
mentation, as  fermented new bread, vegetables,
raw fruit, the  ingestion  of varieties of food, and
fermenting liquors  should be avoided.   In  this
subject, however, I  can  add nothing to what  I
have advanced in  the article  on Indigestion.
(See y 55, et seq.)

  Bidliog.  and Refer. — Hippocrates,  Opp.  p.  1080.
(Vom. nigra.)—Celsus, 1. ii., c. 13.—Oiibasiu.-, Synopsis,
  [" We present some  of the Formula! which we have
found most successful in allaying idiopathic vomiting :
  i.  R  Catechu,  }\. ;  Columbo, grs. xxx. ;  v\ inter's
Bark, grs. xx.;  Boiling "Water, fl. jiv.   M.  Digest for
eight hours;  strain, and add Sirup  of Bed Roses, fl. ?j.
M.  In tea-spoonful doses, repeated j,ro re natei.
  ii.  R Powdered Columbo, 3iv. ; Opium, grs. iv. ;  Oil
of Peppermint, gtt. x.;  Sirup sufficient.  M.   Beat into
a maps, and form thirty pills.  Give two three times a
day in spasmodic vomiting.
  iii.  R Columbo, ~ss. ; Boil in Water, iij. to five fl. ?. ;
Btrain, and add Carbonate  of Potassa, grs. x.;  I emon
J uice, fl. uij. ; Tinct. of Opium, gtt. xii.  M.  A tea to a
table spoonful every hour as an anti-emetic.
  iv.  R ( reasote, gtt. j.; Camphor Water; Comp. In-
fus. Gentian, afi,  fl. svj. M.  A tea-spoonful occasion-
ally.
  v.  R  Tinct. of Opium, fl. -ss.; Decoct,  of Starch, fl.
Jiv.  M.  lor an enema in obstinate vomiting.
  vi. R Burgundy Pitch, Siij.; Yellow Wax, ="ss. ; Bow-
dered Cinnamon,  :vj. ; (til of Pimento;  Oil of Lemons,
fiii, \ij.  M.  Melt  the resin and wax together, and strain ;
when they begin to thicken, on cooling,  mix in the cin-
namon previously  rubbed with the oils, and make a plas-
ter.  This plaster  over the  stomach will very generally
relieve nausea and vomiting, and relieve gastric uneasi-
ness when nausea  is not present.
  vii. R Bicarbonate of Soda, "jss. ; Bowd. Cum Ara-
bic, uj. ; Oil of Mint, gtt. iv. ;  White Sugar, -ij. ; Car-
bonic Acid Water, 5iv.  M.  A table-spoonful occasional-
ly ; very useful.
  viii.  R Powdered Ipecac, grs.  ij.; Carb. of Sodn, grs.
x.; Sirup,of Poppies, sj.; Mint Water, 5vj.  M.  In tea-
spoonful doses, to check siasmodic vomiting.
  ix.  R  Infusion of Spearmint,  fl.  jvj. ; Burned Bran-
dy, ?j. ; Baregoric, - ij. ; White Sugar, Jss.  M. A table-
spoonful every fifteen minutes.
  x.  R 1 icarb. Potassa, -j. ; Bowd. Gum Arabic, "j.;
White Sugar, -ij.  ; Seltzer Water, ivj.;  Tinct. of Cam-
phor, gtt. xi.  M.  A tea-spoonful  frequently.
  A strong mustard cataplasm over the epigastric region
will often prove more successful than any internal reme-
dies. These cases, however, must not be. treated empir-
ically, but always  in reference to the pathological cause.] 
1514
WORMS—Introduction to.
I. vi., c. 41.—Alexander Trallianus, 1. iii., c. S.—Paulas j
J'.gine'.i, 1. i.. c. 4-'. — Avieenna, Canon. 1. iii.,  fen. 13,
tract. 5, cap. S. — Sennertm,  Pract., 1. vi.,  p. 9, c. 3. —
Riverius, Observat. Cmnmunic, p. 349, 602.—F. Salan-
di, De Yomitu ac de aliis Affectibus prseter Naturam,
8vo.  Veron., 1609.—Zacutus Lusitanus, Prax. Admirab.,
1. iii., obs.  115.  (Excrescentia per os reddita.) — Blan-
kard, Collect. Med. Phys., cent, vii., n.  40. — Schurig,
Lithologia, p. 150. (Calculi ejected.)—Dicmerbroeck, Anat-
omy, 1. i., c. 7, 8. (Enemata vomited.) — Benivcnius, De
Abditis Morb. Causis, c. SS. (With rejection of flesh-like
masss.)—Fabricius Itildanus. cent, iv., obs. 32 ; cent, v.,
obs.  117. (Chronicus.)—Koenig, Specimen Lithogenesias
Humana?, K'^5. (Calculi ejected.)— Willis,  Bharmaceut.
Ration., par. i., cap. 3.  (Caused by Tobacco ap.died to the
Head.) — J. Veridet, Tractatus de Prima  Coctione et de
Ventriculi Fermento, 12mo.  Geneva,  1692, par. ii., p.
231.—Riedin, in Med., 1695.  (Produced by Tabasco ap-
plied to the Head.) — Huxham, in Philos. Transact., no.
382; et Opp., vol. iii., p. 8. (From diseased Onientum.)
—Bonet, Sepulcretum, 1. iii., s. viii.,  obs. 39, 40, 42; et
s. xiv., obs. 20. C'l'/s-m tta per os reddita.) — Jessop, in
Bhilos. Transact, no. 117.— Lister, in Ibid., no. 417. (Lar-
va; varia insectorum per os  reddita.) — Hoffman, De
Vomitu, Opp. iii., p. 147.—De Doloribus  Brsecordiorum,
obs.  ii., Opp. ii., p. 273.— C. Trioen, Observat.  Medico-
Chirurg. Fasciculus, 4to, plates.  Lugd. Bat., 1743. (Clys-
matapi'r os reddita in ileo.)—Harris, De Morbis Acutis
Infantum, p. 30.—Stroem, in Acta Soc. Reg.  Med. Davn.,
t. iv., p. 214.—Bleuland, De Difficili  Alimentorum ex
Ventriculo in Duodenum  Frogressu, 4to.  Lugd. Bat.,
1787. — De Haen, Rat. Med., par. ii., p. 63; par. iii., p.
95 ;  par. vii., c. 4. ("Insmata per os reddita: quoniodo
id fiat t) — M. Stoll, Pr.elect., t. ii., p. 169, 429. — Tho-
mina, Annales Wurceb.,  b. ii., p. 171. — Geqffroy, in
Journ. de M d., t. viii., p. 244. (Saccus hydatidosus per
os rediiitu<i.)—Crumpe, in Med. Facts and Observat., vol.
viii., no. 23 ; et in Transact,  of Royal Irish Academy,
vol. vi. (Larva of Insects rejected.)—Osiander, Denkwiir-
digkeiten, b. i., 2, st. 3.— Wall, in*Bhilos.  Transact., vol.
iv.,  par. ii., p. 481. (Excreta  singularia.) — Hodges, in
Mem. of the .Med. Society of London, vol. v.—Vaughan,
in Ibid., vol. ii., art. 13.—Klein, Chirurg.  Bemerkungen,
p. 245.—Zeviani, in Mem. de la Societe ltalienne, t. vi.,
p. 93. (Vom. urinnsa.)—Thilenius, Medic, and Chirurg.
Bemerkungen. p. 3<»2. (Angustatio ifjuni.)—J. P. Frank,
De Curand. Horn. Morbis, 1. v., 2d p:, p.  370-47S.—/!«-'
tenrieth, in  Hufeland Journ. der Bract.  Ileilk., b. iii., p.
2GS. — Baeleley, in  Kdin. Med. Comment., vol. xviii., p.
240.  (Habitual in Morning.)— Barthez, in Memoires de
la Societe Medicale d'Emulation, iii. ann., p. 401.— Wich-
mann, Ideen zur Diagnostik, b. i., p.  159.  — Bouvenot,
Recherches  sur le Vomissement, 8vo.  Baris, 1801; 3d
ed., 1S07. — Ranque, in Bulletin de la Societe de Mede-
cine  de Paris, p. 143; et App. ad Journ. de Med. Con-
tin.,  t. xii. (L irva reddita.) — Dumanoir, in Journ. de
Med., t. lxxxvi., p. 78.— A. Portal, Memoires sur la Na-
ture  et Traitement de plusieurs  Maladies, 5 tomes,  Svo.
Baris, 1S08, t. iv., p. 272, et pluries; et Observations sur
les Maladies du P'oie, 8vo.  Baris, 1513, pluries; et (.'ours
d'Anatomic Medicale, t. v., p. 174.—J. Copland, in Ap-
pendix to Translation of A. Richerand's Elements of
Physiology, &c, 2d  ed., 8vo.   Lond., 1829,  p. 577.—
Sp.mgenb rg, in Horn. Archiv., &c.  March, 1812, p. 261.
—Cooke, in Dublin Journ. of Med. Sciences, July, 1837,
p. 367.—J. W. Arnold, Das Erbrechen; die yyirkung und
Anwendung der Brechmittel, 8vo.  Stuttgart, 1S4H.—J.
Budgi>, Die  Lehre vom  Erbrechen;  nach Erfahrungen
und  Versuchen.   Mit einer Vorrede  von Dr. F. Xiiise,
8vo.   Bonn, 1840.—Anon., in  British and Foreign Med-
ical  Review, &c, vol. xv., p. 60.— W. Brinton, in Ibid.,
vol. xvii., p. 162 ; et vol. xix.,  p. 479.— C.  Murchison, On
Gastro-colic Fistula, &c., in Edin. Med. Journ. for July
and  Aug., 1857.  (Gives numerous Cases and References
to Papers on Vomitinq,  &c,  from Perforation of the
Stomach, <fc<?.).—Also Transact, of Bathol.  Society of  Lon-
don, vol. viii.; and Lancet, 1857, i., p. 48.—Med. Times
and  Gazette, 1S57, i., p. 471. — Gairdner, in Edin. Med.
Journ. for July, 1855, p. 81—W. B. Carpenter, Principles
of Human Bhysiology, &c, 5th ed., Svo.  Lond., 1855, p.
66.—See also Biblioq. and Refer, to the diseases of the
Stomach, Liver, Duodenum, Intestines, &c.
  [Amer. Bihlioq. and Refer. — See various American
Treatises on the Practice of Medicine, already  so often
quoted; also American Journ. Med. Science, vol. viii., p.
242,  &c.—N. York Journal of Med., vol. ii., p. 167:  Re-
view of Langston Parker, "The Stomach in its Morbid
States," &c.  See ref. to art. on Indigestion.]

WORMS—Vermes — Vermin ation — Entozoa
   (from  evrog,  within; and  &ov, an animal).
   2.Kul.?JKucitg, ilpivc vel  thuvvg,  Gr.  'ETipivdo-
   f\.oyla, Ramsay.   Verminatw, Pliny.  Helmm-
   thia,  Good.    Helminthologia,  Helminthiasis,
  Swediaur.   Parasitismus intestinalis, \ oung.
  Vers, Fr.  Wiirmer,Wurmsucht, Germ.  Vcrmi,
  Ital.  Worms, Inverminatwn, Intestinal Worms,
  Animal Parasites.
  Classif.—I. Class, I.  Order.   (Sec Preface.)
  1.  Defin.—Animal parasites  are indipendent
oreranized beings, descended from peculiar animal
parents, which require, in order that they may be
enabled to complete their  development, growth, or
reproduction, to  take up abode  either constantly or
temporarily in or upon a  second animal organism
of a different kind, from which they also derive their
nourishment.   Human parasites are those which
select the human body as  this second organism.
  2.  The above  definition is a modification of that
given by Dr. Kuckenmeister,  in  the very able
translation  of his work On Animal and Vegetable
Parasites, by Dr. Lankester.   Leuckart (Para-
siten und Parasitismus,  in Viertodt's Archiv,
1852) remarks,  that whenever "an  animal is too
small and too imperfectly armed to overcome and
destroy another living being upon which its in-
stincts direct it  to seek for nourishment, it must
be contented with robbing it, by feasting upon its
blood, juices, and  solid parts."   As respects the
human body especially, it would be more correct
to state that, whenever the vital force of this body
is reduced by disease, inanition, and exhaustion,
it is then exposed to the  invasion  of those para-
sites which are peculiar to it; and that these para-
sites are developed and multiplied with a rapidity
generally in proportion to the diminution of vital
force or of vital resistance to their invasion and
multiplication.   The only animal parasites which
appear in or upon the human  body belong to the
classes of insects  and worms, and  probably also
to the  infusoria.  " As  far as we know, these
parasites of man are not  subject to the attacks of
secondary parasites."  Many of them are common
to man and other mammalia, while others are pe-
culiar to  him.
  3.  It has been very justly remarked by Dr. Lan-
kester, in his excellent and instructive preface to
the work just referred to, that the study of animal
parasites involves  questions of the highest scien-
tific and practical interest, and that it teaches that,
though scientific theories may sometimes be bar-
ren  of immediate practical  results, they cannot
fail to free the  mind from prejudices  which lead
to erroneous practice,  and even to disastrous re-
sults.  On  this ground,  therefore, he  refers to
some apparently of the least practical topics, with
the hope of assisting the reader  to  understand
those generalizations which the subject of animal
parasites involves.   But  however barren tlie con-
sideration ofthe generation and reproduction of
organic beings may at first sight appear to be, it
is of the  utmost importance in respect of its ulti-
mate or practical results ;  and Dr. Lankester has
done medical  men a great service  in furnishing
them with a succinct and correct summary ofthe
results of the recent researches of Dr. Kucken-
meister  and others  as to this  subject, especially
as regards the history of the human entozoa.  Dr.
Lankester justly remarks that, although it was
easy to  account for the existence of intestinal
worms, by  referring it to the ingestion of their
eggs, yet a difficulty presented itself regarding
hydatids, which evidently  had  an independent
animal existence.   Hydatids exhibited no sexes,
they produced no eggs, and readily supported the
theory of" spontaneous, or equivocal generation."
Even as  this theory was driven successively from 
WORMS—Introduction to—Origin  of.
1515
every other part of the animal and vegetable king-
doms, it " found refuge among the strange and
paradoxical creatures imbedded in the tissues of
man and other animals,  far removed from  any
external influences."  The time has, however, at
length arrived when it can be  demonstrated  that
the cystic worm is no longer to be regarded as the
result of a " fortuitous concourse of atoms," but
that it is the offspring of the tape-worm, undergo-
ing one stage of its growth, through which it must
pass before it can attain to the  more dignified de-
velopment of its parent.  In many cases the cystic
worm has  the power of developing, at this stage
of its growth, a large number of creatures resem-
bling itself, and these have, each  of them, the
power of developing themselves into tape-worms.
" The cystic worm—let it be an Echinococcus—
has originated from the egg of a tape-worm, the
embryo  of which  has found  its way  from the
stomach and intestines, through their walls, into
the tissues of the body.  This  worm consists of
a vesicle or bag, to which  is  attached a head,
called the 'scolex.'*   In Cysticercus, the hyda-
tid ofthe pig, there is but one scolex, but in Echi-
nococcus there are many scolices.   Now this  sco-
lex, or  scolex-head, as it is sometimes called, is
the stock or germ—the head—from which all the
segments of a tape-worm proceed.   The cyst of
Echinococcus, then, has the power of producing a
large number  of these heads, each of which  may
grow into a tape-worm.  The  cyst—the original
cyst ofthe worm—is, in the language of Steex-
strup, ' a nurse.'   Kuckenmeister and the Ger-
mans call it a mother cyst.  But  this cyst  will
produce not only scolex-heads, but other cysts
like  itself.  These  are ' daughter cysts;'  and
these secondary cysts will also produce scolex-
heads.   They are also ' nurses  ;' and in virtue of
their existence the mother cyst becomes, in the
language of Steenstrup, a ' parent nurse.'   The
second cyst may contain,  as it frequently does in
the Echinococcus  altriapariens of Kuckenmeis-
ter, a third cyst—a ' grand-daughter cyst,' which
is also a ' nurse,' and thus on."  (Lankester, in
Preface to his  Trans, of Kuckenmeister, &c.)
  4. Neither these cysts  nor scolex-heads  have
any sex.   Nor do they acquire sexuality as long
as they  remain in the flesh in the hydatid condi-
tion ; and  to  this  state of the worm Professor
Huxley applies the term " agamozoid."  In order
to acquire the  conditions  necessary to the devel-
opment of sexual  organs, the cystic form of the
worm must be followed by another animal.  " The
scolex-head then  becomes, in  its  turn, truly a
' nurse,' and this of a most prolific kind; for, the
cysts below being displaced, the numerous  seg-
ments ('proglottides,'  as they have been called)
begin to make their appearance.  The conditions
are now such, that sexes  appear; each segment
is merely a capsule containing  a male and female
generative apparatus,  and nothing else.  Eggs,
the result of the union of sperm-cells and germ-
cells, are now  produced in myriads.  These pass
into  the external world,  and,  being swallowed
and digested, set free  the embryos, which again

  * The word " Scolex"—o-K<«Xr,f, AVurm, or Spulwurm,
Germ., or round worm, was employed by M uller to des-
ignate, generically, imperfectly-developed forms of tape-
worm. " The head was the most characteristic part of
these creatures, and gradually the term ' scolex' was ap-
plied to the heads of all forms of cystic or tape worms.
The term scolex  has now no generic signification, as the
creatures to which it was applied were immature forms
of other genera."  (Lankester, in Preface, &c.)
become cystic, as above described."  (Op. cit, p.
xiii.)
  5. These phenomena are not peculiar to ento-
zoa.  Steenstrup observed them in the medusa,
the claviform polypes, the salpae,  and the trema-
tode entozoa.  Professor Owen has also adduced
similar cases, in the exposition of his views on
"Parthenogenesis," or the successive production
of procreating individuals from one ovum, or asex-
ual reproduction.  Not only are there some among
the lowest animals, in  various stages  of develop-
ment, capable of producing buds, or  individuals
like themselves, without sexual union, and em-
bryo-bearing eggs, but there are also  among the
articulata, both in the  Crustacea and  insects, fe-
males producing eggs, which proceed to the de-
velopment of perfect animals without any sexual
intercourse, or union  of sperm-cells and germ-
cells.   Such a phenomenon is so opposed to the
general opinion as to the necessity of sexual in-
tercourse  for the  development  of  the embryo in
the higher animals, that many have not hesitated
to express their disbelief in it.   Dr. Lankester
thus expresses himself respecting it:  " Regard-
ing, however, the  phenomena of reproduction
from the point of view afforded us by the entozoa
and other forms  of lower animals, we must re-
ceive  the  facts in both cases equally cautiously,
and judge according to the evidence.   Von Sie-
bold, in his work on ' True Parthenogenesis,' af-
fords  good evidence for believing that the queen
bee deposits two kinds of eggs, the one of which
has come  under the influence of the  sperm-cells
of the male, and the other not.   A very curious
point  in this history is the fact that while both
eggs produce young bees, the impregnated eggs
produce worker or female  bees, while the unim-
pregnated eggs produce male or drone bees.   In
a recent communication to the Royal Society, Mr.
Lubbock has shown that species of the entomos-
traceous crustaceous genus Daphnia produce liv-
ing young in all respects like their parents, with-
out any sexual intercourse.  It would appear, then,
that up as high as the most developed forms of ar-
ticulate animals, we have evidence that there is
no real difference between the functions of repro-
duction and generation."*  (Op. at, p. xiv.)
  6. I. The Origin of Animal Parasites, more
  * Dr. Lankester, for the better understanding of these
and other general remarks he has offered, has subjoined
the following diagram:
                   GENESIS.
   Growth.         Reproduction.       Generation.
     Homogenesis.
(Reproductive force  acting
  through similar cells.)
  It is represented in—
A. Flants, by Bhytoids.
   1. Isophytoids.
     Buds.
   2. Allophvtoids.
     Bulbilli
     Bulbs.
     Sporules, &c.
B. Animals, by Zooids.
   1. Isozooids.
     Gems or buds.
   2. Allozooids.
     " Nurses" (Steenstrup).
     "Agamazooids" (Hux-
       ley).
     "Yirgin    Aphides"
       ((/wen).
     "Agamic eggs" (Lub-
       bock).
     " Drone bees"  (Sie-
       bold).
    Heterogenesis.
 (Ueproductive force acting
  through dissimilar cells,
  sperm - cells  and germ-
  cells.)
  It is represented in—
A. ITants, by
   1. 0 ynophytoids.
     Female flowers.
     Pistillidia, &c.
   2. Androphytoids.
     Male flowers.
     Antheridia, &c.
   3. Androgynophytoids.
     Hermaphrodite flow-
      ers.
B. In Animals, by
   1.  Gynozooids.
     Females.
   2.  Androzooids.
     Males.
   3. Androgynozooids.
     Hermaphrodites. 
1516
WORMS—The  origin of.
especially of the worms  which often infest the
human body, has long been a subject of specula-
tion among naturalists and physicians.  One class
of writers believed that these parasites, at least
many of them, originated in  the endowment of
animal molecules with vitality from the parent
body, favoured by certain  states of the vital forces
of that body, the states originating their  organi-
zation also promoting their growth and propaga-
tion.  Since the progress of microscopic research
consequent upon the improvement of our instru-
ments, this doctrine, which  till then had been
gaining ground, has received  a signal overthrow,
chiefly at the hands of German helminthologists.
Von Siebold, one of the most recent and ofthe
ablest of these, remarks on this topic, " that he has
gradually arrived at the  conclusion that  these
parasites do not originate by ' equivocal genera-
tion' from substances of a dissimilar nature ; and
physicians and naturalists thought themselves
justified in assuming that the parasitic worms in
the intestines  of men and  animals owed their
origin to ill-digested nutriment, or that they were
developed  in  the most widely different organs
from  corrupt juices.   They  took it fo^ granted
that certain morbid processes  in any organ were
competent to give  rise  to  parasites,  assuming
that the elementary constituents of an organ af-
fected by disease, separated themselves from their
natural connexion, and not perishing, but trans-
forming themselves into  independent organisms,
became  parasites.   It  was certainly more con-
venient thus to speculate than to endeavour to at-
tain,  by patient researches  and careful  experi-
ments, a secure insight into the hidden workings
of nature.   It was by the latter method that the
hitherto unanticipated development of the sexual
apparatus was discovered in many parasites, such
as round worms, thread-worms, tape-worms, and
flukes, in which such an immense mass  of eggs
and young can be generated, that it seems unnec-
essary to  look farther for their  origin.   As  to
tape-worms,  it is well known that a single indi-
vidual is often composed of many hundred joints.
Each joint is capable of laying many hundred
ova, so that the number of the progeny of a single
tape-worm is enormous.   Dr. Eschricht, of Co-
penhagen  (Das Physische Leben in Popularen
 Vortragcn; Berlin, 1852  ; p.  112-115), possesses
a tape-worm expelled by a patient of his, which
consists of 1000 joints;  and some  of the joints
contain more than 1000  ova.  According  to this
writer,  a careful examination of the reproductive
organs  of a female  Ascaris  lumbricoides shows
the number of ova to be innumerable." (Von Sie-
bold, Op. at.,]). 4.)
   7.  The precise mode in which such an immense
brood of these parasites make their way into the
interior of animals was  long imperfectly under-
 stood.   It was, however, ultimately ascertained
that  intestinal worms undertake emigrations in
 order to reach that animal whose organs are fitted
 by nature for their habitation.   Von Siebold
 states that the young of the tape-worm  (which
 inhabits the intestine of  the higher animals only)
 "leave the place where they were brought forth,
 or laid  as eggs (that is to say, they emerge from
 the intestine of their parent's host), and seek  an
 opportunity to enter into the intestine of some
 other creature. It is easy to convince one's self of
 the emigration of the tape-worm, by examining
 the excrement of animals infested by them, at
 those times of the year at which they attain their
sexual maturity.   We then observe that some-
times single joints, or connected series of joints,
full of ova, sometimes immense masses of the ova,
are passed with the fseces.   The same thing holds
good with regard to the ova of the Distomata that
infest the livers of our ruminating animals ; their
eggs, after they have been transferred from the
liver to the gall-ducts, being washed out with the
bile into the intestine, and evacuated with the
dung  These emigrations of  the young of the
intestinal worms benefit  not only the creatures
they infest, but themselves.   There are many
kinds of intestinal worms  in whose eggs the em-
bryo is never hatched, if they remain in the place
where they have been laid."
   8. The description (German like) given ofthe
accidental but frequent ingestion or passage  of
the ova of parasites  into other animals, and the
dignifying of this passage into an emigration, as
if it were an  act of instinct,  imparts an air  of
imagination to what is nevertheless the fact  of
the frequency of this passage, and of its conse-
quences.  This writer states that these parasites
" must wander to some other place  in order  to
develop their  young, or  to allow of the  escape
ofthe young already developed in them.  These
young must then either wait for, or seek, an ani-
mal to lodge in, having entered into which, they
are capable of  attaining  sexual maturity.  By
such emigrations the infested animals are at the
same time  freed from guests  whose increase
would be both troublesome and prejudicial.  For
example, what would happen if the millions  of
eggs that a single round worm or tape-worm can
produce were developed and generated in the same
intestine in which they were laid 1   Would not
the intestine, after the young had attained their
full growth, and brought forth others in their turn,
become at last so choked up as to disable this part
of the digestive apparatus, so that the whole or-
ganism of the unhappy animal must perish along
with his parasites'!"   (Op. at., p. 5.)
   9. These emigrations and immigrations ofthe
young of intestinal worms, or, in less imaginative
language, this discharge and passage of their ova
from and into other creatures, are very important,
though long an unregarded part of the history of
their propagation ; and numerous facts have been
discovered showing that the origin of intestinal
worms in the viscera of  animals can be readily
accounted for according to natural laws, without
recurring to the mysterious hypothesis of " equiv-
ocal generation."  An important  circumstance
favourable to the preservation and passage of the
ova of parasites  into animals  in  which they be-
come developed  is the hardness of the shells
which envelop them.  Owing to this the  germ
or embryo of many of them are protected from
external injury, and their vitality preserved  for
many months, and until circumstances admit of
their development.   After leaving the dwellings
of their parents the ova pass into privies, drains,
dust-heaps,  &c, where, surrounded by more or
less moisture, and subjected  to various grades
of temperature, and contained in manures, and
spread on fields and meadows, they are, either in
the state of ova or in that of more advanced  de-
velopment,  taken with various articles  of food
into other animals, or they are washed by rains
into streams or brooks, and are swallowed in  the
drink.  Many of the young intestinal worms, ac-
cording to Von Siebold, more or less developed,
but still enclosed in their egg-shells, remain quite 
WORMS—The metamorphoses of.
1517
inactive in their passive emigrations, and it is of
course a mere  chance whether they reach their
goal or not.  The young of others, having left
their egg-shells, may take a more active share in
the process, creeping out of their holes and cor-
ners in wet weather, or in damp mornings, upon
plants or grass, and enter animals suited for their
habitation and development with the food.  By
preventing  sheep from  being driven out  in the
morning till  the dew is off the  grass, or from
grazing in  wet swampy pastures, these animals
are so far protected from Strongyli and Distomata.
The origin  of the thread-worm,  known  as the
Filaria  insectorum, that lives in  the bodies  of
adult and larval insects, could not be accounted
for,  and was referred  to  equivocal generation ;
especially as they contained no trace  of sexual
organs.  But Von Siebold ascertained that they
were not true Filaria, but belonged to the pecul-
iar family of thread-worms, comprising the gen-
era Gordius and Mermis; and that these parasites
wander away when full grown, boring their way
from within through any soft part of the body of
their host, and thus creeping out.   " These para-
sites do not  emigrate  because they are  uneasy,
or because  the caterpillar is sickly, but from that
same internal  necessity  which  constrains the
horse-fly to leave  the  stomach and intestine of
the horse where he has been reared; or which
moves the  larva of the gad-fly to work its way
out of the boils on the skin of oxen.  The larvae
of both these insects creep out in order to become
chrysalises, and thence to proceed to their higher
and sexual condition."  Now this desire to emi-
grate is implanted in very many parasitic insect
larvae, and  the  perfect full-grown,  but sexless
thread-worms of insects, are in like manner moved
by this desire to wander out of their previous
homes  in order to enter upon a new period  in
their lives, which ends in  the development of
their sexual organs.
   10. As some kinds of parasites that have emi-
 grated are never met with below a certain  size, so
 some kinds that have already made their way into
the interior of animals are not to be found under
 a certain size.  It is known  that  many parasites
 do not  enter into the animals in which they  are
 to  pass through their farther stages of growth,
 until they  have attained a certain degree of de-
 velopment elsewhere.  This  is particularly  the
 case with such intestinal worms as remain para-
 sitic in the last stage of their existence, viz., that
 of sexual maturity, while the Gordiacea. quit their
 parasitical  life, in  order to become sexually ma-
 ture  away from the animal they have infested.
 During these  early wanderings, the  worms in
 question, Von Siebold  remarks, commonly  un-
 dergo a change of form, often accompanied  by
 other phenomena of so highly  remarkable and
 abnormal a  character as to render their meta-
 morphosis or phases of existence almost incom-
 prehensible.  By  degrees a mass of observations
 of remarkable metamorphoses of intestinal worms
 accumulated and  formed  a complete  chaos  of
 seemingly irregular phenomena, until the Danish
 naturalist, Steenstrup, succeeded in  evolving a
 certain order out of this  confusion, by the  dis-
 covery therein  of a  hidden  underlying  law of
 nature,  by which all the phenomena that  had
 seemed so devoid of plan could be reduced  to
 order.   He  named this law the  "■Alternation of
 Generations," and advanced two  points of differ-
 ence between it and metamorphosis; the first is,
that the young of those animals which come un-
der the former term  are  not  only  unlike their
parent at  first,  but remain so ; the second dis-
tinction is, that this  young generation, so dis-
similar  to the parent animal, brings forth new
creatures,  which either  themselves  or their de-
scendants  revert to the original form of the first
parent.  Whereas, in  simple metamorphosis, the
dissimilar  young  pass by gradual changes into
the likeness of the parent animal, and until this
metamorphosis is complete are incapable of gen-
eration.  Thus  in the alternation of generation
the parent  animal produces  dissimilar young,
which Steenstrup terms " nurses," whose de-
scendants  only take her form.   " A most import-
ant circumstance which characterizes these nurses
or ' Agamozooids'' physiologically is,  that  they
bring forth young without themselves possessing
any real sexual apparatus.   Those agamozooids,
in fact, multiply by division, by external or in-
ternal gemmation; they develop within  their
bodies germs which become new creatures.   But
these germs do not deserve the title of eggs, nor
is the place where they are developed to be called
an ovarium, since the germs which Von Siebold
distinguishes by the name of ' sporulae' are not
only  devoid of the ordinary constituents of an
ovum, a vitelline membrane, yolk, germinal vesi-
cle, and so-called germinal spot;  but the farther
development of the germ-body is not preceded by
those conditions which are essential to the devel-
opment of true ova  within  an ovarium.  The
organ in which, in certain agamozooids, the ' gem-
ma!  are formed,  cannot,  therefore, be properly
termed an ovarium, and I shall distinguish it by
the name  of ' sporularium.'1  No '  nurses' present
any sexual distinctions, and hence their method
of multiplication and propagation,  which takes
place by means of sporulse formed within sporu-
laria, or by ordinary budding, or by division, must
be arranged  amid  the modes of asexual  repro-
duction."   (Von Siebold, Op. cit, p. 13,  14.)  I
must refer the reader to what this writer farther
remarks on the topic of alternation of generation,
especially as it occurs among the  Trematoda and
 Ccrcaria.
   11. From his researches, Von Siebold infers
that certain sexually matured Trematoda—Monos-
tomum, Distomum—generate young within their
sexual organs, which are not developed into sex-
ual individuals similar to their parents in form and
structure ; but that each embryo is converted into
an animal of remarkably different  form—into a
 Cercaria-sac, which has the nature of a sexless
nurse, since, without  possessing sexual organs, it
nevertheless generates  young Cercaria.   These
 Cercaria  again differ  from their parents, but grad-
ually become sexually perfect, and in form and
 structure  take the likeness of their grand-parents.
 If we follow these Trematoda, which are subject
 to the alternation  of generations, in their wander-
 ings, we shall find that  they meet with many
 obstacles  to the completion of their developmental
 course, which is the  entering into the viscera of
 an animal in which they can become  sexually
 developed.   The destruction ofthe various forms
 of Trematoda, by the untoward circumstances to
 which they are liable, is compensated by the fact
 that  they are furnished by the alternation of gen-
 erations  with the  means of greatly multiplying
 the various developmental stages of their descend-
 ants—a sufficient number of individuals always
 remaining  out  of the  numerous young  of the 
1518                              WORMS—Migrations  of.
nurses and larvae, which achieve the propagation
of their species.
   12. The history ofthe Ccrcarice  explains many
phenomena  erroneously interpreted by the sup-
porters  of the doctrine of equivocal  generation.
It was difficult to understand how living entozoa
could have originated in the viscera  of animals,
sometimes in organs deeply seated  or cut off from
all external communication, and could there prop-
agate their kind ; the mode of origin—by equiv-
ocal generation—assumed for them apparently
accounting for the circumstance of these entozoa
being unprovided with sexual organs.   Frequent-
ly, also, young or imperfectly developed intestinal
worms  were met with in the substance  of or-
gans, and were attributed  to  equivocal genera-
tion, " though in reality these entozoa were in the
act either of emigrating, or immigrating, or else
were tarrying until the  creature  they infested
should be swallowed by some other animal, when
the passive immigration for which they waited
would take place.   Many  wandering parasites
are unresistingly suffered to bore  their way into
and remain  in the  organs of animals, while cer-
tain kinds are stopped by becoming enclosed in
a  coagulable  lymph thrown out  by the organs
they  traverse."   There  are  two  kinds  of cysts
connected with  parasitic worms :  in  the one the
cyst is thrown out  by the parasite itself, as in the
case of the  Cercarioz ; in the other, the organ in
which the encysted parasites  lie imbedded fur-
nishes the walls of the cyst.   In such cysts or
capsules are found the most diverse kinds of in-
testinal worms, whose farther course may be very
various.  " Many of the encysted young of in-
testinal worms experience no farther change, but
only remain for a longer or shorter  period until
such time as they may,  together with their host,
pass  into the intestine  of  some animal of prey
suitable for their future development.  To this
kind belong  the Cercaria;  already  mentioned.
There  is also  a small,  imperfectly  developed,
round worm, hitherto  always erroneously  de-
scribed as a perfect intestinal worm, under the
name of Trichina spiralis, which  remains a long
time in its cyst without either growing or devel-
oping sexual organs.  This minute Trichina spi-
ralis is met with not only in the substance of the
muscles of  man, but also in the pleura and peri-
toneum of the most widely different kinds of ver-
tebrate animals, enclosed in oval  capsules about
a quarter of a line in length."   After a certain
time of confinement is allotted to this little worm,
and its deliverance not effected, it dies and un-
dergoes a process of calcareous degeneration, its
form being  altered or entirely destroyed.  Other
encysted intestinal worms  succeed in obtaining
nourishment  through the walls of their prison,
and thus go on growing.  Those, however, which
are intended by nature to attain their sexual ma-
turity only in the digestive organs of certain ani-
mals cannot arrive at this condition in their cysts,
and must, notwithstanding their farther growth,
fail in the  attainment  of the power of sexual
propagation, until  the animal  they inhabit is de-
■ voured by the predaceous creature whose intes-
tine  is alone fitted to allow of the passage of
these asexual intestinal worms into the last stage
 of their development.   (Von Siebold.)
    13. From what has been stated wc gather that
those young intestinal  worms which are devel-
 oped at a distance from the nidus of their parents
 succeed, in the end, in reaching those situations
where they may repeat the part of their progeni-
tors, and reproduce their kind.   The embryo par-
asites that have only just left their eggs disperse
in all directions, so that they may immigrate into
other animals, whenever an opportunity offers.
Many thousands  of these  embryos of necessity
never attain their object, owing to the numerous
casualties they are liable to.   However we may
accept the facts  displayed in the researches of
Von Siebold and others, it by no means follows
that the emigration or immigration of these para-
sitic animals  is the result, as they suppose, of
instinct.   The parasite having arrived at the full
stage of sexual development produces numerous
ova, many of which necessarily  are so  circum-
stanced,  by situation, dissemination, &c, as to
admit of their  passage  through the  different
phases and metamorphoses of evolution and de-
velopment ; but that these changes, and the emi-
grations resulting  from the circumstances com-
mon to all or most of them, admit of the inference
that instinct has any thing to do with the phe-
nomena ; or  that  their temporary or continued
residences, their journeys or passages  from  one
place or animal to another—their migrations, &c ,
proceed from  their possession of this endowment
or principle,  or  that their migrations  and resi-
dences are otherwise  than altogether passive,
cannot be received or credited without farther
evidence.  But,  after thus stating a disbelief of
the  instinctive faculties of these parasites, the
facts connected with their propagation  and evo-
lution become practically of importance.*
   14.  Instead of viewing  the migrations of the
embryo or young  parasites as passive, and the
accidents connected therewith as  equally so, Von
Siebold considers the former as altogether in-
stinctive, and the latter as stray migrations.  But,
while altogether disbelieving that instinct has any
thing  to  do with the  matter, this writer's views
deserve consideration.   The point  of  most im-
portance, he  remarks, is  " that  these  embryos
should select, as their temporary residence, such
creatures as will be consumed by those animals,
whose intestines served their parents as a habita-
tion and  birthplace for their young.  But many
of these young, immigrated, intestinal worms will
die without reaching the last  stage of their de-
velopment, in consequence of their host and in-
voluntary carrier escaping from his natural ene-
mies.  Again, many embryos  will be led astray
  [* If we understand by the instinct of animals that un-
known faculty or endowment implanted in their consti-
tution by the Creator, by which, independent of instruc-
tion, observation, or experience, and without a knowledge
of the end iu view, they are impelled to the performance
of certain actions tending to the well-being of the indi-
vidual and the preservation of the species, there is as
much reason to believe that the  minutest organisms in
nature are as perfectly  controlled  by it as the largest.
That it is  not infallible in either is evident from the fact
that both are sometimes  at fault, and commit  mistakes;
but then these errors are quite as frequent among the
one class as the other.  Indeed, facts would seem to es-
tablish that insects, and even worms, are endowed with a
much more exquisite and flexible instinct than the larger
animals.  Such pliability to circumstances, such adapta-
tion of means for accomplishing an end, as is observed in
the bee, the spider, the ant, the silk-worm, the moth, the
caterpillar, the locust and its larvse, &c, can nowhere be
found among birds, fishes, or any of the higher species of
animals below man; and the same remark, we think, will
apply to human entozoa and ectozoa in all their varied
conditions and modes of existence.   No one can road "An
Introduction to Entomology,'' by Kirby and Speni-e, one
of the Bridgewater Treatises, without being  convinced
that instinct is more strikingly manifested in  the insect
tribe than in any other class of animated nature.] 
WORMS—Cla:
ssification of.                           1519
by the migratory impulse (1), and pass into ani-
mals which never become the prey of those whose
digestive canal is their goal."  The embryos which
thus " fail  in  their object" are here viewed as
"strayed parasites ;" and Von  Siebold remarks
that " the Trichina spiralis,  which is found in
human beings, and which  must be regarded as
an encysted sexless nematoid worm,  can hardly
have  found its way into the  muscular structure
of man, except by having  gone astray:  so also
the Cysticercus cellulosa, which not  unfrequently
appears in the muscles and other organs of man,
and which is  an  asexual  taenioid  agamozooid.
The Cysticercus cellulosa changes  to a sexual
tape-worm in the intestinal canal of certain mam-'
mals; the Trichina spiralis,  after transportation
to another and more favourable situation, will also
become sexually developed."  Many of the young
of the intestinal worms, which only attain the
last stage of their development in  the digestive
canal of the  vertebrata, are said, by this writer,
to pass, in the course  of their wanderings, into
the wrong organs [their instincts, I may  infer,
have not yet been fully developed or perfected !];
for instance,  into the muscular substance, the
liver, or  the  peritoneum ; here they  remain un-
developed,  while other individuals  of the  same
brood, which have found their way into the in-
testines of the same animals, arrive at maturity.
"The Triamophorus nodulosus, infesting fishes,
offers an example of this, developing into a long
sexually mature tape-worm, in the  intestines of
pikes and perch, while at  the same time  these
fishes often harbour other tape-worms, which are,
however, always sexless, in cysts in their  liver.
These last must certainly be  also regarded as
strayed parasites."
   15. Von Siebold believes that, in the bodies
of vertebrate animals,  the  small embryos of in-
testinal worms bore their ways not  unfrequently
through the walls of the blood-vessels, and fall
into the current of the circulation, and are car-
ried thus to distant parts.   Embryos of intestinal
worms, to which the term of hsematozoa has been
given, have often been discovered  in the  blood
of birds, reptiles, and fishes.   These  hsematozoa
never increase in size,  nor become farther devel-
oped in the blood, but often stick  in the  small
blood-vessels of organs, which afford a more con-
genial soil for their farther growth; and hence
appear, on some occasions, worms  in the brain,
in the spinal marrow, and in the eyeball of man
and animals.   The Cysticercus  cellulosa, the Caz-
nurus ccrebralis, and the Echinococcus hominis and
veterinorum, have been occasionally found in these
situations, and  have served  as  an argument for
the doctrine of equivocal generation ; [also the
Filaria.]   "With the migrations and alternation
of generation  among  the intestinal worms two
other phenomena are connected, which were for-
merly quite unnoticed, but which now have been
generally observed.   In the vicinity of those sex-
ually perfect intestinal  worms which,  in  their
wanderings, are subject to  the  alternation of
generations, only eggs, or  recently-hatched em-
bryos, are met with; but the  farther stages of
development are always wanting, since they first
make their appearance  after the emigration of the
young to other places.   Farther, many of  these
intestinal worms, taken while in the act of mi-
grating,  arc never  found below a  certain size,
since they  do not commence their wanderings,
either as nurses or larvae, until they have already
reached a certain  stage of their development."
(Op  at, p. 30.)  Would it not be more correct
to view these evolutions of parasites from germs
and ova, and their passages, or passive migra-
tions, during their development, as accidents con-
nected with the numbers generated, and with the
locations and transitions of the embryos—their
development and sexual perfection being results
of favourable circumstances which happen only
to a few of the many generated—instead of view-
ing these migrations and their consequences as
events produced by the  instinctive endowment
which Von Siebold has conferred on these para-
sites?  While the possession of this endowment
by these animals  may be disputed, the facts ad-
duced by this writer, respecting their  origin, de-
velopment, and alternation  of generations, are
more deserving belief and consideration.
  16. II.  The  classifications  of intestinal
worms have been so numerous and so different
the one from  the other, that an attempt to place
them before the reader would not be  consistent
with  my limits and with expectations of utility.
Recent researches, also,  have thrown doubts on
the principles by which the older arrangements
were guided ;  and the orders, genera, and species
of entozoa, which  have been found in  the animal
kingdom, are so numerous as to prevent even a
brief notice of them at this place.  I must, there-
fore, refer the reader to  the more recent works
enumerated in the Bibliography, and especially
to those  of Dr. Joy  and M.  Felix  Dujardin.
Dr. Kuchenmeister has given a classification of
animal and vegetable parasites, which, as far as it
refers to the  human entozoa, I shall,  with some
alterations, adopt.
  17. I.  Class, Infusoria.—II. Class, Vermes,
Helminthia.—i. Order,  Platyelmia.—A.  Sub-
order, Cestoidea.   (a) Genus,  Bothriocephalus.
(b) Genus, Taenia.—B. Sub-order, Trematoda or
Trcmatoidea.  (a) Genus, Monostoma.   (b)  Ge-
nus, Distoma.—ii. Order, Nematelmia.—A. Tri-
chocephalus disp'ar, Trichina spiralis.—B. Oxy-
uris  vermicularis.— C. Strongylus gigas, S. lon-
givaginatus.—D. Ancylostomum duodenale.—E.
Ascaris lumbricoides.
  18. 1st Class.—The  infusoria  are destitute
of high organization.   They are simple, vitalized,
membranous structures, which live by mere endos-
mose.  The vibriones, the bursaria, monades, and
bodones " are a peculiar attribute of fermenting
and  putrefying fetid  animal substances, or  al-
ways presuppose  a half-dead  soil, and do not
derive their nourishment so much from living
substances as from matters which the living body
has expelled, or are in the course of expelling as
foreign to it; they are properly only to be re-
garded as indirectly parasitic upon  the human
body."  Ficinus found sluggish bean-shaped in-
fusoria 1-1000 to 1-1500 of an inch,  and some-
times double this size,  and of a globular form, in
the perspiration ofthe feet, on the places where the
epidermis was thrown off, as well as on the moist
folds  of the skin in young children ;  and others
have met with them in purulent and foul secre-
tions  from the vagina, urethra, bladder, putresci-
ble urine, &c.
  19. i. Trichomonas (Dujardin).  T. vaginalis.
— "Corpus nodulosum,  gelatinosum,  lacteum ;
cauda brcvis; flagellum  corpore triplo longius.
Motusvaallans.  Longit. 1 -222."  This parasite
occurs only in women with gonorrhceal discharge,
or with an abundant vaginal secretion containing 
1520                           WORMS—General view of.
mucous and pus globules, and never in a healthy
vaginal secretion. Kollikf.r and Scanzoni found
it in the vaginal—never in the  cervical—secre-
tion of both pregnant and unimpregnated women,
especially in the creamy and acid secretion, some-
times in the neutral,  but never  in the alkaline.
Owing to its resemblance to the  mucous corpus-
cles, it has been confounded with them.  The
body of this parasite  is 0 01 to  0018 millim. in
length ;  the  flagellum,  0028 to 0 08 millim. in
length ; and furnished with 4 to 8 short cilia, in
continual movement, which facilitate its recogni-
tion.   The capability  of infection by these  infu-
soria has not been determined, although very prob-
able.
  20. ii. Denticola hominis (Ficinus).  " Genus
valde dubiosum" (Kuchenmeister).—This  para-
site, according to Ficinus,  is an aciliated infuso-
rium, with the mouth on the ventral surface, and
probably furnished with a carapace, resembling
the paramesia and kolpoda ; but he  considers it
more allied to the monodcs and vibriones.  The
genus  he believes to be numerous ; and he infers
that every mammal has its peculiar species.  Dogs
and horses, he says, next  to man, exhibit  these
infusoria in abundance.   He states that he found
them especially in the interstices of the molars ;
more  rarely  on the   mucous membrane of the
mouth, scarcely in the saliva; bat most abund-
antly where the teeth have been neglected, and
in hollow teeth.  They  adhere, form  filaments,
and advance between the teeth and gums, push-
ing between the roots of the former and the lat-
ter, destroying their  union.  These effects are,
however, prevented and remedied by  the  usual
operations  on the  teeth, and by aromatic, tonic,
astringent, and antiseptic dentifrices.
  21.  2d Class.—a.  Vermes, Helmintha, are
of the greatest  importance to both the patholo-
gist and the practical physician.  The parasites
belonging to this class are destitute  of many of
the organs possessed by the higher animals.  They
have no distinct respiratory organ;  the oxygen
necessary to their existence can only be taken up
in their fluid food.   Hence they are enabled to
exist within the human  body, either in its closed
or open cavities, or in its tissues.   " They con-
stitute the true entozoa, and furnish  no repre-
sentatives  to the  series of human  Epizoa,  al-
though some of them may be destined, in the
course of their development, to pass a portion of
their lives in water, or perhaps (as in the case of
the Cercaria) as epizoa upon other animals.  Sex-
ual organs may always be detected in those speci-
mens of these animals which have attained their
last grade of development."  The senses of sight,
smell, and taste are wanting in all these parasites,
but their sense of touch appears to be highly de-
veloped.  The intestinal canal is wanting in the
Cestoidea.   In the Trematoda  it forms a  caecal
canal, in which the mouth also performs the func-
tions of the anus; while  in the Nematoidea it
becomes a complete alimentary canal,  with a
mouth, oesophagus, stomach, intestine, and  anus.
In the tissues  of the Cestoidea  is a tendency to
the formation of an envelope of  a calcareous na-
ture,  which  is  wanting in the Trematoda and
Nematoidea.   These  three kinds of true Helmin-
tha are characterized, 1st.  By a  general sense of
touch; 2d. By a vascular system, of four longi-
tudinal lateral canals in the Cestoidea, and of a
fine network of vessels in the Trematoda, which
are less distinctly marked in the Nematoidea; 3d.
By a muscular system, composed of transverse
and  muscular fibres,  without transverse  stria:;
4th.  By  the  structure  of  the epidermis,  which
consists  of a homogeneous finely checked sub-
stance, closely approaching the character of chi-
tine ; 5th. By the property  of giving off a strong-
ly refractive, albuminous substance, in oleaginous
drops, when  in contact with water;  and,  Gth.
By their  scarcely effecting their development with-
out apassiveand active migration of their embryos
and immature young.
  22. b. As to the last of these characters, KiicH-
enmeister, more rationally than was stated, as
shown above, by Von Siebold, remarks that " this
migration itself is passive  during the embryonal
state, and as long as the embryos are still enclosed
in the egg-shells or envelopes, during which pe-
riod  they usually emigrate once, passively, into
the external world, generally with the excrements
of the hosts of their parents ; and then again, pas-
sively in general, into the intestinal canal of the
animal in which they are to acquire a higher de-
velopment.   From the latter moment commences
their active  migration,  by  which they seek the
situations, usually external  to the intestinal canal,
in which they are to undergo their metamorphosis
into  the next higher step or steps of development,
which is generally accompanied by an encysting
process.   Finally, as a general rule, at least as
regards the trematoda  and cestoid worms, they
must afterward migrate, passively, once more
into  the intestine of the animal in which they are
to attain maturity ;  that is  to say, they must pass
with the food of their new  and final host into its
intestine."  (Op. at, p. 4.)
  23. c. General pathology shows that the worms
cannot effect their active migration without caus-
ing some irritation of the regions through which
they pass, whether this migration  is performed
by the youngest brood,  as is  usually the case, or
by the more or less mature animal, as rarely oc-
curs, and chiefly among the Nematoidea.  The
passive migration of all immature parasites into
the human intestine takes place without any per-
ceptible morbid phenomena.
  24. d. The general prognosis of this class of
parasites  may  be  stated as follows : 1st. The
young animals engaged in their  migration are
the most dangerous ; 2d. Next to these, the mi-
grating mature individuals, which inhabit the in-
testinal canal, produce the most dangerous symp-
toms ; 3d. The animals which reside in cysts or
closed cavities can become  dangerous only when
they attain an enormous size ; but, when small,
they maybe present without doing any mischief;
4th.  Most ofthe mature individuals are more ac-
cessible  to curative means than those of lower
stages,  especially  those which live outside the
intestinal canal.
  25. e.  The principles  of  treatment for the Hel-
mintha are,  1st. The destruction or removal of
the  mature  worms, and of  their  progeny; 2d.
The  observation of a rational prophylaxis, founded
on the modes of  life  and migrations of the im-
mature individuals; on the constitution and cir-
cumstances,  and  the  habits  and modes  of life,
of people subject  to  these parasites ; and on a
knowledge of the nature and peculiarities of the
situations in which these plagues are endemic.
  26. III. The  animals of  which I have now  to
treat belong  to the first sub-class  of Diesing—
Helmintha achathelminthica: animalia cvertebrata.
inarticulata  (i.  e., cxtremitatibus articulis nullis 
VvORMS—Generation a
pradila), nunc mollia, aut elastica,  ebranchiata,
selis rctractilibus nulhs.   I have, following Vogt,
Virchow, and Kuchenmeister, divided this class
into two  divisions:  i.  Platyelmia, flat worms;
and, ii. Nematelmia, round or thread worms ; and
again dividing the first section or order into, 1st.
The Cestoidea, Vogt ;  the  Cephalocolylea, Die-
si ng ;  or the  Platyelmia  colonias exhibentia, or
fiut-worm colonies, of Kuchenmeister ; and, 2d.
The Trcmatoidea, Vogt ; Myzelmintha, Diesing ;
or Platyelmia  isolata, isolated flat-worms, Kuch.
  27. i. Order, Platyelmia.—Entozoa  sohtaria
aut composita, androgyna.   Corpus depressum vel
teretiusculum,  molle, organis ad fixandum aptis
 praditum.  Anus nullus; canahs abanus aut di-
visus (rarissime  simplex), aut nullus.   Cavitas
corporis non dislincta.   Metamorphosis in pleris-
que; larva gemmipara aut sporalipara.  (Leuck-
art.)
  28. A. Sub-order, Cestoidea.— Cephalocotylea,
Diesing ; Platyelmia composita, aut colonias  ex-
hibentia,  Plattwurm-Colonien, or flat-worm colo-
nics, Kuchenmeister ; Bandwiirmer, tape-worms
—Animaha tomotoca, per longum plerumque tem-
 pus larva nutria juncta  et una cum ea corpus
elongatum, articulatum, polymorphum formantia.
Larva (Scolex,  vulgo caput)  pyriformis, foveis
aut oscuhs suctoms quatuor vel duobus instructa,
sapissime unciata.  Proles sexualis (Proglottides,
vulgo articuli) organis externis destituta,  cmbryo-
nes uncinuhs armatos gignentes.  Canahs aba-
nus nullus.  (Leuckart.)—Quinque varia invc-
muntur in ns metamorphoses:  1.  Animal matu-
rum (Proglottis); 2. E'mbryonesunanulati (Grand-
nurse, Grossamme);  3.  Scolex  passivam vitam
agens sub forma  vermis cystici seu Cysticerca,
sub  forma Platycerca, et sub forma Accrca; 4.
Scolex aclivam vitam agens (Nurse, Amme); 5.
Strobila.
  29. It is only recently that the cystici, or hyda-
tids, have been shown to be only a stage in the
development of the Tama, and not to be a dis-
tinct family among the Helmintha.  Hippocrates,
Aristotle, and many anatomists and physicians
up  to  the times of Redi and  Hartmann—in
1683-5—regarded the Cysticera as hydatids; but
the distinct animal nature of these was not rec-
ognised until  the work of Redi  appeared, and
not fully established until the researches of Ty-
son  were  communicated to the  Royal Society in
1691.  (Philosoph. Transact,  No. 193,  p. 506.)
Pallas, in 1766, stated that all cystic worms are
forms of tape-worms, and belong to a single spe-
cies—" Tania hydatigena, cystic tape-worm"—
which only presents  some differences, especially
in the caudal vesicle, according to the animal it
inhabits.   But neither Tyson nor Pallas, by the
terms Tania hydatigena, or  Lumbricus hydropi-
cus,  given by  them to cystic worms, expressed
any opinion as to the genesis of these worms, or
their derivation from ordinary tape-worms.  Go-
eze, in  1780, and Wagler, advanced but little
the views of Tyson ; and, although  the  subject
of cystic worms was considered by  Zeder and
Rudolphi, it  made no progress in their hands.
At last, in 1842, Steenstrup's theory of the  al-
ternation of generations  made its way, he believ-
ing that the cystic worms were early steps in the
development of helmintha, which were unknown
to him.   In  1845, in consequence of  Steen-
strup's discovery, Dujardin first asserted that
the cystic worms were undeveloped animal forms,
and youno- states of tape-worms;  and that they I
    III.             96
   Growth of Tape-worms.                1521

 were produced from those germs of tape-worms
 which, instead of the intestine, had got into the
 parenchyma of the body of their host, and, under
 the influence of this unusual dwelling-place, had
 advanced to  the abnormal  state of development
 which is called a "cystic worm."  Simultane-
 ously, Von Siebold, in Germany, expressed the
 same opinion with Dujardin in France.  At first,
 however, Von Siebold inclined towards Steen-
 strup's view, and  said : '• In its form, its suck-
 ers, and its circlet of hooks, the head ofthe asex-
 ual cystic worms possesses such a striking sim-
 ilarity to the heads  of certain  tape-worms, that
 one  is tempted to believe that the cystic worms
 are nothing else than undeveloped and larva-form
 tape-worms." He subsequently, nevertheless, ar-
 rived "at the most  decided conviction  that the
 cystic worms are strayed tape-worms which have
 remained undeveloped and become degenerated, and
 of which the "body grew out in the foreign soil
 into a vesicle, without developing sexual organs."
   30. In 1850, Van Beneden, the Belgian zool-
 ogist, declared the vesicular worms to be larva-
 like, or  young  states (scolices) of Tania,  and
 compared them with the larvae of Tctrarhynchus.
 According  to him,  the head of the tape-worm
 (scolex)  is  produced  from the egg of the tape-
 worm.  If an egg of a tape-worm reaches the
 intestinal canal of an animal in which it may be
 farther developed without interruption, the joint-
 ed mature tape-worm (strobila) immediately grows
 from the egg in uninterrupted succession ; but if
 it does not reach an intestine of this kind, a lon-
 ger or shorter period of rest ensues in the farther
 development as soon as it has arrived at the evo-
 lution of the  head of the tape-worm (scolex); in
 this case the anterior part of the head sinks into
 its inflated hinder part, and it becomes a Cysti-
 cercus, or a cysticcrcal animal  form.  Kuchen-
 meister, however, finds two errors in  this infer-
 ence.  1st. It is not proved that a tape-worm can
 pass through all the  phases of its development
 in the intestines of its host; and, 2d. And just
 as little  as  the caudal vesicle is produced subse-
 quently by dropsical degeneration (Dujardin  and
 Von Siebold), docs the ready-formed  head sink
 into  its inflated hind part, in order to become a
 Cysticercus.
   31. As Goeze had suggested in 1780, Kuch-
 enmeister, in 1851, administered various cystic
 worms to different animals.   For this  purpose
 the  latter selected the  Cysticercus pisiformis of,
 the  rabbit, and also the C. fascinlaris, and gave
 the  former  to the dog and the  latter to the cat,
 and in the intestines of both  these animals he
 " succeeded in rearing taeniae rapidly approaching
 maturity."  From these experiments  he makes
 certain deductions, of which the following  are
 the  most interesting: 1. The caudal vesicle oc-
 curs in  all individuals of all  species of cystic
 worms, even though they live in the most various
 zones and different animals.   2.  The universal
 loss of the caudal vesicle has its analogue in  the
 metamorphosis of many animals.  3. All cystic
 worms, in the earliest period of their existence,
 have the head constantly inverted towards  the
 caudal vesicle.   4. The state  of rest in which
 the cystic worms must live in the interior of their
 caudal vesicle,  in  order  to  their development,
 would be inconceivable, if  they had to  collect
 the  nutritive  fluid  for  themselves, and  did not
 contain  it in them.  5. The  cystic worms  are
I not strayed dropsical tape-worm nurses, but tape- 
1522                     WORMS—Developm

worm larvae furnished with  a provisional  organ
(caudal  vesicle), probably being a reservoir  of
nourishment, and incapable of sexual multiplica-
tion, for which there is neither room nor suffi-
cient  nutritive material.   6.  The  cystic worms
constitute a necessary step  in the development
of the Tama.   7. We cannot speak of dropsy
or degeneration, and not even  of straying, be-
cause we do  not yet clearly  perceive how the
brood could  get to the dwelling-place of the cys-
tic worm.  And, 8. Cysticerci, when transferred
to the intestines of other  animals, do not become
developed into jointed tape-worms, unless the
species of Cysticercus is  suited to the intestines
of particular animals ; thus, the Cysticercus pisi-
formis was not developed in the intestines ofthe
cat, but it was  fully developed in those of the
dog.  Kuchenmeister asserts that all  eminent
German  zoologists now  agree with him in be-
lieving "that every cestode worm, and not mere-
ly the Tania, pass through a cysticercal  state;
that the cysticercal larva lives in various paren-
chymatous organs, and the free scolex (strobila)
usually in the intestine of a different host; and,
lastly, that the tape-worm  head (scolex) is pro-
duced in the interior of the previous embryonic
body (i. e., the caudal vesicle), and remains en-
veloped  by this until it  gains the situation for
which it is ultimately destined."
  32. But to place beyond all doubt that the cys-
tic worms were necessary steps in the  develop-
ment of Tania, it was also requisite to prove their
production from the embryos of the tape-worm
brood.  " It is true that the six characteristic em-
bryonal hooklets have not yet been detected upon
true vesicular worms, but we shall shortly see that
the laws of analogy, as well as experiment, afford
us a glance into this process."  After various ex-
periments, Kuchenmeister proceeds to state that,
he resolved to resume those experiments with the
Tania Cccnurus in order to obtain the remarka-
ble phenomena of the vertigo in sheep.  On the
15th of May, 1853, he obtained the cystic  Coznuri;
on  the 25th of July mature  proglottides of the
Tania were passed by the dog to which the Coz-
nuri were administered; and  these, in  order to
make the experiment under the most unfavoura-
ble circumstances, were  administered to a per-
fectly healthy  two-year-old wether, a description
of sheep which are  usually  free from  Coznuri.
On the  10th of August the sheep was vertigin-
ous ;  and on  the 13th it was necessary to kill
the animal;  and in the brain he found fifteen
young vesicles of Cccnurus,  partly on  the sur-
face ofthe brain, which was reddened by inflam-
mation, partly in the substance of the brain, and
even  in  the  ventricles.   In  January, 1854, six
lambs were  fed with Tania Coznurus.   Of these
five became  vertiginous  in about eleven days.
Leuckart fed, in October, 1853, a colony of white
mice with Tama crassicollis.   In January, 1854,
he examined his mice, and found them infested
by cystic worms. Kuchenmeister subsequently
proved that, by the administration of mature spe-
cies of Tania, as far as  they  were accessible to
him, to suitable animals, only the cystic worms
belonging to these species  can be reared ; but
not any kind of cystic worm at pleasure.  From
the concordant experiments of Haubner, Leuck-
art, Van Beneden, MoLLER,and himself, Kuch-
enmeister  considers that this much  is  estab-
lished :
   33. "1. Mature Tania have hitherto been rear-
ent of  Tape-worms.

ed successfully from all vesicular worms admin-
istered when a suitable host was selected ; thus,
from  Cysticercus pisiformis  the Tania serrata
vera was obtained;  from Cyst, tenuicollis,  the
Tania  ex  Cyst,  tenuicolli; and from  Coznurus
cerebralis, the Tania Canurus; all  three in  the
intestine of a dog:  from Cyst, fasciolaris,  the
Tania  crassicollis,  in the intestine  of the cat;
from  Cysticercus cellulosa, the Tania solium, in
the human intestine ; from Echinococcus vetcrino-
rum (Scolicipariens of Kuchenmeister), a Tania
Echinococcus, in the intestine of a dog;  and from
Cysticercus longicollis Hyperdai, the Tania cras-
siceps, Rud., in the intestine ofthe dog (Leuck-
art)."
   34. " 2. From the eggs of Tania  solium  in
pigs, from those of  T. Canurus  in sheep and
cattle, of T. serrata vera in rabbits, of T. cras-
sicollis  in rats  and mice,  of T.  ex  Cysticcrco
tenuicolli in sheep  and lambs, the corresponding
vesicular worms  have been reared.   The experi-
ments with the eggs ofthe Tania ofEchinococcus
have hitherto remained unsuccessful."
   35. Up to a recent period it was the most gen-
eral opinion, still entertained by some, that the
tape-worm (tape-worm chain) was a simple ani-
mal, with  numerous  segments.  Nevertheless,
some older physicians correctly perceived that
tape-worms were not simple, but compound ani-
mals.   By many the several segments of Taznia
were regarded  as  separate  worms  ;  and what
Dujardin  has  recently called  proglottides are
described by them  in the human tape-worms as
" Vermes cucurbitini."  At the same  time they
fell into the great  error  of not regarding this
chain as produced by a successive formation  of
joints placed one behind the other from the head,
but expressed the  remarkable opinion that the
tape-worm was produced  by the adhesion of the
individual  " Vermes  cucurbitini" one  after the
other, by which  means the many-jointed  body
was formed.  The opinion that the tape-worm
was a  compound  animal—an animal composi-
tion—was first expressed by Leuckart.  Soon
afterward, Eschricht and Steenstrup express-
ed this  opinion more strongly, and Van Beneden
proved  it, after Dujardin had described the seg-
ments of tape-worms which occur isolated, as pe-
culiar animals, under the name of proglottis.
   36.  i.  The mature Animal,  or Proglottis.—
" From the moment that  the  hindmost segment
or segments of a tape-worm colony  has become
so  far  developed  as to contain the six-hooked
brood ready formed and enclosed in the egg-
capsules, this segment seeks  to break loose, ei-
ther by itself or in company *ith several others,
in order to continue an  independent  existence,
either in the same place (the intestine of its pre-
vious host) or in a different one (in  the external
world).   All this varies according to the species.
In  Tania, Tetrarhynchus, &c, each joint usu-
ally breaks loose;   in  Bothriocephalus, a series
of joints."  In those in which no regular forma-
tion of segments exists,  no single  proglottides
or  segments can break  loose, but  only single
brood-places, or  fragments of the body of the
cestode worm with such brood-places ; or the
eggs must escape singly.   The proglottides have
for the  most part a flat quadrangular form, very
similar  to the Trematoda,  and usually a white or
yellowish, rarely a reddish or brownish colour;
they  have neither  mouth,  anus,  nor intestine.
" As  the eggs possess  a much greater diameter 
WORMS—Development of Tape-worms.
1523
than  the vagina, they cannot pass through this,
but can  only escape out of the proglottis when
the vagina  acquires a larger opening, by tear-
ing, &c.   This takes place sometimes even in the
intestine of the first host, and the eggs escape
separately into the  outer world with the excre-
ments, which then  appear as if sprinkled with
fine white sand; or immediately without the in-
testine, where the progress of the proglottis is
seen  indicated by a white milky streak.  Some-
times the proglottis does not  burst in either of
the above-mentioned places, but  gets uninjured
into the  intestine of a new  host, in which case it
distributes its brood only after it has been  de-
stroyed  by  digestion.   According  as  the eggs
reach the intestine of their host in this way sep-
arately, or enclosed in the  proglottis, and there-
fore in a mass, solitary  or  numerous specimens
of a  cystic,  or of the analogous state,  are pro-
duced within  one  and  the  same  host."  The
proglottides  thus perform an  active migration
from  the intestine  of their previous host,  and
are passively or contingently transferred into  the
intestinal canal of a new host.   With the dissem-
ination of their brood their function ceases.
   37. ii.  The six-hooked Brood, enclosed in sepa-
rate  Egg-capsules.—These are  called eggs,  al-
though   their development differs greatly from
that  of  ordinary eggs.  The embryos enclosed
in the egg-shells are globular naked vesicles, un-
like their parents ;  the smallest of them measure
only 0022 mill., and the largest 0 05.   They are
destitute of any organs, possess an epidermis with
a double outline,  and usually bear six, but in the
Tctrarhynchi only four, very small microscopic
hooklets on their anterior extremity, so that they
carry their  destination,  that  of boring  forward
through  the  tissues, as it were, written on their
foreheads.   The bodies  of these small but very
dangerous vesicles, whether armed  or unarmed,
are always  capable  of  motion.  The  embryos
which are destined to migrate into cold-blooded
animals  are  much larger, possess larger hooks,
and exhibit distinct movements in the usual tem-
perature  of a room.   Those destined for warm-
blooded animals are much  smaller, with smaller
hooklets, and exhibit distinct movements  only
about the temperature ofthe stomach.   (Kuch.)
   38. iii.  The Destiny of the six-hooked Brood when
set free.—A. What is the fate of this brood until it
reaches its settled dwelling-place external to the  in-
testinal canal ? As soon as the embryo becomes
free in any part of the digestive canal of an ani-
mal which suits it, according to Van Beneden, it
brings together the central pair  of its embryonal
hooklets  like a wedge, and at the same time,  by
thrusting and twisting, begins to force them for-
ward.  Having in this way made a  little prog-
ress, it assists itself farther with the two lateral
pairs  of hooklets.    Kuchenmeister supposes
that,  having  thus penetrated  into  the tissues,
they pass into the  blood-vessels, and thus they
are conveyed either  into the liver  by  the vena
porta, and remain fixed in the  finest  ramifica-
tions  of the  blood-vessels, or into the  brain,  or
into other parts.  The migration ofthe young of
the Cestoidea to the places where we meet with
them  as vesicular worms, or in analogous states,
takes  place in the following way :
  39.  1st. A portion ofthe six-hooked brood, in
all species of Cestoidea, may reach their dwelling-
place  directly and by active migration, by boring
their way.   2d. Others, by an uncertain duration
 of this migration, reach the vessels  of the new
 host, penetrate these, and are conveyed with the
 blood  to  the  smallest ramifications,  where they
 (a) either become developed in these ramifica^
 tions,  the walls of the vessel becoming their en-
 velopes ;  or  (b) they migrate passively into the
 neighbouring tissues, after  the rupture of the
 walls ofthe vessels, in consequence ofthe swell-
 ing of the embryo ; or (c), after being detained in
 these ramifications, they enter anew upon an act-
 ive migration, passing into the  tissues by means
 of their hooklets, and increasing in size.
   40.  B. What farther  takes place with  the em-
 bryos when they have come to rest in their new
 dwelling-places 1  The third stage of the develop-
 ment of the  Cestoidea consists of the so-called
 vesicular worms  and their analogous  asexual
 forms, "  which, in accordance  with the altera-
 tion which the embryonal vesicle undergoes in
 the different species of tape-worms, and with the
 different  animals  infested by them, may be di-
 vided  into  cysticercal (vesicular worms), platy-
 cercal  (forms with a flat, inarticulate, tail-like ap-
 pendage), and acercal (or  tailless) forms.  It is
 a common peculiarity of all the three forms here
 mentioned, that they are cestode-heads produced
from the embryonal vesicle, which occur still in the
 interior of the embryonal vesicle, or upon it in a
 state of rest.   We may therefore best compre-
 hend this stage under the name of  resting sco-
 nces."  The metamorphosis or  transition of the
 embryos  to the resting, and  usually cysticercal
 scolices, may be stated as follows:
   41.  1st. "The embryo, still furnished with its
 six hooklets, begins to swell by the reception of
 fluid (liquid nourishment) which is secreted from
 the place in which it has established itself: this
 is at first a fluid similar to protoplasm, but after
 the formation of the enveloping  cyst,  or after the
 cessation of inflammation, when the creature lives
 free in the interior of serous cavities, it does not
 agree so much in its  composition with the serum
 of the blood as with the  ordinary products of the
 secretion  of serous membranes."  (Luschka.)
   42. 2d  As  soon as the embryo has in this way
 rather  rapidly enlarged to a certain size,  and ar-
 rived at a state  of repose, the  round vesicle thus
 formed, when it does not project freely  into a
 serous cavity, and has not fallen into one, sur-
 rounds itself with  an envelope, which  protects it
 and assists it in procuring repose.  These envel-
oping cysts constitute an absolutely new  forma-
tion, which is analogous to serous membranes,
 and which constantly increases  in size with the
growth of the young cestode vesicle.  When,
however, the brood of a cestoid worm gets freely
into serous cavities, it either never attains to this
 formation of an  enveloping cyst, or does so at a
rather late period, and at a time when the  young
embryo has become a vesicle of very considerable
size, and often exhibits the Taenia head in  an ad-
vanced state  of development.   In places  where
the young cystic worm again falls into repose, a
fresh exudation  of plastic matter adapted  to the
formation of cysts takes place, the walls  of the
cyst being rich in blood-vessels.   (Kuchen.)
  43. 3d.  By the  reception of the secretion of
the serous membranes, the young cestoid vesicle
swells  up. At its anterior end,  and at the point
where  the six embryonal hooklets are situate, a
funnel-shaped pit  is  at  first  formed, and  this
gradually  penetrates more deeply into the  paren-
chyma  of the embryonal body).   In the bottom 
1521                      WORMS—Development of Tape-worms.
of this  pit the first traces  of the head  appear,
while the lateral walls of the depression  become
converted  into the  body—the central  body—of
the future  cystic worm, and the remaining por-
tion  of  the embryonal vesicle, wliich is  not in-
verted, or not implicated in the metamorphosis,
becomes the so-called caudal vesicle.  This inver-
sion  and first formation of the head  most fre-
quently  commences at the anterior surface of the
vesicle,  and are seen distinctly in the cestodes
of Anon cmpiricorum, for in these the six  small
hooks are placed  in  pairs  at the point of transi-
tion  of  the central  body into the caudal vesicle
of the worm.  The central body  and the head
are always developed in the interior of the em-
bryonal  vesicle, and during  the whole period of
the vesicular state the head always has its apex
directed towards  the caudal vesicle, even  when
the central body, which encloses the head in the
form of a hollow canal, has not sufficient room
in the embryonal vesicle, but is pushed out of it.
(Kuchen.)
  44. 4th.  From the experiments of Haubner,
Kuchenmeister, Leuckart, Roll, Van Bene-
den, Eschricht, &c., with the  various Tama
which pass  through a vesicular condition, the
following  appears:  According to Leuckart,  at
least  in experiments with  T. serrata, we find
twenty-four hours  after  administration the six-
hooked  embryos  in  the blood  of the large ab-
dominal veins, especially the vena portae ; and on
the fourth  day, in the livers of rabbits to which
they have been administered, small, white, clear
vesicles of 03 millim. in diameter, but rapidly
increasing  in size,  which on  the  sixth are al-
ready 1  mill, in diameter.   In T. serrata  the act-
ual embryo,  after  the  lapse of  fourteen  days,
measures  15 millim.; in Coznurus it is  about
the size of a grain of millet at this period.  The
small vesicle (the worm), after it has begun to
grow clear, acquires, in  its interior,  numerous
large, clear enucleate vesicles, which, according
to Leuckart, are similar to sarcode drops.   In
the parenchyma we recognise a  cortical  layer,
which becomes thinner, and the cells of which
are converted into  muscular envelopes by fibre-
formation,  and a medullary layer, in which elastic
vesicles or cells occur in  great quantity.   From
the appearance of  the medullary substance, the
growth of the little worm,  which is capable of
motion  even before  the muscular layer is devel-
oped, advances with rapidity.  Even in  the first
fortnight, and shortly afterward, the form of the
young cestoid worm varies  according to the spe-
cies.  Some, such as the younger  Coznuri and
 Cystic, cellulosa, tenuicollis, and fasciolaris, are
spherical; others, such as Cystic, pisiformis, and
probably also Cystic, longicallis and fistularis, are
oval.   Many of those seated upon the surface of
organs, projecting  into  closed serous  cavities,
wander for a time in the organ, and finally fall
into these cavities, the oval forms appearing to
 wander more than the round ones.  About four-
 teen days after administration, the above changes
 take place almost  universally and  in  all places.
 But those individuals which have not  found a
 situation  favourable to their development under-
 go a retrograde metamorphosis, passing " to the
 state of caseous, granular, or atheromatose mass-
 es, in which we may seek in vain for any remains
 of the  embryo,  although this certainly  is pres-
 ent. Many cases of miliary tubercular disease
 cf particular organs may indeed  consist  of noth-
ing else than the dead, fatty, and calcified young
of worms."
  45. 5th.  In the third or fourth week, when the
young brood  of  Cysticercus pisiformis measures
about 2 millim., and that of the Canurus is  of
the size of a pin's head, we may  sec, according
to Leuckart, beneath the epidermis a layer  of
muscular fibres.   Then follows a fatty structure,
and then the  medullary substance.  At the point
where the head is to be formed, a turbidity is pro-
duced by the aggregation of small nucleated cells,
in the interstice between the muscular and me-
dullary layers.   This is the first  foundation ofthe
head of the tape-worm.  Opposite to this turbid-
ity a pit is  observed externally, the inner wall  of
which is formed by the  inverted epidermis, and
which passes through nearly the whole depth  of
the globular  foundation of the head ; this latter
appearing like a peg attached to the inner wall
of the worm.  In  the central mass of the head,
especially in its upper half, calcareous deposits
appear, at  first  sparingly.   Two or four vessels
are also observed rising in a tortuous form through
the upper part  of  the lobe, and passing over on
the external sac-like envelopes.  The vesicle now
becomes larger  and clearer, and  the medullarv
layer, pushed against its peripheric layers, grows
thicker, while vessels and calcareous corpuscles
make their appearance, especially  in the anterior
part of  the body, between the muscular and epi-
dermic  layers,  but not in  the  former, in some
cases before, in  others after, the formation ofthe
cephalic process.  From the time when this proc-
ess commences, the caudal vesicle ceases its ac-
tivity in the true Cysticerci; its functions are
then  only  passive, serving as a reservoir of nu-
triment, or as a  protection to the head, which re-
quires  repose for its  farther development, and
preserving sufficient room for  this end.   I can-
not follow the descriptions of Kuchenmeister and
other helminthologists farther, as respects the de-
velopment of the head and its hooklets, &c, but
must refer the reader to Dr. Lankester's trans-
lation of the work of the former, and  to the other
works referred  to in the Bibliography.   I may,
however, notice the following conclusions of this
observer:
   46. 6th.  In the progress of the metamorphosis
of the  six-hooked cestoid  brood into scolices, it
has been shown that a portion of the Tania pass
through a  true  cysticercal (bladder-worm) state,
while the other  part, without ever arriving at this
state, furnish exactly the same structure  (ces-
toid heads—scolices).   This latter part Kuchen-
meister has divided into platycercal and accrcal
forms.—(a) True Cysticerci occur only in warm-
blooded animals, especially mammalia; and cys-
ticercoid forms principally  in  cold-blooded ani-
mals.—(b) The eggs of all Tania which pass a
cysticercal stage are distinguished by the small
size  of the  embryo, and  its six  hooks,  and  by
their brown, hard shell beset with asperities.  The
eggs of the Tania with only a cysticercoid phase
of development  have softer, colourless, transpar-
ent shells, are much larger, and contain a much
larger embryo, furnished  with larger hooks.—(c)
 Tania with a cysticercal  phase of development
are inferior to  the platycercal and acercal forms
in  regard  to the length and cylindrical  form of
the rostellum.— (d)  Tania  with a cysticercal
stage possess during this  a highly developed  re-
ceptaculum capitis, which forms a part of the  fu-
ture  neck, in which, as  long as this stage  lasts, 
WORMS—Development of Tape-worms,
1525
the head is introverted.  The allied platycercal
and acercal forms are destitute of the accumula-
tion of fluid, and of the receplaculum.—(e) If the
six-hook cestoid brood  gets into animals which
are not  suitable to it, or into  such organs in  an
animal  otherwise  suitable, it is  destroyed  in a
very short time, even in the few  first days of its
immigration ;  the form  of miliary tubercular dis-
ease of  the organ may  thus have frequently oc-
curred.   This may be demonstrated by adminis-
tering mature proglottides  to various  animals.
—(/) A great number of the cestoid embryos
which become developed to the scolex state die,
and are destroyed either by a natural or a patho-
logical death.   We only know that their life may
extend  even  to several years, but  inflammatory
processes and alterations of  the secretions ex-
tending to them from  the organs  they inhabit
may  destroy  them  more  or  less  rapidly, and
change  them  into masses consisting of choles-
terine, calcareous, fatty, suety, and similar sub-
stances.
   47. iv.  The Scolex passing into activity.—On
this topic I must refer chiefly to recent writers,
more especially to Kuchenmeister, and notice
merely a few of the more prominent parts of their
descriptions.   As a  general proposition, it is  in-
ferred " that the animal infested  by cystic worms
is usually the source of food,  or the prey, of that
infested by tapc-icorms."  The host of the cystic
worm is devoured by a carnivorous predaceous
animal, and by this means the  cystic worm  ar-
rives, together with his previous  host,  in the
stomach of the carnivorous animal.  During the
process of  digestion,  the enveloping  cysts  in
which  the cystic worms were  enclosed,  or, if
the  animal  lived free  in  cavities,  these  latter,
perhaps both, are digested, or opened previously
by the  teeth of their devourer, when the cystic
worm escapes into the cavity of the stomach.
Here the worm extends itself; its  caudal vesicle
collapses.  On the caudal vesicle and the middle
of the body of the  cystic worm digestion begins
to act perceptibly.   The body at the same time
elongates and extends itself, but  the head and  the
short neck are still inverted, as during  the cysti-
cercal state.   But now the head  and neck extend
themselves.   The head, the hooks still exhibiting
the position of cysticercal existence, their apices
being directed backward towards the suckers, and
their shafts towards the apex of the head, draws
 itself, as it were, outward through the neck, by
 turning itself inside out.   As a matter of course,
 the whole worm is  thus turned inside out; and
 the margins  of the  head and neck which were
 previously turned in, become  the free outer sides
 of the worm.   A portion of the  reccptaculum ca-
 pitis is then cast off, with the body and the cau-
 dal vesicle, and a portion wraps  itself into  the
 funnel-shaped constriction of the  young Tania.
   48. At various times,  sooner  or later, accord-
 ing to the evolution and age of the cystic worm,
 the formation of segments commences, and with
 this, consequently, this stage of development is
 concluded.   It should  be recollected that  Tania
 cannot be reared from such scolices as do  not
 exhibit perfectly-developed hooks.   They die  im-
 mediately.   The first transformation of all cystic
 worms introduced into the intestines of a warm-
 blooded animal takes place in the same way ;  but
 (he process  stops before the commencement of
 segmentation, in those cases in  which the intes-
 tine  of the animal in which  the vesicular worm
has arrived is unfavourable for it and its future
development.  Thus circumstanced, it lasts but
for a short time, no trace of it remaining a fort-
night after.   The transformation of the platycer-
cal forms into mature Cestoidea takes place ex-
actly  like that of the cysticercal forms; in the
acercal foims no casting off of a portion of the
former embryonal vesicle takes  place, but the
whole of it is retained, and the formation of seg-
ments commences immediately upon it.  It still
remains to consider—How the scolex, after enter-
ing upon its activity becomes converted into a tape-
worm colony—Strobila.
   49. v.  The Strobila, or the so-called Tape-worm
Colony.—"Immediately after the healing of the
cicatrix on the neck and on the former reccptacu-
lum capitis, there commences between the pos-
terior end of the head and  this  cicatrix a bud-
ding forth of the body, produced without sexual
propagation,  and which becomes constricted into
segments by  transverse furrows or wrinkles.  By
the constant production  of new  masses  on this
place, that previously formed is continually pushed
farther back, so that this cicatrix is at last re-
moved to a considerable distance (varying accord-
ing to the species) from the head.  During this
time the individual segments increase, and  grow
in the same ratio as their removal from the head:
they at the same time acquire sexual organs, male
and female, in each segment, and which are very
rarely, and probably never wanting in the colony.
Finally, when they have attained a sufficient size
and maturity, they produce the embryos ($ 41, 2),
and last of all cast themselves free in the form of
the proglottides (§ 36).   If we  were to give  a
definition of the strobila—it is a series of joints,
or individuals, which are formed from the active
scolex in the space between the part of the latter
that must be called the head proper, and its cica-
trized extremity, by a sexual reproduction; which
are in direct union with the scolex,  and which,
when examined from the anterrbr to the posterior,
present asexual segments, half and fully formed
sexual segments, and segments engaged in sexual
retrogression, the last of which have become truly
independent individuals." (Kuchenmeister, Op.
cit.,  p. 84-5.)  Thus we have seen how the seg-
ments with their ova and embryonic structures,
are developed; and, when they have become the
hindmost of the colony, cast themselves loose.
   [Five  different  conditions,  then, may be dis-
tinguished in the development and history of the
Taeniae:  1. The embryo, with six tenaculi; 2. The
 Cysticercus; 3. The  Scolex; 4.  The jointed Ta-
nia ; 5. The independently living and sexually de-
veloped joint or section, proglottis.  The develop-
ment of the  cestodae presents us therefore,  as de-
scribed by our author, a true instance of alterna-
tion  of generation.   Three different generations
succeed each other in these animals : the embryo,
with six tenaculi, as great-nurse; the scolex, as
nurse ; and  the isolated living proglottis, as the
generic animal.  The great-nurse is the product
of sexual development;  she has her origin  in the
germinated  ovum ; while the two other genera-
tions are the products of budding or sprouting ;
the nurse from the grand-nurse ; the  generic an-
 imal from the  nurse.  The intermediate condi-
tions of cysticercus and strobila must/be charac-
terized as  polymorphous colonies.  The strobila
might be compared to a colony of polypi, in which
each individual is growing out  of the postericr
body of the scolex, their native soil, thus forming 
1526
WORMS—Description of the Bothriocephalus latus.
  but one and a continuous line.   Such a treble al-
  ternation of generation is also found in other ani-
  mal organisms.   It is to be understood  that by
  the alternation of generation the generic animal
  produces only an unsexual race which is dissim-
  ilar to its parent, and  remains so ;  and this gen-
  eration produces, by budding, generations of new
  animals which,  either themselves or  their  off-
  spring, return to the original form of the stock.]
     50.  My limits admit  not of a full description
  of the  minute structure of the  fully-developed
  Tania.   It will  be found in the work just quoted.
  I may, however, briefly state that no digestive ap-
  paratus has been found  in these  animals.  Most
  writers assert that up to this time no  nerves have
  been detected  in them; but Huxley states that
  a  single ganglion is situated  in  the  axis of the
v head, and that it sends off nerves to the  suckers
  in some Tania.  The most important points are
  the dissemination of calcareous corpuscles in their
  structure, and the formation of circulating vessels.
  With the development of the  scolex it  was seen
  that a union of four principal lateral vessels takes
  place in the head, and that smaller branches are
  given off from these trunks.   These vessels prob-
  ably open outward near the receptaculum capitis
  or neck, or about the situation of segmental pro-
  duction ; but the ultimate structure, connexion,
  and termination  of  these vessels have not been
  precisely  determined.   The muscles consist  of
  transverse and longitudinal fibres, which may be
  recognised most readily in the neck.  The suck-
  ers, peculiarly  muscular parts,  present radiate
  fibres uniting in the middle of the  sucker, under
  which lies a layer of circular  fibres, and  the ros-
  tcllum.  It has  not been  ascertained whether or
  no muscular fibres  run to the  hooklets ofthe em-
  bryo.   The hooks of  the  Tania appear to ride
  upon the skin or integument, or in slight impres-
  sions.   The movements of the hooks seem to be
  produced  by changes  in parts of the head, par-
  ticularly of the rostellum.   The sexual organs,
  both male and female, exist in each  segment, in
  which numerous eggs  are produced.   A  very
  minute description of these  organs—the penis,
  testes, vagina, uterus, &c.—is given by Kuchen-
  meister.*

     * The developmental history of the Cestoidea may be
   understood, if considered as follows :
     "i. The  mature sexual animal, which is produced by
   asexual gemmation, separates from the colony as soon as
   it has attained its majority,  migrates actively from the
   intestinal canal of its host into free nature, and thence
   passively into the  stomach of another usually herbivorous
   animal.  It hears  within it,
     " ii. The grand-nurses or embryos produced by sexual,
   and perhaps by asexual, reproduction, furnished with four
   or six hooks, which are destined to enter passively into the
   stomach of an herbivore, and thence to  migrate through
   the body of the latter,  either actively, or by the interven-
   tion of the vessels, active—passive—actively.  (The asex-
   ual propagation of the brood in the Cestoidea is rendered
   improbable even by the fact that, in  the whole develop-
   mental series of these Cextoidca, a sexually mature ani-
   mal has never been met with.)
     '■ iii. The resting scolex  (nurse), produced by asexual
   gemmation in and by the large six-hooked embryo, still
   concealed within  this  embryonal vesicle, or lying beside
   it enclosed in peculiar cysts, or in closed serous cavities.
   In its non-gemmiparous part the embryonal vesicle ac-
   quires, according to the  species of cestoid worm, and ac-
   cording to the different hosts  (cold  or warm-blooded),
   sometimes the form of a  globular vesicle, sometimes that
   of a flat band-like strip,  and sometimes is only just suffi-
   cient to cover the scolex, lying quite close upon it, when
   it really forms nothing but a receptaculum capitis.  Thus
   we obtain three forms aUied to each other in their degree
   of development:  the cysticercal forms (Venues cystiei,
   including C'cemiri and Echinococci); the plnty, ercal (sim-
   ilar to Stein's cestoid worm of Tcncbrio moli'tor, and Von
  51. The  Cestoidea, or Cestode  worms, occur
in man  either in  the mature state, and then in
the intestines only (Bothriocephalus latus, Tania
mediocanellata,  Tama nana); or in the  larva or
scolex state (Cysticercus visceralis seu tenuicollis,
Echinococcus veterinorum, seu scolicipariens, and
E.  hominis  seu  altriapariens); or, lastly, in  all
known stages of development (Tania solium and
Cysticercus cellulosa).
  .52.  Genus 1. Bothriocephalus = Dibothri-
um.—This division is abundantly represented in
predaceous fishes, more sparingly  in piscivorous
birds, especially the marine Raptorcs, and rarely
in a few mammalia.   Of  the  terrestrial  mam-
malia  inhabiting  inland  places, man only har-
bours  Bothriocephali.   Kuchenmeister defines
this genus,* and  the species  here to be consid-
ered, as subjoined,-!  and  gives  the following  as
the synonymes of the species, Bothriocephalus  la-
tus or Dibothrium latum ; Tania lata, T. grisea,
T. vulgaris, T.  membranacea, T. dentata, T. in-
ermis;  Tcnie a anneaux courts, T.  large, T. a
epine; Lindwurm, Baandwurm, Bacndelorm: the
tape-worm, jointed worm, the short-jointed worm.
  53.  i.  General Description.—The colour  of
the living worm  is bluish white.  Specimens pre-
served in spirits change greatly in colour.  The
active scolex, or head, is  obtusely  conical.  The
two lateral pits  (analogues  of the sucking disks
of  Tania) are  nssuriform,  and appear, like the
sucking disks on the feet of flies, rather to effect
adhesion than to draw nourishment, which is prob-
ably introduced through the entire skin.  The neck

Piebold's from Arion empiricorum);  and the acercal (cer-
tain  embryos of Tetrarhynehi).  Kvery  one of these is a
normal form ; even the cysticercal forms are neither mor-
bidly degenerate, nor become dropsical, nor strayed.
  " iv. The resting scolex, transferred into the intestine
of an animal, becomes converted into the scolex passing
into activitn.  The latter is distinguished from the rest-
ing scolex by the extension of the entire body, by the al-
tered position of  the adherent  apparatus  (suckers and
hooks), by the attachment in the intestinal canal, and in
the cystercal and platycercal forms, by the casting off of
the barren portion  of the embryonal vesicle, and the form-
ation of  a cicatrix on this  spot.  In the acercal forms
nothing is cast off, nor is there a cicatrix formation.
  " v. The strobila—equal the tape-worm colony, budding
immediately from  the scolex, which has become active by
asexual propagation (gemmation), is more or less dis-
tinctly jointed, and becomes sexually mature posteriorly.
Its last segments, which are cast off, and lead an independ-
ent existence, are  called proglottides (i.), and bear with-
in them  the embryos produced by sexual reproduction
(ii.)."   (Kuchenmeister, Transl. by Vr. Lankestee, p.
93, 94.)
  * " Cestoidea, 2  osculis suctoriis, aut 2 foveis margi-
nalibus, oblongis aut longitudinalibus oppositis instruc-
ta.   Cnpite subtetragono, depresso, articulato plerumque,
inermi.  Pori gcnitales omnium articulorum in linea
mediana animalis et in ejus superficie abdominali siti.
Scolices extra tubum intestinalem in cystidibus pcculia-
ribus ad vcrmium platycercorum modum, aut in tubo in-
testinali animalium  minorum aquaticorum statu imma-
turo viventes; Strohilte in tubo intestinali animalium
aquaticorum, rapacium,  avium maritimarum et ma7nma-
lium viventes; Broglottides vcrcp. inlerdum absunt, inter-
dum adsunt, scepissime in longa articulorum sirie con-
juncta dehiscentes.   Embryones sex hamulis armati;
ovulorum testce sa'pissime coloratce.
  t " i. Bothriocephalus latus = DinoraRiCM latum.
—Caput oblongum, incrme, 2 bothriis-foveiswarginalibus,
formam rimce aut fissurce (fente) adoptanlibus; collum
subnullum; articuli numero circa 2000, maturi omnino
latiores (ad 2T millim.), quam longi, socialitef decedentes;
pori genitales in linea mediana siti, masculus major et
superior, ex quo penis lards et brevis promim t, femineus
minor, posterior inferiorque. Scolex quiescens ignotus;
scolex activus cum strobila in hominis  tubum intestina-
lem incolens, Umgitudinem 7-8 ulnarum, secundum  Du-
 jardinum ad 20 ' metres' (?) exhibet
   " Embryones 6 uncinulis (?) armati, in ovulis 0*023—
32 mill, longis et 0-002 mill latis, ellipticis, flavo-fuscis,
operculo dehiscentibus inclusi."—Kuchenmeister. 
WORMS—Bothriocephalus  latus—T^eni^e.
1527
is  more  distinct in  young than in old  speci-1
mens, the transverse wrinkling, i.  e. segmenta-
tion,  commencing immediately  behind the head.
The strobila, or jointed  body, presents  a ventral
surface, on  which  the  sexual  apparatus opens,
the opposite being the dorsal surface.   Each seg-
ment has four margins—two free lateral margins,
slightly undulated,  and an anterior and posterior
margin, articulated with  the   upper and  lower
segments in the colony.   The form varies  ac-
cording to the preponderating contraction  of  the
longitudinal or transverse fibres, the breadth, how-
ever, being  much  greater than  the length—as
three to  one.   In the central line the  segments
are thicker  (up to V") and darker; the  lateral
margins flatter and whiter.   The vascular system
consists of lateral longitudinal  cords, which con-
tain  a limpid fluid.  A respiratory system and
organs of sense are wanting.   The sexual organs
generally are single  in  each segment, but they
are sometimes double.
   54. A. The Ova and Embryos.—The former ex-
hibit an  external hard  brittle shell, which often
breaks so as to represent operculated ova, like
those of the Trematoda.   From the  opercular
opening  a limpid vesicle emerges, in which, how-
ever, Kuchenmeister did not find the six hooklets
which Von  Siebold considers  similar to those in
the circlets  of the Tania.  Possibly a part  of
the eggs of the  Bothrioccphali  are  not produced
with undeveloped embryos, so  that the  latter are
perfectly formed only when free in nature, as the
eggs of the  Ascarides.   The resting scolex exists
in the fishes, especially marine fishes.   In these
certain cestode worms  live, having a band-like,
 inarticulate  appendage, but exhibiting  no com-
 mencement of sexual  development.   These  be-
 come converted into mature Bothriocephah in the
 intestines of higher fishes, or of the marine birds
 of prey.   Whether the cestode worms  are de-
 veloped in the intestines of fishes in which they
 are found, or are conveyed there in one or other
 of the animals on which these fishes feed, in
 which they  had been converted into scolices, aft-
 er the animal had swallowed the eggs of the  ma-
 ture  Bothriocephah, is still undecided.   Probably
 the ova and scolices are developed as already de-
 scribed (§  37-47).  As the host  of the Cysti-
 cercus is devoured by an animal, in the intestine
 of which the scolex, being set free, immediately
 develops itself.
   55.  B. We  have no data as to the production
 of the Bothriocephalus latus in  man.   This worm
 has  been found in the cat, but is extremely  rare
 in all terrestrial  animals.   The cat has evidently
 obtained it from the intestines  of fishes, which in
 sea-ports and on the sea-coasts are left in large
 quantities, and are used as manures.   It is dif-
 ficult, notwithstanding, to account  for the pres-
 ence of  this animal in  man.   The  ova from the
 proglottides of  this worm may, however, be in-
 troduced into the human intestines by means of
 vegetables,  where the intestines of fish have been
 used as  manures, or where they have been con-
 veyed in sewerage water.   The passive migration
 of the embryo into the intestine of another  ani-
 mal, and its conversion in this intestine into an
 asexual band-like scolex,  is much more probable
 than the development of all the  grades in the same
 intestine, on account ofthe dissimilarity existing
 between the embryo and  its parent.
   56.  C. The  physiological relations of Bothrio-
 cephalus are chiefly its weaker vital  manifesta-
tions, and the smaller number  and less perfect
development of  its sucking organs, than  those
of the Tania, which explain its easier expulsion
from  the  intestines.   The  power  of imbibing
fluids by the bodies of the Bothriocephah, and all
Cestoidea, has been proved by Eschricht and oth-
ers.   Transudation takes place in small, pellucid,
oleaginous drops (sarcode).   While the Nema-
toda and Echinorhynchi  swell up by imbibition,
the Cestoidea, owing to an abundant  exudation,
experience only a slight swelling from imbibition.
Whole series of segments of the Bothriocephah
pass  off spontaneously,  but never single seg-
ments, as in the Tania.   The duration  of the
life of the former is not known.   More than one
or two worms of this genus  are rarely found in
the same  intestine, and their length seldom ex-
ceeds twenty feet.
   57. Genus 2.  Taenia.*—i.  Taenia solium, and
its Scolex-nurse= Cysticercus cellulosa.
   Synonymes.—Tatviai, Aristotle; n'kaTcia IZ-
pivc, Hippocrates;  Lumbricus latus, Pliny ;  Ta-
nia solium,  Linnaeus et Auct.  permulti;  T. cu-
curbitina, Pallas, Goeze, &c.; T. vulgaris, Wer-
  * " Second  Order  (Kuchenmeister), T.eni.e.—Caput
subglobosum aut tetragonum; acetabulis osculis suctoriis
4, rarissime 6, muscularibus, orbicularibus, symmetrice
ojrpositis, valde contractilibus; rostello imperforato, re-
triictili, in scolicibus quiescentibus inverso, in activis s.
Tceniis maturis propulso, hamulorum simplici, duplici,
aut multiplied corona armato; corpore plerumque albo,
piano, depresso, bilaterale aut triquetro, articulato (Stro-
bila) ; articulis maturis androgynis, aut non scxualibus
(?), sponte et alio post  alium dehiscentibus, Trematode
cuidam similibus (Proglottides); systemate vasculoso per-
claro; poris genitalibus lateralibus, plerumque alternan-
tibus, masculo majore et anteriore, femineo minore et
 postcriore; genitalibus perfectis.  Scolices quiescentes et
immaturi formam cysti-, platy-, aut acercam ineuntes.
Scolices activi cum strobila longitudine et latitudine valde
variantes.  Embryones 6 hamunculis armati, parvuli,
pervivaees; ovulei in illis qui formam cysticercam ineunt,
minima, pileata, fiavescentia, in  ceteris nwjorv, losviora
et clariora."
  I. T^ENI^E WniCH OCCUR IN MAN IN THE MATURE STATE.
— i. "Ta?nia solium, and its scolex nurse = Cysticen us
cellulosa.—Taenia matura = Scolexactivus cum strobila:
 longit. 4 — 5 metres = 6 — 8 ulnarum, latit. ad 13 millim.
 Caput =scolex  sensu strictiore,  breve, antrorsum pla-
num, 0-56 — 0-75 —1-0 mill.  Int., acetabulis validis, pro-
minentibus 0-192 — 231"' = 0-434 — 0-521 mill, long., et
0-182— 224'"= 0-410 — 0-505 mill, lat.; rostello parvulo
 04 mill, ad latera  nigrescente; hamulorumi2, 24, 28, 30,
 plerumque 26, duplice ordine, longit. 0-167 quoad ma-
 jores, 0-11 mill, quoad minores hamulos (secund. Leuck-
 art), 0-18 et 0-12 secund. meas mensuras, ungve  et stylo
 hamulorum ex longit. fere similibus, formd hamulorum
 omnino vastd; loculis hamulorum perclaris, nigrescenti-
 bus; collo perparvo, fere nullo; corpore antrorsum max-
 ime attenuato, deorsum ad 10—14 mill, lato, articulato,
 poris genitalibus  alternantibus, interdum irregulariter;
 utero ramis 6 —10 —13, irregulariter alternantibus, dc-
 nuo ramificatis instructo; corporibus calcareis in capite'
 rarioribus (0-004'" = 0-009 mill. long, et lat), in corpore
 crebrioribus ct majoribus (0-005'"= 0-012 mill.).  Pro-
 glottides ad 16 mill. Umgm et ad 6 lata?, ad inferiorem
 partem crassiores, margine magis toroso et angulis ma-
gis prominentibus, quam ad superior cm partem, ut in
 aliis  Tosniis, ovulis 0-016'"= 0-036 mill, long.,  0-016'"
 — l.t'"=0-030 mill. lat.; testdovulorum rrassiore (0-0063
 mill.).   Embryonibus 6 hamulis ornatis, 0-028 — 0-032
 mill. long, et lat.,  migratione indigentibus.
   " Habitat—Solitarie aut  soddliter (eid 40 usque)  in
 tubo  intestinali hominis, inque terris diversissimis; vix
 in Cane domestico.
   " Scolex quiescens = Cysticercus ccllulosev, vesicd cau-
 dali haud  magna (ubi plurimum 15 mill, in diametro)
 transverse ellipticd; corpore inverso, transverse  rugato,
 8—10 mill, longo.  In  tubum intestinalem translatus
 intra 3 menses maturcscit  Habitat in tela cellulose! to-
 t.ius  corpoiis  et nonnullis corporis cavitatibus clausis
 (oralis, cerebro, &c.) imprimis in homine, Sue scrofd do-
 nitxtici't, rarius ferd, Simiu, Cervo, Capreedo, Cane do-
 mestico (Arachnoid, et musvl.) valde dubiosus in peri-
 tonea Cam's domestici et Maris Ratti.  Per injuriam  a
 nonnuUis  < cenurus cerebralis hominis nominatus"—
 KtCHENMElSTER. 
OF TAENIA solium.
lo'ZS                      WORMS—Scolex

ner;  T. dcntata,  Gmclin, Nicolai;  T.  osculis
marginahbus sohtariis, Bradley,  T.  armata hu-
mana,  Brera;  T. lata, Reinlein ; T. fencstrata,
Delle Chiajc ; T. stigmatibus lateralibus, Bonnet;
T. sccunda. Plater;  T. solitaria, Leske; T. ar-
ticulos demittens, Dionis ; Halysis solium,  Zeder ;
Pentastoma coarctata, Virey; Vermis cucurbitmus,
Plater: Kurbiswurm. Kiirbisformiger; bewaffna-
ter Bandewurm ;  Kettenwurm, Germ.  Tenie a
longs  anneaux; T.  sans  epines; T. de la se-
conde espece ; le solitaire ; ver solitaire ;  T. ban-
delettc, &c.   The following names are also giv-
en it, in common with  Bothriocephalus  latus and
Tania mediocanellata: le ver  plat,  Bandelorm,
tape-worm, jointed worm.
  58.  Tania solium  presents five steps of devel-
opment. 1st. The sexual animal—Proglottis; 2d.
The  grand-nurse—six-hooked  embryo; 3d. The
resting Scolex—Cysticercus cellulosa, in  the pa-
renchyma, areolar tissue, and cavities ofthe body ;
4th.  The active  Scoltx-nurse, that is the Cysti-
cercus cellulosa,, which will become a Tania so-
lium in the intestines ;  and, 5th, the Strobila, the
series of segments of Tania solium produced  by
gemmation from the  fourth step.
  59. A. The mature Taenia.—The name Ta-
nia solium  is incorrectly applied to  this worm,
inasmuch as frequently two  or three  occur in
the same person.   Dr.  Pfaff has seen  seven ex-
pelled, Kuchenmeister ten, Heller thirty, and
Kleefeld counted forty expelled from one pa-
tient.
  60. (a)  The Strobila.—The head, although va-
rying somewhat in size, is  seldom larger  than
the head of a common pin.   It is of a blackish-
brown colour, especially around the base of the
short rostellum, and in the sacs around the base
ofthe hooks, and in and around the sucking disks.
The hook-sacs, as well as the hooks, are placed in
a double circular series.  The one series does not
materially differ  from the other.  As in  all the
Tania, the  points and spines  of all the hooks
fall in the  same  circle, or in two circles  lying
close together, the number and position of the
hooks  corresponding with the sacs, and varying
from 22 to 28.  The  sucking disks are nearly cir-
cular, or somewhat oval, and surrounded by  a cir-
cular collateral branch ofthe longitudinal canals,
by which a sort of vascular net is formed.   Close
behind the sucking disks, and near the  head, the
vessels collect in four main branches, which are
united quite at the front of the head by  a  com-
mon transverse branch, thicker than they.  In the
vessels of various Cestoidea, Virchow,Wagener,
and others, have seen a sort of ciliary epithelium
projecting into them, and moving in the  fluid.
The calcareous corpuscles reach about to the mid-
dle ofthe sucking disks.  They are few and  small
on the head.  The slender neck, of about 6'" in
length, exhibits no traces of transverse striae or
segmentation.   The calcareous  corpuscles are
somewhat more  abundant, and also larger  than
in the head.  Behind  the neck commences the
true jointed body of the Tania, in which Kuch-
rnmeister  counted 825 segments in one speci-
men ten feet two inches in length.  The  propor-
tionate  size  of the segments gradually  increases
posteriorly, or as  they depart from the  head—in
length from 1-12'" to T".   In this species,  as in
all Cestoidea, contact  with water causes  the emis-
sion of Dujardin's sarcode, in oleaginous drops.
The  sexual organs appear from about the 280th
to the  300th segment, and  onward, from the
head, in the median line of the Cestoidea, at first
as a simple brownish-yellow canal, with  short
lateral  oflshoots, towards  which two transverse
slightly coloured lines (seminal cord and vagina)
run from the sides.  The alternating pori  gem-
tales first appear  about the 317th segment, and
become distinct in the 350th.  The sexual or-
gans  are  more and more  developed from  the
350th  to the  600th segment, where ova  com-
mence, which  become mature from the  650th to
the 700th  segments.  Both male and female or-
gans generally exist in the  same segment, and
are minutely described by Kuchenmeister.  Each
joint, when divided, presents, 1st. Epidermis of a
chitinous  structure, without calcareous  corpus-
cles ;  2d.   Longitudinal fibres,  with calcareous
corpuscles  , 3d. Transverse fibres, with few cal-
careous corpuscles ; 4th.  Sexual organs.
   61. B. Scolex of Taenia solium.— Cysticercus
cellulosa.—The former is identical with the latter,
as proved by the identity of the head in both ; by
the general and particular circumstances under
which  T.  solium  occurs,  and by converting, by
experiments in feeding, Cysticercus cellulosa into
Tania solium, and the eggs of the latter into Cys-
ticercus cellulosa.
   62.  (a)   The ordinary habitation of the Cysti-
cercus  cellulosa is the flesh ofthe pig ; and Tania
solium is almost entirely unknown where the use
of this flesh is avoided, as among the Jews and
Mohammedans, who strictly adhere to their relig-
ious precepts.  On the other hand, Tania solium
is abundant wherever the breeding of pigs occurs,
as in  Poland, Hungary,  Pomerania, Thuringia,
England, &c, " and especially among those en-
gaged  in  trades  which bring  them in  contact
with raw pork, and therefore with raw Cysticerci,
as butchers, cooks, sausage-makers."  Kuchen-
meister found Cysticerci in the water used  in
washing sausages.  The direct proof of the iden-
tity  of this cystic worm  and  Tama solium  is
shown by  the following experiment upon a mur-
derer condemned to death.   Exactly 72, 60, 3G, 24,
and 12 hours before his execution, 12, 18, 15, 12,
and  18 specimens of Cysticercus cellulosa were
administered to him partly in rice or vermicelli
*oup of a  blood  heat, and partly in blood-pud-
dings.   The Cysticerci had already lain seventy-
two hours  in a cellar before Kuchenmeister dis-
covered them.  The last administered had conse-
quently Iain about 130 hours out ofthe living or-
ganism, and he hardly believes that  those Cysti-
cerci, which had  lain  more  than  eighty hours,
were still capable of development, any more than
he can believe this to be the case with the Cysti-
cerci contained in smoked sausages and hams.
On dissection forty-eight  hours after execution,
he found ten young Tania, of which six were de-
prived  of their hooks, but  four distinctly showed
the hooks of T. solium.   The little  Tania were
4 to 8  millim.  in length, and  had attached them-
selves  by their hooks and  proboscis to the intes-
tine, and possessed a small band-like appendage,
2 to 5 millim. long.  The preceding experiment is
proof of the conversion ofthe cystic worms into
Tania  in  the human  intestine, and also of the
mode of infection.   Kuchenmeister  is convinced
that the scolex of a Tania retains  its power  of
development in its dead host only as long as no
putridity occurs.
  63.  (b)  The farther proof of the identity of T.
solium and Cysticercus cellulosa is derived from
the structure  of the head of tho latter.  " This 
WORMS—Description  of Taenia  mediocanellata.                 1529
cystic worm, like all others, forms a vesicle  the
size  of a pea or very small  bean, with a little
white head in its  interior, from which the true
scolex may be evolved by pressure.   This scolex
bears a head with four, and sometimes six, suck-
ing disks  (the  latter especially in  the human
brain), round which  the vascular  system  runs,
and collects into two longitudinal canals on each
side.   The short rostellum  bears  from twenty-
two  to  twenty-eight hooks, placed in  a double
crown.   Besides these, the head exhibits a spar-
ing brownish-yellow, or blackish-brown pigment,"
and five sacs round the stems ofthe hooks.   The
neck is  very short, poor in calcareous corpuscles,
opaque, and colourless ;. the body is  wrinkled,
abounds with calcareous corpuscles, and the head
is inverted into it as long as  the caudal vesicle is
alive and uninjured.   After the death ofthe worm
the head becomes everted.  (See also $ 46, et seq.)
  64. (c)  Proofs of the Conversion of the six-hooked
Embryos enclosed in the Eggs of Tania solium into
Cysticercus cellulosa.—Kuchenmeister, in 1851,
expressed the opinion that the pig  infects  itself
with Cysticercus cellulosa when it meets with the
eggs and  proglottides of Tania solium upon the
pastures;  and in  1853  Van  Beneden  adminis-
tered T. solium to two pigs, and thereby rendered
one  pig measly.   The following year Kuchen-
meister fed three sucking-pigs, on the 7th, 24th,
and 26th  of June and 2d of July, with segments
of tape-worms, partly given off spontaneously and
partly artificially expelled.  On the 13th of July
they were again fed with artificially expelled seg-
ments.  " One of the pigs  was killed on the 26th
of July, and exhibited  young  Cysticerci corre-
sponding  with  the  days  of administration, of
which the largest individuals formed vesicles of
the size of a hemp-seed, with a central turbidity,
i. e., the commencement ofthe head.  The second
pig was killed on the 9th of August, when thou-
sands of Cysticerci were found in all parts of the
body; the largest  individuals were as large* as
peas, and  exhibited  a distinct head, while  the
smallest were only  of the size of a hemp-seed.
The third  pig, which was killed on the 23d of
August, was uniformly  set, throughout all parts
ofthe body, with Cysticerci of various degrees of
growth and development.   The  largest were al-
most perfectly developed ;  others resembled those
last described.  He undertook the examination of
a weighed piece ofthe flesh, and found 133 Cysti-
cerci cellulosa in 4L drachms of it.   If we  calcu-
late  from this quantity the number of Cysticerci
which would have existed in  1 stone, or one fifth
cwt. of the pork, we obtain the great number of
88,000 individuals in this weight.   A  fourth pig
of the same litter, to whom  no Tania  had been
administered, exhibited no traces of Cysticerci on
dissection."  (Kuchenmeister, Op. cit, 121, 21.)
   65. Leuckart repeated and confirmed the above
experiment, and recognised, in the mode in which
 Cysticercus cellulosa is developed from the  em-
bryo of T. solium, exactly the same type as  that
above described as the type of the formation of
the so-called Cysticerci in  general.   It may, how-
ever, be noted that this worm acquires the vesic-
ular form, and becomes covered with a vascular
net,  rather early, and at a time when no trace of
the head can be observed.  The first appearance
of the head  commences in  Cyst,  cellulosa soon
after the seventh week, at which time the embryo
is about 2 5 millim. in diameter.
  66.  (d)  The Scolex of Tania solium,  Cysticer-
cus cellulosa, has hitherto been found in the most
various muscles; in the muscles of the heart, in
the cellular tissue, in the brain, and in the eye of
man.   In these  it acquires various forms  and
sizes, according to the space afforded for its de-
velopment.   In  the ventricles of the brain  and
eye, its caudal vesicle attains even the  size of a
walnut, and  remarkable forms.    The  size  and
form  of the  Cysticercus are determined chiefly
by excess of nourishment, and by softness, loose-
ness, and other properties ofthe tissues in which
it occurs.   The form is not material, the nature
of the worm  is the same.
  67. (c)  The symptoms it produces differ with
its seat or position.   It is almost harmless in the
sub-cutaneous cellular tissue.  In muscles it often
occasions but little inconvenience.  In  the mus-
cles of the heart, however, it may cause softening
and other organic lesions.   But its situation in
the deeper muscles, even in the muscles of the
heart, admits not of diagnosis.   The situation of
this Cysticercus in the eye is very important.—a.
It  has been found between the conjunctiva and the
sclerotica, where it is  of least serious occurrence,
as it may easily be removed by operation, as in
cases recorded  by  Horing,  Estlin, Baum,  and
others.—b. In the anterior chamber.  It was  first
seen in the  living  subject  by Soemmering  and
Sch'ott, and in the  posterior chamber  by Von
Graefe.—c. In the vitreous humour by  the last-
named writer and others.—d. In the retina  and
under  the retina in very rare cases.   In these
latter situations this  cystic worm  has  been de-
tected during life chiefly by means of the ocular
speculum of Helmholtz.  In most of these cases,
partial or complete loss of sight by the affected
eye,-squinting, movements of the worm, inflam-
mation  of the structures, followed by partial  dis-
organization, and a greenish tint of the vitreous
humour, were  the  symptoms chiefly observed.
In rare instances only were tape-worms present,
or Cysticercus present in other parts of the body.
—e. Cysticercus cellulosa in the human bruin sel-
dom  occurs, and as  seldom  can be recognised
during life, unless conjoined with cerebral symp-
toms, vertigo, &c.—•/.  Cysticerci are observed in
other parts of the body, or Tania solium has ex-
isted at an earlier period of the life ofthe patient.
   68.  ii.  T^nia mediocanellata*  (Kuchen-
meister).—Description, (a) The epidermis of
the animal  is  distinct, soft, consisting of deli-
cate decussating lines, without calcareous  cor-

  * " Taenia matura.—Species longissvma (ad 12 —14 ul-
nas longa), latissima, crassissima.   Capite inerrai, per-
magno, ad 2 millim. lat, valde nigrescente; acetabulis 4
pcrmagnis (ad 0-367'" = 0-829 millim. long, et 0-259'"=
0-711 millim. usque lat).
  " Systemate vasculoso : in capite simpliciore, quam in
T. solium; Corpore calcar. : ad 0-012 millim.  in capite,
ad 0-018 millim. in articulis magnis, magisque numero-
sis quam in T. solium.   Rostellum nullum.  Collum
perbreve, sed distinctius, quam in T. solium.  Articuli
posteriores latissimi, ad 17 millim. lat. etadO —14 mil-
lim. long, crassi; poris genitalibus irregulariter alternan-
tibus.   Proglottides permagnce et pervicaces, saipissimc
sponte et sine fa>cibus humanis ex ano demissce, agro-
tumque valde perturbantes; in maxima sua extensions
25 — 30 millim. long, et ad 7 millim.  lat.
  " Uterus permultos ramos (ex utroquc latere usque ad
30) in margine libero clavaeformes, non amplius dentri-
tice, ad summum bifurcatim divisos, inter se parallelos.
Ovula maais ovalia, lewiora, et clariora, quam in T. so-
lium, ad 0-036 millim. longa et 0028 — 33 lata. Testa
rrassa uti in T. solium.   Embryones 0-028 — 32 millim,
longi, 0 023 — 2Qlati.
  " Scolex quiescens ignotus.  Fortasse in sue aut bove,
fortasse in animal, inferior. ordinum."—Kuoiienmeis-
teb. 
1530
WORMS—Description of Taenia nana.
puscles.  Underneath are longitudinal fibres, run-
ning through the w hole body of the animal;  these,
as well as  the next layer of transverse  fibres,
contain the calcareous  corpuscles  embedded in
them.   The size ofthe sucking disks, which are
quite black, gives the head of this Tania a consid-
erable bulk.  Transverse vessels run through the
space between the sucking disks, and from these
a branch runs to and around the disks, until the
four longitudinal vessels are developed from them
in the neck; these vessels becoming thicker as the
segments increase in size.  The segments, which
have a great tendency to increase in breadth, arc
at first 1 millim.  in length, and about  three in
breadth.  Afterward, also, the breadth  predom-
inates  over the length  for a considerable  space.
But this proportion does not  continue  down-
ward, and segments of 1—H in- of length and
only 3—4 lines in breadth are met with.   That
the last segments or proglottides have a tendency
to pass away without fjeces is beyond a doubt;
but this also takes place with T. solium, although
more rarely.  The  segments usually pass when
the patient is standing, and passing along the
thighs, occasion a moist and cool sensation, and
are found creeping  over the surface.
  69.  (b) This Tania, when artificially expelled,
breaks off close to  the  neck.   After the lapse of
about ten weeks from this expulsion, a fresh'pas-
sage of proglottides takes place.   From the spon-
taneous passage of these without faeces it may be
inferred that the reproduction and  growth of the
segments are extremely rapid, and that the  animal
must be more injurious to its host than T. solium.
Kuchenmeister mentions a case  in  which the
number of proglottides, which passed almost dai-
ly,  amounted, in the aggregate, to upward of 100
feet in 80 days; and that in the course  of this
time li foot of tape-worm was passed and re-
generated each day.   The internal irritation of
the rectum  and  anus, produced by  these seg-
ments when  forcing their passage, and the un-
pleasant clamminess they occasion, especially by
the deposition of their eggs, which often also oc-
curs at this  time,  and which  appear like to  a
white  moist  sand, are  very  distressing  to  the
patient.  In the case just referred to, from 5—15
proglottides passed daily from  the patient with
the faeces; and as these immediately laid their
eggs, the faeces looked as if sprinkled with white
sand.
   70.  (c)  The  Scolex is unknown.  In Dresden
it cannot be rare, as this Tania is not uncommon
there.  It is not improbable that the cystic worm
belonging to this species may occasionally occur
among the specimens pronounced to be Cysticer-
cus cellulosa.  This point might have  been de-
termined by  feeding  pigs with the eggs of the
 Tania. An intelligent patient, from whom Kuch-
 enmeister expelled this Tania by means of his
preparation of the extract of pomegranate root,
 states that he had  observed his taenia soon after
 dining frequently, at  an eating-house, on raw
 beef-steaks and green salad and radishes.  The
 scolex was either seated in  the beef, or in mol-
 lusca in the salad or on the radishes.   " The em-
 bryos resemble in size and structure those of T.
 solium.  Their migrations are unknown."  Its
 habitat appears to be in Europe and Africa.
    71. Variety* from the Cape of Good Hope.—
  * " Xihilnotum, nisi Strobila;parsposterior.  Articuli
per totum corpus, cristd longitud.irw.li prcediti, crassi, et
 longi.   Pori genitales marginales alternantes. Uterus et
A number of segments of this Tania were  ex-
pelled by pomegranate bark, and, like T. medio-
canellata, were very difficult of expulsion.   They
were destitute of head and neck.  Its total length
must be at least 6—10 yards.   Its segments  are
very thick, white,  and fat; in the mature state
more than  one  inch in  length, and 3—5'" in
breadth, and extremely massive.  They are dis-
tinguished by  having a longitudinal  ridge along
the whole of the mature and immature segments.
This Tania  is rich  in cholesterine.   Mr. Rose,'
who sent the segments to  Kuchenmeister, states
that the migrations of the six-hooked embryos
and the scolices are unknown, that it is impossi-
ble that the latter should live in the flesh  of pigs,
as the worm was obtained from a Hottentot, and
the Hottentots, like the Jews and Mohammedans,
eat no  pork.   A thick Tania occurs  in Abyssin-
ia, among Mohammedan inhabitants.  The Hot-
tentots  probably brought this tape-worm with
them from the Caffre wars, in which they enjoyed
themselves among the cattle ofthe Caffres.  The
scolex probably lives in their cattle  and  sheep.
May not the scolex have been a Cysticercus te-
nuicollis ?*
   72.  iii. Taenia  nana t (Bilharz ; Von Sie-
bold).—This small filiform Tania has broad and
perfectly developed segments, and  a large quad-
rangular head, at the angles of which the round
sucking disks are  placed upon globular cleva-

ovula simillima illis Taeniae mediocanellatse. VerisimiU
limum est, strobilam mihi  notam proliferatam esse a
Taeniae mediocanellatse scolice quodam G osculis ornato."
—K uchenmeistee.
  * [In a recent  work by Mr. Parkyns, entitled  " Life in
Abyssinia" (New York, 1S15, 2 vols.), we find  it stated
that the whole population in Abyssinia are affected with
tape-worm ; that out of above forty persons, male and fe-
male, employed by the writer as servants only two were
exempt from it.  It is in that country ascribed generally
to eating raw meat, which is a universal custom.  Mr. P.
states that the Abyssinians are in the habit of taking phys-
ic regularly once every two months to relieve themselves
of the malady;  that they also use the kaupo,  both the
flowers and seed, besides the bark of another tree whose
botanic name is not given; although the kaupo is always
preferred, when it can be had.  The dried flowers are
ground or powdered as fine as possible, and a strong infu-
sion made, of which the patient drinks half a pint, fast-
ing : about six houre after, a good quantity of beer is
drunk.  Mr. Parkyns supposes, a3 many  white persona
who visit the country are infected with taeniae who do not
eat raw meat, that the cause is to be sought for in the
climate or in the use of bread made of a species of millet.
Vol. ii., p. 224, 5.  Kuchenmeister, however, has proved
by his experiments that individuals fed on pork tainted
with measles, and containing the cysticercus, become sub-
ject to tape-worm.  Various German writers have sup-
posed that these entozoa are destroyed by boiling, salting,
and smoking the pork.  Dr. Hiecke, of Nordhausen, has
published a paper in which he recommends the prohibi-
tion of the sale of pork unless it has undergone these proc-
esses ; and, in support of these views, he states that taenia
is an exceedingly frequent complaint in the neighbour-
hood of Nordhausen, where there is a large consumption
of raw pork by the people;  and, on the other hand, that
at Altmark, where this practice is  not prevalent, he has
only seen six cases of this disease among about ten thou-
sand patients who have been under his care during a pe-
riod of fourteen years.—hxt. Med. Jour.,  Dec, 1S56, p.
560.  Also, for June, l->r>5.   The  same subject, the pro-
duction of taeniae by eating raw pork, is also ably treated
by Professor Allen Thompson, in Glasgow Journal, July,
18,1855. Professor Bennett entertains doubts whether
the salting of pork is capable of destroying the vitality of
the cysticercus.—Ed. Med. Jour., Feb. 18,1855.  See, also,
Henke's Zeitschrift, 3, 1855.]
  t " Corpus filiforme, depressum;  Caput antics obtusum,
collum versus sensim attenuatum, acetabulis subglobosis,
rostello pyriformi uncinulorum bifidorum corona arnia-
tum.  Articuli  transversi; cirri unilaterales, ovula glo-
bosa; testa laevi simplici (?) instructa 1-100"' magna.
 Longitudo totalis 0—10"'.  Patria JEgyptus, in howiinit
intestino tenui semel reperta numeropermagno."—KOcn-
enmeisteb. 
WORMS—Description  of  Echinococci.                      1531
tions.  The head is flat in front, and gradually
diminishes in breadth, and  passes into  a long
slender neck, which  is  followed  by segments
which  become broader, until at last the hinder
segments are three or four  times  the width of
the head.  These  Tania occupy  only a  limited
space of the  ilium.   The ova are globular.   The
six hooklets of the  embryo Tania are distinctly
Been in the fresh ova.   From the number of the
Tania found, and their very small size, Kuchen-
meister has believed  this worm to be a  Tania
echinococcus.
   73.  iv. Symptoms and Diagnosis of the ma-
ture Cestoidea occurring in the Human In-
testine, OF BOTH BOTHRIOCEPHALI AND TiENI^E.
—Kuchenmeister  remarks that the stronger the
patient is, the less  the irritability of his system,
the more regular his appetite and food, the fuller
and richer his nourishment, the fresher his colour,
the less he is inclined to diarrhoea, to anaemia,
and chlorotic symptoms, the less  does  he com-
plain of tape-worm.   According to most writers,
chlorotic or anaemic symptoms are increased by
the great appetite of the tape-worm for proteinic
substances, calcareous salts, and fat; and accord-
ing to the degree of the symptoms are also the
complaints  of the patient.   Seeger gives the
following statement of the  frequency of partic-
ular symptoms in  100 cases of tape-worm: In
68 instances nervous affections and  general or
partial convulsions occurred—epilepsy, hysteria,
abdominal spasms, convulsive cough, dyspnoea,
melancholy,  and hypochondriasis.  In 49 cases
nausea,  with faintness and vomitings, was pres-
ent ; in 42, various pains in the abdomen; in
33, disordered digestion and irregular states of
the  evacuations;  in 31, irregular appetite and
voracity; in  19, habitual or periodical hemicra-
nia;  in  17,  sudden colic ;  in 16,  sensations of
undulatory movements in the abdomen up to the
 chest; in 15, vertigo,  delusions of the  senses
 and defects of speech;  and in 11, shifting pains
in various parts.  These symptoms are deceptive ;
 many of them will be  often experienced after the
 worm has been completely expelled;  and even
viewed  in connexion with the patient's  habits,
 occupations, and residence in a locality in which
the  Cestoidea are known to be prevalent, are not
 of themselves diagnostic of the existence of tape-
 worm.  It is only  by  the discharge of segments
 of the worm that the nature of the disease can
be satisfactorily recognised.   The passage of the
 segments per anum, either with  the faeces, espe-
 cially  when  there  is  diarrhoea,  or without this
 accompaniment, is  the most frequent.  The dis-
charge of them by the mouth is extremely rare,
and can occur only when there is  violent vomit-
ing, and when there is dangerous obstruction of
the bowels.   The passage of them through the
intestines into the  peritoneal cavity, or into the
urinary  bladder, or through fistulae opening on
the  surface  of  the body, can occur only when
ulceration of the  intestines  has been  followed
by perforation and a fistulous communication Jn
either of these  directions, or after wounds pen-
etrating into the  bowels.   These several ways
by which segments of tape-worm were passed
externally were known to the older writers, and
were ascribed by them to the mechanical or per-
forating action of the  worm.   But it is singular
that, whenever ulceration and perforation of the
bowels occur coincidently with the presence of
worms, an instinctive desire of the latter to es-
cape from the bowel, through either the morbid
opening or the natural passages, is observed.
  74. v.  Immature T^eni^e found in the Hu-
man Body externally to, but not within, the
Intestines.—These form the Cystici and Aceph-
alocystides of older writers.  The Cysticercus
cellulose, being identical with Tania solium,
has been noticed when treating of that tape-worm
(v 62, et seq.).  I shall only briefly notice the other
immature Taeniae occasionally found in the human
body externally to the intestines.
  75. A. Cysticercus tenuicollis (Eschricht),
Cysticercus visceralis (Auct.).—As the mature
Tania of this  cystic worm is  not found  in man,
but chiefly in  the dog and wolf (Tania margi-
nata), I shall  not occupy any part of my limited
space by describing  it, but refer the reader to
Dr.  Lankester's translation  of Kuchenmeis-
ter's work (p. 178).
  76. (a) The Scolex  or immature state* of this
Tania, however, being sometimes formed in man,
especially  in  former  times, requires  a brief no-
tice at this place: it forms the Cysticercus tenu-
icollis of recent  writers, and  the C. visceralis
hominis  of earlier authors.  The rarity of this
scolex in human  subjects in  modern times has
induced  Virchow and Diesing to doubt its oc-
currence, while Eschricht has proved its rare
appearance in man, especially in the liver.
  77. (b) The structure  of this cystic worm is
rendered remarkable by its frequently enormous
caudal vesicle, which  in animals may attain the
size of a child's head, by the concentric wrinkles
or rings, visible externally, which pass round the
worm, and which  are  crossed by very fine  longi-
tudinal striae,  so that when it is laid upon a plate,
and held on the same plane with the eye, the an-
imal has a finely checkered appearance.   In the
dead Cysticercus tenuicollis,  incrusted with cal-
careous  matter, these concentric rings  may be
recognised, and the calcareous deposit often forms
a plastic-like  cast of the form and structure of
the cystic  worm.   The parietes, also,  when  a
transverse section of the dead  Cysticercus is
made, present a structure consisting of concen-
tric strata, analogous  to that of the Echinococci.
Here, however,  it is so  extremely fine and deli-
cate, that there is  great trouble in detecting it.
  78. B. Echinococci.—Some naturalists admit
only of one species or variety of Echinococcus,
others of two, and others of even a greater num-
ber.  Von Siebold divides this  species into E.
hominis  and E. veterinorum; but, from the ac-
counts  of various writers, both varieties  have
been found in the human subject.
  79. 1st Var. Echinococcus scoliciparienst—
Echinococcus veterinorum, of authors.

  *  " Scolex quiescens=Cysticercus tenuicollis.  Vesica
caudali tenui permagna (1, 2, 4, 6" et ultra); Corpore
14 — 30 millim.  et ultra longo, 5 —10 millim. lato, cylin-
drico; Collo 8 —15 millim. longo; Capite uti in Taenia
filis 2 gelatinosis. pone collo ex receptaculo capitis aut
scolicis in vesiece cavitatem emissis.   Metamorphosis in
Tosniam 10 —12 hebdomadis post pastum peracta.
  Habitat.  Rarius in hominis abdomine (mesenterio et
hepate), so?pius in Ruminantium, Equi,  Suis Scrofos
Seiuri, Simice, &c., cavitate abdominali."—Kuchen-
meister.
  t  Taenia matura.—Taenia minima, ad 3 millim. longo,
corpore 3-aut ^-articulato.   Capite subgloboso, 0-3 millim.
lato; rostelloparvulo, rotundato, 0-125 mill, longo; oscu-
lis suctoriis magn;s 0-13 mill.; hamulis in duplice ordine
positis 28—36, quorum majores ex Leuckartii mensura
0045, minores 0-038, ex meis mensuris 0-034 et 0-028 ha-
bent.  Collo longiusculo.  Articulis 3—4, quorum ulti-
mus toto corpore longior (2 mill. long. 0-5 mill, lat.) est.
Utero mediand  loculis et stoUmibus nee rami's propriia 
1532
WORMS—Description  of Echinococci.
  Synon.—Tama visceralis granulosa, Goze ; j
T.  granulosa,  Gmelin ;  Vcsicaria granulosa,
Schrank; Hydatis  erratica, Bllmenbach; Po- |
lyccphalus  hominis, Goze ; Pol. granulosus, Ze-
df.r ;  Pol. Echinococcus,  Zeder ;  Echinococcus
veterinorum, Rudolphi ; Echin. giraffa, Gervais ;
Echin. simia, Rudolphi, aliique; Echin. granu-
losus, Rudolphi ;  Echin. infusorius, Leuckart ;
Echin. polymorphus, Diesing ;  Echin. scoliapa-
riens, Kuchenmeister.
  80. (a) The mature  Tania has  hitherto not
been found in the  human subject.  Von Siebold
in 1852, and Kuchenmeister in 1854, bred this
Tania by giving  Echinococci to dogs.   The de-
scription in the subjoined definition  gives all that
is required to be known of it; but the eggs and
six-hooked embryos must occur at some period  in
the human intestines, in the water and raw arti-
cles  of diet,  especially vegetables,  fruits,  roots,
&c.   Like the embryos of  other Tania, how-
ever, they escape  the human eye.   "Their mi-
gration is  certainly performed,  like that  of the
embryos of  other Tania, by their perforating
the intestine and getting into the abdominal cav-
ity, where they prefer  attaching themselves  to
the liver or the kidneys, or to the organs in the
thoracic cavity.    A  portion of  them, however,
may migrate along the ductus cholcdochus to the
outer surface of the liver."  They take up their
position in the same way as the other Cestoidea,
the envelopes formed around them being similar,
but much thicker.
  81. (b) The Scolex forms  a  vesicle which, ac-
cording to Eschricht, measures 2£ to 3 inches,
and is firmly attached to the organ in which it
dwells.   The enveloping cyst is like others, but
more concealed  and more abundantly permeated
by protcinous unorganized substances, by which
its walls are thickened.   It may be partly sepa-
rated into layers,  the inner being smooth, like a
serous surface.  A second vesicular body fits ex-
actly to the inner  surface of the innermost layer
of this enveloping  cyst, and is the true  cystic
worm, the  so-called mother  vesicle  of the  Echi-
nococci, that  is, the  six-hooked embryo, which,
continually increasing, has attained an extraor-
dinary size.   It is almost impossible to  get the
cystic worm  uninjured out of  its cyst, to which
it adheres  so firmly.  The  walls of this worm
are elastic, and tremble like jelly, when touched,
even after they are empty.   They never collapse
altogether  as seen  in  Cysticerci,  nor  lie, like
these, even when  dead, at the  bottom of the en-
velope cyst.   Their cut  margins roll themselves
up, and present a gaping appearance.  The trans-
verse section of this cystic worm shows a struc-
ture of more or less numerous consecutive circu-
lar strata, varying according to age.
  82. c. The structure of this cestode has been
described by Eschricht, Von Siebold, and oth-

instruetd; Ovulis ovalibus, 0 034 long, et 0 030 lat., testa
0-0019 mill, crassa, cavitate interna 002T lat. et 0-030 long.
  Habitat.  In Canis domestici, imprimis in Canis lanii,
fortasse etiam in Canis lupi, tubo intestinali.
  Scolex quiescens.=Echinococcu8 scolicipariens.   Vesica
minus pellucida, membranacea, in pariete ad 1 — 2 mill.
crassa, expluribus 0 005 —0-01 mill, crassis lamelliscon-
centricis composita,  parvulas gemmas  (brood-capsules)
stylosas gignens. in quibus scolices singuli proliferantur,
magnitudinem 30 mill, et ultra exhibens.  Scolices sociales
gemmis disruptis liberc in vesicam emissi, parvuli, capite
Teznim modo dictce.  Metamorphosis in Tosniam post T —
8 hebdomades peracta.
  Habitat.  Interdum in homine, plerumque in aliis ani-
malibus plerumque domesticis ex ordine ruminantium et
herbivoracium."—KvcnmiAEi&Tm in Op. cit, p. 192, 3.
ers, who say that its parietes consist of two sim-
ilar membranes, loosely connected, the  outer be-
ing firm and cartilaginous, and the inner thin and
smooth, resembling a mucous  surface, wliich is
beset with small elevations of a size up to ±"\
which are partly very young scolices in the act
of development, partly farther developed scolices
of 1-10'", and  partly the  points on which  such
scolices formerly sat.   In the fluid contained in
these vesicles there are also free scolices, part of
which are still  furnished with the  remains ofthe
stalk.   For other minutiae of structure I must re-
fer the reader to Dr.  Lankester's translation of
Kuchenmeister's work.
   83.  This  cestode worm is found chiefly in the
liver  of man and  ruminating  animals.  It has
been  detected also  between the choroid coat and
the retina of the human subject.   When present
in the liver, this organ is generally swollen, espe-
cially posteriorly, pale, or of a  uniform greyish-
brown  colour.   Its surface  presents  larger or
smaller spots  «f  a whitish-yellow colour,  of a
regular form,  and very  slightly  raised.    This
species is  generally  seated so  deeply as hardly
to project above the level of the  surface of the
organ, unless it is  very largely developed.
   84.  d. The symptoms caused by this Echino-
coccus are usually  slight,  limited, and equivocal.
The vesicles seldom  exceed the size of a  wal-
nut or hen's egg.  Even  when they are present
in  numbers, their diagnosis  is most  difficult.
When they are small or few, the disturbance of
the functions of the liver may be slight. When
more numerous or more  fully developed,  there
are generally pain  and uneasiness in the hepatic
regions, with increased pain on  pressure  and
percussion; the dull  sound on percussion being
more extensively heard, and the liver being often
felt from one to two inches below the false  ribs.
There is also irregularity of the bowels, the evac-
uations being unhealthy,  and often deficient in
bile.  Jaundice  is sometimes observed.   But all
these symptoms may be caused by other lesions
ofthe liver.
   85. B. Echinococcus altricipariens. Echin.
hominis, Auctorum.
   86.  Kuchenmeister* believes that this species
has been confounded with the preceding.—a. Its
mature Tania  is  unknown.   Nevertheless, he
thinks that  it probably occurs in the human in-
testines, and indeed in the intestines of those in-
dividuals who suffer, or have  suffered,  from the
species of Echinococcus belonging to it in  some
part of their bodies, and in whom  such  a colony
of Echinococci has opened towards  the intes-
tine.  This Tania may also develop itself in the
intestines of domestic carnivorous animals.  That
the eggs and embryos  must occur at some  time
  * He gives the following definition of its Scolex : " Ves-
ica animata Echinococco scoliciparienti sindlis sed omnino
eo multo major (ad \ ped. in diarnet).  Scolices singuli
quiescentes majore hamulorum minorum numero (46, 52,
et ultra) armati parantur, aut ex modo Ech. scolicipari-
entis, aut in gemmis aut capsulis a vesica; matris super-
fide interna solutis in quibus iterum scolices et vesicm se-
cundaria} scolices gignendi si praditce gignuntur (mother-,
daughter-, and grand-daughter-vesicles); aut fortasse in
vesicis, qua? divisione quadam aut sectione ex  vesica ma-
tre in vasibus animilis hospitis repente et serpente for-
mantur.  Wsica mater nihil  aliud est nisi vesieula em-
bryonalis 6 hamulis armata, et valde amplificata; vesieula
filia et neptis hamulis 6 destitutes, quia ex vesieula cm-
bryonali rectd vid non exortm sunt.
  " Habitat  Xon solum in homine, sed etiam, auetori-
bus Haubnero et Creplino, in mammalibus majoribus do-
mesticis, et quidem in diversissimis et hominis et illorum
animalium corporis regionibus. Ovula, hucusque iejnota." 
WORMS—Description of  Echinococci.                      1533
or other in the human body must be admitted, al-
though  they escape observation frpm their small
size.
  87. b. The  Scolex—the Echinococcus  altrici-
pariens—occurs not only in man, but also in the
larger  domestic  animals,  especially  herbivora.
It is very prevalent in Iceland.  Dr. Schleissner
states that he saw  fifty-seven human patients
suffering from Echinococcus in that island ; that
it occurred more frequently  inland than  on the
coast; and that it constituted  one  eighth of the
diseases of the place.   Dr. Thorstensohn, of
that island, says that every seventh living  human
being in it suffers from Echinococci; that females
are more liable to them than males, and that their
abundance increases with age, men being  most
frequently  attacked by them between their thir-
tieth and fortieth, and women  between their for-
tieth and fiftieth years.
  88. c. The  characteristics of this  species of
Echinococcus,  as distinguished from the  preced-
ing, appear to be as follows: (a)  The envelop-
ing  cyst, and  the mode of annexation  of the
inner wall  of this  cyst to the primary vesicle of
the  Echinococcus, derived  from  the  six-hooked
embryo, are  similar  in  this  and the foregoing
species; but  the  cyst formed by Echin.  altrici-
pariens is much larger than that of Echin.  scoli-
cipariens, and hence projects  far above the level
of the  organ in which the colony exists.—(b)
Owing  to  its much  greater bulk a  proportion-
ately increased interference with the functions
of the  organ results, and  eventually with the
whole organism.—(c) As regards the animal it-
self, we find not only single scolices or a single
vesicle  in  such a colony, but  the constant pro-
duction of fresh vesicles with young (daughter
and grand-daughter vesicles), sometimes with, and
sometimes without, the production of separate sco-
lices adhering directly to the walls of the  vesicle.
According to  Thorstensohn and Schleissner,
the  hydatids  occurring  in  Iceland exhibit  this
structure.   " The  hydatid sacks,"-  they state,
"are formed  not  only  in  the human liver, but
also in  many parts of the abdomen, and are  often
of enormous size.   Hundreds of hydatids  are fre-
quently evacuated through the external opening
of the  sac, or with  the  stools, and in vomiting.
They do not, however, occur only in the interior
ofthe body, but also very frequently in the  skin,
where they appear like  large saccular swellings.
The course  of the  disorder  is  very chronic."
Kuchenmeister  states  that   the  vesicles  pro-
duced do not, like the  original  mother-vesicle,
bear six embryonal hooklets, as they never have
occasion for them.   The  six hooklets may be
sought  for in vain,  even in the mother-vesicle,
as, although certainly present, they  must,  from
their extreme minuteness, escape detection on
such a large vesicle.  The smallest ofthe grand-
daughter vesicles are but just visible, and  enclose
four, five,  or  more scolices, which adhere  peri-
pherically, by  a small stalk, to the  inner wall of
the common cyst, but  converge with thin free
ends towards the centre  ofthe  cavity ofthe small
vesicle.  In very large daughter-vesicles scolices
also swim about freely.—(d)  The scolices pro-
duced  or nursed  by the mother-, daughter-, or
grand-daughter vesicles are in general more slen-
der than those ofthe preceding  species: they have
the head with the double circlet of hooks,  more
frequently  protruded during life, at least within
the  larger diucrhtcr-v^He?.  exhibit distinctly
marked sucking-disks, and bear a greater num-
ber (46  to  54) of hooks, which appear  more
slender than in the preceding species.—(e)  The
dwelling-places of this species  are not limited.
They may occur in the liver, the lungs, the kid-
neys, the sheaths ofthe testicles, the  spleen, the
ovaries, the breasts, the throat, in the sub-cutane-
ous tissues,  in the bones, &c—(/) With the in-
crease  ofthe secondary and tertiary cysts in the
mother-cyst  the swelling advances; and the more
rapidly this  takes place, the recognition  of the
malady and  its natural cure are facilitated; in-
asmuch as the mother-cyst is often burst by the
distention, and probably in many  cases becomes
destroyed.   Sometimes, however, the burst col-
ony appears to' heal and to recommence the pro-
duction of fresh daughter-vesicles.
  89. d. The prognosis of this species is more un-
favourable than that ofthe preceding, " although
the diagnosis is easier, on account of the more
rapid growth and greater bulk ofthe swelling, the
occurrence of the hydatid-buzzing, and the more
distinct sensation of fluctuation.  The structure
of the  walls of the mother-vesicle is the same in
both species, and is characterized by  the numer-
ous parallel  concentric layers in the substance  of
the walls, which  appear more distinctly marked
in the  daughter-vesicles, and make their appear-
ance with remarkable clearness after treatment
with caustic potash, with the addition of a drop
of red  ink."  (Lankester's  Transl. of Kuch£n-
meister, &c.)
  90. e. The Diagnosis of Echin. altricipariens.—
The  symptoms produced by a colony of these par-
asites vary with the organ in which it is located,
and with the size and pressure  of the tumour it
develops.  At  an early stage  of their growth
these animals generally occasion little inconven-
ience,  and when  largely increased in bulk  they
produce phenomena which vary little from those
occasioned by tumours of the same size in similar
situations.  Their superficial or deep-seated po-
sitions, and  their vicinity to, and pressure upon,
nerves  and   blood-vessels, will  also  modify ef-
fects, or even indicate their existence.  But it is
comparatively rare to obtain  certain evidence  of
the presence of a colony of Echinococcus in the
body, unless the passage of the gelatinous  vesi-
cles already  described  from the cavities after the
bursting of such a colony, or from the punctures
or incisions  made into tumours.  At the same
time, the little scolices of the Echinococcus must
be found in the vesicles, part of these retaining,
others  wanting their  hooks,  their sucking-disks
being often  indistinct.   When the vesicles pass-
ed have an  opening,  the  little scolices slip out
very easily, and if the  structures just mentioned
be not  found, it is doubtful whether or no a steril
colony  or an acephalocyst be present.
  91.  Before perforation or bursting  ofthe cyst
has occurred, the tumour produced by it being
very considerable, an examination  of it should  be
made by palpation and percussion, and if there  be
an obscure or sensible fluctuation, and when an-
eurismal symptoms are wanting,  and when the
general health  is either good, or not injured  to
the extent that might  be expected from the size
of the  tumour,  if it were of a malignant nature,
then an explorative puncture should be made  to
complete  the diagnosis, and  the evacuated  fluid
examined by the microscope in order to ascertain
the presence of  Echinococcus scolicis, or of al-
buminous gelatinous shreds of Echinococci.  By 
1534                         WORMS—Trematoidea—Monostoma.
these means  only can the  nature of a cystic or j
sacculated,  fluctuating or elastic tumour be  de-
termined, and the  existence of these  parasites
ascertained.*
  92.  Without these  proofs the  diagnosis can
never be brought beyond one of probability.   A
sacculated or cystic swelling filled with fluid can
alone  be inferred.   The most  useful  objective
symptoms are the  existence of such a tumour,
which is elastic to the touch, and of a peculiar
consistency and form, in places  where swellings
do not  usually occur; but  when these do make
their appearance, they are generally Echinococci.
The highest  degree of probability  that  an  un-
opened tumour belongs to a colopy of Echino-
cocci is  attained  when  the swelling occurs in
places such as the liver, spleen, kidneys, lungs,
breast,  testicles,  throat, &c, where  Echinococci
are otherwise brought to light, either artificially
or naturally.   On percussion, the finger, placed
over the swelling, often feels a  trembling or os-
cillation of the  mass underneath it, especially
when several gelatinous tremulous cysts are en-
closed within a larger vesicle; these being set in

  *  Acephalocysts.—Laennec, in  1S04,  viewed these
structures as independent animal organisms.  Von  Sie-
bold and Kuchenmeister  more recently opposed  this
view; and very lately the last of these writers, in conse-
quence of his experiments with the eggs of Tcenia;, consid-
ered that Acephalocysts are six-hooked  cestode embryos,
tlvenrowth of which has proceeded without hinderance, but
which, nevertheless,  have remained barren; or, more cor-
rectly, which have never attained to proliferation and the
production of scolices."   If Acephalocysts occur where
normally-developed Echinococci usually have their abode,
they cannot be called strayed cestode embryos,  but only
cestode embryos ichich have been disturbed in their nor-
mal development and remained barren.  Kuchenmeister
considers the following to be the characteristic marks of
Acephalocysts : 1st.  A vesicle adhering to the inner walls
of a larger cyst from which it is capable of being detached,
or is already detached, in particular spots, but never all
over, and collapsed  in wrinkles, and which presents very
sparing calcification in its white and scarcely discoloured
walls.  2d. The transverse section exhibits walls consist-
ing of  distinctly developed, parallel, concentric layers.
3d.  The walls have a peculiar elastic  gelatinous trem-
bling.  4th. The contents consist of a watery fluid, or of
a substance of a purulent consistence, and contain the mi-
croscopic elements  of calcifying encysted protein mass-
es in the act of resorption.  5th. The vesicle sometimes
conceals, in its interior, secondary cysts, with gelatinous
walls, in which, however, we seek in vain for scolices of
cestodea or their remains, especially their hooks.  " The
Acephalocysts which are  referred to  here belong  to the
following three species of Taeniae : 1. Acephalocysts de-
rived from Tania Echinococcus scoliciparu ns.   Many of
those acephalocysts which bear  no daughter-vesicles in
their interior must be referred to this  species.  2. Aceph-
alocysts derived from Tania Echinococcus altricipariens.
These are acephalocysts with  a formation of daughter-
vesicles.  3. Acephalocysts derived from Tanice ex Cysti-
cerco tenuicolli."   KOchenmeistee  remarks respecting
these last that what EsonRicnT regarded as possible has
since proved to be the case; for that in one administra-
tion of eggs of T. ex Cyst tenuicolli to a lamb, he found
a steril Cysticercus tenuicollis in the midst of other equal-
sized and fully-developed Cysticerci of this species.  This
stt ril individual bore perfectly distinct indications of life.
All-structures, he adds, which are really acephalocysts,
and  which are living steril specimens of Cmticerci and
Ccenuri, are distinguished from those derived from Echi-
nococci in that the walls of the latter consist of very dis-
tinct concentric layers, tremble like jelly, and are extra-
ordinarily elastic; while the walls of the analogous struc-
tures derived from  Cysticerci are considerably thinner.
have not the elastic consistence of jelly, and consist of
such fine and delicate concentric layers as hardly admit
of detection.  Such  being the origin and nature of Aceph-
alocysts, it is obvious that the phenomena produced by
them cannot be materially different from those caused by
the two species of Echinococcus.
  The subject of Acephalocysts has been already treated
of under the article Hydatids ; but instead of viewing
them as in that article, as independent organisms, the
more recent Continental microscopists and experimenters
have shown them to originate as now stated.
motion by the percussion, appear to produce this
trembling or  •scillation, which,  however,  fre-
quently  is not felt.
  93. /.  The etiology of the Echinococci  is man-
ifestly the ingestion of  one or more of the eggs
or six-hooked embryos ofthe Tania  Echinococcus
altricipariens at some time of the life of the pa-
tient.  The mode of life of persons in some lo-
calities and in some circumstances may be  fa-
vourable  to the passage of the eggs of this Ta-
nia into the stomach ;  and it is now well under-
stood  that certain Cestodea often  have  a very
limited habitat.   " The duration of the life ofthe
Echinococcus does not appear to be very short.
According to Eschricht, one patient must have
borne his colony eighteen years."
  94.  g.  The prognosis of the Echinococci varies
according to  the  organ in which they are seated,
to their  situation in that organ, and to the pri-
mary and consecutive injuries caused by them to
the  organ and to the  whole system.  But  the
prognosis is  upon the  whole more  favourable
than is generally supposed, especially when the
general health and the powers of vital existence
are duly  promoted.  "The tumours, when they
are accessible, are among the number of curable
tumours  ; they may cure themselves by bursting,
and when they are once got rid of relapses in
the same colony are rare and exceptional cases,
and every Echinococcus produced  usually owes
its  existence to a new immigration of embryos.
But for  this  very reason the continuance of the
mode of life  in endemically affected places fur-
nishes a more unfavourable prognosis.  The nat-
ural cure by  the  bursting of the colony, and the
passage of daughter-vesicles, may be accompanied
by symptoms dangerous to life, or, if it take place
in the direction of the larger bronchi, by difficulty
of breathing, or may even lead to actual suffoca-
tion."  (Op.  cit., p. 227, 228.)
  95. B. Sub-order,  Trematoidea.—Synon.—
Myelmintha,   Diesing ;  Egelwurmer;  Platyel-
mintha isolata, Isolated flat-worms, Kuchenmeis-
ter.
  Definit.—"Animalia solitaria, plerumque her-
maphroditica,  rarissime sexu  distincto, et poris
plerumque suctoriis, medianis  aut lateralibus in-
structa.   Canalis cibarius furcatim divisus  aut
ramosus, rarissime simplex.   Evolutio fit ple-
rumque  mctamorphosi et  sapissime generatione
alternante, rarissime sine illis."—Leuckart.
  96. This sub-order is  divided by Kuchenmeis-
ter into two Families,  the Monostoma and  the
Distoma.
  97.  (a) Monostoma.*—Synon.—Cucullanus;
Festucaria;  Fasciola;   Amphistoma;  Distoma;
Monostoma;  Monostomum.—It  is very doubtful
whether  or no any species of Monostomum has
been found in the human body.  Professor Jung-
ken was  said to have found eight Monostoma in
  *  " Corpus depressum vel  teretiusculum.  Caput con-
tinuum, vel collo discretum.   Os terminate vel anticum,
ut plurimum acetabuliforme, integrum, crenulatum, in-
erme vel armatum.   Apertura genitalium perclara, du-
plex; mascula infra os, interdum acetabuliformis, pent
protractili; feminea pone masculum, minima, ut pluri-
mum inconspicua.  Porus excretorius supra caudos api-
cem antico margine caudali.  Animalia mammalium,
avium, amphibiorum et pisciwn corpora, i. e., prater
tractum intestinalcm organa variainhabitantia, libereaut
folliculis inclusa."   (Diesing.)  Metamorphosis et gene-
ratio altcrnans inter evolutionem, uti in Distomis.   The
ventral sucker is therefore deficient, and Diesing gives a
warning, " Cave, ne Bothriocephalidearum articulum soli-
tarium pro ' Monostomum'  habeas, autporum genitaleiv,
interdum callosum, cum acetabulo confundas." 
WORMS—Description of  Distomata.
1535
an incipient cataract; and hence Von Nordmann
named the species Monostomum lentis.
  98. (b)  Distoma*  (Kuchenmeister); Disto-
mum (Diesing).—a.  Distoma  hepaticum^—Dis-
tomum  hepaticum — The fully-developed Disto-
mum hepaticum has been minutely described by
Kuchenmeister,  but I must refer the reader for
his description to his work, or  to its excellent
translation by Dr. Lankester.—a. I may, how-
ever, briefly state that its skin  and  parenchyma
consist of muscular layers—of longitudinal, trans-
verse, fusiform, and short fibres ; that its organs
of sense are  wanting, and its nervous system has
not been described ; that its alimentary apparatus
presents a  mouth, pharynx, and  excretory organ ;
that its female sexual organs lie towards  the ven-
tral surface of the animal, and consist of a germ-
stock, with  its efferent duct,  two vitelligines, a
short oviduct, a  sac-like uterus,  and a  vagina;
that its male sexual organs consist  of  testicles,
a ductus spermaticus, a  vesica  seminalis, and a
penis;  and that  "the Distoma are  hermaphro-
dites, with the following sexual  actions :  self-
impregnation with and  without copulation,  and
impregnation and copulation with a second indi-
vidual."  This distoma  occasions great  devasta-
tion in  the  livers of herbivorous and  domestic
animals, especially  in wet seasons ; but it very
rarely occurs in man.
  99. 6. Diagnosis.—Distoma in the liver causes
dilatation and inflammation of the gall-ducts, and
destruction by pressure and disappearance of large
portions of the parenchyma of the  liver in the
vicinity of the enlarged  ducts.   These  changes,
however, cannot  always be  recognised, or  re-
ferred to their true source in the human subject,
as several  lesions of the biliary organs  and ap-
paratus  occasion  the same  symptoms  as  they
produce.   The distoma  may even cause  many
  * " Corpus depressum vel teretiusculum, armatum vel
 inerme. Caput continuum, vel collo discretum.   Os termi-
 nate, velanticum, utplurimum acetabuliforme. Acetabu-
 lum unicum ventrale sessile, velpedicellatum, medianum,
 ab extremitate postica plus minusve remotum.  Aper-
 tura genitiles approximator, scepissime ad cxitum con-
 junctm (r.loacd instructor), supra vel infra acetabulum
 sitai.  Animalia plerumque hermaphrodiHca, rarissime
 sexu distincto.   Ovula embryones parentibus rarissime
 similes, plerumque dissimiles aut fimbriates, aut fimbriis
 destitutos continenfia, qiuire evolutio fit metamorphosi et
 generatione alternante.
  " Statu immaturo aut libere in natura vagantia, aut in
 organorum parenchymal, imprimis in animalibus iufe-
 rioribus inclma.  Statu maturo entoparasita animalium
 prmprimis vertebratorum, aut libere in  variis organis et
 cavitations apertis et clausis viventia, aut in folliculis in-
 clusa."—Dujardin et Diesing.
  t " Corpus planum, armatum, saltern in  juventuti,
 mta'e magisprofectd aelhuc in collo.  Individua juniora
 4"'=9 mill, longa, lK"=3-3 mill, lata; aelulta 8—14'"
 =13 — 31 mill longa, 3\ — 6"'=8 —13^ mill.  lata.
  " Collum  subconicum, breve.   Os  hauel nodulosum,
 terminale, triangulare, 1-4 mill, latum.  Acetabulum 15
 mill, latum, ore majus superum ad colli basin, aperturd
 triangulari, 3 — 4 mill, pone os situm.
  " Orificia genitalia fere contigua, medid in parte inter
 os et acetabulum sita^  Penis cylindricu*, 3 mill, longus,
 0-5 mill, latus, falciformis, prominens, uncinulis par-
 vulis armatus.  Testiculi niaximd ex parte medid in cor-
poris posterioris parte siti, ex trunco mediano et ramifi-
 cationibui, adjinem cceeis, eompositi.  Organa vitcllina
 ad latera animalis sita,  inter se horizontali  quodam et
 transverso ramo conjuncta et statim in uterum  simplicem
 magnit.udine crescentem, multifarie volutum transeuntia.
 Ovula flava, mitra quadam parvula aut obtegulo, dehis-
centia, 0 056 — 0 063'" (V. et Par.) = 0-126 —0-144 mill.
longa, et. 0-035 — 0-03S"'=0-079— 0-086 mill. lata.
  " Embryones Cercariarum utriculi aut Redios, nee minus
Cercarun liberae, si omnino hcec forma pratbetur, ignotae.
Migrationum modus nondum cognitu*.  Distomum juve-
nile immaturuni semel sub cute humand invenlum."—
Kuchenmeister.
 of the  phenomena  of gall-stones passing along
 the ducts, with or without more or less of jaun-
 dice ;  but these cannot assist in establishing a
 diagnosis, the passage only of the animals  with
 the faeces or with the matters vomited being the
 only proof of their presence in the human sub-
 ject.
   100. c. It is obvious that no  prognosis of the
 Distoma malady can be formed unless the animal
 be discharged and recognised.   When this takes
 place, although the prognosis is upon the whole
 unfavourable, yet there may not be any immedi-
 ate danger.   The life of the patient may be pro-
 longed, or even a recovery ultimately obtained, by
 promoting the secretions and excretions by suit-
 able means, arid by supporting vital force and re-
 sistance.
   [Several years since we  prescribed for a rail-
 road  engineer  in  the State of Ohio, who  com-
 plained of a  sensible movement in the epigastric
 region,  with considerable  derangement of the
 digestion, loss of  appetite,  pain,  anorexia, bil-
 ious  symptoms, &c.  He said he  was  positive
 there was a living animal in his stomach, which
 he had  probably  swallowed while drinking at
 some  of the  stagnant pools while pursuing his
 vocation  as  surveyor and engineer.   Meeting
 him some months after, he  stated that he had
 passed the animal  after taking a powerful  purg-
 ative ;  that it was from three to four inches in
 length, flat, alive, and of a dark colour,  &c.  It
 was  evidently  an  enormous Distoma.  In the
 same  region  of country, the livers of animals,
 especially the ox and sheep,  and frequently the
 hog, are  infested with the same parasites under
 the name of fluke-worms, which frequently prove
 destructive to life.   We  have often seen the ox
 liver  perforated by these animals like a honey-
 comb.]
   101. /?. Distoma lanceolatum* (Mehlis).   This
 species was seen in the human subject by Buch-
 olz,  Chabert, and Mehlis.   It is narrow and
 elongated, and distinguished by its long neck, by
 the want of any spinous coat, and by the female
 organs especially occupying the abdomen, and the
 testicles the anterior part of the body.   Schaef-
 fer,  Rudolphi, and  Mehlis  established this as
 a distinct species  of Distoma, and  showed that
 Goeze, Zeder, and Bremser were wrong in re-

   * " Cotpus laive, lanceolatum, }>lanum, aliquid pcllv-
 cidum, aut orulis flavofuscum, 4 5 —12 millim. seu 2 —
"C"' longum, 2 ad 2-2 millim. aut 1 — 2'" latum in an'e-
 riore peirte tenuius, acetabulo finitum, in posteriore ali-
 quid obtusum.   Collum  continuum, conicum, planum,
 longius quam in T>. hepatico.  Osfere terminale, globo-
 sum, 0 4S mill, latum, acetabulum orbiculare, 0-49 mill.
 latum, 1-1 mill, pone os situm, ore majus.  Oesophagus
 0-43 mill,  longus, bulbus oesophagi 0-10 mill, latus; in-
 testinum bifurcatum,  rectum, simplex, non ampliui ra-
 mi ficatum, 0 04 mill, latum
   " Genitalia inter os et acetabulum ventrale sese aperi-
 cnHa,  inter intestini  bifurcationem sita.  Vesica semi-
 nalis exteriorz=cirrhus claviformis; funiculus spcrmati-
 cw flexuosus; penis longus, cylindricui, plerumque rec-
 tus; testiculi 2 majores  et tertius minor vesicam semi-
 nalem internam exhibens; unus pone alterum et pone
 acetabulum ventrale siti, vix lobati.  Organa  vitellina
 multo minora,  quam in D. hepatico, albida, lateralia,
 ramijicata, 1 —lj mill, longa. in ovarium et uterum in-
 trantia, longiora quam in h'xst. hepatico et tenuiora, sed
 colore obscuriore  prcedita,  laultifarie voluta.  Ovula
 multo minora,  qvim  in Dist.  hepatico, 0041 »»'!!.=
 0018'" Par. 0-01S.V"  Vienna longa, et 0-0246 mill —
 0-010S'" Par. 0-011'" Vimwi lata, sed in statu maturo
 multo obscuriora quam in D. hepatico, et nigro-rubra.
  " Systema excretorium: Vasa Viteralia, ad collum us-
 que prominentia, ibique recurrentia et intumescrn'iA
 minore, ad animalis apicem sitd,finita"—Kuchenmeis-
 ter. 
1536                        WORMS—Description of Distomata.
 garding it as a young Distoma hepaticum.  It is
 stated  by Kuchenmeister  to be less  injurious
 to the structure of the biliary  apparatus than the
 D. hepaticum.   The  diagnosis  is  possible only
 when it passes off.   The prognosis is probably
 more  favourable than in the case of  the other
 parasite.
   102. y.  Distomum  heterophysis *  (Von Sie-
 bold).—This parasite has  hitherto been found
 only  in two  instances, but in very great num-
 bers, in the small intestines, by  Bilharz.   Its
 influence on  the animal economy is  unknown.
 It is unnecessary to give a  farther  description
 of it than that contained in the subjoined defi-
 nition.
   103. 6.  Distomum  hamatobium\ (Bilharz).—
 a. This parasite was  first found in 1851, in the
 blood of the portal vein.   It appeared as a white
 elongated entozoon, resembling a nematoid worm
 when  examined with the naked  eye  ; but was
 found to  be Distomum, with  a flat body  and a
 cylindrical  tail  ten times as  long as  the body.
 This tail was no loosely attached, deciduous por-
 tion of the body, as in the  Cercana, but a con-
 tinuation of the body of the worm itself,  which
 was flat and rolled towards the ventral surface.
 This  first  animal found  was  clearly recognised
 as the male;  another subsequently found in one
 of the mesenteric veins of the same subject was
 ascertained to be the  female.   For a minute de-
 scription  of the  sexual organs, eggs, and  devel-
 opment of this  animal, I must refer the reader
 to Kuchenmeister's work.  It may, however, be
 stated that, according to Professor Griesinger,
 this  parasite  is  so extraordinarily abundant in
 Egypt as to have been found 117 times  in  363
 dissections.   It would appear that the Distoma
  * Descriptio.—" Dist hcter., hcrmaphroditum.  Cor-
pus ovato-oblongum, deprcssum, subtus planum, supra
 leviter convexum.   Acetabulum  oris subapicale, infun-
 dibuliforme, par turn.  Acetabulum ventrale pauluhim
 ante medium situm, magnum (acetabulum oris decies et
 ultra  superans), globosum.  Pharynx  muscularis, glo-
 bosa;  canalis cibarius ante acetabulum ventrale in 2
partes ccecas divisus. 'Cirrhuspost acetabulum ventrale
 situs, et oblique cum sinistrd ejus parte coalitus, globosns,
 acetabuliformis, circulo incompleto set arum 72 minutis-
 simarum, ramulis 5 secundis instructarum  coronatus,
 testiculis organoque germinifero globosis. Longitudine }
 — V"; latit.  \"\
  "Patria.—JEgyptus; in hominis intestino tenui bis
repertum, numero permagno."—Kuchenmeister.
  t Descriptio vermis secundum Bilharz.—" Distomum
 haematobium, sexu distincto. Maris corpus  mollc, albi-
 dum, filiforme, parte anteriore totius longitudinis octava
 vel nana (' trunco') depress^, lanceolata, subtus plana vel"
 concava, supra leviter conveza, superficie losvi, reliqwi
 corporis parte (' cauda') terete, margihe corporis ab acc-
 tabulo ventrali retro utrinqir- versus faciem ventralem
 conflexo, eoque modo canah m, •gnnceceiphorum, efpciente,
 apicepostico, attenuato, superficie externa tuberculispili-
geris conferta,superficie c-inidis  in'irinre linea mediana
 Imvi etpartibus late'ralibus aculeis minutissimis scabra.
 A cetabulum oris apicale subinferum, triangulare.  A ce-
 tabulum ventrale  sub finem ' trunci. inserlum, orbicu-
 lare eadem magnitudine cum acefabu'o oris.   Superficies
 utriuque acetabuli granulis crebris minutissimis scabra.
 Canalis cibarius sine pharynge musculari ante acetabu-
 lum ventrale in 2 partes divh<ufi, in posteriore 'caw: a?
 parte denuo unitus, ccecus.  Porus genitalis inter aceta-
 bulum ventrale et canalis 'gyn&cophori' originem situs.
  '■ Feminos  forma dissimilis,  tenerrima,' gracillima;
corpus tceniaiforme, leeve, hyalinum, antice sens'im valde
eUtenuatum, cauda canali nullo  apice ane:ustata.  Ac*--
 talu'.a et canalis cibariu% u< in mare.  Porui genitalis
 cum margine posteriore acetabuli ventralis coaliius.
  '■•Longit 3 —4ftn.; mas feminam latitudine multo
superans.
  '• Patria.—JEgiiptus; in hominis vena port-rum ejus-
que ramificationibus et in vesica urinarice parietibus.
 In yenis meseraicis reperiun'ur marcs feminam in ca-
 nali gynazcophoro gerentes, in vcnis intestinalibus et he-
 paticis, in vena licnali semj>er vi>ivi"
 get  into  the blood-vessels  and  lay their eggs,
 which at last escape from  the ruptured  vessels
 in the  intestinal and  urinary mucous  surfaces.
 Dr.  Reinhard saw, hanging out of a vessel ac-
 cidentally opened  by  Kuchenmeister, one  of
 these Distoma, which bore  his female with him.
 The action  of  their eggs  and embryos  on the
 mucous coat of  the intestines  and urinary or-
 gans, and on the biliary apparatus,  is of a very
 dangerous nature.
   104.  b.  In the intestines are  found deposits
 upon and beneath the mucous membrane, verru-
 cose and lobate  fungous excrescences,  and also
 the  aggregations of the eggs in the vessels of
 this membrane, " where the eggs are often fixed
 in rows in the mucous and sub-mucous tissues,
 in and beneath   the croupous exudations upon
 the  intestinal ulcers; and,  lastly, after  the  rup-
 ture of the  vessels  upon the free surface  of the
 mucous membrane."
   105.  c.  Action on  the Liver.-—"The  entire
 trunk of  the portal vein is sometimes filled with
 mature animals,  with  eggs in the substance of
 the  liver; and it is not impossible  that the Di-
 stoma  situated in these places may  give rise to
 a tough, dry, ansematous consistence of the liver,
 or perhaps even  to  abscesses."
   106.  d. The alterations in the urinary bladder
 produced by Distoma hamalobium are at first cir-
 cumscribed spots of  hyperemia, with bloody extra-
 vasation and swelling of the mucous membrane,
 or tenacious mucus, with grayish-yellow masses
 of exudation, in  which the  eggs are imbedded.
 " It  is rare that the  whole inner wall of the blad-
 der  is injected  and ecchymosed.  The  urine is
 mucous, but pale and clear; and Bilharz found
 eggs in the urine passed."   In later stages, yel-
 lowish discoloured  elevations, mixed with many
 pigment  spots.   These  elevations often form a
 soft coat, sometimes a  line  in thickness,  mixed
 with bloody  extravasations,  firmly  attached to
 the  mucous membrane.  Sometimes calcareous
 incrustations of the egg-shells, the deposition of
 the  salts  of the  urine,  and  the  aggregation of
 eggs, give  the  whole  a sandy  texture.   Very
 rarely  this  coating  covers true ulcers with loss
 of substance.  At  other times, single or  aggre-
 gated vegetations, varying from the size of a pea
 to that of a bean, of a yellowish colour or  ecchy-
 mosed with  blood,  are found on  the  vesical mu-
 cous surface.   In  the  smooth-edged spaces of
 these vegetations, sitting in the sub-mucous tis-
 sue, formed by the diverticula of its vessels, and
 only constituting productions of the vessels, Bil-
 harz first found the Distoma, and in the mucus
 and  exudation over  these  spots their eggs.   Wc
may conclude from  this that the  Distoma collect
there, and in similar situations,  to lay the eggs
which are to be passed off.
  107. e.  The mucous  membrane of  the ureters,
either alone  or with that of the bladder, or even
with that of  the  pelvis of  the kidney, in  rare
cases, is attacked  in a similar manner.   A grav-
elly  matter,  in  molecular masses of imbedded
eggs of Distoma,  either  empty or containing em-
bryos, with blood, exudation  corpuscles, and crys-
tals of uric acid, is sometimes passed in the urine.
Individual embryos  also  occur free, but Griesin-
ger  found these in a dead state only.  In  conse-
quence of the thickening of the inner coats of
the ureters, complete or  partial occlusion of these
ducts with dilatations above  it, with  retention of
urine and its  consequences, sometimes supervene. 
WORMS—Description of  Nematode Worms.                    1537
The kidneys are somewhat swollen  and congest- I
ed with blood, and the mucous membrane of the
pelvis is much  injected.  The kidneys, in rare
instances, ultimately degenerate  in  a fatty  or
suetty state.  " The aggregation of eggs of the
Distoma are not unfrequently the  nuclei of de-
posits of gravel  and stones, consisting chiefly of
crystals of uric  acid in the kidneys, ureters, and
bladder, and thus give rise to the well-known con-
sequences of stone and  gravel.  This is the Li-
thiasis of the Egyptians, described by  Prosper
Alpinus in  "Medicina iEgyptiorum."
   103. The seasons appear  to have some influ-
ence upon the frequent occurrence of this worm,
as it has been observed to be more abundant from
June  to August,  and more rare  in  September,
October, and January.   This difference is prob-
ably owing  more to the kind and quality of the
food in  these months,  than to temperature  or
season.
   109. /. The symptoms of this parasite are man-
ifested chiefly in  the  urinary apparatus, and in
the urine itself,  at an early period of  the lesions
produced by it.  Causeless hematuria, especially
if frequent, and attended by anasmia, emaciation,
and disordered bowels, should be a cause of sus-
picion, especially  in tropical countries.   The di-
agnosis, however, during life, can be certain only
when the eggs are found in the bloody urine and
in other evacuations, as  they were by  Bilharz.
   110.  e. Distomum ophthalmobium*  (Diesing)
—This  parasite was found  in the eye of an in-
fant, between the lens and the capsule, by Ge-
scheidt.  The infant was five months old, and
was born with cataracta  lenticularis, with partial
suffusion of the capsule.   Four specimens of this
Distoma were found, and were recognisable by
the naked eye.
ii. Order, Nematelmia—Nematoidea.— Thread
    worms, Round worms.
   111. The worms now to be treated of are the
First Order of Rudolphi.—"Nematoidea:  Cor-
pore  elongato, tereti, elastico."  Diesing, in his
"Systema,"  arranges them  as the Sixth Order
of his first sub-class, and defines them—"Nema-
toidea : Corpus elasticum, cavum, subcylindricum;
tractus  cibarius simplex; caput in proboscidem
hand protractile.   Endoparasitica, tandem rarius
extus libere vagantia."   They form  the  second
order of Kuchenmeister's second sub-class, and
he defines them as follows: " Nematelmia :  Cor-
pus teres, elasticum, sape attenuatum, filiforme;
ore ccntrah,  vel sub-cenlrali; canalis cibarius aut
distmctus aut obsoletus, anoque destitutus.  Met-
amorphosis  in paucissimis.   Migrationes activa
aut passwa in permultis."
   112. Mature Nematode  worms are met with
in the human subject in  the cavities of the body,
having  mucous  surfaces,  in the sub-cutaneous
cellular tissue, with an artificial external commu-
nication, and during their youth,  and in an im-
mature state, in various muscles, especially prim-
itive muscular fasciculi.   The division of this
order of worms  into numerous genera and  spe-
cies has  been  attempted by Dujardin, Von  Sie-
bold, Diesing, and others, but without sufficient
agreement  to admit  of  farther reference to it
than is made by Kuchenmeister, who does not
adhere to a strict classification, but  rather re-

  * " Corjms  ovato-Utnceolatum,  drprcssum,  variabile.
Collum bnve subcylindricum. Os terminale orbiculare.
Acetabulum ore i mains, subcntrale, appertura circu-
lari.  Lonaitud. i — V";  latifui. V". "—Diesing.
      III.               97
I views them in accordance with their dwelling-
| place in the human body, and selects for them
 the name most generally employed.  It was for-
 merly thought that the 'Nematoidea were the most
 accurately known of Entozoa ,  but at the present
 day  we. have more positive knowledge  of the
 history  and development of the cestode worms,
 and  even of  the  Trematoda,  than  of this, the
 order of round worms.
    113.  "The distinct presence of  a digestive
 apparatus, divisible into mouth,  oesophagus, stom-
 ach, intestine, and anus, the  separation  of the
 sexes into two individuals, the certain detection
 of a nervous  system in  some  of them, and the
 apparently jointed structure of the round worms,
 bring them  near to the  articulata.   In  the hu-
 man subject we must take into consideration :  1,
 the Trichocephali and  Trichina; 2, the Oxyuri;
 3, the  Strongyh and  Ancylostoma; 4,  the Fi-
 laria; and, 5, the Ascarides."   (Op. cit, p. 289 )
    114.  A great  part  of the  nematode  worms
 appear  to reach maturity only  after they have
 undertaken various immigrations and emigrations
 during their youth.  One species of round worm
 common to man is to some  extent capable of
 migration also in the mature state.   The migra-
 tion in  the early stage of development consists
 of  the  escape outward  of  the eggs  of these
 worms with  the human  fseces, with  which they
 get into dung-hills, sewers, &c, and experience
 the  transitions described above (§  7, et seq.).
 My limits admit not of an account of the sexual
 and other organs of this order  of worms,  and of
 the various  stages of their  development; suffi-
 cient reference to  these  topics  for practical pur-
 poses has already been made, and the reader may
 farther peruse the minute descriptions of Kuch-
 enmeister and Von Siebold, and of other recent
 observers, to whom I have referred.
   i. Trichocephalus.*—Synon. Trichuris, Roe-
 derer ;  Ascaris, Linnaeus ;  Mastigodes, Zeder ;
 Trichocephalus, Goeze, Dicing, Dujardin, &c.
   115.  1st.  Trichocephalus dispar,\ with its prog-

   * Descript.  Systemat. — "Corpus longissimum, ex 2
 partibuv formatum, quorum anterior tenuior, filiformis,
 posterior crassa, organa stxuilia continens.
   " Ma* : tenuior quamfemina; penis simplex; organon
 copulatorium auxiliare spinosum, ex 3 branchiis coinpo-
 situm.
   " Femina : mare major et  cramor; vagina maculosa
 in abdomine scse aperiens; uterus simplex; ovarium sim-
 plex.  Animalia ovipara, vix aut rarissime vivipara.
   " Otula oblonga, subfusca, in utraque extremitate collo
 quodam  parvulo prominente ornata (en une sorte de
 goulot court, Dujardin)."—Kuchenmeister.
   t  Systematic description of Trichocephalus dispar.—
 " Cutis transversa striata, marginales rii ins ad anum
 versus magnitudine adductas exhibrns.  Caput 0-02 mill.
 latum, retractile,  obtuso-acuminatum,  interdum per-
 parr/i papilla instructum.  Tractus inteitinalis consti-
 tuitur ex cesophago ab initio recto,  angustissimo paullo
 post toruloso, sensimper totum collum intume.scnte; ven-
 tricic'us pyriformis, ad lat ra sui glandulas 2 perpar-
 vas aut appenelics alosas aut nervorum ganglia gerens.
 Animalia faecibus humanis pro nu'rimento u'entia.
 Mas: omnirw  colore clarior, fusco-albior; dreiter 37
 mill, longus (caput et collum 22 ; truncus aut abdomen
 15); in trunco OHmill. —1-0 mill, latus; formam sjnra-
 lem amans.  Testis et funiculus spermaticus sini2)lex ad
 intestini  tenuis formam volutus; unci cum tubo intcsti-
 nali ante  anum in cloacam communem apertus.  Penis
 simplex; 3-35 mill, longus; 0-042 mill, ad extremitate,a
 infundibuliformem, 0-027 mill, ad apicem versus latus;
 vagind lervi cylindricd instructus.  Extremita<i caudalis
 organo copulatorio auxiliario, spinis armato, svhrylindri-
 co orneita, cujus longitudo 9-451  m?7f.=0-108"' Par.=
 0-203'" V.,  latitudo in parte libera  0090 mi77.=0-039"'
 Par.=^04Y" V., in  parte opposita fere 0-049  mi7L=
 00216'" P.=0-022'" V. est.  Cloacae communis  muscu-
 losoz in maribus longitudo circi'-r 4 mill.=2'" P.; lati-
 tudo 0-261 mill.=0-il6'" P.=0-119'" V.;  latitudo fora- 
1538                    WORMS—Description of Trichina Spiralis.
cny  known  as  Trichina spiralis,* Owen  and
Luschka.
  Synon.—Trichocephalus dispar,  Goeze ;  Trt-
churis, Roederer and  Wagler ;  Ascaris,  Lin-
N.tus ;  Mastigodes, Zeder ;  Trichina, Filaria,
Auct. ;  Trichure, Fr.
  116. A.  This  worm  was  first  discovered by
Morgagni  in the caecum and vermiform append-
age  of  typhous  patients;  and Roederer  and
Wagler, in 1761,  recognised  it  as  a distinct
worm, in  the  " morbus  mucosus," or mucous
fever, so prevalent in Germany in the middle of
the 18th century.  It was long supposed to ex-
ist only in  the intestines of typhous patients, but
it is now fully ascertained to have no particular
relation to any  disorder of the human bowels.
It is found chiefly or only in the lowest region
of the small intestine,  near the ileocffical valve,
in the caecum, and colon.  From the dingy colour
of the worm, it is liable to escape detection, and
only is detected with ease when the lower intes-
tines are free from their thick and coloured con-
tents, as in disorders attended by diarrhoea.  If
carefully sought after, these worms will be found
more frequently and in greater numbers than is
commonly believed.  Rudolphi found many hund-
reds in the situations just named.   Bellingham
saw upward of 100 in the caecum only of one
patient in Dublin.  They occur in both children
and adults, and in Europe and Africa.   Kuchen-
meister's work and its translation  by Dr.  Lan-
kester, contain very minute descriptions of the
organization of this parasite.  The subjoined sys-
tematic description  is sufficient for all practical
purposes.
  117. B.  Trichina spiralis (Owen and  Lusch-
ka), as  the brood of Trichocephalus dispar, en-
gaged in  migration.—This asexual worm  was
first described by Owen  in 1835,  although pre-
viously seen by Tiedemann in 1822, and by Hil-
ton and Wormald in 1833.  It was afterward
seen and described  by Paget, Knox, and others.
The seat of this  worm  is, as is well known, the
muscles of voluntary motion, and indeed all the
muscles  excepting the heart and  the sphincter
ani, where it has not  yet  been found.  In the
places where capsules of  Trichina are seated,
fatty tissue is constantly inserted, chiefly at their
minis cloaem ipsius=(the lumen of the canal formed by
the cloaca) 0 130 mill.—0-i 58'" /\=0059'" V. Sperma-
tozoida globuliformia ad 50 mill, longa.
  " Fernina : in trunco rectior, minus curvata, rndfre ali-
epdi latior, minusque elastica et flexibilis, ob ovulorum
in utero et in ovariis copiam, eaque de causa colore magis
fusea; extremitate caudali obtuso acuminata.
  "Ovula/usracum. generis speciminibus; 0-054 mill.=
0022'" P. et V. longa; media in parte 0-025 mill. =
0-0112'" P. et V. in apicibus 0-01 wriH.=0-004S'" P. et V.
lata.  Embryonum migrationes adhuc ignotm.  Verisi-
millimnm est, Trichinas, quas dicunt spirales, Tricho-
cephali elisparis embryones esse."
  * Description of Trichina spiralis.—" Corpus plerum-
que in xpiras 2 rctortum, ad anum versus crassius et obro-
tundatum, ad caput attenuatum; tubus in'estinalis, uti
apud Trichoc. disparem, ab initio multifarie retortus,
ventriculw  pyriformis cum  lateralibus 2 appendicibus
alosis (lobulis aut glandulis aut nervis), intestinum rec-
tum post coarctationem quondam iterum incrassatum,
rectuque vid ad anum in extremitate posteriore e&que
crassiore apertumprofectum.  Funiculus quidam secun-
dus in utrdque extremitate cascus et semilunaris genita-
lium primordia format (?).
  "Longit.  vesicularum 0-2 —0-5 —0-7"'=0-4 —1-0 —
1-5 mill.; latitudo fere mediam ptrtem exhibet.
  "Longitudo vermiculi extcystide liberati et evoluti se-
cundum  Luschka i — V"'.  secundum meas mensuras
1-115 mt7/.=0-50"' P. et 0 513'" V.; latitudo in capitis
apice 0-008  miM.=0-Q036"' P. et 0-0037'" 1'.,- la'itndo
extremitritis posterioris seu ani 0-024 wuZ£.=0-0108'" P.
=0-111'" F."—KtOHENMEISTER.
anterior and  posterior extremities; the fat being
apparently deposited to fill up the space produced
by the Trichina having  penetrated between the
muscular fibres.
  118. a. The development of  Trichina  spiralis
seems to be as follows :  " When a human being
has swallowed the eggs, or the youngest brood
developed into ready-formed embryos which oc-
cur in the eggs, or perhaps also when any female
Trichocephali residing in the small intestine scat-
ter their eggs with the ready-formed embryos in
them, and when in either case the egg-shells are
burst, and  the embryos set free in the  intestinal
canal, the desire of migration awakens in them,
and they set out, like the embryos of many other
Nematoda, in the shortest and  easiest way to-
wards the tissues which  they  prefer as their
resting-place."  That in  this case, as in  that of
the Cestodea,  the digestive canal may  be  the
place of immigration from the exterior, is shown
by the fact that the muscles of the tongue, phar-
ynx,  and oesophagus, as well  as  the  sphincter
ani internus, are visited by the Trichina.   In
some cases the blood may be the  bearer of the
migrating  brood.   Meissner  found the  young
attached to the inner walls of blood-vessels  and
of the heart; and both  he and Leuckart think
that the circumstance of the brood of  cestode
worms being found  so abundantly in the blood-
vessels  shows  that the blood is their most usual
course of  migration.  Kuchenmeister believes
that both courses of migration are followed by
penetrating the tissues,  and by the blood.  The
Trichina  having  found  a  resting-place,  a cyst
closely adhering to the tissues is formed around
it.  This cyst consists of concentric layers of a
fibrous or lamellar substance, with imbedded cell-
nuclei.   The brood reposing in  this cyst approx-
imates the head and  caudal extremities in spiral
turns, without, however,  contracting a part of
the head, and  is then perhaps surrounded, even
on the part of the worm, with  a peculiar layer,
but certainly enveloped  on the  part of the host
with  a capsule and cyst, in which the  worm in-
creases in  size ; and, besides the intestinal canal,
develops the primitive foundations of  an organ
which belongs to the generative apparatus.  The
material for the capsule or cyst  enveloping  the
Trichina, according to Luschka, is formed from
the inflammatory exudation produced by the  pas-
sage  and  site of the worm; and hence the  cyst
varies in appearance with the  time which has
elapsed since the immigration, the oldest cysts
exhibiting granules of lime-salts combined with
an  organic substance, this deposition of lime-
salts increasing with the age of the cyst.  San-
ders and  Kirk state that there  are around  the
worm—1,  an external fibrous envelope ; 2, a tol-
erably thick layer of a white, transparent,  ho-
mogeneous substance ; and, 3, an internal round
capsule.
   119.  b.  The contents ofthe cyst consist of one
or more animals, and a  small quantity of fluid,
which keeps the inner envelope extended (which
envelope  Kuchenmeister and  Luschka  believe
to be derived from the animal itself); the fluid is
sometimes clear, especially in  the comparatively
young Trichina.  In cysts with worms recently
dead or destroyed, it showed traces of organic
decomposition.  In cysts with worms which  have
been long dead, or in those which contained no
worms, which are rare, is found a clear, thickish
fluid, with  small  formative elements,  or only  a 
WORMS—Oxyuris Vermicularis described.
1539
 few elementary granules.  These wormless cysts
 probably  had previously  enclosed  a  Trichina,
 which had died, and that a  complete  solution
 of the worm  had taken  place, or which had mi-
 grated  from  the  cyst,  and wandered  to  some
 other situation, where it had  again become en-
 cysted.
    120.  As  to the  destination  of the Trichina,
 there is no doubt that a  great  number, if not all,
 of those wliich occur in the muscles of man be-
 come abortive and die.   The  latter then lie  in
 their cysts, in the midst of the cyst-fluid, which
 is in course  of sebacification, desiccation, and
 calcification, rolled  in spiral convolutions, in the
 same way as the Trichina seen in a living state.
 These spiral structures are, however, broken up
 into  fragments, which indicate a ringed appear-
 ance  or  a segmentation of the bodies  of  these
 animals.  " But how these encysted  nematode
 worms, with our present state  of civilization, can
 reach, before  the period of their death—which,
 however,  only occurs very late, perhaps  in 30  to
 40 years, or after a still longer period in particu-
 lar cases—places  in which they are in a position
 to pass through their farther and higher develop-
 ment, is beyond  my power to  divine"  (Kuchen-
 meister).   On this subject the  experiments  of
 this writer, and of Zenker and  Leuckart, have
 thrown no light.
   121. c.  The reasons which have induced Kuch-
 enmeister to regard  the Trichina of Owen and
 Luschka  as the young brood  of Trichocephalus
 dispar, and to consider  both  these  nematode
 worms,  hitherto placed separately, as belonging
 to one species, are the following:  1.  The skin
 of both has  a peculiar ringed and jointed struc-
 ture, which presents itself more distinctly than in
 many other Nematoda.  2.  In both, a longitudinal
 stria runs down the sides, indicating the limit to
 which the contractile parenchyma ofthe worm, in
 which its internal organs are imbedded, reaches.
 These  striae are  certainly  the  points of attach-
 ment of the  parenchyma  to the inner wall ofthe
 integument of the  Trichina.   3. The alimentary
 canal  is organized  in exactly  the  same way in
 both.   The mouth and anus are situated exactly
 in the centre  of the two extremities  of these
 bodies, the anterior and  posterior;  this  circum-
 stance  excluding  the Ascarides, Oxyurides, and
 Strongyli, and most of  the Filaria,  from any
 relationship  with Trichina  spiralis.   4.  The sec-
 ond tube  which occurs in the  abdomen, togeth-
 er with the  intestinal  canal, favours  the iden-
 tity of the two worms ; the  course of this  tube
 admitting  of being  so developed as  to produce
 either female or male Trichocephali.   For these
 reasons  Kuchenmeister regards the  Trichina
 as the brood of Trichocephali engaged in migra-
 tion, by swallowing which  we infect  ourselves
 with  the  Trichocephalus dispar  of both  sexes.
 The symptoms  produced  by  these worms have
 not been observed  or stated.  Even the immi-
 gration of the  brood of Trichina appears  to  take
 place without  any  general  reaction, and is  also
 borne without injury for many years.
   122.  ii.  Oxyuris ^sharp-tail (from  oijde  and
 ovpu).   This  name  applies  only to the  female,
 but by no means  to  the male.  This worm  is
 differently classed  by Dujardin and  Diesing,
 whose classifications are too artificial, and too
 subdivided to admit  of notice at this place.   The
 Oxyuris, according to  Dujardin and  most other
authors,  is a genus  of Nematoda  separated from
 Ascaris.  ' This writer  gives  the subjoined  sys-
 tematic description of it.*
    123. A.  Oxyuris  vermicularis, Bremser, Du-
 jardin, Von Siebold, Goeze,  Rudolphi, Die-
 sing,  &c.;  Fusaria vermicularis,  Zeder ;  Kin-
 der-, Mastdarm-,  Madenwurm;  Thread worm.t—
 a. Three forms as to size, sex, <$rc, of these worms
 are met with :  1. The mature females, which are

   » " Ceyrpus cylindricum aut fere fusiforme, sublongum,
 in feminis retrorsum subulatum; caput inerme; os ro-
 tundum (m statu contractionis) aut triangulare (in statu
 actioms), tnlabiatum;  oesophagus musculosus cylindri-
 cus aut clanfoi-mis et canali triquetro perforatus • ven-
 tnculus globosus cavitate triangulari; intestinum in fe-
 minis ante apwem  caudoz acutce, in maribus in centro
 cauda! apertum.          s
   " Mares : feremicroscopici; plerumque spirales in fine
 posteriori' obtusi; penis simplex, uncinatus.
   " Feminse :  cauda acuta; vagina semper in parte ver-
 mis  anteriore sita; uterus bdocularis cum ovariis  2.
 Ovula  Icevia,  oblonga, non symmetrica, multo  longiora
 quam latiora,  omnino magna: 0-064 mill. 0-136 longa."
   t " Corpus album; cutis transverse striata, in marginc
 utroque cum duplice ordine dentium acutiorum et obtusi-
 orum, secundum, Dujardini mensuras 0-018 — 0-023 mill.,
 secundum meas in feminis 0-024 — 0030-mtM.=0-0108 —
 0-014'" P.= 0-011 —0-015'" V., in maribus autem 0-008
 mill — 0-0036'" P.=0-0l>37'" V., inter se distantium;
 caput 2 appendicibus lateralibus, vesiculosis epidermidis
 duplicaturd; os rotundum, antice margine trilabiatum et
 angustum; asophagus carnosus, musculis longitudinali-
 bus et transversis, canali triquetro; ventriculus strictura ;
 cesophago sejunctus, globosus, cum cavitate interna tri-
 quetro, et valvu'arum apparatu;  epithelia polyedrico
 cum nodu'o pellucido sparsim instructus.
   " Mas : 2-05 mi7?.=0-90"' P.=0-95'" V. ad 2-5 mill, ad
 3-37 mill, longus (si caudam semper curvatam tanquam
 lined recta  ex'ensam mensvs  est);  in capite una cum
 appendicibus  0-094  mill. =0-041'" P.=0-042'" V.,  sine
 a./pendicibus 0-024 i?t!7?.=0-010S'"P.=0-oil"' v., medio
 in corpore 0-123 m>/;.=0054"' P.—0-055'" F., in cauda
 0-023 wu7L=0-0144'" P.=0.0148'" F. latus.  (Esophaqus
 a 0-024 rai77.=0-0108"' P.=0-011'"  F. ad 0-041 mill —
 0-0108'" P.=0-011 V.adO-04lmill.=0018'"P.=0-01S5'"
 V. la'itwHnis intumidus est, circiter O'oll mi7Z.=0-137'"
 P.=0-141'" V. longus.  OCsophagum sequitur brevis tubi
 intestinalis strictura 0008 mt77. =0-0036'"  P.=0-0037'"
 F. longa, et 0-016 mi7?.=0 0072"' P.=0-0074'" F.  lata.
 Postea sequitur ventriculus 0-115 mill. = 0-050'" P =
 0-052'"  F. longus, et 0065 wua=0-0288"'P.=00-96'"' V.
 latut, cum valvularum apparatu cognito; tubus intesti-
 nalis paulo  post ventriculum  latitudinis 0-057  mill. =
 0-025'"  P.—0-026'" V. est,  ad anum vero 0-003 mill.=
 0003G'" P. =0-0037'" F.   Penis  simplex, 0057 mill =
 0.025"'P.=0-026 V. longus, ad basin 0 008 mill.=0 0036'"
 P. =0-0037'" V., in apice vero semper ad hamuli instar
 recurvato, latitudinis (adultiorum 0003 rm'M.=0-001"'P.
 et V.).  Funiculus spermaticus et testis simplex;  spcr-
 matozoidia epitheliorium imaginem simulantia.  Cauda
 apex infoveam. suetoriam mutabilis.
   ' Femina: 7 S4 ex aliis ad 10 mi77,=3-48, ex aliis ad
 4-337"' P. =3 57, ex aliis ad 4-56"' F. longa; in capitis
 apice cum appendicibus 0-196 7)it7Z.=0-087'" P.=0-089'"
 F.; sine appendicibus 0 065 ?ra7Z. =0-029"' P.=0-0298'"
 F.," in medio corpore 0.49 ad 059 mt'H.=0-21—0-26"' P.
 =0-22 — 0 27"' F.; cxtremitas caudalis acutissima.  Lon-
 gitudo candce (i. e.,pirtis inter anum et apicem) 1738
 mill—0-701'" P.=0S19'" F.,- latitudo cauda; ad anum
 ipsam 0-26 mill.=0-116'" P.=0119'" V., inde diminuta.
 Oesophagus 065 mill =0-29'" P.=0-298'" V. longus, in
 capitis apice 0065 mill—O-OW" P.=0-298'" V., inparie
posteriore0-098mill.=0-0i3'" P.=Q 044'" V. latus. Stric-
 tura tubi intestinalis pone  cesophagum uti in maribus
perbrevis et 0-028 mill, seu 0128'"P.  et V. lata.   Ventri-
 culus 0-172 mill.—O 0168'" P. et V. U  longus et latus, in-
 terdum latitudine aliquid minor.   Vagina ex Dujardini
 mensuris 1 -8 mill, ex meis ad 1 64 mill.=0-V."pone caput
 sita; in mvis 1  00 —1-2mill. =0-40 — 0-54'" longa et 0-11
 rca'Z7.=0-049"' lata; cum foramine latitudinis 6-13 mill.
 =0 06'", longitudinis 0-15 toi7'.=0-07'" ;  uterus duplex,
 cujus ramus posterior 20 mill—0-0'", cujus anterior 1-35
 mill.=0G'"longus; ramosumomilisimpletorurnlatitudo
ad 0-4 wit7Z.=0-18"' et ultra ovulis expulsis, 02 mill.=
0 03'"; ovarium duplex, in transitu uteri in anum 0.03
?;ti7L=0-015"' latum.
  "Ovula fere oblonga non symmetrica;  ex Dujardini
mensuris 0-055 mill,  lata et 0-004 mill,  longa, ex meis
media in parte ovulorum 0-029 mill.=0 01-2'" P.=0 015"'
 V., in apicibns circiter 0012 mill.—0005'"  P.=0000'"
 V. lata et 0 05 mill.=0-022'" P. et V. longa.   Embryones
viventes in ovulis nonelum vidi."—Kuchenmeister. 
1510
WORMS—Strongylus described.
remarkable for their size, thickness, and white-
ness, for their acute capillary tail, and for an ob-
tuse, broad  head.  2. The young immature fe-
males resemble the pale-gray colour of the males,
but they are somewhat larger than they, and are
recognised by their acute tails, and by the female
sexual organs  in grades of development varying
with their age.  3. The mature males are remark-
able by  their  pale silver-gray colour,  and their
obtuse anterior and posterior extremities, as also
by the penis.   All  the three  forms occur abund-
antly in one and the same intestine.   The skin,
head, and oesophagus, and intestine are similar
in both sexes.   The nervous system of the Oxyu-
rides is, according to Walter, greatly developed,
although hitherto overlooked.  They have  both
cephalic and caudal ganglia,  with other ganglia,
plexuses, and lateral filaments,  which  are  mi-
nutely described by Walter and Kuchenmeis-
ter.  The primitive nervous filaments are pro-
duced from the processes of the ganglionic cells ;
by  the union  of several primitive  filaments of
this kind, narrower or broader branches are pro-
duced.   The  skin  of  the  oxyurides consists of
an  external epidermis, and beneath this a  deli-
cate but densely fibrous corium.  The parenchy-
ma of  the body does not  extend into the  tail.
The muscular  system  is highly developed.  The
alimentary apparatus consists of a mouth, oesoph-
agus, stomach, intestine, rectum, and  anal cleft.
For a minute description  of these and of the
sexual organization, my limits oblige me to  refer
the reader to the works of the authors just named,
who ascertained that the males  of  the oxyuris
vermicularis are much more numerous than was
formerly supposed.
   124. b. The locality of these worms in the hu-
man body is the lower  portion of the intestinal
canal, especially the rectum.   They occasionally
stray upward,  but  rarely higher  than  the lower
part of the  small intestine.   They wander, how-
ever, out of the  anus and into the  vagina of fe-
males.   Although most frequent  in  boys  and
young  persons, yet they are not uncommon at
all more advanced ages, even in  the most aged,
in whom I have repeatedly found them the  most
tormenting.   They are gregarious, forming  balls
in  the large   intestines, frequently along  with
other worms, especially  the Ascaris lumbricoides.
J. P. Frank found them in the intestines  of an"
infant so young that the umbilical portion of the
cord had not separated.   They  are,  of all the
Helmintha, the most frequent tormentors of every
age and of every people ; for they are not limited
to particular parts of the world.
   125. c. Symptoms.—These vary with the num-
ber of the worms and their position.  A few
hardly occasion any marked symptoms; but when
numerous, in the lowest part of the rectum, they
occasion extremely distressing itching and an ir-
ritating annoyance, difficult to be described, ex-
tending to  adjoining  parts.  Certain articles of
diet, as onions, carrots, fruits, &c, render the
worms more  restless and irritating during the
whole day; but they are  generally most annoy-
ing when the patient goes  to bed.  When the
patient falls asleep, grinding of the teeth, excite-
ment of the sexual organs, and  restlessness are
caused by them.  The consequences of this local
 and constant irritation are, especially at, and sub-
 sequently to,  the  period of puberty,  increased
 sexual irritation, masturbation, &c, in both sex-
 es, r.nd in the female sex most distressingly when
the worms  wander into the vagina, when they
occasion not merely pruritus, but also leucorrhcea,
&c.   The loss of rest and the irritation they pro-
duce ultimately impair nutrition, give rise to pal-
lor, anaemia, and loss  of flesh ; irritation of the
nostrils, sneezings, discoloration  of the counte-
nance, or a dark circle around the eyes, dilated
pupils, and various sympathetic phenomena.
   126.  d.  The  diagnosis,  however,  of  these
thread worms can be established  with certainty
only by  examining the  faecal evacuations, espe-
cially after the administration of an enema.  The
prognosis, although the  complaint is unattended
by danger, is not favourable as respects  either a
speedy  or a permanent cure.
   127.  iii.  Strongyli* and their  Allies —This
genus of worms has been often described ; but,
of the  less recent writers, more especially  by
Rudolphi and  Bremser.    The  species which
most particularly interests the physician  is,
   128.  A. The  Strongylus gigas-\—Ascaris vis-
ceralis aut renalis, Gmelin ; Lumbrici in  renibus,
Blasius ;  L. renalis, Redi ;  Fusana visceralis
aut  renalis, Zeder.  Kuchenmeister  remarks
that Brf.mser has shown this worm, which oc-
curs, although rarely in the abdominal cavity, the
omentum, but especially in  the kidneys and uri-
nary bladder, more rarely in the lungs and liver,
and only when strayed in the intestinal canal of
martens, dogs,  wolves,  seals,  otters, oxen, and
horses, is still  more' rare in man ; and that a
number of those accounts of worms passing off
through  the urinary  passages  are delusions.
Since  a minute  knowledge of the pathology  of
the kidneys has been acquired, it may be inferred
that many of these cases would be recognised as
fibrinous casts thrown  off  in  the urine during
disease of these organs.  That these worms arc
extremely rare,  even in  the kidneys, must  be
admitted, since  Kuchenmeister  has never met
with a case in his own practice.   He has, more-
over, thrown rational doubts on the authenticity
of most of the  cases on  record,  showing that
these cases, at  least  some  of them, may have
been instances of mistaken diagnosis.  Dr. Lan-

  * "A.  Strongyli veri.  Corpore subcylindrici, idrinque
attenuato; capite nudo rar.us alato, 2 appendicibus late-
ralibus arniato; ore terminali, nudo vel sex papillis  in-
structo, vel orbiculari; cesophago trianqulari,mvsculoso;
cute tenui.  Mas:  appendice multilobata aut radiata;
penis simplex vel duplex, multilobatus, ad digitorum in-
star.  Femina: caudd obtusd, recta; ano in parte eau-
dali; vagina antrorsum situ ; utero simplioi aut bilocu-
lari; ovulis magnis (0 06 — 0-12 mill.).  Animalia ovi-
aut vivipara."—Kuchfnmeisteu.
   Dujardin arranges the Strongyli veri as the xivth Ge-
nus of his Nematoides.  Diening places the two species,
Str. gigas and Str. longiveieiinnlus, in his Gen. liv., Eu-
strongylus, thus defined by him :  " Corpore subcylindrico,
utrinque sensim attinuato, capite corpore continvo, ore
terminali, orbiculari, papilloso; bursa maris terminali,
Integra; pene filiformi longo, haudvaginato; vagind aut
antrorsum aut retrorsum sitd.  Systemati ganglioruw.
distinctissim o.  A nimalia ovi- aut vivipara, extra tubum
intestinalem habitantin."
   t " Corpore rubro, cylindrico, longissimo, utrinque atten-
uato, striis aut annulis transversis interruptis et 8 fasciis
fibrarumlongitudinalium instructo; capite obtu-<o, trun-
cato; ore orbiculari 6 papillis aut nodulis planiusculis,
appropinquantibus; cesophago 15—22 mill, circiter lon-
go, tenui et angustiore quam canalis intestinalis.
   " Mas : corpore antrorsum maetis attenuato, 140 ad 140
wuH.=10"— 1' longo, 4 — 6 mill, lato; caudd obtusd cum
bursd membranacedpatelliformi, circa 3 mill, laid, trun-
catd; pene tenuissimo simplici.
   " Femina: corpore utrinque attenuato, 2 decim. ad 1
metr.=b" — 3' longo, 5 — 12 mill, lato; caudd  magis
rectd, obtuso-rotunda/d; ano triangulari, oblongo, sub
extremitate caudali sito; vagind antroryum sita; utero
simplici; ovulis fere globulosis."—V, uciienmeister. 
WORMS—Ancylostomum described.
1541
kester, however, states that there is a fine spec- i
imen of this worm taken  from a human kidney
in the Museum of the Royal College of Surgeons
of England.
  129. a. When fresh, this worm has a reddish
colour.   In spirit this colour fades, and the worm
assumes a grayish leaden hue.   Four longitudin-
al stripes arc observed on it.   The  total  length
of a female specimen was 19 Saxon inches.  Du-
jardin states that the vagina opens 1 to  2 inches
from the caudal extremity.   Diesing says that
the ganglial system of nerves is most  manifest
in this worm,  a remark which is confirmed by
Blanchard, Otto, and Von Siebold.
  130. b. The symptoms of this worm are equiv-
ocal, for there can be no evidence of its existence
to be relied upon  until it is discharged, thereby
demonstrating  its existence.   Another species of
Strongylus, the S. longevaginatus of Diesing, has
been said to have been found in the  human sub-
ject, but without sufficient proof.
  131. iv.  Ancylostomum.*—Anchylostoma,Du-
bini ; Aiicylostoma, Creplin.— This worm was
found by Dubini in Milan, in 1838, in the duode-
num and upper part of the jejunum ; and subse-
quently also by Pruner, Bilharz, and Griesin-
ger, in the countries watered by the Nile.  Ac-
cording to  Von Siebold, it has never been found
in Europe  to the north of the Alps.   Dubini es-
tablished this as a distinct genus from the Stron-
gyli, by the symmetrical arrangement of the dent-
al apparatus.   We are, however, at present ac-
quainted only with a single species of it.
  132. .1.  Ancylostomum Duodenale.i—Bilharz,
having had his attention called to this worm by
Von Siebold, in consequence of Pruner having
found it in  Egypt,  observed it in every  body he
examined after death in that country, sometimes
in small numbers, sometimes in hundreds, less in
the duodenum  than in the jejunum, between the
transverse  folds of  the mucous membrane.  One
male is found to three females.   At  the oval end,
a large, obliquely truncated horny  capsule, fur-
nished with four strong teeth on the projecting
portion of  the  upper margin, is seen.  The oval
orifice is turned to the surface opposite to the
  ""Vermes subcinerei, vivipari, corpus cylindricum;
 caput aliqnil attcnuatum; pharynx infundibuliformis,
 colore subfusco, parietibus resistentibus.  Os acetabuli-
 forme, subcorneum; apertura oris ampla cirenlaris i,ub-
 dorsalis; dentes in f undo oris intra apertures marqinem
 abilominalem 4, uncinati (os in altitudine infundibuli 4
 uncinis intus recurvatis munitum et in fundo cum emi-
 ncntiis conicis, in tabularum explications iunguli tegu-
 mentarii' nomina'is, in uncinos versis, utrique generi
 communibus, Dubini); oesophagus carnosus, qui ad clavce
 irutetr inter deseendendum largitur; cutis tramverse stri-
 ati, unde 2 eminentice conicos promincn', uno alteri op-
 posila, inter sextam, anteriorem partem longitudinis ver-
 miculi totalis et inter reliquas posterior es vermiculi partes,
 qua quinquies sextam longitudinis totalis partem exhi-
 oent; anus lateralif et aliquid ab extremitate caudali re-
 mota. Extremitas ctudalis maris bursam terminalem
 integrum subtus excisam multiradiatam exappendicula-
 ta.ni,; penem duplicem longissimum exhibens; feminse
 obtiu.ii, nperturamgenitalem retrorsum sitamprosbens."
 —Diesing et Dubini.
  t " Caput apice rotundatum; oris limbipapillis conicis
 inat [iialibus, duabus minoribus,  uncinis papillis imposi-
 tisapicibus convergentibus.  Corpus subrectum v.parum
 curvatum, antcrioreparte transparent, ventrieulo globoso
 nigrescnte, posteriore fiavido-fuscum, maris antrorsum
 aitenuatahi, extremitate caudali intlexd; bursd  cyathi-
 formi bilobd ll-radiatd, cujus radii ita sunt positi, ut
 triplicem eorum ordinem  conspicere possis, in utroque
 enim latere ordinem quatuor, media in parte trium radi-
 orum (radii.t  lateralibus u'riiwque 5 simplicibus: Die-
 sing) ; radio dor soli  apice furcato; femince extremitate I
posticdacuteconicd.  Longit. mar. 3 — 4'"; fern. 4—5'";
 crassit. ad i'"."—Diesing et Von Sieuolo.
sexual and anal  orifices.   The  animal attaches
itself by its mouth so firmly to the mucous sur-
face that the mouth  is torn away when  it is
detached by  force.   Its  nourishment  is blood,
as proved by its  intestine being filled with this
fluid.
  133. a. Pathology.—This worm is of great in-
terest and importance, and is often fatal to those
afflicted with it.  Griesinger, the best chemical
observer of this worm, states that this worm at-
taches itself firmly by biting into the  mucous
and  sub-mucous  membranes ; and that the spot
on which a worm has been attached is indicated
by an ecchymosis of the  size of a lentil, in the
centre of which a white spot the size of a pin's
head appears, which is pierced  by a hole pene-
trating into the sub-mucous tissue.  From these
wounds the blood enters freely into the intestine
of the worm, which is filled with blood from the
punctured places.  Frequently the mucous mem-
brane of the intestine is studded with flat, livid,
brownish-red elevations of the  size of a lentil.
This is owing to the collection  of the blood be-
tween the mucous membrane and muscular coat.
In some cases a  specimen of the worm is found
lying in the cavity thus  formed, covered with
blood, with which it has completely engorged it-
self.  The manifest consequence of this infliction
is anamia.   Griesinger imputes the "Egyptian
chlorosis,"  which he  had previously described,
and  which, he avers, attacks one fourth of the
population, entirely to the presence of this worm.
  134. b. Symptoms.—At an early period, pallor
of the face, general surface, lips and gums ; pal-
pitations of the heart, especially on any exertion,
sounds in the jugular veins on auscultation, las-
situde, debility without emaciation, are the chief
phenomena.   Subsequently disordered digestion,
irregularity of the  bowels, and  Catarrhus intes-
tinalis are complained of.   These symptoms may
continue an indefinite time; but if not removed
by  a decided treatment,  the consequences are
most serious, and  generally fatal.   Emaciation
often does not commence until  late in the dis-
ease.  CEdema of the extremities and eyelids ; a
pale yellowish or greenish yellow hue of the gen-
eral surface;  a  withered, dry,  flabby, and cold
state of the integuments,  and a  remarkable pal-
lor of the outlets of mucous canals ;  remarkable
apathy, and sense of exhaustion ; constant and
distressing palpitations, the  sounds of the heart
being often heard at the distance of several feet;
murmurs in all the larger arteries, and a rushing
or purring sound in  the jugulars, slowly super-
vene.  The pulse  is uncommonly quick and small;
the  respiratory movements are weak, frequent,
and short; the urine is abundant, pale, and rarely
contains albumen.   Giddiness and headache are
commonly experienced.  Constant hunger, sin-
gular  appetites,  and  slight  febrile  movements,
sometimes with  enlargement of the  spleen and
atrophy of the liver,  are observed.  With indul-
gence and full diet this state may last for years ;
but  in very many cases the progress of the mal-
ady is rapid.   Even in the best circumstances
the  patient is pallid,  sickly, and miserable, ex-
hibiting a high degree of  anaefnia and hydremia.
Various acute affections often supervene and com-
plicate  the disease, and  a chronic diarrhoea or
dysentery ultimately carries off the patient.   Fa-
tiguing labour, a  lowering or antiphlogistic treat-
ment, and debilitating agents hasten dissolution
A restorative regimen, change  of climate, and 
1542
WORMS—Filaria Medinensis described.
 judicious treatment, often arrest the complaint.
. All the phenomena consequent on the presence
 of these  parasites  are characteristic  of a very
 slow but  continued loss of blood,  which, if  not
 arrested, goes on until  the quantity and the qual-
 ity of this fluid are no  longer sufficient to sustain
 life ; death supervening with faintness, dyspnoea,
 and fatal  syncope.
    135.  c. On examination after death, the organs
 and  structures generally are wasted, pallid, and
 softened.   The  spleen is often enlarged;  the
 liver is pale and  atrophied ;  the veins  are nearly
 empty ; the heart and large venous trunks contain
 only soft, small  brown coagula, with very little
 fibrin.   In many even  ofthe large venous trunks
 there is only a dark serous-looking fluid, with a
 few  pale, large, and   colourless blood-globules.
 The  substance of the  heart,  especially the inner
 layers of muscles, are very pale and even fatty.
 This organ is generally  large, thick,  hypertro-
 phied  or  dilated, particularly  on  the  left side.
 The  endocardium and valves are often irregular,
 as if thickened in parts.  The brain, the lungs,
 the muscles, the digestive mucous surface, &c,
 exhibit remarkable pallor and anaemia ; the cellu-
 lar tissue and muscles  being softened, flabby,  and
 in parts exhibiting a watery infiltration (§ 134).
    136.  v. The  Filaria.*—These form the sev-
 enth genus of the first-class "Nematodes" of Du-
 jardin, and the fortieth genus  of the sixth order,
 "Nematoidea" of Diesing.    From the Gordii
 they are distinguished  by structure, mode of life,
 the nature of the  youngest brood, and  by  the
 circumstance  that they  readily  burst in water,
 like other Nematoda, which is  not  the case with
 the Gordii (Diesing).
    137. A. Filaria Medinensis.f—Plutarch re-
 fers, in the ninth question of the eighth book of
 his "Symposiacon," to the statement of Agathar-
 chides of Cnidus,  the geographer and philoso-
 pher, " That the  people on the Arabian side of
 the  Red  Sea  suffered many  strange  diseases;
 among others, worms, like little snakes (dpanov-
 ria pucpu), came out upon them, which  gnawed
 their legs and arms, and when touched retracted
 themselves, coiled themselves up in the flesh,  and
 gave  rise to the most insupportable pains;  but
 that this evil has been found only then, and nei-
   * Diagnosis:  " Vermes  albi, subfusci, aut ruOri, cor-
 pore filiformi, elastico, cylindrico, ut plurimum longissi-
 mo;  capite corpore continuo, inermi aut spinulis reciis
 et cornels (dentibus seu papillisprominentibus Autorum)
 armato; ore terminali non labiato, vel  labiato rotunda,
 aut triangiilari; o?sophago brevi, tubuloso, rectiore quam
 intestinum; ano terminali aut ante cauda apicem sito;
 cute Imvi aut leviter oblique striata.
   " Mas: caudd plerumque obtusa, interdummembranam
 acxssoriam alosam exhibente; spiculis filiformibus in va-
 gina, tubulosa aut  ligulatformi, ex  Dujardino incequali-
 bus, curvatis (?).   Femina : vagina antrorsum proxime
 ad os sita, plerumque duplici (Filaria rigida) aut mul'i-
 plici (exc.  quinqueloculariin Filaria labiato, Nathusius);
 ovulis ellipticis aut globosis, laceribus.  Nunc ovi- nunc
 vivipara?."
    t" Mares omnino ignoti aut potius ab auctoribus neg-
 lecti et omissi, quin ob minorem magnitudinem minorcs
 efficiunt et molestias et dolores et vix unquam, majores tu-
 mores; sed uti Diesingius ipse enarra', a Clellandio in
 Calcutta Journ. Nat. Hist.,1. 359, PI. X.,fin. 1, delineati.
    " Feminse: corpore longissimo (ad 3  ulhas et aliquid
 supra), subalbo, filiformi, subapiali, secundum Dujar-
 dinum antrorsum, sM secundum Diesingium et quidem
 quod ipse afiirmare pos'Mtn retrorsum, sensim attenuato,
 adl"  seu adl — 21 mill, lato; ore orbiculari, spinulis
 4 crueiatim oppositis; caudd all apicem. uncinate,  sub-
 acute!,  in apic 0 065 —O-OSS mt77.=0-02S — 0-036'" Par.
 =0-029 — 0-037'" V. la'd,  interdum in vrmis ipsius cute
 ita afftxd, ut vix apicm libtrum facerc possis; vagina
 ovulis; embryonibus 1" longis, vix \"' latis.  Species vi-
 vipara."—Kuchenmeister.
thcr before nor since among any other people."
Many authors, with much appearance of justice,
believe that the fiery serpents, which Moses states
to have been so destructive to the Israelites when
journeying in the vicinity of the Red  Sea, were
Filaria Medinenses, and consequently that Mo-
ses is the first writer to  notice this worm, and
that the fiery inflammation produced by it gave
rise to  the appellation bestowed upon it by the
Hebrew writer.*   That the Filaria was consider-
ed a species of serpent by the ancients, is proved
by  the  Greek name  dpaKdvriov,  dracunculus,
which was given it, and  by the  inflammation,
pain, and swelling which occurred with the break-
ing out of the worm.   The mortality among the
Israelites may  be explained by their ignorance
of the proper treatment, and of the danger con-
sequent upon the breaking of the worm.   Aven-
zoar states that,  in his country, "JEger in con-
tinent post dolorem vehementem in parte affecta
exortum  moriatur."   The  distemper being en-
demic in the place where the Israelites were so-
journing (in Arabia Petraea), in circumstances of
great difficulty and even distress, and during the
hygienic privations of encampments in a barren
country, it is not surprising that it then and there
assumed an epidemic and fatal character.
   138.  Synon.—The Filaria Medinensis has re-
ceived a variety of names, viz., the Dracunculus;
the  Drac. tibiarum;  the   Drac. Persarum; the
Guinea-worm, or G.  thread-worm, from its fre-
quent occurrence  on the coast of Guinea; the
Guinea dragon;  the  Guinea  hair-worm; Pha-
raoh's worm;  the  Skin-worm;  the leg-worm; le
Dragonneau, le ver de Guin'ce,  le ver Cutane, by
the French;  Guinischcr Fadenwurm;  Guinischc
Drache, Pharaohswurm, by  the  Germans.
   139.  a.  Our  knowledge  ofthe natural history
of this  worm, and  of the early stages  of its de-
velopment, is very deficient.   Kuchenmeister
states that it  is of the thickness of pack-thread,
its anterior extremity obtuse, the mouth circular,
without lips, but beset with four hooks, or more
correctly with four styles, or acute straight spines;
the vagina opens  in  the  vicinity of the mouth,
and the vagina and uterus are probably double,
as  in  most Filaria.   The  length of the worm
  * Upon referripg to a translation  ofthe Bible from the
Hebrew into Latin,  with  very copious annotations, by
Immanuel Tre.melli and Francis Junius (the former a
learned Rabbi converted to ( hristianity, the first and sec-
ond editions of which, published in London in 1579-80,
and 15S4, in quarto, are in my library), I find that he
translates the Hebrew description as follows: " Turn im-
misit Jehova in populum ilium serpentes prcsteres, qui
mordernnt populum :  ita moriabatur populus multus ex
Israele."   Here  Tremelli translates the Hebrew into
venomous serpents; but in a note he states that according
to the original they were fiery serpents.  To this transla-
tion of the Bible and to its copious annotations, the trans-
lators of King James's Bible, and modern annotators, are
more indebted than has been  made to appear.  Fpon re-
ferring farther  to the very rare edition of the Vulgate,
also in my possession, which was  printed in 1481, and
known by the term " Fontibus et Grwis," &c, the ser-
pents are called "fiery serpents (Misit Deus ignitos ser-
pentes)—which inflicted wounds and death on many."
This edition of the Bible is in folio, on a thick, beautiful
paper, the ink being a bright jet-black, without the name
of cither printer or publisher, and without the verses be-
ing numbered, but with the initial letters illuminated and
coloured.  These translations vary only in the term " ven-
omous" being used by the former for " fiery;" while the
statement  in the latter,  that these serpents "inflicted
wounds and death on many,"  may be considered as near-
er the truth, as  the infliction of wounds does not imply
that death  was always  the result.   Some translations,
which retain the appellation "fiery," very justly explain
it by stating it  to refer entirely to the inflammation and
pain produced by these animals. 
WORMS—Filaria Medinensis  described.
1543
varies from several inches to three yards.  State-
ments of greater dimensions are probably founded
in error.   The whole surface ofthe worm and its
tail exhibits the well-known fine rings, placed at
a uniform distance.  The substance of the body
is homogeneous, finely granulated,  and exhibits
no  traces of muscular fibres.   Its  oesophagus,
intestinal canal, uterus, &c, require no descrip-
tion.*
   140. b. The  worm is indigenous  only  in the
hot zone, and, even when  transported into colder
climates,  does  not appear to  propagate itself.
Even in the hot zone  it  does  not  occur every-
where, but only in particular countries, like all
the Helmintha, and is entirely in certain places in
affected countries; as, for instance, in the Gambia,
Angola, Canlabah, &c.  The places in which the
Filaria  Medinensis more particularly occurs are
Senegal  and the coast of Guinea, the East  Indies,
Persia, Arabia Petraea, the coasts of the Red  Sea,
especially towards the  south, the shores  of the
Ganges, Bombay, the Caspian Sea, Upper Egypt,
Abyssinia', Nubia.   It was introduced into Amer-
ica by  negro  slaves,  especially  into  Surinam.
Throughout the countries now mentioned it at-
tacks aborigines and foreigners without distinc-
tion.  According to Pruner the  worm often be-
comes epidemic, in wet seasons  and in marshy
districts.  Bremser states that  it  is  most fre-
quently seen in the East  Indies from November
to  January (the rainy season);  and  in  Upper
Egypt, according to Bilharz,  shortly after the
inundations ofthe Nile.
   141. c. The  mode of production  ofthe worm
is still enveloped in obscurity.  English officers,
who never went about with the feet and arms un-
covered, remained free from this worm.  Pruner
thinks that  the germ  of  the worm  is  an inde-
pendent marsh  animal, which is converted into a
Dracunculus within the human body.  Forbes
believes  that he found the brood  of the Dracun-
culus free in the red, ochrey mud of the  drying
marshes.  However, the aborigines  think that it
comes from the marshy grounds into the skin.
The ordinary seat ofthe worm is the sub-cutane-
ous cellular tissue, especially of the lower ex-
tremities, around the ankle.   It  may, however,
occur under the skin  and muscles  in  all other
parts of the human body.  Instances  of  its oc-
currence in  other parts of the  body besides the
extremities  are recorded  by Kampfer, Bajon,
Baillie, Pere, and have been seen by myself
in Africa.  M'Gregor, in  172  cases, states  that
it occurred 124 times in the feet,  33  times in the
lower, 11 times in  the  upper part of the thigh,
twice in the scrotum, and twice in the  hands.
Pruner  found  a specimen behind the  liver, be-
tween the layers of the mesentery.  Sometimes
the worm lies coiled up in a small  space, some-
times it is extended ; and  in the latter case, if it
lies on  the surface, it feels as a varicose vein.
Pere saw it lying in a snake-like  form under the
whole ofthe skin ofthe abdomen and a part of
that of the chest, and similar cases of its exten-
sion are  on  record.  " These examples will suf-
fice to give a clear idea of this worm, of which,
moreover, as many as  twenty-eight, thirty, nay
  * Bremser gives the following systematic description of
this worm :  " Longissima cylindrata, elastica, fere equa-
litercra^a, capite attenuata, ore minimo, circulari, cauda
maris medium sui finis ad locum, quintali spirali, promi-
n.mte  sublata, inflexa; feminse semitereti, acutiuseula,
inctu-va preodita; in hominis  tela cellulosa suhcut.inea,
praesertim pedum; in regionibus tropicis figi solita."
even fifty specimens have been observed in  one
man."   (Kuchenmeister.)
  142. d.  Diagnosis.—If the worm is superficial,
with a hard  substratum, its  growth is seen to
take place with extraordinary rapidity, from 4'"
it becomes several  inches long in  a couple  of
days.  It  is then easily killed by  poultices  of
boiled garlic, after which it is absorbed without
injurious  consequences.   Frequently the worm
occasions  little or no annoyance for a long time.
Dampier and Isert had quitted the district of
these worms for 6 to 8 months, and Wengler's
patient for 4 to 6 months before the worm be-
trayed itself.  According to Kampfer and others,
this  latent state may continue 12 to 15 months,
and  in rare cases  ev^n until the third year.   In
other instances, emaciation,  notwithstanding a
good appetite and absence of fever, takes place,
terminating at last  in fatal exhaustion.  When
the worm is making its way  out, a small pustule
appears at the point where it will break through,
sometimes with, and sometimes without, prelim-
inary annoyance, or headache, pain in the stom-
ach, nausea,  fever,  &c.   At the point where it
br6aks through, inflammation, swelling, and sup-
puration occur several days previously, and con-
tinue until the worm is extracted.   If it lies over
or near to a joint, the use ofthe limb is prevented,
and  the symptoms are still more severe.   In the
case of Drummond,  after pain and stiffness ofthe
leg,  a reddish swelling, with a black point in the
centre, was formed above the inside ofthe ankle ;
and at the same time he  felt a firm, round, catgut-
like  substance  twisted  under the integuments.
About  three  weeks after  the  first sensation of
stiffness, he was seized with a sudden insupport-
able itching over the whole body, with fever, vio-
lent  colic, vomiting, and purging;*after which,
shiverings without perspiration followed.  In the    •
mean time the swelling had  burst, and a hard
white  substance appeared, but so  deep that it
could not be laid  hold of, the animal having
buried itself deeper among the muscles.   The cat-
gut-like twisted substance formerly felt was not
now present.  In the following night  the ankle
and vicinity were much inflamed ;  and three days
afterward a thread was passed round the animal,
and a bloody ichorous discharge continued for six
or seven weeks from the wound, which healed up
gradually to a small point, when the worm again
came forth, and was fastened with  a thread, roll-
ed upon a stick, and drawn out twice a day.   In
twenty days the extraction was completed.  Two
or three days after  the  formation of vesicles on
the inflamed  part these open  up, or are opened
by a lancet, when matter, blood, and sanies,  and
two  or  three inches of the  anterior end of the
worm come forth.   If this end be carefully pull-
ed, several inches more often  follow.  All this is
coiled  around a little  roll of linen or a small
stick, and fastened  over the wound with a com-
press and adhesive plaster;   and  the  worm  is
thus wound out by  repeated, careful operations,
twice daily.  The worm rarely comes away on
the first attempt, several days, or even weeks, be-
ing  required before this is  accomplished.   Mr.
Busk, in  the Transactions of the  Microscopical
Society, has given one ofthe best descriptions of
this  worm.
  [There  are several species of Filaria not de-
scribed by our author:
  1. Filaria Medinensis, or Guinea-worm, above
described.  This is  the  most  common and best 
1344              WORMS—Filaria and Ascaris Lumbricoides described.
     known species, being found  chiefly in warm cli-
     mates, where it is often seen in the morning dew,
     sometimes 10 or 12 feet long, and not thicker than
     a horse-hair.  Bacon states  that he saw two in-
     stances where it had burrowed under the mucous
     membrane of the eyeball.  As yet, only females
     have been observed in the human body—vivipa-
     rous.
        2.  Filaria Bronchialis.—This  species is  de-
     scribed by Treutler, and so named from its oc-
     currence in the lungs of persons labouring under
     phthisis.   It has also been called Hamularia lym-
     phatica; and  by Rudolphi, Haularia  sub-com-
     pressa.  This  is also met with  in the  lungs of
     the inferior animals, especially when affected with
     tubercles.  Dr. Hodgkin states that he often found
     the  filaria in  the  lungs of  the boa constrictor.
     They are usually about an inch long, roundish,
     blackish-brown, sometimes spotted white ; and at
     one extremity, two projecting  hooks. This species
     of filaria is probably  allied to those worms which
     are  not  unfrequently found  in  the bronchi  and
     lungs of animals belonging to the  genus Mustela.
        3.  Filaria Gracilis, found in apes and monkeys
     in great abundance, grows to a length of 10 or 12
     inches, about as thick as a fine thread, head ob-
     tuse, and tapering slightly at both extremities.
        4.  Filaria Attcnuata, found in  the abdominal
     cavity of crows, and in the cornea of the eye of
     fishes; from one to  six inches  long, and obtuse
     at both extremities.
        5.  Filaria Obtusa, inhabits the intestines  of
     swallows ; head somewhat acute, tail obtuse, body
     comparatively thick and elastic ; has been found
     12 inches in length.   Rudolphi  has traced out
     its intestinal canal and ovaries.
        6.  Filaria Truncata, about 5 inches long, head
     truncated, tail somewhat thick, obtuse, termin-
•    ated by a very sharp point;  inhabits the larva or
     caterpillar of certain species  of moths (Tinea pa-
     dclla.)
        7.  Filaria Ovale.—This species went formerly
     under the name  of Gordius  piscium (hair-worm
     of fishes), because it is found in the liver of the
     carp, &.c.   It is  3 or 4 inches in length, head
     oval, tapering forward ; tail round.
        8.  Filaria Capsulare;  from half an inch to one
     inch long, and resembles in  thickness a middle-
     sized  thread.   Borders of mouth recurved, tail
     obtuse, papiliform, ending with a sharp point.
     Often met with in the herring in large quantities ;
     very tenacious of life, as it will live for many days
     in a dry place, and even revise after having been
     long frozen  in masses of ice.   This species has
     been formed into a  genus by Zeder, and  other
     naturalists, under the name of Capsularis.
        9. Filaria  Papillosa.—The Filaire  equi  of
     G.meliv, and the Gordius equinus of other writ-
     ers—the  species which  inhabits  the eye of the
     horse, from  1 to 7 inches in length, and  one third
     of a line in diameter—of a yellowish-white or ash
     colour, sometimes of a brownish hue ; head slight-
     ly obtuse;  mouth orbicular;  neck studded with
     papillae;  tail slender and curved.  It  occurs in
     different parts ofthe horse, chiefly in the muscles
     and intestinal canal, though  it has been detected
     in the brain, as well as the aqueous humour of
     the eye.   They often occur in the eyes of horses
     in the East  Indies, as well as the muscles of the
     loins, causing paralysis.  The Transactions ofthe
     American Philosophical Society, vol. ii., contains
     two communications on this subject, one  by F.
     Hopkinson, Esq., entitled " Account of a Worm
in a Horse's Eye;" the other by John Morgan,
M.D., describing the same phenomenon.   Similar
cases will  be found in the Ed. Med. and SAg.
Journ. for June, 1826, and the Bulletin des^ici-
enccs Medicales, Feb., 1826.  See, also, " An Ac-
count of a Filaria  in a Horse's Eye, with Remarks
on similar Phenomena, and the Mode of their Ori-
gin," with a plate, by C. A. Lee, in Amer. Jour.
of Science and Arts,  No. II., vol. xxxix.]
   143.  vi. Ascarides. — These  worms  are ar-
ranged by Dujardin as the nineteenth genus of
the Nematoda;  and by Diesing as the twentieth
genus of the sixth order of the Achathelmintha
clastka, but the  Oxyuri are also introduced by
him into  this genus.   The classification  of Die-
sing is so involved that more confusion than elu-
cidation is the result.   Refining,  hair-splitting,
and drawing distinctions, which  are either ob-
served  with difficulty, or not at  all, are  not the
least faults of some modern observers.  I subjoin
Dujardin's systematic description of this genus.*
The only species to be here noticed is the,
   144. A.  Ascaris Lumbricoides.—Synon.—As-
caris gymnoascarida, Diesing ; Ascaris  lumbri-
coides,  Linnaeus ; A. gigas, Goeze ;  Lumbricus
teres, Auct ;  Fusaria  lumbricoides, Zeder ;  but
the Linnaean name is very generally retained.t
   145. a.  Description.—The  head of the worm
is distinctly composed of three papillae, which
can undoubtedly  be  spread out upon the intes-
tine, in a  broad,  circular, sucker-like surface, in
  * '• Ascarides : corpore albo aut subflavo, sulcylindri-
co, utrinque attenuato, fusiformi, 4 striis longitudinali-
bi's subalbis, opacis, linearibus, instructo; cute trans-
verse striatd; capite tubus, valvulis (labiis) convexis aut
semilunaribus, interne fenestratis; cesophago valde mus-
culoso, cylindrico aut clavceformi; ventriculo cavitatem
trinnnu larem prcebente.
  " Mas  minor quam femina;  extremitate caudali ali-
quid curvatd, et involutd, nunc nudd, nunc  membrand
alatd duplici, aut duplici tuberculorum et papillarum
ordine aut rarissime acetalulo instructd caudd breviore,
obtusiore, quam in feminis; spiculo aut pene duplice plus
minuice longo et arcuato.
  "Femina caudd rectiore et longiore; vagind simplici
antrorsum  sitd; utero bi-aut multiloculari;  ovariis fili-
formibus,  longissimis, duplicibus aut  multiplicilus;
ovula elliptica aut globulosa, extus lavia. Species ant ovi-
aut viviparae, plerumque in tubo intestinali viventes."
  t " Vermes albi aut ruhro-pallidi, cylindrici, in txtre-
mitatilus atlenuati, fusiformes  elastici; cute  transverse
subarticulata striis transcersis 0-02 mill, inter se distan-
tibus, ex diwbus stralis composita, 4 lineis lateralibus
longitudinalibus subalbis majoribus, capite distincto, par-
vo (0 7 mill, lato), tribus valvulis semilunaribus, promi-
nentibus, ad margines hyalinis armato, interne dentieu-
latum musculorum, stratum ad galli jubce modum pra>-
bente; cesophago musculoso, 6 — 8 mill, longo, filiformi,
triquetro, ventriculo clavceformi (0-7 mill,  lato, 2 — 3
mill, longo) parvulo, intestino simplici valvulis aut  villis
ct epithelio  polyedrico sparsim instructo.
  " Mas  : 150 ad 170 mill.=4 ad 6'" long., 3-2 mill, lat,
cauda aliquid depressa, conica, inflexa et eurvata, spicu-
lis 2 planis, subensiformibus, fere rectis, 1"8 ?/<»7l. ad
2-12 mill, longis, 0-18 ad 0-23 mill, latis.  Organo sper-
matid simplici, 1-2(10 mill longo, testiculo caico perpar-
vo, retortiformi, funiculo spermatico albo-intumido, due-
tu ejaculatorio  angustiore ad ani lotus sese apcrienti.
Spermatozoidia globuliformia, granulosa, in ftminev va-
gina maturescentia.                        »
  " Femina: 200 ad 275 mill, et supra hnga=& ad 18";
media inpartc 4 ad 5 5 mill, lata; caudd conica obtusd;
aut aliquid ante cauda apicem sito (1 mill, circiter); va-
gind simplici ante corporis dimidium sitd, ex magnitu-
dine feminnrum variabili (ex c. 85 will, pone caput in
femina 215 mill, et 103 mill, in femina 214 mill, longa);
utero ab initio simplici, bipartita aut biloculari.  Ovaria
filiformia, sensim attenuato, retrorsum usque ad anum,
et antrorsum, supra vaginam aliquantulum  pergentia.
Totalis utriusque ovarii longitudo ad 44' Lips.
  " Ovula  immatura subtriquetra, numero 4 ad 8 con-
glomerate,  matura isolata, rotunda, ad 0 087 mill, lata,
cum tes'd tenui, Imvi; in natura libera sensim embryones
evolventia." —Kuchenmeister. 
WORMS—Symptoms of Ascaris Lumbricoides.                   1545
the sucking act ofthe worm.   Bremser has seen
the opening and closing of these papillae, and de-
scribed the mechanism.   He even reports that at
the moment of opening he saw a little tube pro-
trude from the centre, which is the true oral ori-
fice.  Wedl thinks that this is the cleft probos-
cis, which  is  everted from the oral aperture for
the reception  of nourishment.   The true oral
aperture is, however, formed by the opened lips
or papillae; the  small tubule in the centre rep-
resents  the introitus faucium.  Its protrusion is
probably as much by its own muscular structure
as  by the  contraction of the general muscular
structure of the body.  The males and females
may be  distinguished by their form and external
appearance.  The abdomen of the female is slen-
der, and fusiformly pointed.   The  male is bent
like a hook, and sometimes presents, a short dis-
tance from the tail, a pair of white, delicate, pro-
jecting  hairs, which  are the protruded penis.   If
the  female be pressed, or allowed to  swell  in
water, a prolapsus of these tubes (ovaries), and a
discharge of a milky substance (eggs), takes place
in the anterior half of the animal from the vaginal
orifice.   If the male be pressed,  a milky juice
(seminal globules) flows  out  in the vicinity  of
the anus, without the occurrence of a prolapsus.
The intestinal canal is  whitish and muscular at
its commencement;  the oesophagus is composed
of  thick layers of longitudinal and  transverse
fibres, and passes rapidly, and  without any mark-
ed constriction, into  the intestinal canal, the pa-
rietes of which are thin, internally covered with
epithelium, and  shines  through, of a brownish
colour, from the brown excrement.  This  intes-
tine has a musular coat, which is connected with
the cutaneous longitudinal and circular muscles.
The external integument  consists  of six layers.
Under the outer layer  are two layers  of fibres
crossing each  other obliquely, and two laid at a
right angle over each other, and between the for-
mer and latter two a sixth homogeneous   layer,
which appears to contain a peculiar odorous fluid
of an oily and reddish appearance, and exhibits
refractive phenomena (Kuchenmeister).
   146. b. Symptoms.—Very  generally the  host
and his  guests, the  Ascarides, agree very well
together, until, owing to  causes affecting these
animals, or the digestive organs of their host, a
disagreement between them takes place, and va-
rious disorders or symptoms ensue.  When these
worms arc  few in number, notwithstanding their
size, they often occasion but little  disorder, and
live amicably with their entertainer on unelabo-
rated chyme, until their numbers, changes of diet,
and other occurrences produce more or less ail-
ment.   In  most cases, when their numbers are
not great, a good, or a  too good appetite, is the
chief injury they do ; and in this respect they are
much less noxious than the much  smaller Ancy-
lostoma.   Great numbers of these worms  in the
intestines, and a firm aggregation  of them into
coils and knots, sometimes with the small thread-
worms intervening, often occasion much disorder,
according to the mechanical obstacle and  the  ir-
ritation  they may produce.  Colic, ileus, consti-
pation, diarrhoea, flatulency, congestions  of the
brain, especially in children, and  various   reflex
phenomena manifested  in distant  parts, and on
voluntary muscles both of the trunk and  of the
lower extremities, are then not unfrequent oc-
currences.  Besides  the influence of inordinate
numbers—of 200  to 350—knotted  into  balls,
which  I  have expelled from the bowels of both
children and adults, the irritation and the conse-
quent effects produced by even small or moderate
numbers are  often serious;  for, owing to  states
of the digestive organs of their host, to  the influ-
ence of certain kinds of food, or of change of diet
upon them, or to the agitation arising in them
from the influence of season, and to the period-
ical seeking of the females by the males, much
disturbance may ensue, or the worms may travel
or stray into parts of the digestive canal not usu-
ally visited by them, and thus induce very seri-
ous effects, which may even terminate  in death.
These  effects, however, will depend much upon
the irritability and other circumstances of the pa-
tient, the number of the wanderers, and the parts
which  they have reached.  When  irritations  of
the intestinal canal  occur, and produce watery
diarrhoea, cholera, &c, these worms are thereby
affected ; they swell up, lose their powers of ad-
hesion, and are often  carried  away per anum.
But one or  more  worms  may pass unusually
high in the intestines, may rise through the py-
lorus into  the stomach, and occasion  retching,
vomitings,  &c, irritation in the oesophagus,  fe-
ver, delirium, and  upon the  discharge  of the
worm  all rapidly disappear.   But  before  rising
so high in  the digestive canal, one or more may
pass into the common duct, or even into the cys-
tic, or  the  hepatic,  or the pancreatic ducts, and
produce  symptoms  similar or approaching  to
gall-stones, or inflammation, spasm, and disease
of these ducts.   These  latter  occurrences arc,
however, very rare;  for generally the secretions
passing along these ducts into the duodenum are
not much relished  by these worms, and these
routes  are  not  pursued by  them.   When the
worm  passes  into  the  stomach, it may rapidly
rise  into the  upper part  of the oesophagus  or
into the pharynx, and even get entangled in the
larynx and  produce the most distressing effects.
But such  occurrences, although observed, are
very rare.  After long periods  of abstinence or
inanition they have been found to migrate and
escape from  the anus, mouth, and  nose ; and
such migrations are not uncommon in the course
of continued and remittent fevers.
  147. The symptoms  produced by Ascarides,
while  they continue in  the intestine, are me-
chanical, direct, and reflex.  The former are the
phenomena of the usual catarrhal  affections  of
the  stomach  and intestines (gastro-intestinal ir-
ritations) in every grade;  costiveness, tormina,
colic;  a sense of weight,  of irritation, or of a
ball, or gnawing and itching near the umbilicus ;
disordered,  craving, and  irregular  appetite, and
digestion, &c.  The latter are hiccough, subsultus
of the  abdominal muscles,  cramps  of the  lower
extremities, yawning, increased secretion  of sa-
liva, snuffling  or tickling of the nose, but rare of
the  anus, unless  upon the passage of a worm.
  148. The question has been often entertained
as.to the possibility of these worms  perforating
the  parietes of the healthy intestines, and mak-
ing their way into  places more or less distant
from their  usual residence.   That  these worms
can never perforate the healthy intestine, the  struc-
ture of its head and its thin lips being adapted only
for suction and not for  boring, is the opinion  of
Rudolphi,  Bremser, Rokitansky, Bemberger,
J. P. Frank, Kuchenmeister, and myself, in op-
position to  that of Von Siebold and Mondiere.
Therefore it may be concluded that when these 
1546
WORMS—Symptoms of.
worms are found in situations external to the di-
gestive canal, they have reached it by some pre-
existing ulceration, perforation, or fistula.
  149. Many, especially ofthe older authors, have
attributed a prognostic and generally an unfavour-
able import to the discharge of worms during fe-
brile diseases, and more especially during typhoid
fevers ; and this opinion is not limited to the As-
carides, but is extended  to the  flat worms, and
they have argued  that the worms in these cir-
cumstances  are like the  rats, and have  the pre-
science of deserting a sinking ship !   But as the
discharge of worms from a fever-patient  does not
occur until  after the  seventh day, according to
Zimmermann, it is  much more probable that they
travel from the intestines, owing to the  food ob-
tained by them being insufficient or not  suited to
them, and to the secretions ofthe intestines being
injurious to them, and in search of more abundant
or more suitable aliment.  The ulcerations ofthe
intestines and the morbid matter from these ulcers
in the advanced stages of continued fevers, will
also tend to expel or to occasion a discharge of
these worms, which, when observed, may be just-
ly viewed, both as  an indication ofthe existence
of these lesions and ofthe extreme danger ofthe
malady.
  150. vi. A General View of the Symptoms
produced by Worms in  the Digestive Canal.
—Most ofthe symptoms produced by worms may
arise from other causes; but a careful recognition
and observation of these  symptoms, of their suc-
cessions, grouping, &c, aTe requisite for the due
regulation ofthe treatment, and for the ascertain-
ing of the  species of worm which is  present.
The symptoms produced most commonly by the
individual species of worm have been noticed
with reference to each; but recent writers  have
been more intent upon the microscopic  descrip-
tions  of these parasites, and  upon drawing mi-
nute distinctions, &c, than upon more useful and
practical  considerations connected with them.  It
is justly  argued that  the discharge of the  more
common  species of worms infesting the intestinal
canal is the  only true diagnosis of verminous dis-
eases ; but this discharge, even  in the most se-
rious  cases, may  not occur without  means be-
ing used to  effect it; and it is by a knowledge
of these  symptoms, independently of such  dis-
charge, that we are led to administer the means
most likely  both to establish this diagnosis and
to effect a cure.
  151. A. The more direct and local symptoms, or
those more immediately caused by worms, are—a
capricious and variable appetite—at one time a
craving and insatiable  hunger or an unsated de-
sire of food ; at other times, nausea, or cardialgia,
borborygmi, loathing, retching, or vomiting, being
present;  a sense of weight in the abdomen, with
distention, gnawing, or erosion ;  a feeling of cold
internally, or of emptiness or inanition, often with
palpitations, or leipothymia, or faintness  ; a drag-
ging, twisting, or lancinating pain in the abdom-
inal regions, especially near the umbilicus, or tor-
mina, spasms, colicky attacks, tenesmus, constipa-
tion, or irregularities ofthe intestinal functions ;
leucorrhcea, and itching, or a mucous or watery
exudation from the anus, sometimes a  mucous
diarrhoea, tenesmus, and  bearing down  pains in
adult females, or derangements ofthe  catamenia,
or even abortion ;  and in children more especially
tormina,  colic, constipation, and  intus-susception
of the bowels, with various cerebral symptoms
about to be  noticed.  In both sexes " manustu-
pratio" is not unfrequent, even at an early age.
  152. B. The symptoms caused in more distant
parts bv sympathy with the seat of irritation, or by •
direct and reflex sympathy, are chiefly a frequent, .
dry,  and tickling  cough ;  hiccough, anxiety at
the praecordia, or  pungent pains passing under
the false ribs and at the epigastrium; a sense of
something  in the  oesophagus, sometimes with
tickling in  the  pharynx ; partial  amaurosis and
dilatation  of the pupils ; sneezings, itching and
dryness of the nose and nostrils,  sometimes epi-
staxis, itching of the skin, without eruption; grind-
ing or grating ofthe teeth, and sudden startings
when asleep; subsultus and spasms of the ab-
dominal muscles;   partial or general convulsive
movements  without complete loss of conscious-
ness ; chorea or twitchings, or irregular contrac-
tions of particular muscles, especially those of
the face and lower extremities ; and more or less
fully developed, general, or epileptic convulsions.
The urinary excretion  is sometimes disordered,
and  dysuria or frequent micturition complained
of, the urine being whey-coloured,  turbid, &c,
with or without a  sediment.
   153. C.  A general verminous cachexia  is not
unfrequently present, manifested by a pale, tumid,
or livid state of the features;  by a sunken  ap-
pearance of the eyes  and a leaden hue beneath
them ; a general pallor, and more or less anaemia
ofthe surface ofthe body, lips,  &c.; a perverted
state of the  sense  of smell, or the entire loss of
smell; a strawberry hue ofthe tongue, or mucous
sordes on the tongue, and about  the  teeth and
gums, stridor of the teeth, and a peculiar foetor
of the breath, sometimes a more or less evident
affection of the voice  and speech; a morose, ir-
ritable state of temper, vertigo, frightful dreams,
timidity, somnolency ;  slight or low delirium, risus
sardonicus, and prostration of strength.  The bili-
ary secretion is sometimes scanty, and in some
cases even jaundice is observed.  The abdominal
secretions are very often disordered, and the func-
tions of excretion generally impeded. These and
other effects—local and sympathetic—are  mani-
festly produced :   1st, by the irritation  of the di-
gestive mucous surface, which may, in the cases
of certain worms, and  in susceptible constitutions
especially, go on to inflammation  and its conse-
quences ;  and, 2d, by the changes theee animals
produce in the chyme  and chyle derived from the
ordinary  food,  and upon the  secretions of  the
gastro-intestinal surface, and upon those  of the
liver and pancreas. The former of these effects,
namely, those consisting of gastro-intestinal irri-
tation and its consequences, will  also contribute
to the production of the latter; but  it cannot be
doubted that much of the  nourishment  which
should be taken up by the intestinal surface is
intercepted  by  these  parasites, while  a portion
of the fluids, lacteal or serous, are removed from
this  surface by  the suction exerted by these ani-
mals.
   154. All  the symptoms  now enumerated  are
not observed in the same case, but many of them
either coexist or appear in succession, and are
variously grouped  in different subjects, so as to
render a diagnosis  very difficult between this and
other complaints.   When the cachexia, debility,
and sympathetic disturbance ofthe brain and its
functions are considerable, more especially when
the circulating  fluids are diminished in quantity
from deficient aliment, or impaired in quality by 
WORMS—Causes and Prevention of.
1547
 imperfect assimilation and depuration, the symp-
 toms may assume  a febrile character, sometimes
 mistaken for a form either of low fever, or of gas-
 tric fever, but more correctly recognised by some
 of the older writers by the term worm or vermin-
 ous fever.   (See also v 73.)
   155. vii. The causes of worms may be in-
 ferred from what has been stated above; yet it
 may be of use to notice  some  particulars  too
 generally overlooked by the recent writers, who
 have insisted upon the propagation of worms by
 means of ova, &c, and who may be considered
 as having disproved the  doctrine  of  equivocal
 generation, or, more  correctly,  of spontaneous
 formation.   A knowledge of the  predisposing
 causes furnishes important indications in  both
 the prevention and the treatment of vermino'us
 diseases;  for, although the obsolete doctrine of
 spontaneous formation rendered this knowledge
 of the greatest interest, inasmuch as it was found-
 ed upon antecedent changes in the constitution,
 yet these changes  are by no means devoid of in-
 fluence in favouring the development of the ova
 and embryos of parasitic animals.   There can be
 no doubt that  children of weak, aged, and vitally
 exhausted parents ; the female sex, debilitated
 males ;  and persons of all ages, who have been
 insufficiently  or improperly fed in early  life, or
 of a relaxed fibre or asthenic diathesis, are much
 more subject  to worms than those  who are oth-
 erwise circumstanced.   A  tender  and delicate
 state of health in  early life;  the use of crude,
 viscous, gelatinous, and vegetable  food ;  what-
 ever tends to lower the  orgajjjc nervous force
 and vital resistance ; a relaxed and asthenic habit
 of body;  hereditary conformation; a residence
 in crowded and insufficiently  drained cities and
 towns, or in cold and moist situations, especially
 in those which are  abundantly covered with veg-
 etable productions  peculiar to the country, and a
 scanty use of such condiments,  as  salt and hot
 spices, as the climate may require, predispose to
 the  generation of worms.   In places where salt
 cannot be obtained in  quantities requisite  to the
 wants of the  economy, as  in  some intertropical
 countries, the hot spices are used in its place by
 the natives.  Those who contend, and, from re-
 cent researches,  with manifest  truth, that the
 presence of ova is  necessary  to the generation
 of human parasites, consider that the  predispo-
 sition produced by  these causes favour this gen-
 eration, and that robust health and a sound con-
 stitution are  subversive of their development.
 Those who argue  for their spontaneous forma-
 tion believe that these causes not  merely pre-
 dispose to this formation, but  also  directly pro-
 duce it; and that, owing to a weak and imper-
 fect  chylification and assimilation, or to a  meta-
 morphosis of the secretions, a material is evolved
 which,  under  the  favourable  circumstances in
 which  it is placed, and owing  to a  vital emana-
 tion  from the body  in which it lodged, assumes
 an organized and separate existence.   These doc-
 trines,  however opposite—the  former assuming,
 as predisposing causes,  merely what the  latter
 contends to be direct and exciting, or efficient,
 causes—agree  in that which is  of  the greatest
 importance to the physician : they both point out
 the best indications for preventing the continued
 or the  future generation of worms, where they
already exist or have existed,  and for guarding
against  their invasion in  circumstances which
render  such invasion more or less probable.
    156.  IV. Treatment of Worms.—The treat-
  ment of worms  should have reference, 1st. To
  their prophylaxis, or  prevention ;  2d.  To their
  expulsion;  and,  3d.  To the prevention of their
  recurrence.
    157.  i. Prophylaxis.—A. As to the first of
  these intentions, it must be admitted that the ac-
  complishment of it is always difficult, and often
  impossible.  Our knowledge, also,  of the modes
  and channels by which these parasites are con-
  veyed into and propagated by the lower animals
  and human subjects  is imperfect.  Admitting
  that they originate in ova  which experience  the
  changes in  the  processes of their development
  above  described,  we  still find it difficult to ac-
  count for the presence of these ova, and for their
  passage into the human stomach.   That the ova,
  as  stated above,  may attach themselves to raw
  vegetables  and fruit,  is  not improbable.  The
  feeding of domestic animals also upon the garb-
  age or  viscera of fish, fowls, or the mammalia,
  certainly favours the production of worms,  es-
  pecially those of the cistoid order, in these ani-
  mals ;  and  the  ova  from  these, where perfect
  cleanliness in  all respects is not observed, may
  be conveyed in the food or drink, or by the hands,
  especially  unclean hands, into the  human body.
  The amount of knowledge as to this topic  ap-
  pears to be limited to the  observance of perfect
  cleanliness in all its bearings, including the  ut-
  most care  as to  the purity of the water used,
  and as  to  the use of raw vegetables and fruits.
  Marsh, stagnant,  and even  river water ought not
  to be used; or if the latter  be taken, it  ought to
  be previously boiled  or filtered.  Vegetables and
  fruits should be carefully washed, especially fallen
  fruit, if eaten in  a raw state ; and  the  domestic
  animals ought to  be confined to their proper pla-
  ces, and neither petted nor fondled.  The diet is
  also of some consequence ;  and no kind of ani-
  mal food should be taken unless it be sufficiently
  cooked.  The raw flesh of animals,  especially of
  pigs, and imperfectly cooked viscera of animals,
  and all  unnatural modes of living, and neglect
  of the strictest attention to cleanliness in respect
  of diet and modes of living, should be most care-
  fully avoided.
   158. B.  But it is not only the prevention of
  the  ingestion of ova into the human body that
  should be studied, but also the means of render-
 ing these ova inert, or rather of preventing their
 development in the digestive canal.  As  with the
 former,  so  with the latter means of prevention,
 our  knowledge is very imperfect.  We may,
 however, infer that those predisposing causes of
 worms enumerated above  should,  as much  as
 possible, be removed or counteracted.   Without
 a due attention to the removal of the predisposi-
 tion, which  favours the generation and develop-
 ment of the entozoa, the treatment of verminous
 diseases will prove inefficient as regards the issue,
 and empirical in practice, especially when view-
 ed in relation to the  scientific application of the
 resources which the progress of knowledge and
 the discoveries of our contemporaries have placed
 within our reach.   In furtherance of this indica-
 tion, the diet and the treatment should be adopt-
 ed that are most efficacious in promoting the or-
 ganic nervous force, and the tone of the digestive
 organs, and in removing tenacious mucus and
jntuitous sordes, which often  adhere to  the di-
 gestive mucous surface, especially  in asthenic,
 leucophlegmatic,  and debilitated  subjects, and 
1548                             WORMS—Treatment of.
which often form the nidus in which the ova of
parasites are lodged and hatched.   It will gen-
erally be noticed that the secretions and excre-
tions, which  in  all persons form  the  principal
part of  the faecal discharge, are seldom thrown
off from the secreting  surfaces so quickly and
entirely in  the delicate and debilitated as in the
robust and  healthy; but remain or are  retained
in the former class of subjects, and become the
soil in which these animals are reared.
   159.  C.  Persons who are, or who have been,
subject  to  verminous diseases,  ought  to adopt
that kind of food, and to have  recourse  to those
medicines which their feelings and observation
indicate as being calculated to distress, injure, and
ultimately to destroy or eject  intestinal worms.
A due attention to such means  is required not
only for the expulsion, but also for preventing
the future generation of these parasites.  Anoth-
er object, and one, indeed, which is the basis of
the prevention  and of  the  treatment of worms,
is to determine in as accurate  a  manner as pos-
sible, from  the  character of the  symptoms, and
from the examination  of the faeces, the species
of the animal which is to be dislodged.  While,
however, this diagnosis receives its due attention,
care must be taken not  to mistake other diseases,
which  possess  many of the same  features,  for
those proceeding from  the  presence of worms.
This error is likely to occur frequently,  since the
one class of disorders often reciprocally  bear the
relation of  cause and effect to each other.   Nor,
in many cases, will it be attended by any serious
consequences, farther than  from  wanting appro-
priate direction, the treatment must be inefficient,
and  redundant and superfluous.  It should also
be kept in  recollection  that worms  arc more apt
to be generated during  fevers, and during conva-
lescence from fevers, especially such as are epi-
demic, adynamic, or nervous, or are  gastric or ex-
anthematous, than in  robust health, or  even in
other circumstances.   The  generation  of para-
sitical animals in these maladies is not  confined
to the surface of the intestinal  canal only.   It is
not unusual to observe the parasites usually pro-
duced,  in favourable circumstances, on  the ex-
ternal surface of the body, become remarkably
abundant during and  after these  fevers, espe-
cially when the  diseased secretions are allowed
to accumulate from a neglect  of ablutions and
of frequent  change of  linen.   The appearance
of animal parasites on  these occasions  was ex-
plained  by the supporters of spontaneous forma-
tion, in the way above  noticed (§ 6,  et seq.);
while it was viewed, by the believers in genera-
tion from ova, as the result  of a more favourable
occasion being furnished for the development of
the ova  during these diseases.
   160.  One of the earliest  methods of prevent-
ing and of curing verminous diseases,  resorted
to by many physicians, is to remove or attempt
to remove,  by purgatives or drastic means, the
tenacious mucus adhering  to the digestive mu-
cous surface, and which, as they believe,  forms
the nidus or lodgment of worms;  and they be-
lieve that the quantities of mucus dislodged from
the bowels during and  for some time  after the
exhibition of vermifuge, and  other purgatives,
are proofs of the accumulation of this mucus on
the intestinal surface.   That this mucus or sordes
may be excessive in  many cases,  may be ad-
mitted ; but  it  may also be allowed  that the
greater  portion  of this mucus is  produced  by
the irritation of the intestinal mucous membrane
by these purgatives.  This method of prevention
and treatment, when moderately and appropriately
prescribed, may be of service in many cases , but
it should not be overlooked that the rough opera-
tion of these medicines often leaves a debilitated
state of the intestines after their operation, which
disposes them to  generate, and  prevents  them
from throwing off the mucous sordes and worms
which these medicines were employed to remove.
They cannot by any mechanical property, or by
any chemical or other influence on the intestinal
secretions  and excretions, always remove  them
from the extended surface covered by them in the
manner or so  completely as contemplated ; and,
even when the proposed end is completely attain-
ed, the intestinal functions are left in  a more fa-
vourable condition than before, to reproduce both
mucous sordes and  worms, especially  if any of
the ova still remain unexpelled.  Therefore, in-
stead of trusting to the medicines usually  em-
ployed  as  anthelmintics, vermifuge  purgatives,
alterants, &c, our attention ought to be directed
(in some cases  instead of these  medicines, in
others  in addition to them, and subsequently to
the use of them) to the  adoption of remedies
which  promote the  organic nervous forces, and
the digestive and vital energies  in general, there-
by increasing  the healthy and vigorous discharge
of the  various functions, and the due evolution
and evacuation of the  secretions and excretions
from the digestive organs.  (See also the treat-
ment after the  expulsion of worms.)
  161.  ii. Direct and Curative Treatment.—
J. P. Frank, whose experience of the  treatment
of worms, when he wrote on the subject, had ex-
tended to half a century, considered that drastic
purgatives  and anthelmintics at the commence-
ment of the treatment were seldom so servicea-
ble, especially against taenia, as more gentle meas-
ures, which, in his opinion, should be first adopt-
ed, and be followed by more energetic  remedies.
But  the diversity not  only of these  medicines,
and  of the combinations and  methods  of pre-
scribing them, bewilder the inexperienced, until
repeated opportunities of observation enable him
to  select those  means  and combinations upon
which confidence can be placed.   Kuchenmeis-
ter  justly  remarks that, if the  multitude  of
remedies recommended  for any disease is an ev-
idence of their want of power against it, the ther-
apeutics of worms are  extremely defective.   In
truth, the  treatment of these  parasites leaves
much to be desired as respects the efficacy of
the medicines  prescribed for them, the pleasant-
ness of the most efficacious among them, and the
disagreeable effects which often accompany and
follow those most to be  relied upon.
  162. A.  The treatment of tape-worm will
firstly, and more especially, occupy attention, as
it will  comprise the most  efficacious medicines
and methods which have been employed, not only
for these worms, but also for many of the others
which have been noticed above;  and  when the
treatment of these latter comes under considera-
tion, then a brief reference to what has already
been stated  will  be sufficient.   Kuchenmeister
tested  a great many of the medicines recom-
mended against tania, by placing live tape-worms
in a mixture of the particular medicines with white
of  egg,  and by determining the time in which
they died by the assistance of the rotation appa-
ratus, the two  poles of which he introduced into 
WORMS—Treatment of Tape-worms.                       1549
the mixture.  According to these experiments,
the tania lived for many hours, or even for days,
in the mixture containing the cuprum oxydatum
nigrum, in that containing dohchos pruriens; and
for several hours in castor-oil, and in a salad made
with pickled herrings, onions, garlic, &c.   Tin
has little or no effect, or  merely  the  same effect
as the cow-itch.  Electricity has no destructive
action  on Tania.   "It is otherwise, however,
with kousso, in the infusion  of which, mixed
with milk, the  tania died within half an  hour
of their introduction ; and with oil of turpentine,
in a mixture of which  with white of egg, they
died in 1 to  li hour.  In a decoction of Bruyera
(kousso)  mixed with white of egg,  the  Tania
died in  H to 3 hours.   In  a decoction of rad.
punicai granatorum, mixed with white of egg, in
3 hours; and with  the  same  decoction, mixed
with milk, in 3 to 3$- hours.  In a mixture of ex-
tract, filicis  maris ather. with  white  of egg, the
Tania died  in  3^ to 4 hours.   The  so-called
filicine (filicic acid of Lutz), mixed with white
of egg, also has an energetic action on the Ta-
nia, which  die  therein  in the course of a  few
hours, and exhibit cedematous swellings in vari-
ous parts."   The  particular methods of expul-
sion, arranged according to the remedies, have
been enumerated by Meyer, Seeger, and Kuch-
enmeister ; but the faults which this last-named
writer finds with his two predecessors, viz., that
in the enumeration of methods these are thrown
together in a disorderly manner, may also be im-
puted to  himself, although in a less degree.
   163. a. Methods with  Tin. — Frank com-
mences the treatment with the powder of tin, or
its filings, given in a simple sirup, either alone or
with sulphur, or the extractum absinthii.   After
having pursued this plan during three  or four
days, allowing only a spare diet, he prescribes,
in  addition to the  tin, a moderate dose of jalap,
low diet being still observed.   Dupuis prescribes,
without  any preliminary treatment, at six  and
at half-past  six in the morning, each time a pow-
der of Stann. rasp.  Angl., 9ss.; Tannini puri,
ji.; Gigutti(cambogia),gr.vi.; Elaosacchari caju-
puti, gr. ijss.; and  after each dose  the patient
drinks two cups of black coffee.  In two  hours
the worm is expected to  pass off, usually with
colicky pains, on the occurrence of which strong
black coffee is immediately given.  For the sub-
sequent  treatment, a tincture of  iron is advised.
Becker  recommends the chemically  precipitated
tin. According to him, it is certain in its action,
does not irritate the intestines  mechanically, and
is  preferable in doubtful cases.  It  is, however,
difficult  to  be obtained.   Kuchenmeister pro-
tests against the administration of tin-filings, as
being, in his opinion, a much too irritating medi-
cine.  But he has twice prescribed  tin, precipi-
tated from chloride of tin, in  an extremely fine
powder,  making it into  an electuary with honey,
a little  extr.  punic. granat., extr. filicis  maris
ather., and cambogc or jalap.  Even young and
weakly children support  this remedy very well.
On one  occasion the entire worm passed, dead,
on the second day.  In the other case, an adult,
several yards passed after this medicine, but the
remainder of the worm was expelled by his ordi-
nary mixture (§ 181).   He considers the medi-
cine to be uncertain, but suitable to  children and
persons who are much reduced.   Tin, in various
combinations, has been  prescribed,  also, by Al-
ston, Mayer, Matthieu, Hautesiark, and  Ar-
tenrieth ; but its operation, as they have  pre-
scribed it, is often either ineffective, or too  irri-
tating to the digestive mucous surface.
  164. b. Methods with the Male Fern.—The
Aspuhum filix mas, which is always efficacious
against the Bothriocephah, is much less so against
Tama.   Buchheim  prescribes a soft resin, ob-
tained from this plant,  with good effects.   The
most efficacious preparation, according to Kuch-
enmeister, is the athcreal extract of Filix  Mas,
the powder being mixed with the extract, so as
to increase the surface of contact of the medi-
cine ; or the extract being mixed with pomegran-
ate root, which latter he prefers.—(a) Wawruch's
method is a preliminary treatment of three to four
days, consisting of  strong beef-tea with white
bread, three times a day, taking at the same  time
the following  resolvent:  R- Rad. taraxaci ct ci-
chorei, aa, 5j. ; decoqueper £ hora: colatura fvj.,
adde ammon. chlor.  pracip., 9j. ; syrupi achorei
cum rhco, fss.  M.   Two table-spoonfuls every
two hours.  With this,  daily laxative clysters of
milk, linseed, herb,  althaeas, flor. verbasc., and
flor.  papaver.  are  ordered, and  on the  evening
before the expulsion, a  very rich gruel  (£ lb. of
water, and 2 to 4 ounces of butter  and wheat
bread).   The expulsion  is attempted  by taking,
" in  the morning, fasting,  a  thick  gruel;  and
about five, six, and seven o'clock  a clyster of
linseed and milk; about eight o'clock, two table-
spoonfuls of castor-oil;  at half past eight, pulv.
rad. filicis maris 3ij.—3iv.; at nine o'clock, two
table-spoonfuls of castor-oil; at half past  nine,
the fern-powder again;  at ten o'clock, two table-
spoonfuls of castor-oil;  and at half past ten, the
third powder.   After each dose the patient wash-
es his mouth with tea made from flor. tiliae, and
summitat. millefolii; and in the  intervals he
chews flavid.  cort.  aurantior., of which a  dose
of §ss. is prescribed.   At one o'clock  he takes
a powder of camboge and calomel, aa, gr. v.—vj.,
with 9ss. sacch. albi, and applies emollient poul-
tices over the abdomen.   If the worm be not ex-
pelled, castor-oil is again given in half an hour;
in a second  half hour, camboge powder ;   then
castor-oil again ;  and possibly, if no inflamma-
tion  occurs, the powder  of camboge and  calo-
mel again at half past four.  At the  same time,
a clyster is administered every hour!"   The  sub-
sequent treatment consists of the removal of the
inflammatory state of the intestines by leeches,
mild diet, &c.
  165. (b)  Weisshaar's method is a modification
of the above.   On the  second, third,  and fourth
day of preliminary  treatment, a pickled herring
diet; and on the following day  he  attempts the
expulsion of the worm nearly as advised by Waw-
ruch, excepting that he gives the castor-oil in
meat broth, and, instead of orange-peel, candied
calamus.  Of the fern-powder he gives only xv.
—xx. gr. pro  dosi, with 15  to 20 grs. olei filicis
maris ; and even the latter only to irritable  sub-
jects.  Recently he prescribes 60 to 80  drops ol.
filicis maris with f ss. oi. ricini; in half  an hour,
two table-spoonfuls of castor-oil;  in an  hour, the
first powder of camboge and calomel; in half an
hour, oil again ;  in another half hour,  the second
powder  of camboge  and* calomel, and  so forth.
He states that he easily expels T. solium by this
method; but that T. mediocanellata (v 68 to 70)
requires  strong doses of oil of turpentine.
   166. (c) The Wurtembcrg method is one ounce
of fern-root boiled for an hour with three pints of 
1550
WORMS—Treatment of Tape-worms.
     water ;  one drachm of fresh cort. mezcra is added
     to the hot decoction, which in ten or twelve min-
     utes  is  strained,  and then  mixed with  two  or
     three drachms of finely-powdered fern-root.  This
     is taken in the morning fasting, cither at  once,
     or in three portions at intervals of an hour.   In
     three or four hours sickness and disorder of the
     stomach  cease; and then calomel, freshly pre-
     pared sulphate of iron, aa, gr. x.—3j., accord-
     ing  to  age, are  administered, and repeated  if
     vomiting occur.   The worm is said to be gen-
     erally expelled in  the evening;  when this is not
     the case, a rich gruel  is given on the same  even-
     ing ; and on the following morning, fasting, rhu-
     barb and jalap, aa, gr. x.—xv.—3ss.
       167.   (d)  Alibert's  and  Dubois' methods are
     nearly  the  same,  and as follows:  After a pre-
     liminary treatment for eight days, to which gar-
     lic, roasted under the ashes, is added,' the  abdo-
     men is to be rubbed several times a day with a
     liniment of camphor, with balsams and nut-oil,
«    and with crushed bulbs of garlic, also a ptisan
*    of helminthocorton and filix mas, and  a nightly
     enema  of marsh-mallow water  are prescribed.
     Without this preparation, Alibert prescribes,
      No. 3S0.  R Rad.  Filicis Maris, -iv.; Coque cum Aq.
     Font., tb iij., usque ad remanentiam lb ij.;  Colaturae
     adde i-yTupi Helminthocort. Jij.  M.
     This is to  be drunk in cupfuls during the day.
     After three  hours of repose, calomel  and  corn.
     cerv. ust, of each gr. iij., made into a bolus with
     conserv. rosae q. s., are  given.   In the evening,
     §j. of oil of sweet almonds; and on the second
     day the following purgative :
      No. 381.  R Scammonii, gr. xviij.; Rad. Filicis  Maris,
     §j. ;  Cambogiee, Calomel., au, gr. xij.  M.
     To be taken  in three portions in sugar and water.
     Dubois, after the  preliminary treatment just no-
     ticed,  prescribes,  early  in  the  mornin'g, §ss.  of
     filix mas in broth; and every  half hour one  of
     the  following:
      No. 3S2. R Res. Jalap., Scammonii, Cambogiae, aa, 3ss.;
     Syrupi Rhamni Cathart., q. s., ut fiant Boli, sing.  gr.  vj.
       168.  (c) Biching's and Sceger's Methods.—The
     former commences with draughts and  clysters
     of cold water, and with full diet  and cold baths.
     With this diet, but without the  cold water, ac-
     cording to Seeger, a saturated  decoction of Jss.
     of fern-root is drunk cold after every meal,  when
     the  worm will be  expelled in from three to four-
     teen days.  Seeger's plan, according to Kuchen-
     meister, is  suited to irritable and weak persons.
       169.  (/)  Nuffer's and  Odier's  Method.—The
     evening before the treatment the patient takes a
     thin gruel with two ounces of butter ; a quarter
     of an hour  afterward, a glass of wine, and, if
     necessary, a clyster.   The next morning, fasting,
     3iij.  pulv. fil.  maris in ?iv.—=vj. aq. tiliae.   If
     vomiting occur, this  is to  be  repeated; and  if
     sickness be felt,  black coffee  is taken.  Two
     hours after this the following bolus is given:
      No. 3S3. R Calomel., Scammonii, iifi, gr. x.—xv.; Cam-
     bogias, gr. v.—vij.—viij. ; Confect. Hyacinth., q. s.  Misce.
     For  weak  patients and children, in two doses.
     If the bolus be thrown up, or not have operated
     in  four hours, or if the worm  hangs out of the
     anus, 3vj.—fj. of  Epsom salts, dissolved in  warm
     water,  are  given.   If the worm be not expelled
     by this, the  gruel and powder are to be repeated,
     but the Epsom salts are to be given instead  of
     the bolus.    Odier directs a  table-spoonful  of
     castor-oil in meat broth every  half hour instead
of the bolus.  This treatment  is said to be cer-
tain against Bolhriocephali.
   170 (g) Blossfeld's and Rapp's method is much
praised   The previous evening a thick mixture
of bread and milk is take>.;  and in the following
morning 3J. pulv.  rad. fil.  maris is given every
hour,  in  an ounce and a  half of  nutmeg tea.
After  six or eight doses the worm is expelled.
Rapp directs the root to be fresh, and administers
5vj—fj. of it one dose.
   17L (h) Mayor's Method.—Mayor, of Geneva,
regards the root of filix mas as  specific against
Bothriocephalus, and tin and pomegranate root
against Tania solium, and states that the powder
of the fern-root should appear quite green, as it
is otherwise inefficacious.   He gives  3iij.—3iv.
in a mixture of balm tea and  fj. of gum> sirup.
This  draught is to be taken at night, and fjss.
of castor-oil the next morning.  Mayor, in some
cases, instead ofthe powder, prescribes the oleum
filicis maris in the form of pills—thirty to fifty
drops in  twenty-four pills, of which twelve are
taken at  night and twelve  in  the morning, and
an hour afterward fjss.  of castor-oil.  In other
cases he  gives the fern-oil, either pure or mixed
with  castor-oil, in  doses of 3ss.—3J. , but usually
the castor-oil  afterward.
   172. (i) O. Bang's Method.—" For three days
the patient takes  only one basin of meat broth,
with  white bread.  At night he has a  clyster of
warm milk.  On  the  fourth day he  takes also
eight cups of black coffee with plenty of sugar,
and  two  to three large  pickled herrings in the
form  of salad, with plenty of vinegar, pepper, oil,
and  onions.   On  the fifth  day he takes altern-
ately,  every two hours,  one third  of a herring,
and a heaped-up tea-spoonful of pulv. rad. filicis
maris, and with this two to three cups of coffee.
At night a milk  clyster and a dessert-spoonful
of castor-oil.    On the  sixth morning, fasting,
two tea-spoonfuls of fern-powder; an hour after-
ward, two table-spoonfuls of castor-oil, and the
same quantity every two hours until the worm is
expelled.   During this he drinks tea; and, lastly,
for the subsequent treatment, iron is used."
   173. (k) Vilersperger's Method.—Without any
previous treatment, he gives 3iij.—3iv. ofthe bark
of the roots freshly peeled, treated with  alcohol
the day  before, and lets the patient lie  in bed.
When no vomiting takes place within two hours,
an aperient of 6 gr. calomel and 3j. of sapo jalap.
in pills is given.   This method is said to be rapid
and efficacious.
   174. (I) J.  P. Frank's method is to commence
either with the exhibition of tin, as above, and to
follow with the male fern, or to begin at once with
this latter, giving about three drachms in a draught
of cold water, and to give frequently cold diluents,
allowing the most rigorous abstinence.   A dose
of castor-oil may be taken the following day, and
repeated every two hours  until copious evacua-
tions  are procured.
   175. (m) Mayer's and  Karsten's Methods.—On
the day when fragments pass off spontaneously,
the patient takes  a herring salad at night.   At
six o'clock next morning, 3iij. of fern-powder in
syj. of aq.  flor. tiliae  is  taken in  tea-spoonfuls
without stopping, and immediately after this a
table-spoonful of  castor-oil, and  then  a cup of
thin broth.  The oil is then continued every half
hour  until ^ij. are taken.  For any  sensation of
fulness and nausea,  hot black coffee is given.
About twelve o'clock the  greater part of the 
WORMS—Treatment of Tape-worms.
1551
worm  is expelled, and  the head passes  at  one
or two o'clock.    Bitters  are  prescribed  subse-
quently.  Karsten's method consists of a mild
aperient and scanty diet  the day before;  and
early in the  morning,  311J. of fern-root in  tea-
spoonfuls.   If sickness  be  felt,  thin  broth  is
given.   Between eleven  and  one  o'clock  the
worm  is expelled without  any farther treatment
Several other methods of employing the male
fern root  have  been  enumerated  by  Kuchen-
meister,  generally premising various means, the
modus operandi and utility of which are not very
apparent.   I  shall next notice two other prepa-
rations of this root—the extract  and the athereal
oil, which  have  been  used with  great benefit.
The compound decoction of male fern, for which I
have given a Formula  in  the Appendix,  will be
found one  of the most  efficacious  modes  of pre-
scribing this  remedy.   (See Form. 62.)
   176. (n) The  cxtractum filicis maris has been
prescribed by several physicians.  Peschier ad-
ministers it as follows:
   No. 384.  R Extr. Filicis Maris ^Ether., 3j.—3ss.; Pulv.
Rad. Fil. Maris, q. s., ut fiant  Pilulse  xx.
To be taken in two  portions half an hour before
bed-time, after fasting  from  five  o'clock  in the
evening ;  next  morning  an  aperient.   Several
physicians have adopted this preparation and its
mode  of exhibition  with  success.   Kieser and
Hiller  gave the extract, for .several days to-
gether, to the total  amount of 3iij. with good re-
sults.   After several days of spare diet, Mosing
gave  fifteen  of Peschier's pills  to the  fasting
patient at  nine o'clock, and again  at half  past
nine.   His prescription is as follows :
   No. S85.   R  Extr. Filicis Man? jEther., 3Jss.; Pulv.
Rad. Fil. Mar., q. s., ut fiant Pilula? xxx.
After the last  dose, he gave fiij. infusi  sennae
compos, at once.   Funk administered the extract
 night and morning with sirup and gum, and after-
 ward  gave castor-oil every hour until it operated
 freely.  Noss prescribed an aperient on the pre-
 ceding day, and the  extract to the  fasting patient
 with sirup—3ss.—3ss.  of the extract twice with
 an interval of an hour ; then castor-oil every hour.
 Albers,  after a  restricted diet  for  one to three
 days,  and on the day before the  exhibition ofthe
 extract, prescribed a purgative of Glauber's salts;
 and on the following morning, 3ss. of extract of
 male  fern while  fasting, and the  same quantity
 an hour afterward ;  one to two  hours afterward,
 castor-oil.   Rayer  gave  seventy-two drops of
 Peschier's thin  extract of fern made  into  pills
 with the powder of the root, of which eight are
 to be  taken at night, and  eight  in the morning;
 two hours afterward, castor-oil.   Magendie  pre-
 pared a tincture  from  the buds of the fern, and
 made  it into pills with the powder of the bark  of
 the root, each containing  a drop ofthe tincture
 From eight to twenty were said to be sufficient
 for expulsion of the worm.   The circumstance
 of no  farther accounts ofthe  employment of this
 tincture having  appeared  is not in  favour of  its
 efficacy.
    177. (o) The athereal oil of male fern has been
 much employed and praised by Dr. Jenner.   He
 caused the patient  to  be  kept  without food for
 sixteen or eighteen  hours  before he gave the oil;
 and he farther recommends  the following mode
 of administering it: " For an  adult,  two  pills
may be taken at bed-time,  containing three grains
of calomel, and eight of compound colocynth pill;
the following morning,  a dose of castor-oil. A lit-
tle broth only should be given till the bowels have
been  thoroughly cleared out.   As soon as  that
object is effected, one drachm and  a half of oil of
male  fern is to  be given on an ounce of some
aromatic water ;  and the dose of oil of male  fern
is to be repeated in six hours, if the first dose has
not proved effectual before the  expiration of that
time.  For a child, calomel and jalap may be  sub-
stituted for the colocynth and calomel.  The dose
ofthe oil of male  fern must be as large^ for the
child as for the adult;  seeing that its action is on
the parasite, and not on the patient, I have never
seen  any unpleasant results follow  its employ-
ment in  the child."   I have, in  several cases,
given #the male fern successfully,  when connect-
ed, many years ago, with public medical institu-
tions ; and since the publication of Dr. Jennlr's
interesting paper on the  use of the  aethereal oil
of male fern, I have prescribed it  in two cases—
in one with  complete success,  but in the other it
failed.   In this  latter, the oil  of  turpentine and
the kousso had  been  prescribed  separately and
after considerable  intervals, and both had failed,
portions  of the  worm only having come away.
An opportunity, however, was not afforded me
of persevering in  the  treatment beyond the ex-
hibition of two doses of two drachms each.  The
oil was procured from an undoubted quarter.   I
give, in the subjoined note, Dr. Jenner's account
of his experience with  this oil.*   In a case re-

  * " The anthelmintics chiefly employed in cases of tape-
worm in this country are turpentine, kousso, pomegran-
ate, and male fern.  The objection to turpentine  is  its
horribly nauseous flavour, and its very  unpleasant effect5*
on the head, and  occasionally on the  kidneys.  It is a
remedy  which  should be used only as a  last resource.
Kousso is expensive  and bulky. Pomegranate is bulky
and nauseous, and, as ordinarily obtained in this country,
not very certain in its action.   Male fern has the advant-
ages of being  inexpensive, only moderately disagreeable
in flavour, so that children take it readily, of small  bulk,
perfectly innocuous to the patient, and more certain than
the other agents in its action on the parasite.  It is one
of the oldest of the remedies for tape-worm, and one of
the very best   The preparation I have used is the oethe-
real oil.  An aperient was given in the morning, the pa-
tient was kept without food for sixteen or eighteen hours,
and then one or two drachms of the oil  of male fern were
administered on a little cinnamon water.
  " I  have notes of twenty-four cases to which the oil of
male  fern was given,  sixteen of these cases were cured
by a single dose.  In three of these  sixteen cases the head
was found; three of  the remaining thirteen were ascer-
tained to be well two years after the administration of the
oil, one a year after,  one seven  months, two six months,
three four months,  one three months; and before the other
two ceased to be under observation, a second dose was
given by way of precaution, as it was to all the patients
when the head was not found, without any taenia coming
away with the stool.
  " Three required two doses of the drug; in one of these
three, some yards of taenia were expelled by the first dose;
for two months after this no joints were found in the stools,
then  a few appeared, and a second dose was given, and
was followed by the expulsion of nine yards of taenia; the
patient continued well two years after this.  In the second
case,  three yards were expelled by the  first dose ; and a
month after, five feet by a second dose; at the expiration
of four months and a half, the patient continued well; in
the third case, five and a half yards of tienia were expel-
led by the first dose, and seven yards by the second, given
two months after the first.
  " Three doses were required in two cases.  The first
dose of the oil, however, given to one of these cases, was
not of good quality.  In one of the two three days elapsed
between the first and  second dose, and four hours between
the second and third.  In the other two days elapsed be-
tween the first and second dose, and one between the sec-
ond and third.  In both cases the head  was obtained.
  11 In one case, viz., that of a child five  years and six
months  old, between  the 15th of July and the 4th  of
August inclusive, five doses of castor-oil, and as many of
oil of male fern, were administered without a decided ef-
fect ;  a few joints of  taenia only being expelled.  On the
17th of August, twenty grains ofthe extract of male fern, 
1552                        WORMS—Treatment of  Tape-worms.
corded in the same journal (August 30, 1856, p.
733) by Mr. Sympson, two drachms of the aethe-
real oil of male fern, given without preparation,
brought away the Bothriocephalus in three hours
after their exhibition, the worm being voided in
two  portions  with its head connected with the
part last voided.
   178. c.  Methods with Pomegranate Bark.—
Diom.'Orides, Celsus, and  Pliny  mention the
radix punica granati as  a vermifuge ; and in the
East  its  reputation  as an  anthelmintic  remedy
has been great from time  immemorial.   It was
introduced  into  Europe early  in  this  century
by Buchanan-, Breton, Flemming, and  others.
S'eeger states that  of 419 cases treated with  it
up to  1852, 371 are reported as complete cures,
24 as  doubtful, and 24 as  unsuccessful.   Kuch-
enmeister  adds that he could  considerably in-
crease the number of successful cases, partly by
his own observations, and  partly by those made
by others, according to his method—this appear-
ing to be his favourite  remedy.  The following
inferences are stated by  him as to the preparation
of the bark:  1st. All experiments to ascertain
the active principle of the bark of the radix pu-
nica granati have failed.  2d. This bark is often
adulterated, or contains much impurity   3d. The
bark of the root is more active than the bark of
the trunk;  ?iij. ofthe former=5iv. ofthe latter
The bark of  the branches has no  action.  4th.
The fresh bark acts more  gently than the dried
bark, but more of  it is required;  fiij - = 5 ij - of
dried bark.   5th. According to several  authori-
ties, the  East Indian bark—which is thicker—
should be preferred to the European.  6th. "Aft-
er maceiation for at least  twelve to twenty-four
hours, the bark is well boiled;  and, according to
Cenedella, it is better  made in earthen than in
metallic vessels;  it is filtered  while  hot, as, on
cooling, active substances appear  to  be thrown
down  again.  The decoction was formerly  most
generally used, but  I prefer the  extract.  The
best method of preparing this is as follows :
  No. 386.  R Corticis leviter contusi Rad. Punicae Granati,
=Jiv.; macerentur per horas  xxiv. cum aqu« destill. i> j.;
obtained from Duncan and Flockhart, of Edinburgh, were
given without effect.  On August 23d, one pint of infusion
of pumpkin-seeds; on September 1st, decoction of pome-
granate ; and on September 5th, infusion of kousso; all
produced copious evacuations, but no tape-worm.  The
child now left the hospital.  In November he was read-
mittiV, and, during my absence, was treated with suc-
cess, by my friend l;r. Ballard, with the oil of male fern.
This  time the child wa3 kept for forty-eight hours with
little, if any, food, before the oil was given.   The child
was free from tape-worm some months after he left the
hospital.
  " One man took the oil two or three times without any
good effect; but then large  quantities of solid faeces were
discharged from its action ; and before it could be admin-
istered in a more effectual manner, the patient escaped
observation.
  "Among those cured by a single dose, and well two
years afterward, was one man who had taken kousso three
times, and oil of turpentine twice.  Several of the others
had taken turpentine and other remedies with permanent
good effect.  In three cases (children), the patients reject-
ed the oil by vomiting; with one exception, all admitted
that it was much less  nauseous than castor-oil.  In  no
case did it cause griping or other unpleasant symptoms.
The shortest time after taking the oil in which the worm
was expelled was half an hour ;  the longest twelve hours;
the ordinary time four hours.  A large quantity of tena-
cious yellow mucus was usually expelled either with or
before, the worm, and often, also, when no worm was pres-
ent, as when the oil was given to ascertain that no worm
remained, the head not having been found.
  " In no case was the worm alive when expelled, and in
no case was it e>:pfUed entire."—(Association Med. and
Journ., Aug. 23, 1358, p. 718.)
posthac coque in 1. ni calore per horas xij., ad remanenti-
am, ?vj. et cola.
To be taken in three to four doses at interval!; of
from half an hour to an hour."   7th.  According
to German physicians, the fresh bark, or the ex-
tract prepared  in the East Indies  from the fresh
bark,  is  to be  preferred.   Even the  fresh bark
cultivated in Germany and in  green-houses  is
more  efficacious than the dried bark.   Waltz's
extract, prepared from the fresh bark in  the East
Indies, is very active, the dose of it being jj.—jij.
8th  " The most efficacious form, under all cir-
cumstances,  is the solution of the extract in a
certain quantity of water.   The extract itself,
made into an electuary with honey, or  adminis-
tered  in  pills, is to be recommended where there
is great tendency to vomit;  but,  on the whole, its
aqueous solution is the best.  9th An alcoholic
extract is also recommended by Deslandes, and
recently  by  Martins , and an sethereal extract
has been prepared by Waitz in  Java.   Of the
latter fiij — ?iv. are administered in Jv. of fennel-
water with syrupi corticis  aurant. fj., in three
doses, at intervals  of half an hour'.'  10th. Al-
though boiling water is, to  a certain extent, suf-
ficient for the preparation of the active substance
of the bark, yet the addition of caustic potash or
soda,  or  of a little  white wine to  the  water em-
ployed in the  maceration, and afterward  in the
decoction, of the bark, greatly increases the effi-
cacy of the extract.  11th. Bark which has been
long kept is  to be rejected as inefficacious.   12th.
Kuchenmeister has recourse to another method
of preparing the decoction and extract beside that
advised above (6th.)   It is as follows :
  No.  3S7.  R Cort. Rad. Punicae Granati,  fvj.; Pulv.
Rhamni Cathart., 5).; Aquae Destillat., tbij.;  Liq. Kali
Caustiei Concent., ttlx. Macera per horas 12—14; coque
leni calore in balneo vapor, per horas 24 ad remanentiam
extracti.
The woody parts are to be  removed by washing
and pressing some time before the conclusion of
the evaporation, the washing water being evap-
orated with the rest.   A  quantity  of this extract,
corresponding with the dose ofthe pomegranate
bark prescribed, is to be dissolved in ?vj.—viij. of
hot water; and, before administration, 3j.—3ss.
extracti filicis maris aether, may be added, when  it
is desired to combine the two extracts.  (See v 176.)
   179. d. Methods of prescribing Pomegran-
ate Bark.—(a) Recent  Bark.—Buchanan pre-
scribes f viij. of fresh bark ofthe root to be boiled
with three pints of water until two pints remain,
and drunk in cupfuls, at short intervals, until the
worm is  expelled.  Kuchenmeister says that by
this violent vomiting, colic, and purging are pro-
duced.    Breton recommends  fij. of the fresh
bark  to  be boiled down  from fxviij. to  fix., or,
according to Gomez, from rbjss. of water to tbj.,
and this  decoction to be taken by cupfuls.  Merat
advises ?ij. of fresh bark to be infused  at night in
tbjss.  of water, and left to macerate through the
night, and to be boiled down to tbj. in the morn-
ing.  After being  filtered and well pressed, this
decoction is to  be taken  in  three equal parts
within two hours.  If vomiting occur after the
first dose, this should not prevent the following
doses from being given ;  but if the patient vomit
these the treatment must be desisted from.  Ac-
cording to Schmidtmuller, after  one  day's fast-
ing, and the administration at  night of fij. of
castor-oil, fiij. of fresh bark  are  macerated  for
twelve hours in ?xij.  of water, and concentrated
to fvj. ;  this is taken  in three  doses within an 
WORMS—Treatment of Tape-worms.                       1553
hour.   Kuchenmeister  remarks that  " in  all
these  methods  evacuations take  place  without
purgatives,  as the  fresh bark usually acts  as  an
aperient itself;  and in this lies the great advant-
age  of the  fresh bark, and a principal cause  of
the  great uncertainty of most  of the previous
methods, in which the dried bark was employed.
To produce the aperient action with  certainty,
the  dried bark needs  the addition of purgatives.
^cording  to my  experience,  the neutral  salts
and  the  true drastics, such as jalap, are greatly
to be  preferred to the oils."  The decoction  of
fresh pomegranate bark may also be prescribed
as stated in the  Appendix.   (See Form.  69.)
   180. This writer prefers the extract, radicis
punicae  granati,  prepared according to the pre-
scription given above (§ 178, No.  387), to  all
other remedies for tape-worm with which  he is
acquainted; for, in almost every case of expul-
sion by  this medicine, the worm was  passed in
one  piece with the head, or unbroken and in a
single coil—sufficient reason, in his  opinion, for
endeavouring to make the administration of this
remedy more agreeable, and its results still more
certain.
   181. (b)  Combinations of  Pomegranate  Bark
and  Male Fern.—This was attempted  by  Von
Klein, and afterward by Kuchenmeister.   The
latter prescribed it as  follows:
  No. 388.  R Extracti Radicis Punicte Granati Aquosi
quantum est ex Rad., ;iv.—^vj., solve in Aq. Destill.
Fervida?,  fvj.—viij.  Adde Extr. Filicis .Maris JEther.,
3j.—"ss.; Extr. Tanaceti Vulgaris, 31J.; Cambogiae, gr.
iv.—vj. ad x.  Misce.
A cupful to be taken  in the morning, fasting;  a
similar dose in three quarters of an  hour.   The
third is  kept in reserve.   If the worm be not
expelled in  an hour and a half  after the second
dose, the last portion is  also to be taken.   If
vomiting occur, a table-spoonful of the medicine
is given  every ten minutes ;  and, to alleviate the
tendency to vomit, the patient is recommended
to gargle, after every dose, with  fresh milk, with-
out swallowing any of it.  Small pieces of can-
died citron  or lemon-peel are  allowed between
the doses.   If no evacuation have occurred three
hours  after the first  dose, and  the  worm have
not  been expelled, an  aperient  is administered.
"With tania solium,  castor-oil  is usually suffi-
cient ; one to two table-spoonfuls every half hour
or hour; or,
  No. 389.  R Cambogiae, gr. vj.—viij.; Pulv. Rad. Jala-
pa?, gr. x.—xv.
To be  repeated in two hours, if required."  With
 T. mediocanellata, this writer has found the best
results with the following aperient:
  No. 390.  R Calomelanos, gr. iv__vj. ; Pulv. Jalaps,
gr. x.—xv.
To be  taken at once.   After the expulsion of the
worm, he advises no treatment, excepting tonics
in cases  of great weakness.
   182. (c) The preliminary treatment, advised by
Kl-chexmeister, is as follows: At  the  seasons
of fresh  strawberries and  grapes,  he gives  half
a pint  of these fruits every morning, fasting, for
six to eight days;  and  on the evening before
the  expulsion, a herring  salad  with plenty of
vinegar, onions, row and boiled ham, and plenty
of oil; and  to very costive persons, 5j. of castor-
oil;  after which  the patient may  drink  a  large
glass of light Rhenish wine, or a glass of bitter
beer.   If the fresh fruits are not to  be had, the
salad alone will suffice.  In very obstinate cases I
     III.                98
 of Tania mediocanellata, he allows the patient to
 take as much confection of senna with extr. tana-
 ceti vulg. (31J. to the ounce of the confection) as
 will produce two  soft motions  daily;  he then
 takes the mixture, and not before.   Fasting  the
 night before is not advised, as the medicine does
 not agree well with an empty stomach.
   183.  e. Methods with Oil of Turpentine.—
 I have prescribed this medicine both as a prelim-
 inary means variously combined, and as a direct
 remedy, or after little or no  previous treatment.
 As a preliminary medicine, I have most frequently
 given it in the following form :
  No. 391. R Olei Terebinthinae, 31J.—3iv. ; ^theris Sul-
 phurici (vel  Spirit. ^Etheris Sulph. Comp.), 3iv.—vj.;
 Tinct. Camphorse Comp. (vel Tinct.  Benzoniie Comp.),
 fss.; Olei Cajuputi, lllxij.—xx.  Tere cum Fulv. Traga-
 canth. Comp., jiij. ; Pulv. Glycyrrh., 3ij., et adde Syrupi
 Rosieet SyrupiTolutani, aa, 3Jss., Aquae Destill., ad 3viij.
 Fiat mist, cujus capiat cochl., j. vel ij. larga, 4tis vel 6tis
 horis, prius agitata phiala.
 Cold water, or linseed tea, barley water, &c, may
 be  taken frequently during the continuance  of
 this medicine ; and in some cases, as soon as any
 indication of disorder of the urinary functions oc-
 cur, a full  dose of  either castor-oil, or of calomel
 with camboge or jalap, so as to  freely evacuate
 the bowels, should be given.   Frequently a con-
 siderable portion of the worm is expelled by these
 means;  but nevertheless the male fern, or  its
 aethereal oil, or the pomegranate bark, should be
 taken, as  prescribed  above  (v 164-181), a few
 hours  after the  exhibition of the  purgative ;  or
 in other cases  a few hours  before, especially if
 the bowels have not been long confined.
   184.  Kuchenmeister states that "the dose of
 this remedy is fij.  at once, in the morning, fast-
 ing ;  and  if  no stools result, another fj.—fij.
 afterward (Fenwick and Copland); or  fj. olei
 terebinthinae, made into an  electuary with hon-
 ey, &c, in two doses at night before going to bed
 (Thompson) ; or fij.—ijss.  (Schmidtmann) ;  or
 with the olei filicis maris (Mayor).   Or the  pa-
 tient for three  days is allowed to eat only water-
 gruel with  small portions of white bread, three
 times a day ;  and on the next day, when fasting,
 to take the following :
  No. 392. R Olei Terebinthinae, ^j. ; cum Vit. Ovorum,
 ij. ; Sacchari Albi Subacti, f ss.  M.;
 and if the  worm is not expelled on this day,  the
 dose is repeated on the following day (Merck).
 Some also  give §ij.—ijss., one half in the morn-
 ing, and the other at night."   This is one of the
 most effective  agents against tape-worms,   as
 Lange, Kuchenmeister, and others admit.  The
 latter of these writers states that tape-worms laid
 in  turpentine  mixed with white  of egg, died
 within  one hour and three quarters; and that
 the touch-stone of  a remedy for tape-worms is
 not whether it expels Bothriocephalus latus  or
 Tania solium, but  whether it is also capable  of
 expelling the T. mediocanellata.  That the oil of
 turpentine  is efficacious in the latter case, he can
 prove ; for the finest specimen of this last-named
 worm  was  expelled by it.   In  general  it acts
 with tolerable rapidity, and entirely.  This latter
 circumstance he regards as a  requisite of a  good
 vermifuge  in cases of tape-worm, especially  as
 the doctor and  the  patient are anxious to ascer-
 tain the expulsion of the head of the parasite.
  185. The principal objections to this substance
 are  its nauseous taste, the inclinations to vomit,
the  unpleasant  eructations,  griping pains, and
disorders of the urinary excretion, it often occa- 
1554                      WORMS—Treatment of Tape-worms.
sions.  It more  frequently produces  these un-
pleasant  eflects when taken  in the form  of an
electuary.  When prescribed in the form of mix-
ture, as above (v 183), or suspended by white of
egg, or taken either pure in a full dose (fj.—ij.),
or with the addition of castor-oil, on the surface of
coffee, or milk, or on any aromatic water, at bed-
time, or early in  the morning, it is generally the
most efficacious, and least likely  to produce any
of the above unpleasant  symptoms.   It is often
taken with  less discomfort  on the  surface of
Hollands or common unsweetened gin.  When
castor-oil is not given with it, and when it does
not act on the bowels in a few hours, either a full
dose of castor-oil, or of  some one of the purga-
tives already mentioned, should be taken without
delay.
  186. /. Methods with  Kousso. — Kosso —
florcs kousso—the dried and powdered  flowers of
the Bruyera anthclmintica, has lately been much
in vogue against tape-worm.  It has  been sup-
posed by several physicians to have  been adul-
terated.  Kuchenmeister supposes that it is not
so much adulterated as mixed with other Abyssin-
ian medicines against taenia, as with the powder
of the root of Verbascum ternacha, and with the
powdered leaves of Jasminum floribundum.  The
dose of the powder of kousso is svj.—jj.  I have
prescribed  this remedy  in  four  cases.   In the
first, successfully in the  case of a medical man
in Hertfordshire, the entire worm with the head
having been brought away after turpentine and
some other anthelmintics were said to have failed ;
but in two cases with only a partial benefit; and
in one case without any  effect.   The writer just
mentioned states that he has always  been more
or less unlucky with this remedy, which, in the
ordinary mode  of  administration, shares all the
defects of the other remedies for tape-worms, and
easily produces sickness and violent pains in the
intestines ; and that the worm has generally been
expelled by it  in  numerous  fragments, and at
most the worm up to the neck; but that he never
found the  head, excepting once, after a second
dose of the kousso, which caused violent pain in
the abdomen.  Several attempts have  been made
in Germany to isolate the active constituents of
this substance, and to prepare infusions, decoc-
tions, and infuso-decoctions of it,  with and with-
out the flowers being retained in them; but al-
though the effect  appeared to equal  or to ap-
proach that of the  powder of kousso itself, yet
little was gained, excepting when the quantity
(3vj.—5j.) of kousso usually employed was mac-
erated in cold water for twenty-four  hours, and
then boiled for half an hour, and  the whole taken
—without  straining—with the  flowers in it, in
two portions ; §j. to fij. of castor-oil having been
given two hours after the second portion.   This
infuso-decoction was said to  have  been well
borne, and to have acted with certainty.
   [To avoid the nauseating effects of kousso flow-
ers, however different the mode of administration,
the  resin of the flowers, extracted  in the same
manner as the resin-of jalap, has been recently
recommended.   Two scruples to one  drachm  of
the resin are dissolved in about three drachms of
alcohol.   This solution is then poured on a piece
of sugar weighing  about half an ounce.  After
the sugar has dried by evaporation of the alcohol,
it is powdered, three drachms of powdered sugar
being added.  The  whole is then divided into five
doses, four of which are given at six, seven, eight,
or nine o'clock in the evening; the remaining at
six o'clock in the morning ; syi hour later, six to
nine drachms of Glauber's salts are given, dis-
solved in water.]
  187. g. Notices of several other  Medi-
cines and Methods against Tape-worms.—(a)
The  Spigelia anthclmintica has been  employed,
according to Noverre, in the West Indies; but
its effects are unpleasant, and it not easily admits
of use in Europe.—(b) Sabadilla has been giveh
in a dose of half a drachm of the powder  in the
morning, the patient having been purged on the
previous day with rhubarb and Glauber's salts.
The  sabadilla powder is  given  with the same
quantity of fennel sugar,  and the  patient after-
ward drinks  one to two  cups of chamomile or
elder-flower tea.  If vomiting be produced, worms
in the stomach are  thrown up.  On the second
day the same dose of sabadilla is taken; and if
no more of the worm appears, half the quantity
of this medicine is  taken  morning and  evening
of the third and  fourth days.  On the fifth  morn-
ing,  while fasting,  a  purgative is  administered,
and  the  living or dead worm is brought  away.
For children  from two to  four years, two grains
of sabadilla powder is a  sufficient dose.  This
medicine is of service  against ascarides.—(c) The
schebdi—the Phytolacca dodecandra or Abyssinka.
The  fruit of this plant has been tried in Europe,
and  fragments of the  worm  have  been brought
away; but sufficient trials have  not been made
of its efficacy.—(d)  The fructus saoria, the fruit
of Masa  pkta, Hochstetter, has been given in
doses of ;j.—?jss. with uncertain results.   This
remedy  is easily taken.  Its taste is less repuls-
ive  than that of other remedies.   Nausea, vom-
iting, and slight pain  in the abdomen are often
experienced from it.   In  two cases the worms
were expelled by it up to the head, but always
in fragments.  This remedy appears to be deserv-
ing recommendation for ascarides and oxyurides.
—(e) The Mucuna—cortex mucuna—from Mucu-
na anthelmintica.  The dose of the  powder is
3vj., and is usually, in  the East, given with honey
in a stiff paste.   Single fragments of the worm
were brought away by it, but the  medicine was
probably injured by  keeping.
  [The  petroleum has been found very successful
in the treatment  of tape-worm.  The mode of ad-
ministering is to combine half an ounce  of the
petroleum with  six drachms of  the tincture  of
asafoetida, and give forty drops three times a day.
  The seeds of the pumpkin (Pcponis semen) have
recently obtained considerable reputation for the
cure of tape-worm.  They have the very remark-
able property of being bland and almost tasteless,
while at the same time they yield to few, if any,
anthelmintics in point of efficacy.  Two ounces,
or even more, as they  are perfectly harmless, may
be given for a dose.    They should be taken upon
an empty stomach in  the morning, before  break-
fast ; first depriving them  of their outer covering
and rubbing them into an electuary or paste, with
sugar and a little water; or a larger quantity of
water may be added, forming an agreeable emul-
sion. The whole should  be  taken in successive
draughts, and in two  hours  after  followed by a
full dose of castor-oil.]
  188.  h. Drastic  Purgatives with  and with-
out  Calomel.—Bremser's and Schmidt's meth-
ods of employing these medicines arc too severe,
and  are often productive of inflammation  of the
digestive mucous surface, which may not be al- 
WORMS—Treatment of Tape-worms, etc.
1555
 Iayed for some weeks.   I will not, therefore, men-
 tion them.  According to Ettmuller's plan, the
 patient takes, at seven o'clock in the evening, cal-
 omel., gr. xij., lapid. cancror., 9j.;  and about nine
 o'clock, olei amygdal. dulc, fjss.;  which usually
 operate twice in the night.  At seven  and nine
 o'clock next morning he takes cambogiae, gr. xij.,
 rad. Valerianae, and  senj. cinae, aa, gr. iv., when
 the worm is afterward expelled.  I much doubt
 this result.   It is quite unnecessary to state the
 various modes in which the changes  are rung
 upon the purgatives believed to be most appro-
 priate in cases  of tape-worm, by writers of no
 mean reputation, and the several  ways  these
 medicines may be combined and successively ad-
 ministered.   Calomel, camboge, jalap, castor-oil,
 the sulphates of potash, soda, magnesia, &c, va-
 riously conjoined  or administered  in  succession,
 with or without valerian, oleum tanaceti, &c, are
 the chief medicines advised.   But, in order to be
 efficient, their doses and the repetitions of them
 are such as  to  risk the supervention of inflam-
 mation ; and  in a large proportion of cases they
 fail altogether.
   189. i. Inferences.—(a)  Simple methods of
 treatment with the filix mas and its  athereal oil
 and extract (() 176, 177), are sufficient to remove
 the Bothriocephah.—(b) For the expulsion of
 Tania solium, the combination of the aqueous
 extract of the bark of the pomegranate root, with
 the addition ofthe aethereal extract of male fern,
 is considered by Kuchenmeister as the most effi-
 cacious, camboge, gr. iv.—viij.,  being preferable
 to the saline addition mentioned above.—(c) The
 Tania mediocanellata is  generally expelled by
 the same combination, especially when a powder
 with calomel  and  jalap, or camboge,  is  given
 afterward. — (d)   In very  obstinate  cases,  the
 methods with tin, or  those with  turpentine, or
 with these latter following the  former, may be
 employed with  care and  circumspection. — (e)
 The  kousso  does not promise any advantage
 over  the above  remedies, if, indeed, it  be  equal
 to  any of them.—(/)  When the worms depend
 from the anus, the German physicians advise a
 cup of strong black coffee with  plenty of sugar
 to be given immediately.  A dose of calomel and
 jalap, or this followed by castor-oil, appears to be
 more efficient.
   190. k. Treatment with Kamala (the red pow-
 der obtained from the capsules ofRottlera tinctoria,
 Roxburgh).—This substance, long known in India
 as a valuable dye for silk, has been  much employ-
 ed against tape-worm, which is very prevalent in
 the Punjab and Northwestern Provinces of India,
 and has recently been prescribed with success in
 this country by Dr. Leared and  others.   This
 peculiar red powder may be prescribed in  doses
 of half a drachm to three drachms suspended in
 water.  " A single dose is often  found sufficient,
 and in  general it is not necessary to give any
 other medicine before  or after.  In some cases,
 however, where a small dose of kamala has been
 administered, castor-oil has been  afterward given
 with good effect.  Dr.  Gordon has  prescribed
 kamala in the dose  of one drachm, repeated at
 intervals of three hours.  Kamala  may be given
 also in the  form of tincture, the formula  for
 which, recommended by  Dr.  Anderson, is  as
 follows:
  No. 303.  R  Kamala?, ?vj. ;  Spiritus rectificati, fxvj.
 Marcera per biduum et cola.
An  aethereal  tincture  may be prepared of the
 same strength;  but it is said to offer no partic-
 ular advantage over the alcoholic.   The dose of
 tinctura kamala is from 3j. to 31V., diluted with
 some aromatic water."  (Dr. Hanbury, in Phar-
 maceutical Journ., Feb., 1858, p. 405.)
   191.  Drs. C. Mackinnon, Anderson, Corbyn,
 and Gordon have praised the anthelmintic pow-
 ers of this medicine.  Dr. Mackinnon states that
 the results have been so satisfactory, that he has
 continued to  employ this  whenever  a case of
 taenia presented itself, and that he has given it in
 sixteen cases without a single failure.  In none
 of his cases, excepting one, did he ever exceed,
 for a single dose, three drachms.  This dose usu-
 ally purges from  five to seven times; and the
 worm  is usually expelled, dead, in the fourth or
 fifth stool.  In about half the cases some degree
 of nausea and slight griping were experienced ;
 in the remaining half no inconvenience whatever
 was felt.  Dr. Mackinnon states the following
 as the results of his experience of this medicine :
 " 1st.  That kamala is a safe and efficient remedy
 for tape-worm, and more certain than either tur-
 pentine or kousso.  2d. That, to a strong Euro-
 pean, three drachms may  be safely given  as a
 dose.   3d.  That to  a person of feeble habit, or
 to a female, one drachm and a half, followed, if
 necessary, by half an ounce of castor-oil, is a suf-
 ficient dose."  Since the above was published,
 Dr. Mackinnon has  administered this medicine
 to nearly fifty  patients, and  in two  instances
 only was  no  worm  expelled.  (Medical  Times
 and Gazette,  Dec. 19, 1857, p. 628;  and Indian
 Annals of Med.  Science, vol. iii., p. 86.)
   192.  Dr. Anderson  states that, " after  three
 drachms of the powder (of kamala)  have been
 administered,  the  worm is usually  expelled in
 the third or fourth stool.  It is generally passed
 entire, and  almost always  dead; and in all the
 cases I have examined (about fifteen) I was able
 to detect the head.  In only two cases do I know
 of the worm being passed alive.  The advantage
 ofthe tincture over the powder consists in its ac-
 tion being more certain and milder, and in its be-
 ing rarely accompanied by nausea and griping.
 In two or three cases,  only two or three.stools
 followed the dose usually  given, and the worm
 was expelled in  the second stool; in one patient,
 only one stool was caused  by the medicine, and
 in it the worm came away dead." (Ind. Ann. of
 Med. Sc, vol.  iii., p. 82.)  Dr. Anderson alludes
 to ninety-five cases of tape-worm in which kamala
 was prescribed,  and of this  number (eighty-six
 were European  soldiers) he was  aware of only
 two in which no worm was expelled.  Dr. C. A.
 Gordon remarks that " with this medicine there
 is no unpleasant effect.  It  is not even necessary
 to take a dose of purging medicine as a prepara-
 tive ; and, beyond a  trifling  amount of nausea
 and griping in some instances, no unpleasant ef-
 fects are experienced; while by far the greater
 number of persons to whom it is administered
 suffer no  inconvenience whatever beyond what
 they would from  a dose of ordinary purging
 medicine."  (Med. Times and Gaz., May, 1857,
 p. 429.)
   193.  Dr. Anderson and Dr. Gordon agree in
 stating that the frequency of taenia in the North-
 west and Upper  Provinces  of India  arises from
 the free use of animal food of a very unwhole-
some character by the European soldiers ; while
among the Hindoo  natives, whose food is entirely
vegetable, this  parasite is unknown.   Foul-feed- 
oma, Oxyuris vermicularis, etc.
1556           WORMS—Treatment  of Disti

ing and  half-starved pigs,  cattle  and sheep, as
well as ducks, turkeys, fowls, pigeons, equally
foul-fed and diseased, are often made articles of
diet by the European  soldiers,  and are  justly
viewed, by the physicians  mentioned above, as
the causes of the  prevalence of tape-worm in
this class.
   194. iii. Treatment of the other Worms.—
A. Echinococci, cysticerci, and acephalocysts rare-
ly admit  of treatment, and only of surgical treat-
ment.  This subject is sufficiently noticed in the
article Hydatids.
   195. B. The comparative rarity ofthe  Distoma
hepaticum (Y  98-100),  and the  difficulty of its
diagnosis, render the prophylaxis and treatment
of this worm, in some respects, matters of subor-
dinate importance.   The prevention is either dif-
ficult  or  impossible, owing  chiefly to our imper-
fect knowledge of its developmental history.  As
far as this history may be inferred from  the sm>
joined remarks of  Kuchenmeister, the  prophy-
laxis  must be  founded  on  it, and be viewed as
conformable with what has been stated above.*
(y 157-160).   The  direct  treatment  of  Distoma
hepaticum can rarely be ventured upon with suc-
cess, owing, first, to the almost impossibility of
its diagnosis, unless its presence be inferred from
the passage upward or downward of some indi-
viduals of this species ; and next, from the serious
nature ofthe lesions produced by it.  Even grant-
ing, then, the  detection  of the malady, medicines
can be exhibited  only with great uncertainty as
to their beneficial effects.  As, in many  of these
cases,  the biliary functions are  more or less in-
terrupted, and organic vital force impaired, it be-
comes necessary to attempt the restoration of the
former, and the development of the latter, by suit-
able means.   To remove biliary obstruction, cal-
omel and other mercurial preparations combined,
according to the peculiarities of the case ; the
nitro-muriatic  acids internally and  externally;
the preparations of taraxacum, and  the  mineral
waters of Carlsbad, Marienbad,  Kissingen, and
similar springs.  Durand's medicine against gall-
stones and obstruction of the gall-ducts  has also
been recommended.  This  medicine  consists of
equal quantities of oil of turpentine and sulphuric
ether.  It may be given in moderate and  frequent
doses ; or the oil may be conjoined with alcohol;
or with nitric  ether, or with the sjycet spirits ot"
nitre.  These appear to be appropriate  for this
  * "Although it is still unknown to us how the embryo
becomes metamorphosed, and into what cercaria-sacs or
redice it is converted, and where thc*e cercaria-sacs or
redias live; although we do not know whether the brood
of D. hepaticum is tailed or tailless, and where it encysts
itself, whether free in the water in the manner of Monos-
tomum, in aquatic mollusca or insects, or in higher ani-
mals which. occasionally visit stagnant waters, yet there
is much probability that the herbivorous or omnivorous
domestic mammalia infect themselves with free encysted
young Distoma, either by devouring snails which adhere
to the grass of the meadows, especially in moist pastures,
or by drinking from impure, stagnant waters (marsh ur
pond water).  Exactly the same  thing  would then  take
place in man, by means of snails adhering to salad, fallen
fruits, radishes, turnips,  and  other roots.   Nay,  such
Email snails might even be introduced with  dry fodder
into the stomachs of our domestic animals during the
winter, by their eating the small species, passing their
winter sleep in their closed shells,  or the shelless slugs
adhering to roots protected from frost in warm cavities or
cellars.  Whether the production of D. hepaticum in the
human liver may take  place by drinking impure water,
must remain quite undecided. The finding of a young
Distomum in the sole of a woman's foot appears to be
in favour of an immigration, and a mode of existence sim-
ilar to the Cercaries."—(Op. cit., p.  270, 1.)
parasite, as the efficacy of the turpentine against
other worms, and  the rapidity of the absorption
of it into the circulation, are indications in favour
of the use of it in cases where the existence of
this animal is inferred.   Kuchenmeister states
that the principal ingredient  of  the remedy of
Durand has been  successfully administered for
distoma of some of the  lower animals ; and that,
upon his recommendation, turpentine  was ad-
ministered to several sheep, and  followed by a
purgative; but the results  were not fully ascer-
tained when he wrote.  The propriety of enabling
the constitution to throw off the parasitic animal
by the exhibition of tonics conjoined with altera-
tives and deobstruents, such as the bichloride of
mercury with preparations  of cinchona ;  the ex-
tract of taraxacum with  the  solution of potash,
and with tonic and bitter infusions or decoctions;
and the nitro-muriatic acids with these latter and
with taraxacum, cannot be reasonably doubted.
   196. C. The Distoma hamatobium, so remark-
ably prevalent in  Egypt  ((/ 103-109), cannot be
encountered with  any means of prevention or of
cure, upon which any reliance may be  placed.
Griesinger, who  has furnished the chief amount
of information  respecting this parasite, considers
that—1st, the waters of  the  Nile used without
filtration ; 2d,  the bread, grain,  and dates em-
ployed for food ; and, 3d, the use of half-putrid
fish, being the  chief  causes of its existence—the
prevention of it must be  based on the avoidance
of these  causes, and of the circumstances con-
nected with them,  which  admit  of avoidance.
As regards the cure, calomel and turpentine are
chiefly recommended by  Griesinger, the  latter
being readily absorbed into  the  circulation, as
first shown by me in a memoir on this remedy,
published in the London Medical and  Physical
Journal for 1821.   He also advises the use of
onions, garlic, &c.   The  tinctura  ferri muriatis,
and other preparations of iron, of camphor, asa-
foetida, &c, variously combined, and long persisted
in, may also prove of benefit, especially as anaemia
and chlorosis form a marked characteristic of these
cases.
   197. D. The Oxyuris vermicularis (I) 123-126)
is always treated with difficulty, and, according to
my experience, with greater difficulty in old than
in young subjects.   Kuchenmeister states that
internal remedies  in general are  but little to be
recommended.   I am of a very different opinion,
based upon very considerable experience.  This
writer advises  the long-continued use  of a tea
made from the florcs vcrbasci.  The flowers are
left in the infusion, and used with it.  The fine
hairs appear to irritate and  disturb the worms
mechanically.   The remedies already noticed for
the cure of tape-worm, especially  turpentine, the
pomegranate root, the filix  mas, &c , often bring
away the thread-worms, but they are soon regen-
erated.   The permanent removal of them cannot
be effected by these  or by similar  means.  Medi-
cines calculated to act upon the lower bowels, and
to restore the tone ofthe digestive mucous sur-
face, and to correct the state of the intestinal se-
cretions and excretions, are  especially  required
against these worms.  Dr. Pockels recommends
the powder of filix mas and jalap in some suitable
vehicle; Kuchenmeister, the preparations ofthe
semen  cinae—the  santonicum, or  semen  contra
vermes—internally for two days, and afterward
strong purgatives, followed by clysters ;  Dujar-
din advises enemata with valerian, or garlic, or 
WORMS—Treatment of Strongylus, Ancylostomum,  etc.
1637
wormwood, with the addition of aloes ; and many
administer clysters of salt water, or a solution of
salt in water  with olive or castor oil.   When the
patient is distressed by these parasites during the
night these or similar enemata should be admin-
istered at bed-time or shortly before.   Numerous
preparations of the santonicum, and various com-
binations of this seed with other  substances, as
the powder (3j.—3ij.),the infusion, the decoction,
the extract—in  the form of electuary, mixture,
confection, bolus, &c.—with valerian, or jalap, or
calomel, or aloes, or rhubarb, or sulphate of pot-
ash, or with sulphate of iron, or with alkaline car-
bonates, are contained in the Continental phar-
macopoeias, and  employed against  this and other
species of worms.
   198. The means which I  have usually employ-
ed, for many years, against the Oxyuris vermicu-
laris, with the view not merely of removing them,
but also of preventing their regeneration, and of
improving  the functions of the bowels and the
state of the general health, are combinations of
preparations  of iron with those of aloes, taken in-
ternally for some days, or even weeks, according
to their effects ;  and afterward enemata with olive
or castor oil, spirit  of turpentine, or asafoetida,
camphor, salt, &c, in gruel, according to the pe-
culiarities of the case.  The mist, ferri may thus
be  conjoined with the decoctum  aloes compos.,
or with the tinct. aloes ; or the pilula ferri comp.,
or sulph. ferri, may be given with the pilula aloes
cum myrrha, the pilula galbani comp. and cam-
phor.   Electuaries  may also  be prescribed in
other cases,  with the carbonates or oxydes  of
iron, the santonicum  and   confection of senna,
with a small proportion ofthe confection of black
pepper;  and, if these do not completely  remove
the annoyance, the use ofthe enemata already rec-
ommended should be adopted (see Form. 71, 80,
105,106,149,151, and 153).  In some cases where
these are required, the long flexible tube should
be  introduced above the sigmoid  flexure of the
colon, so that the remedies  may reach above this
part ofthe bowel.   Having removed the  worms,
it will be of service, in order to prevent their re-
generation, to continue the use of  the prepara-
tions of  iron in conjunction with aperients and
the other medicines which  the circumstances of
the case will  suggest.   The following pills have
been found by me,  for many years, to be  most
successful in removing and in preventing the re-
generation of the oxyuris vermicularis and the as-
carides lumbricoides, both of which parasites are
often present in the same case  :
  No. 394.  R Ferri  Sulphatis ;  Quinae  Sulphatis; Cam-
phor.!', aa, gr. xvj.;  Pilulae Galbani Comp., 3ijss.;  Fi-
nite Aloes cum Myrrhi, 3j.; Pulv. Capsici, gr. xvj.; Olei
Cajuputi, HI xx.; Mucilag. Acaciae, q. s.  Misce, contunde
bene, et divide in pilulas xxxvj., quarum capiat unam,
duas, vel tres, bis terve in die.

The aloes, in combination with sulphate of quinae,
acts energetically on the bowels ;  therefore the
dose of these pills should be regulated according
to their operation—a larger dose being given for
the expulsion of  the different species of ascar-
ides ; and  the smaller doses for the  prevention
of their regeneration.   The enemata already rec-
ommended should also be administered after the
pills have been  taken during two, three, or five
days, the repeated exhibition of these latter ren-
dering the former more efficient and generally

   199. E.  The  Strongylus  gigas  (v 128-130).—
This worm, which is found chiefly in the kidneys
and urinary bladder,  can hardly be inferred  to
exist during life unless its discharge takes place,
which  very rarely occurs.   Kuchenmeister re-
marks that if several worms, or one large female,
be present, the kidneys  will be enlarged, so that
the enlargement may be detected by palpation,
percussion, and perhaps by inspection ;  but the
cause of this swelling, or any flow of blood  from
the urinary  passages, or of any existing reten-
tion of urine, could be  referred to  the presence
of these worms only when any of them are passed
from the bladder; and in this case the treatment
would  be chiefly  to alleviate irritation  by mu-
cilaginous and oily medicines, and emollients, de-
mulcents,  &c.   The oil of turpentine internally
and externally may probably be of use  in  some
instances.
   200. F. The  Ancylostomum  duodenalc (Y132-
135) is one of the inflictions on Egypt and some
other tropical countries, and to Griesinger we
are indebted for all we know respecting it   Un-
acquainted at first with the real cause of the dis-
ease which it occasions—with the prevalent anae-
mia, chlorosis,  &c, produced by it—he  had pre-
scribed iron, quinine, calcaria phosphorica (phos-
phate of lime ?), &c, with much benefit  in  slight
cases, but never with complete success in  those
which were severe.  Kuchenmeister states that
in one of his last dissections a sudden light broke
in upon him on this subject, when  he found the
duodenum, the jejunum, and even the upper half
of the ileum, entirely filled with fresh red blood,
only coagulated here and  there, and thousands
of Ancylostoma on the mucous  membrane of the
small intestine, each with  its  little ecchymosis
resembling the bite of a  leech.   Although  he
thus left Egypt, and could collect no farther clin-
ical observations, he told the Arabian prosector,
"You must now employ calomel and other an-
thelmintics against these  Ancylostoma  and the
Distoma of the portal vein ; in short, against the
tropical chlorosis,  as well as against haematuria,
stone, dysentery, abscess of the liver, and all the
undetermined diseases of tropical countries, per-
haps even some of the tropical  fevers, and inves-
tigate the latter illness itself, with  reference  to
the most  recent  helminthological  discoveries."
Above all  things, Griesinger praises  calomel
and oil of turpentine  a  priori, the latter, indeed,
especially for  the Distoma of  the  portal   vein,
above  all  for the Ancylostoma,  as it certainly
reaches the  worms  situated in the uppermost
parts of the  intestine ;  in  substance, worms die
in it very readily, and it  also  acts  as a styptic
upon the  injured, bleeding vessels.  This last
remedy, when mixed with castor-oil, or with cas-
tor-oil and a few grains of santonine, or the na-
tron  santonicum, to which vegetable purgatives
are added, must  prove particularly efficacious.
" None of our colleagues working in the tropics
should forget that tropical  chlorosis is  the con-
sequence of the repeated, small intestinal bleed-
ings, which scarcely  betray themselves  extern-
ally, caused by  intestinal worms, especially An-
cylostoma."
   201.  G.  The Filaria  Medinensis (Y 138-142).
—a.  The prevention of this worm may be inferred
from the  causes  and circumstances connected
with its occurrence, namely, the endemic preva-
lence of filaria in certain climates and localities,
its youngest brood living free in the water, or in
wet  grass, marshes,  or  moist soil,  &c.   Hence, 
1558      WORMS—Treatment of Filaria Medinensis and Ascaris lumbricoi
wading through these places with naked feet, or
exposing naked parts of the body to foul or  im-
pure water, should be  avoided as sources from
whence  the brood comes in contact with these
parts in the native countries of this worm.  Pru-
ner states that an infection of the filaria may oc-
cur, as shown by numerous facts, even in those
tropical regions in which the worm is not endem-
ic, an actual transfer from one person to another
or to doo-s and  horses taking place.   Bremser
says that even in his  time the worm had become
naturalized in Curacoa by the importation of  ne-
groes.  No one, therefore,  should use the same
vessels employed by the  patient in bathing or
washing  the feet; and that great caution should
be observed with the bandages of such patients.
  202. b.  Curative  Treatment. — At  the com-
mencement  of its  growth, this  worm  is said,
when superficial, to be easily killed by poultices
of boiled garlic.   When quite superficial, an in-
cision is  made upon it, and the worm pulled  out
with a hook.  Slave-dealers rub in civet and musk
on its first appearance   But the worm often pro-
duces no annoyance for a long time—six to eight
months.  When it inflames and ulcerates the in-
teguments over its seat, the part which appears
is seized, and carefully pulled and fastened to
a roll of linen or stick, and gradually extracted
by turning these twice daily.  Some writers ad-
vise, when the worm is felt, to cut down through
the integuments, making  an incision  of several
inches long, and removing the worm  in a loop,
or wedging into  a piece of wood, and  then pull-
ing now  on one  side and now on the  other, the
muscles being all the while  relaxed.   If inflam-
mation,  swelling, and  pain are  great,  and  the
worm resists dragging, or breaks  off, these symp-
toms are to be treated in the usual way, by poul-
tices of linseed meal, or of onions and bread, or
onions boiled in  milk, or of roasted onions,  &c.
In these cases numerous  means have been rec-
ommended in addition, but none  of them appear
very appropriate or successful.
   203. From the most ancient periods the break-
ing of the worm has been considered  a very se-
rious accident;  and  severe  inflammation, fever,
gangrene, &c, have been, even by some modern
writers, said to have resulted from it.   Accord-
ing to the observations of most authors, who had
themselves  suffered  from  the  breaking of  the
worms,  violent  swelling,  inflammation,  fever,
sleeplessness had occurred, and were cured only
when they were killed.  The diagnosis in cases
of Filaria medinensis should  always be correctly
made, in order to determine the presence of  this
worm, and to distinguish between Fi runculi (see
that article) and inflammatory swellings caused
by it.
   204.  H.  The  Treatment  of Ascaris  Lumbri-
coides (v 144-149).—a. For the prevention of this
worm it  is necessary to bear in mind the circum-
stances in which the eggs may occur, and the
long period during which they may be preserved.
Richter ascertained that the eggs may remain in
sewerage and foul water for some time, and that
they  attain their full maturity, and undergo the
process of segmentation in this situation.  Bar-
ry, Bischoff, and others have shown that alka-
lies and  salts do not  prevent this process.  Ver-
loren, that a period of eleven or twelve months
is required for the completion of this process in
the Ascaris lumbricoides.   Richter and Kuchen-
 meister state that eggs which had been put in
water had not shown any appearance of embryos
several months  afterward.  As to what becomes
of the ready-formed  embryos nothing is known
positively; they  probably  get  into our bodies
with  water,  and  perhaps this  is sufficient  for
their development.
  205. b. The  Cure  of Ascaris Lumbricoides.—
The number of  medicines  recommended  with
this object are so  great that the judgment is dis-
tracted respecting them.  In order to assist the
selection, it has been attempted to determine the
effects of the most reputed vermifuges upon liv-
ing intestinal worms from recently-killed domes-
tic  animals,  by Redi, Andry,  Leclerc, Torti,
Arnemann, Chabert,  and others.  More lately,
Kuchenmeister has had recourse to  similar ex-
periments made in the temperature of the ani-
mal, by mixing the anthelmintic in white  of egg,
and placing the living  worm in the mixture, and
has given us  the following results, " arranged ac-
cording to the  time in which round worms died
in white  of egg mixed with the various remedies :
  206. " 1. Death took place in one to two hours
in white of egg mixed with creasote,  and large
doses of  common salt and corrosive sublimate.
  207. " 2 Death took place in two to five hours
in white of egg mixed with petroleum, cajuput-
oil, oil of turpentine, mustard, weaker solutions
of common salt, and washed herring's milt.
  208. "3. Death took  place in  five to fifteen
hours in  white  of egg mixed with garlic,  onions,
laurel, cloves, wood  vinegar, rad. pun. granati,
tinct. gallarum, concentr. sol. of sulph. soda.
  209. " 4. Death took place in fifteen to twenty-
four hours in white of egg mixed with camphor,
anise, and infusions or decoctions of ginger, gen-
tian, elm-bark,  kousso, and hops.
  210. "5. Death took  place after twenty-four
hours in  white of egg mixed with infusion or de-
coction of parsley, rice, milfoil,  tansy, valerian,
chamomile, wormwood, myrrha, quassia, calamus,
ipecacuanha,  walnuts,  china-bark, willow-bark,
oak-bark, catechu, kino, asafoetida, gum ammo-
niac, Peruvian  balsam, ol. ricini, aqua picis, crea-
sote water,"  &c.
  211. This  writer states that besides the  rem-
edies here enumerated he has tested the semina
cinae  (santonici) with  their preparations.  In a
mixture of white of  egg with coarsely-powdered
seeds the worms live for days ;  and in a mixture
of white of egg with a strong infusion of semin.
cinae, with repeated  additions of unboiled  pow-
der, they also  lived  for days.  In a mixture of
santonine with  water  and white of egg, the
worms lived  for days ; and also in white of egg
with santonine and a little vinegar.  At the same
time, however, the total insolubility of the san-
tonine was proved by farther  experiments.'  In
white of eggs  mixed with castor-oil and santo-
nine the worms died within an hour; but in this
experiment the temperature was raised too  high.
In  a mixture of white of egg with natron santoni-
cum (santonate of soda) dissolved in water, as-
carides lived  more than twelve hours.   These ex-
periments form an introduction to the treatment
advised for Ascaris lumbricoides by Kuchenmeis-
ter,  and more especially to the use of the  prep-
arations  of santonine; but he previously notices
the employment  of the semina santonici by oth-
er helminthologists, who generally prescribed this
remedy in the  form of an electuary.
   212. (a) Storck's Formula:
  No. 335. R  Pulv. Semin. Santonici  (vel Cinae), 3lj.; 
WORMS—Treatment
Rad. Valerianre Min. Pulv., xj.;  Rad. Jalapae Pulv., 3ss.;
Oxymelhs Scill., q. s. ut fiat electuarium molle.
One tea-spoonful every three hours.
  213. (b) Selle's  Tonic Worm Electuary:
  No. 39G.  ft Pulv. Seminum Cinae, 3vj. ; Ferri-Sulph.
Cryst. ; Extr. Chinae Fuse, a;~i, 3ij. ; Syrupi Cinnam., q.
b. ut fiat electuarium molle.
One tea-spoonful three times a day.  This  elec-
tuary is to be preferred some time after the ex-
pulsion of Ascarides, and to ascertain their per-
manent removal.
  214. (c) Hufeland's Worm Electuary:
  No.  397.  R Pulv. Sem. Santonici, ^ss.; Pulv. Rad.
Jalapnj, rj.; Kali Tartar, depur., 3ij. ; "Pulv. Rad.  "Vale-
rianae, 3jss. ; Oxyinel. Scilte, 3vj.;  Syrupi Simp., q. s.
ut fiat electuarium molle.
One tea-spoonful every two or three hours.
  215. (d) Clarus and other German physicians
advised the Semin. Santonici, coarsely powdered,
to be sprinkled  over bread, and  spreading  sirup
of honey over the powder, administering  from
3ss. to 3J. several times a day in this manner, fol-
lowed every third or fourth day by a purgative.
  216. (e) Bremser's Electuary :
  No. 398.  R Seminum Santonici vel Tanaceti Vulgaris
ruditer contusorum, %b*. ; Pulv.  Rad. Valerianae, 31J. ;
Pulv.  Rnd. Jalapae, 5)jss.—ij. ;  Tart. Vitriol. (Potasste
Sulph.), 3jsh.—31J.; Oxymel. Scilte, q. s. ut fiat electua-
rium molle.
A tea-spoonful to be taken two  or three times a
day.  After taking  two  tea-spoonfuls  daily for
three or four days, slime and worms pass off with
more copious stools.  If the  worms  are not ex-
pelled, Bremser administers some more of the
electuary twice or thrice.   If the first pot of elec-
tuary be insufficient, a second is taken, but watery
stools must not  be produced.   He never allowed
more  than two potfuls to be taken; and he con-
sidered it unimportant whether worms passed or
did not pass during its use.  To  relax the bowels
once in the midst of this  treatment he prescribed
the following :
  No. 399.  R Pulv. Rad. Jalapae, 3j.; Pulv. Fol. Sennae,
tss.; Fotassae Sulph., 3J.  Misce.  Fiat pulvis in partes
iij. vel. iv. aeq. divid.
Half a powder to be taken every half, or  every
hour, or two hours, until it operates.   For leuco-
phlegmatic subjects he often gave Chabert's oil
(composed chiefly  of turpentine rendered still
more nauseous), in doses of two tea-spoonfuls in
water, night and morning.
   217. The Semina  Santonici,  Kuchenmeister
states, have been recently displaced by the prep-
arations  obtained from them, and in his opinion
with justice.  He extols chiefly two of them, viz.,
Santonine and the Santonate of Soda; all the rest
being unnecessary.  He considers it to be prefer-
able to administer santonine with  fatty oils, in
order to bring it into solution as readily as pos-
sible ; and for this purpose he prefers to give it
sprinkled upon  bread and butter, or in the  yolk
of an egg with sugar ;  and afterward to follow it
every three or four days with a  gentle purgative
(jalap or confection of senna), or to administer
it in castor-oil—gr. ij. to iv. ofthe santonine* in
?j.  ofthe oil,  to be taken in tea-spoonfuls  until
  * The preparation of santonine is best  effected  by the
employment of ammonia.   It must be tasteless,  when
pure, because it does not dissolve in the mouth.   Dis-
solved in  alcohol, it is bitter.  It is sparingly soluble in
warm water, but is readily in oils.  It is inodorous, has
a slight acid reaction, combines readily -with alkalies, and
becomes yellow in the light of the sun. When impure, it
still contains resins and essential oils, and is consequently
nau->eous to the taste. — (Callonb, in Pharmac. Central-
blatt 1849  p. 413;  and J. Ci.arus, in Handbuch der Spc-
cielien Arzneimittellehrc, 1S53, p. 833.)
f Ascaris lumbricoides.                   1559

purgative action commences.   In  this way the
remedy should be repeated, if possible, for some
days, or every other day, so that  soft stools, rather
than  actual  purging,  should be passed.   Milk
and butter-milk may be taken during this treat-
ment.  " Among  the  santonine lozenges, those
prepared from cocoa, undeprived of oil, are most
deserving praise."  Kuchenmeister remarks that
the most troublesome effects of this remedy are
spasms,  obstructions,  with tenesmus, and even
bloody stools; but that with a careful employ-
ment ofthe remedy (gr. ij. to iv.  with fj. of castor-
oil) he has never  seen ill effects produced by it,
the  administration of it  with  castor-oil always
preventing  intestinal  obstructions.   The  most
annoying symptom, to the  patient only, is the
yellow or blue, or even green appearance of ob-
jects, owing probably to the effect of this remedy
on the nervous system;  but this appears to be
only a temporary  inconvenience, which soon dis-
appears after the  discontinuance of the remedy.
This writer adds that " it follows, as  a matter of
course, to be cautious  in  the use  of santonine,
that he would never give more  than eight grains
of it in two days, divided into doses of two grains
each twice a day,  and  that, on the second day of
its use, he would administer an  aperient."
   218. (/)  The Santonate of Soda.—Natron san-
tonicum has recently been greatly praised by H.
E. Richter and Kuchenmeister, for its success-
ful action in cases of Ascaris lumbricoides.   The
latter of these physicians  states that he has never
seen injurious effects  from this medicine, even
when administered in  doses of eight to ten grains
twice a day to adults.   " The remedy to be given
alone, as every acid decomposes  it, and it must not
be mixed in electuaries."   He  adopts nearly the
following method:  He lets children (or adults)
take  a powder of santonate of soda with sugar
(from two to six  grains)  on a Friday night, and
he repeats the same dose on Saturday morning
(fasting) and evening, and again on  Sunday morn-
ing.  On Sunday, half an hour or an hour after
the last powder, an aperient electuary (confectio
sennae, &c), or a sufficient dose of jalap, is taken,
so that several soft motions may follow.   By these
means the worms usually pass  off alive ; or they
wander forth singly afterward, and without stools,
their residence having become disagreeable  to
them.  Dr. Pockels, who noticed a blackish dis-
coloration of the tongue after santonine, praises,
as a remedy for Ascaris lumbricoides, the root of
Aspidium filex mas in conjunction with purgatives.
   219.  (g)  I have found no remedies more effi-
cacious for  the Ascaris lumbricoides than turpen-
tine, as prescribed above (f) 183-185) and in Form.
216,  and  the infusion  of spigelia and santonicus,
as directed  in Form. 264  in the Appendix.  For
this worm, also, as well as for the Oxyuris vermi-
cularis, the preparations of the semina santonici,
prescribed in the  Appendix, will also be found
successful.   (See  Formula 71, 80, 105, and 106.)
These and  other medicines will be frequently  as
successful without as with the preliminary treat-
ment recommended by the German writers; the
exact operation of such treatment often being not
very manifest.  The great success  derived from
the powder and tincture of kamala, in India, in the
treatment of tape-worms (see y  190-193), and the
effects of this substance upon these worms, prom-
ise similar  results from it, if it were prescribed
against the Ascaris lumbricoides and the Oxyuris
vermicularis. 
1560       WORMS—Treatment of Ascaris lumbricoides—After-treatment of.
   [One flf the best remedies against worms is
the Absinthium (wormwood) tincture, wine infu-
sion, or essential oil.  The tincture, made by add-
ing one part of wormwood to eight of proof spirit,
is powerfully tonic, stomachic, and anthelmintic,
and may be given in doses of from one fluid scruple
to two fluid drachms three times a day; or 2 parts
wormwood to 50 of wine, digested and  filtered,
may be used in 2 or 3 drachm doses, several times
a day.   This is a very useful remedy as a corrob-
orative and preventive, after the removal of worms.
An excellent anthelmintic may be prepared after
the following formula: R Seeds of artemisia, extr.
of tansy, each six grains; oxyde of iron,  four
grains ; oil of valerian, one drop.  M.  The fol-
lowing, though  disagreeable,  is very efficient:
R Black oxyde of iron, 3ss.;  asafoetida, 3Jss.; oil
of tansy, gtt. x.; extr of wormwood, q  s.   M.
Divide into 90 pills ; six three times a day.   The
chenopodium  is a safe and effectual  vermifuge,
used after the following formula .- R Fresh leaves,
5j.; new milk, Oj.; orange  peel, 3ij.  Boil and
strain.  Dose, a wine-glassful  twice  a day.—R
Oil of worm-seed, 3j ; sugar, gum Arabic, each
3jss.; mix, and add mint-water, fijss.  Dose, a
tea-spoonful four times  a day,  for two or three
days, to be  followed by a purge.  In cases of
lumbrici, the following will be found very success-
ful: R Cowhage, 3J.; sirup, fss.; mix.  A tea-
spoonful every morning, fasting, for three days,
to be followed by oil; or, R Cowhage, 3J.; honey,
sufficient to make electuary, given as above.   The
following vermifuge emulsion is a pleasant and
successful remedy for lumbrici:  R Castor-oil, mu-
cilage  of gum  Arabic, each,  fj. ;  sirup  of Cor-
sica moss, water of lemon, contra-chamomile, each,
f. fij.; emulsion of sweet almonds, f. 5viij.  Mix.
For tape-worm, a mixture of one ounce of castor-
oil and two drachms of sulph. ether,  in doses of
a spoonful every two hours, is very efficient.   Of
the spigclia (pink-root) the following formulae will
be found useful: R Powdered pink-root, grs.  x.;
calomel, grs. iv.  Mix.   Take morning and even-
ing, and, after four doses, a cathartic of castor-oil
—R Powdered pink-root, senna, each, 3ij.; savin,
grs. xij.  M.  One every morning for three days,
followed by a purgative.—R Pink-root, f ss.; boil-
ing water, oj.;  macerate for two hours in a  cov-
ered vessel, and strain.   4 fl. drachms to one fl.
§, to children ; 4 to 8 f.  § to adults, morning and
evening, followed by a purgative.—R Pink-root,
jss.;  senna, 31J.;  manna, fj.; fennel-seed, 31J.—
?ss.;  boiling water, Oj.   Infuse.  Half a wine-
glassful to a child two years old, 3 times a day.—
R Pink-root, sy.; bruised rhubarb, 3J.; senna, 31J.;
semen contra, 3J.: manna, 313. ;  coriander, 33s.;
boiling water, Oij.  Infuse.  A small tea-cupful
3 times a day.  Besides these, the simple fluid
extract of pink-root, prepared by displacement,
and the compound fluid extract, prepared in the
same  manner from pink, senna, savin, manna,
sugar, alcohol, and water, will be found extreme-
ly convenient and efficacious in tea-spoonful doses
3 times a day, to young children, followed by oil.
Tilden's fluid extract of pink and senna is a very
successful preparation.
  For ascarides, one ofthe most successful reme-
dies is an infusion of tansy, as  an injection, in
the proportion of one ounce ofthe fresh leaves to
one pint of boiling water.   The  oil  of tansy is
very effectual against the lumbricoid worm also,
as in the following formula :  R Oil of tansy, one
scruple ; extract of gentian, two drachms ; pow-
dered marsh-mallows, sufficient.  Mix, and make
60 pills ; 3 to 5 every two hours.  The  following
is equally efficient: R Tansy, ?j.; wormwood, rhu-
barb, each, ^iij. ;  sherry wine, f. ?ij. ; diluted al-
cohol, fl. f xx.  Digest for eight days, and filter.
Dose, f. 3J.—f- 3ij-,  2  or  3 times a day.  Also,
the extract of tansy  in doses of from 6 to 20 grs.
three times a day.
   Of the purgative  anthelmintics, the  following
are some of the best: R Powdered gamboge, grs.
ij.;  sulphate of iron, grs. vj. ; sugar, 9j.; oil of
peppermint, gtt.  iij.   Mix.   To be taken twice a
day against tape and lumbricoid worms.—*R Calo-
mel, grs. iij. ;  compound powder of scammony,
grs.  xii.  For a dose  for  lumbrici.—R Calomel,
grs. iv.; powdered pink-root, grs. x.  To be taken
two  mornings in  succession, also on afternoon of
second  day, followed by a mild purgative, for chil-
dren over  4 years of age.   As a fortifying  tinc-
ture to  prevent  the recurrence  of worms, equal
parts of the muriated tincture of iron and tincture
of aloes, in doses of 20 drops three times a day,
will prove very effectual;  or powdered  sulphate
of iron  and aloes may be used in small doses.]
   220.  iv. After-treatment of Worms.—It is
often requisite, after the expulsion  of intestinal
worms  has been effected, 1st.  To soothe the ir-
ritation, and to subdue the  inflammatory action
produced in the  digestive  mucous membrane by
the vermifuges and drastic purges which had been
prescribed.  2d. To remove any stray worms which
had become so sickened, or so injured by the treat-
ment, as to be readily thrown •off by means which
would restore the vital tone of the bowels and
farther  injure the worms, and render their resi-
dence  disagreeable  or untenable.   And, 3d. To
prevent the  regeneration  of these  parasites by
removing their ova  and rendering the  digestive
mucous surface  ungenial  to their development.
(a) The first  of  these intentions  is best accom-
plished by emollients and demulcents with small
doses of nitrate  of  potash, of hydrocyanic acid,
and  sirup  of poppies, &c.  When sickness is
troublesome, and no inflammatory action is pres-
ent, a pill  with half a drop of creasote may be
given with each dose of  the above, or may be
taken in the  intervals between each.   The diet
should  be  spare, light, and digestible,  and  the
bowels  assisted by gentle laxatives, such as mag-
nesia, with  or without confection of senna, and
by suitable  enemata, especially by such as con-
tain  castor or olive oil, with  oil of turpentine
when the irritation is  chiefly experienced in the
stomach and upper portions ofthe intestinal canal;
at the same time, the warm bath or terebinthinate
embrocations,  or  a recourse to  these latter upon
leaving  the bath,  will be found of much service.
The  drink  of the patient  should be demulcent,
and in small quantity, thirst in  these cases being
most relieved by sucking small morsels of ice.
   221. (b) The second intention presupposes either
the non-existence or the removal of those condi-
tions against which the first intention was direct-
ed, and  consists in the occasional exhibition of a
moderate or less  irritating dose or doses of the
anthelmintic  suitable to  the expulsion of the
worm found to be present, and the combination
of it with such other means  as the peculiar fea-
tures ofthe case will suggest; a recourse to ver-
mifuge clysters, especially  to those already sug-
gested, or those advised above (Y 194), being had
after the internal  remedies had been taken.
  222.  (c)  The third intention is of no small im- 
WORMS—After-treatment of—Bibliography  and References.           1561
portance, if the permanent cure of the patient be
considered.   For  the original conformation, or
the depression  of vital power, of the patient; or
the irritability  and  exhaustion  of the  digestive
canal  may be so  great, in consequence both of
the existence of these parasites and ofthe means
taken  to expel them, that a tonic  and restorative
treatment becomes imperative in order to prevent
various  unpleasant contingencies.    Besides, in
many  instances, anaemia has become so  consider-
able as to require  a treatment directed more or
less to it,  and to  the  other morbid  tendencies.
In these circumstances not only should due care
be directed to the prevention of intestinal worms,
but  recourse should be  had to those medicines
which are  calculated to restore the vital tone of
the digestive organs, to improve the  state of the
secretions  and excretions  of the body generally,
but ofthe intestines in particular, to promote the
 functions and actions of the bowels, and to ren-
 der the human intestinal canal an unsuitable and
 an uncongenial habitation for the ova  of worms
 and for  their  development.  These  are objects
 wliich should always be entertained after the ex-
 pulsion of worms of whatever species, and should
 be attempted by such means as are most likely to
accomplish them.   It may be asked,  however,
 where are we to  find,  how are we  to combine
these  means, and  how  are we to prevail on the
patient to persevere in their use, or even to have
recourse to them when  he believes himself free
 from  his enemy 1 •  I cannot say that there are no
other means calculated  to attain  these objects,
but I  may enumerate*  those which  I  have em-
 ployed with these  views, combining them vari-
 ously, and exhibiting them in such successions,
 intervals, &c,  and as the circumstances of par-
 ticular cases appeared  to  require.   The  medi-
 cines  which I have thus employed are  the  prep-
 arations  of iron, asafoetida, of cinchona and qui-
 na, of myrrh, camphor, aloes, infusions of willow,
 cascarilla,  and cedar bark, berberine, &c.   The
 compound mixture of iron may be given with the
 decoction or tincture of aloes, &c.;  or the sulphate
 of iron may be prescribed with sulphate of quina,
 compound galbanum pill, and with the aloes and
 myrrh pill.   Camphor may be  conjoined with
 these  latter substances  (y 198) singfy  or in the
 combination  now stated.   The sulphate of  quina
 may  be  given with dilute  sulphuric  acid, and
 sulphuric ether.   The infusions ofthe barks may
 be taken with tonic and laxative tinctures, or with
 the  mineral  acids,  &c, and laxative electuaries
 may be  conjoined with  sulphur, or antispasmod-
 ics,  aromatics,  or spices.
   223. It is obvious that the diet of patients who
 have  suffered from worms should be nutritious,
digestible, and  restorative; while it ought not to
be too rich or full, or calculated to produce general
plethora or local congestions, as of the  liver, &c.
The regimen ought to  be  regulated so that suf-

   * I may here state that the pharmacopceiae of the Unit-
ed Kingdoms are very deficient in vermifuge remedies,
and in formulae for the preparation and combination of
them—a remark by no means applicable to the pharmaco-
poeia; of most Continental countries.  But verminous dis-
eases are much more prevalent on the Continent than in
the British Isles,  in which, however, I am confident that
their prevalence has hitherto been much underrated, and
their importance  undervalued.  The  very general and
noxious vice of smoking tobacco, and of otherwise  using
this poison—so much extended in recent times—has ren-
dered and will still more render, verminous diseases more
prevalent, by weakening the digestive organs, and dis-
posing them to the generation and development of the ova
of worms.
 ficient exercise may be taken in the open air, and
 that all causes of debility and exhaustion should
 be avoided.   The remarks already offered for the
 prevention of the human entozoa (y 157, et seq.)
 are  equally necessary to the prevention of their
 return after their expulsion.

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mento de'  Vermi, 8vo.  Kimini, 1810. — Anon., Notitia
Collectionis Insignis Vermium Intestinalium in  Museo
Historiae Naturalis Viennensis, 4to.   Vienna, 1811.— V.
L. Brera,  Memorie 1 isico-mediche sopra i  Principali
Vermi del Corpo Umano Viventi, 4to.   Crema,  1811.—J.
Reinlein, Animadversiones circa Ortum, &c,  Taeniae la-
tae, Svo.  Wien, 1811.—M. Friedlander, Precis Historique
sur les Ouvrages relatifs aux Vers, Bull, de la Fac. de
Med., 8vo.   I'aris, 1812.—T. Bradley, Treat, on Worms,
12mo.   London, 1813.—IF. Lawrence,  in Med. Chirurg.
Trans., vol. ii., p. 382.—J. EUiotson, in Ibid., vol. xiii.,
p. 51.—G. Breschet, in  Ibid., vol. xiii., p. 53.—J. R. Fen-
wick, in Ibid., voL  ii., p.  24.—T. B. Curling,  in Ibid.,
vol. xxii., p. 274.—V. A. Brera, Tabula ad IUustrandam
Historiam  Vermium, &c, 4to.  Vien.,  1818.—G. A. Her-
gesell, De Morbis Verminosis Intestinalibus, 4to.  Lips.,
1818.—J. G. Bremser, Ueber Lebende Wiirmer in Leben-
den Menschen, 4to.  Wien, 1819. — C. A. Rudolphi, En-
tozoorum Synopsis, 8vo.  Berol., 1819.—A. Strawikowski,
Abhandlung iiber die Wiirmer in Menschen, 8vo.  Wien,
1S19.—G. Montesanto,  Analisi delle Opere su i Vermi da
Bremser e  Rudolphi, 8vo.  Padov., 1820. —Merat, Diet.
des Sc. Med., art. Vers, t. Ivii.   Par., 1821.— J. P. Frank,
De Curandis Horn. Morbis, &c, 1. vi., pars iii., De  Re-
tentionibus, Svo.   Vien., 1821, p. ISO.— J. Copland, Lon-
don Med. and  Phys. Journ. for 1821, and London Med.
Repos.  for 1822.—J.  G. Bremser, Icones  Helminthum
Systcma Rudolphi Illustrantes, fol.  Vien., 1S22.— J. G.
Bremser, Traite sur les Vers Intestinaux; augmente de
Notes par Blainville (transl.), Svo and 4to.   Paris, 1821.
—J. Cloquet, Anatomie des Vers Intestinaux, 4to.  Par.,
1S24—Barry, in Transact, of Irish Coll. of Phys., vol. ii.,
p. 383.   (On the Generation of.)—Gintrac, Rev. Med., t.
iv., 1S25, p. 479.   (On the  Diagnosis of.)—Fontaneilles,
in  Ibid., t. iii., 1825, p. 404—A7. Rumsey, in Trans, of
Med. and Chirurg. Soc, t.  ix.,  p. 389.—Young, in Glas-
gow Med. Journ., vol. i., p. 388.  (Asc. lumb. per ulcus
abdom. evacuati.)—Ibid., vol. ii., p. 136.— H. Cloquet, in
Nouv. Journ. de Med., t. xv., p. 250.  (On Anthelmintics
for.)—Lavini, in Archives Gener. de Med.  Mars. 1823;
et  Philad.  Med.  Journ., vol, vi.,  p. 412.   (Advises the
Crithmum maritimuin —samphire—for.) — Journ. de
Progres des Sciences Med., t. xv., p. 265.—V. L. Brera,
Treatise on Verminous Diseases, translat. by Coffin, 8vo.
Boston, 1327.—Guersent, Diet, de Med., art. Vers, t. xxi.
Paris, 1S28.—T. G.  Van Lidth de Jtude, Reeueil  de Fi-
gures des Vers Intestinaux, fol.  Leide, 1829.— W. Rhind,
a Treatise  on the Nature and Cure of Intestinal Worms,
8vo.  Edin., 1829.—Joy, Cyc. of Pract. Med., art. Worms,
vol. iv.  Lond., 1835.—Bryant, Lancet, Jan. 20, 1838.—
Bellingham, Dublin Journ. of Med. Sciences, vol. xii., p.
341. — M. Felix Dujardin,  Histoire Naturelle des  Hel-
minthes ou Vers Intestinaux, 8vo.  Par., 1815, Planches.
— F. Kuchenmeister,  Ueber Cistoden im Allgemeinen,
und die des  Menschen insbesondere,  &c, Svo. Zitten.,
1S53.—Die in und an dem Kiirpcr des Lcbenden Menschen
vorkommenden Parasiten.   Ein Lehr- und Handbuch der
Diagnose und Behandlung der Thierischcn  und I'flunz-
lichen Parasiten des Menschen, Svo.  Leipzig, 1S55.—A.
Kramer, iragmentarische Notizen und Abbildungeu zur
llelminthologie und Parasitenlehrc, in "Illustrirte Me-
dizinische Zeitung," Band iii., Heft 6.  Mit 2 Tafeln__
T. II. Barker, on Cystic Entozoa in the Human Kidney,
with an illustrative case, 8vo.  London. — Bristoue and
Rainen, on the Trichina spiralis.   " Transactions of the
Pathological Society of London," vol. v., Se-nion 1353-4.
—H. G. Carter, Note on Dracunculus in  the  Island of
Bombay.  "Transactions  of the Medical and Physical
Society of Bombay," No. 2.   New Series.  Years 1853-4.
__G. Bush, Observations on the Structure and  Nature of
the Filaria  Medinensis, or Guinea Worm.  "Transac-
tions ofthe Microscopical  Society," vol. ii., p.  65, et .-iq.
—C. J. von Siebold, leber die Band- und Blasenwiirmer,
nebst einer  Einleitung iiber  die Fntstehung deir l-.inge-
weidewumier, 8vo.  Leipzig, 1854.—R. Leuckart, Die
Blasenbandwurmer und ihre Entwicklung, zugleich tin
Beitrag zur  Kenntniss der  Cysticercusleber,  &c, 4to.
Giessen, 1856.—Huxley, on the Development of Echino-
coccus Veterinorum, in Proceedings of Zoological Society
of London,  Dec.  14, 1S52. — W. Jenner, on  l  ape-ivorm
and its Treatment by the Oil of Male Fern, in Association
Medical Journal, Aug. 23, 1856, p. 719.—T. Synqison, in
Ibid., Aug. 30, 1856, p. 734—E. Lankester, Animal and
Vegetable Parasites of the Human Body: a Manual of
their Natural History, Diagnosis, and Treatment, transl.
from tlie second  German  edition of F. Kuchenmeister's
work, vol. i.;  Animal Parasites belonging  to the Group
Entozoa, with Plates, Svo.  Lond., 1S57.
  [Amee. Bibliog. asd Refee.—A. Brigliam, Worms in
the Urinary Bladder, simulating stone in that organ, Am.
Journal of Medical Sciences, vol. xx., N.S..  p. 59.   (See
similar case in Med.-Chirurg. Transact., vol. ii.,hy Wm.
Laurence.) — Harvey Campbell, Case of Worms in the
Urinary Bladder, Amer. Journal of Medical Sciences, vol.
xxi., N.S., p. 131.—Ibid., Etherial Tinct. of Male Fern
Buds in cases of Intestinal Worms, by Dr. Peschiei, in
doses of 8 to  30 drops in  pills, followed by ol. ricini.—
Ibid., Symptoms  of acute Pleurisy caused by Worms,
vol. ix., N.S., p. 200__Ibid.,  vol.  viii., N.S., p. 473, Case
of Deafness and Dumbness cured by discharge  of Worms
in a child nine years of age.—Ibid., vol. vi.,  N.S., p. 181,
Worms in the Blood of a  Dog, by MM. Grudy au&'Dela-
fond.—Ibid.,  vol. xvi., O.S. — IF. Stokes,  on Worms, p.
198, 201, 202,  203, 204, 206, 217. —John Walker, Amer.
Medical Recorder, vol. vii., p. 433, Case of a Boy eleven
years of age, who discharged over 2000 lumbricoid worms
in a few days under the use of the oil of turpentine.—Ed-
mund Porter,  Account of  a number of Worms found in
the Kidneys  of  a Hog, Ibid., vol. vi., p. 151. — Hairy
 Wolff, Ibid., vol. ix., p. 415, Root of Pomegranate-tree in
cases of Taenia. — Dr. Brocchus, on  Cedar  Apple as a
Vermifuge,  Phil. Jour, of Med. and Phys. Science, May,
1827.—/.  W. Mighels, Worm discharged from the Lungs,
Am. Med. Recorder, vol. xii., p. 450.—Ibid., vol. xi., p.
479, Case in which a number of living Worms were void-
ed  from a Child's Bladder.  — Robley Dunglison,  Com-
mentaries on Dis. of the Stomach and Bowels of Children;
also Practice  of Med., 2 vols.—D. Chiaje, on  Existence
of Worms in the Human  Blood (Polystoma Sanguicola),
Eclectic Journal of Med., edited by John Bell,  vol.  ii., p.
328.—C. L. Seeger, on Anthelmintics, Boston Med. and
Surg. Journal, voL xxiv., p.  57.—J. T. Bradford, Singu-
lar Case of Worms,  Ibid., vol. xxviii., p. 300. — E. G.
 Wheeler, Worms in the Lungs of Swine, Ibid., vol. xxiii.,
p. 304—C. G. Pomeroy, Escape of Worms at the Navel,
Ibid., vol. xxi., p. 175.—Ibid., vol. xx., p. 307, Stutter-
ing occasioned by Worms.—Lewis Emmons, Case of Fi-
larial* in a Woman's Breast, Ibid., vol. xxvii., p. 35.   (150
worms, from three to four inches in length, "with sharp-
pointed heads and tails.")—Case of Trichina Spiralis in
the Human Body, Ibid.,  vol. xxvii., p.  241, 320.—P.
Spalding, Case of Worms, Ibid., vol. xix., p. 301.  (X
lady treated for  several years for dyspepsia, liver com-
plaint, spinal irritation, and leucorrhcea, cured  by the dis-
charge of over 200 lumbrici after taking ol. tereb., follow-
ed by calomel and jalap, and Carolina pink.)—Lr. Cun-
ningham, Tape-worm expelled by Tobacco and Anise-seed.
followed by ol. ricini. — C.  S-oenccr, Singular Case of
Worms, Ibid., vol. xiv., p. 58."— Dr. Garbett, on  Melia
Azedarach as  an Anthelmintic, Ibid., vol.  viiL, p. 199.—
On the Effects of Male Fern Buds in cases of Worms, lb.,
vol. xiii., p._165.—B. S. Brown, Case of Worms, in  which
552 lumbrici were discharged in one week under the use
of calomel, scammony, jalap, spigelia, and senna in large
quantities, Ibid., vol. ii.,  p. 5S3.— E. Schilling, Case of
Cysticercus cellulosa, with Remarks, New York Journ. of
Medicine, March, 1857, vol. ii., N.S., p. 194.  (This was a
case of a female aged thirty-one years, who was affected
with epilepsy, severe headaches, and stupidity, who died
suddenly during an epileptic seizure.   Autopsical exam-
ination revealed several hundred cysticerci adherent to
the inner surface of the dura  mater and the surface of the 
ZYMOTIC
DISEASES.
1563
brain itself, of the size of a pea, suspended by a pedicle
from the membrane, or lying free upon and between the
cerebral convolutions, and even the substance of the brain
and choroid plexus.  Five were found in the muscles of
yie heart;  several were found in the gluteal and deltoid
muscles.  No traces of taeniae were found in the intestines.
Dr.  S. relates also the history of another case, a German
emigrant, who was seized with dizziness and headache,
followed by fatal hemiplegia.  The autopsy revealed a
cerebral abscess, in which was found a shriveled-up cys-
ticercus cellulosa.)—H. Bigelow, Case of Worm discharged
from an Abscess, Ibid., vol. xxxiii.,  p. 486; Ibid., vol.
iv.,  p. 179, 194, on the Production of Intestinal Worms,
by the Editor; also vol. vii., p. 291.  See Stewart, Meigs,
Condie, Dewees, and Churchill, on Dis. of Children; also
Wood, Dickson, Dewees, Eberle, Hosack, Dunglison, and
other Amer. Treatises on the Practice of Medicine; also
American Trans, of Hufeland's Enchiridion Medicum.—
Charles A. Lee, an Account of a Filaria in a Horse's Eye,
Silliman's Journal ofthe Natural Sciences, 1840; also N.
York Journal of Med., vol. iii., p. 237.   (This filaria was
about three inches long, of a -white thread-like appear-
ance, with a larger extremity, which was probably the
head.   It occupied the anterior chamber of the eye, was
constantly in motion, revolving upon itself, and twisting
into every possible shape.  The eye -was not materially
affected, though the lower portion of the aqueous humour
was a little cloudy, perhaps owing to excrementitious de-
posit.   The eye afterward became opaque, and the vision
was lost.)—Benjamin Rush, Medical Inquiries and Ob-
servations, &c, Worms and Anthelmintic Medicines, Svo,
2 vols.—G. Hopkinson, Account of a Worm in a Horse's
Eye, Trans. Amer. Phil. Society, vol. "sX.—John Morgan,
of a living Snake in a living Horse's Eye, and of other
unusual Productions of Animals.—Cloquet, Arch. Gen.,
Dec, 1827.—Larvae of the common fly in the eye of a
man, the eggs deposited during sleep, afterward hatched
out, with a total loss of vision, Lond. Med. Gazette, Aug.,
1833.—Case of Cysticercus cellulosa in the human Eye,
Ed. Med. and Surg. Journal, Jan., 1826.—Filariae in the
Eyes of Horses in the East, Bulletin des Scienoes  Medi-
cales, Feb., 1826.]

  YAWS.   See Venereal  Diseases  ($ 85, et
seq.).
  ZYMOTIC DISEASES.—ZvftoTiX6c, causing
to  ferment;   tjvpooie,  a  fermentation;  rjitaroc
tyfiQaic, a  swelling  of the liver, Hippocrates.
The term Zymotic  has recently been applied by
Dr. Farr  to  epidemic, endemic, infectious,  and
contagious diseases, and has comprised small-pox,
measles, scarlatina, hooping-cough, croup, thrush,
diarrhoea, dysentery,  cholera, influenza,  ague, re-
mittent fever,  typhus, erysipelas, syphilis, hydro-
phobia.   Viewing  the  Greek term to mean a
leaven by which the  organic nervous system, or
the vascular system  and blood, may be infected
or contaminated either  successively or contempo-
raneously, or nearly so, the term well designates
an extensive class of diseases, although  its appli-
cation implies a hypothesis ; but it is well suited
to the arrangement adopted by Dr. Farr in  his
admirable  Annual  Reports of  Deaths,  &c, in
England (which see). 
 
SUPPLEMENT.
SUPRA-RENAL  BODIES. — Synon. — Glan-
  dula ad  Plexum, Glandula ad  Plexum  Ner-
  vium, T.  Wharton.   Glandula  supra-renales,
  Renes Succenturiati, Auct. Supra-renal glands,
  Supra-renal capsules, <$rc.
  1. I. Structure and Functions.—In the pres-
ent state of our knowledge the name "supra-renal
bodies," or  that  adopted  by Wharton, appears
more  correct than supra-renal glands, the  func-
tions  of glands  not having been  proved in  re-
spect  of them ; and the term capsules is equal-
ly inapplicable, even to their more external struc-
ture.   Succenturiati, or reserved kidneys or bod-
ies, are not less appropriate.  The  earliest notice
ofthe connexions  and  nature of these bodies  ap-
pears to have been taken by Wharton, who point-
ed out their relations to the ganglial nerves,  as re-
parked by Dr. Gull.  Nevertheless the functions
and diseases of these bodies received no attention
from physiologists and pathologists (although in
several instances organic lesions observed in them
had been published in the  Ephemerides Natura
Curiosorum, and more recently  by Vetter and
Baillie) until very lately, when  the structure
and functions of  these  bodies  were  remarked
upon  by Nagel, Bergmann, Ecker,  Kolliker,
Leydig, and Grey ;  and their diseases,  espe-
cially  in connexion with  a bronzed discoloration
of the  skin, were first investigated by Dr. Addi-
son, and subsequently by Mr. Hutchinson and
others.  It  is chiefly,  however,  to Dr. Addison
that the distinction of having first directed atten-
tion to these lesions is due.  Although several
cases have been recently observed and recorded—
not always, however, with due care and precision
—still the  number of those in  which a bronzed
state  of skin  appeared more or less  intimately
connected with,  and most  probably caused  by,
disease of these  bodies, is so great as to induce
a presumption that where the former appearance
exists the latter  lesion will be found.   In order,
however, to form  correct views as to the phe-
nomena by which diseases  of  the supra-bodies
are indicated, as well  as  to  the  nature and con-
sequences  of such disease, it becomes requisite
that we  should  previously briefly inquire into
what  is known of the  structure and functions of
these  bodies.  Unfortunately opinions on  these
topics  have been,  and, notwithstanding the  fre-
quency of microscopic  research in modern  times
respecting  them, still continue to be, very unsat-
isfactory.   Dr. Wharton, about the middle  ofthe
17th century, first noticed their connexions with
the ganglia of the solar plexus,  and suggested a
name for them, which appears  more appropriate
than  any  other  which has  more  recently been
given them.
  2.  i. Structure.—Kolliker has very recent-
ly described the microscopic appearances of these
bodies, and noticed what  appears to be their func-
tions, and Dr. Harley has still more recently ex-
amined their structure.—A. The cortical structure
of these bodies is described by the latter observer
as consisting of cells, arranged in irregularly-sized
rows, in a fibro-areolar matrix, the rows of cells
appearing like a number of dark-yellow columns
placed perpendicularly to the surface.  The cells,
when examined individually, seem to be composed
of a homogeneous cell-wall, filled with  granules,
pigment, and some fat globules.  Each cell has a
well-marked nucleus, although not always visible.
The cells are arranged in a number of larger and
smaller masses, which are placed in regular rows,
and thus give rise to the columnar appearance.
In some cases  a column is composed of several
cell-masses  of different lengths, placed end to
end ;  in others  it consists almost entirely  of one
long cell-mass.   Each  column,  as well as each
cell-mass, is separated from the others by delicate
fibrous tissue, in which are included the vessels
and nerves.' Sometimes the cell-masses present
the appearance of long  tubes, enclosing a  single
straight  row of quadrilateral cells.   Each cell-
mass  is  closed  at  the  extremities, and is sur-
rounded by a delicate homogeneous membrane.
  3. B.  The medullary substance, according to
Kolliker, also has a stroma of connective  tissue,
which, prolonged from the cortical lamellae, per-
vades the whole interior, for the most part, in
more delicate fasciculi, constituting a net-work
with narrow, rounded meshes.   In this net-work
lies a pale, fine-granular substance in  which, in
man,  and in recent preparations, pale cells of
0008 to 016"' are generally observed. These pale
cells occasionally present, in their fine-granular
contents, a  few fat or  pigment granules; their
frequently very distinct nucleus with  large nu-
cleoli, their angular form, and occasionally their
single or multiple, or even branched processes,
resembling the nerve-cells ofthe central organs,
although  they cannot definitively be declared to
be such.  Dr. Harley states that the dark slate-
coloured medullary substance is composed of a
net-work of fibres, in the meshes of which are a
number of large nucleated cells, which have been
described by various writers as ganglion corpus-
cles ; but he thinks that these, like the cells in
the cortical substance,  are true secreting cells.
This  great  difference of opinion (so frequently
observed  among microscopists)—the  same nu-
cleated cells being considered  as ganglial cor-
puscles by some observers, and as true secreting
cells by others—prevents, in the present state of
our knowledge, much reliance to be placed upon
the results of microscopic researches,  each suc-
cessive observer being liable to the distrust which
attaches itself to his predecessors.  However, the
following is less liable to objection:
  4. C.  The nerves ofthe supra-renal bodies are,
according to Bergmann and Kolliker, extreme- 
1566        SUPPLEMENT—Supra-renai. Bo
idies—Structure and  Finctions.
ly numerous;  arising, according  to  them, from
the semilunar ganglion  and renal plexus, and
to a small extent  from the vagus and phrenic
nerves; but most  probably  intercommunicating
with,  rather than  arising from, the  latter.   In
man, Kolliker counted in the right  supra-renal
body thirty-three trunks, eight of which were 1-5
to 1-10"'; five of 1-14 to 1-20'"; seven of 1-25 to
1-33"';  and thirteen of 1-45 to 1-50"'; and found
that without exception, or at all events in a very
preponderating proportion, they were constituted
of dark bordered, finer and medium-sized, or even
thick  fibres ; were  whitish or white, and furnish-
ed with isolated larger or smaller ganglia.  They
are especially  apparent on the  inferior half and
inner border of the organ, and appear to be all
destined for the medullary substance, in which,
at least in the mammalia, an  extremely rich plexus
of dark-bordered, finer fibres occurs,  enclosed in
the trabecula and connective tissue, their termin-
ations, however, being nowhere perceptible.
   5. ii.  Functions.—As regards the functions of
the supra-renal glands, in the absence of all phys-
iological indications, and so long as the course of
the nerves in them is not more accurately known
than at present, only very general observations
can be offered.  Kolliker considers the cortical
and medullary substances as physiologically dis-
tinct,  and  that  the  former  may, provisionally,
be  placed  with  the so-termed " blood-vascular
glands," and a relation to secretion  assigned to
it; while the latter, on account of its extremely
abundant supply of nerves, must be regarded as
an apparatus appertaining to the nervous system,
in which the cellular elements  and the nervous
plexus either exert the same reciprocal action as
they do in- the gray nerve-substance, or  stand in
a  relation as yet  wholly unascertained towards
each other.
   6. According to Leydig, the cortical substance
ofthe supra-renal  capsules ofthe mammalia cor-
responds to the yellow, granular, and striped supra-
renal bodies of fishes and amphibia; while the mc-
rlullary substance ofthe mammalian organ, which
is abundantly supplied with nerves and cells, very
like the ganglion  globules,  represents the  other
divisions of the sympathetic ganglia: whence he
concludes that Bergmann's view, according to
which the supra-renal capsules are  closely re-
lated  to the nervous system, is  undoubtedly cor-
rect, and that those organs bear the same rela-
tion to the ganglia ofthe sympathetic nerves as
the pituitary body  bears towards the  brain.  Be-
sides this relation to the nervous system, how-
ever,  they have an intimate one with the vascu-
lar ; and are, therefore, always pervaded by a very
close capillary plexus.
   7. The functions ofthe supra-renal bodies have
been  experimentally investigated  by  Brown-Se-
quard,  Harley, and others, but with  different
results.  We  know how uncertain these results
are in the lower animals, and the amount of con-
fidence which may be reposed in them, not only
in those which were so frequently performed thir-
ty and forty years  since in order to determine the
functions of distinct portions of the nervous sys-
tem, but also  in those more  recently made with
these and with other views.  The former of the
experimenters just named  removed  the  supra-
renal bodies from  fifty-one  rabbits, eleven adult
cats and dogs, eleven young dogs and cats, elev-
en adult  Guinea-pigs, four  young Guinea-pigs,
and two mice  ; and he states that the adult ani-
mals operated on died, on an average, in twelve
hours, while the young or new-born animals liv-
ed thirty hours.  From  these  experiments  Dr.
Brown-Sequard concludes that the supra-renal
bodies  are more necessary to life than  even the
kidneys ; for animals will live two,  or even three
days, after the removal of the latter organs.   Dr.
Harley quotes from a later publication of Dr.
Brown, in which the latter states that, of ten
rabbits from which he extirpated the supra-renal
capsules, six  died between  the seventh and tenth
hour, and four between the tenth and fourteenth
hour after the  operation, and adds, that the ani-
mals died too quickly to admit  of their death be-
ing the result of peritonitis ; and farther, that the
extirpation of these capsules is followed by symp-
toms which do not occur after injuries ofthe per-
itoneum or liver, &c, these  symptoms indicating
that the supra-renal bodies have an  important in-
fluence on the blood, and that their nerves have a
singular power upon  certain parts of the central
nervous system.  He states that this latter influ-
ence manifests itself very distinctly in some cases
after the extirpation or the puncture of one of these
bodies, the animals being sometimes seized a few
minutes before death by vertigo and rolling over.
Dr. Brown-Sequar» concludes, 1st, "that if these
organs are not essential to life, they are at least of
very great importance. Secondly, that their func-
tions appear to be at least as important as that of
the kidneys, for when they are absent death in,
general supervenes more rapidly than  after the
removal ofthe kidneys."  (Archives  Gener., 1857,
p. 374.)
  8. Dr.  Harley  has  published   experiments
which  furnish  different results from those  now
stated; and from  those  he  infers that  " the
supra-renal capsules are  not absolutely  essential
to life;" that "the removal ofthe  right is gen-
erally more fatal than the removal ofthe left cap-
sule;" that  "convulsions do not necessarily fol-
low  the removal of the capsules;"  that, " when
death follows upon the extirpation  ofthe supra-
renal bodies, it is in most  cases in consequence
of the  injury done to the neighbouring tissues;
perhaps more  frequently the mutilation of the
ganglionic system of nerves ;"  that " absence of
the  function  of the  supra-renal bodies  is  not
proved to have any special effect in arresting the
transformation of haematin or  in increasing the
formation of blood-crystals;" and that  the sup-
pression of the functions of these  bodies is not
attended by an increased deposit of pigment in
the  skin, or  its  appendages, in  certain  of the
lower  animals—the  problem of the connexion
of bronzed  skin and supra-renal  capsular dis-
ease being more likely to be solved in the dead-
house than in the physiological laboratory.
   9. Viewing the structure and connexions ofthe
supra-renal bodies as altogether similar to those
of the  pituitary gland, and considering  these or-
gans as very intimately connected,  anatomically
and  functionally, with the ganglia and  ganglial
plexuses, I have been induced to view them as
organs contributing  or subsidiary to the organic
nervous force or influence exerted by the ganglial
nervous system.  Thirty-four years ago I pub-
lished  this  opinion  of the function  of the pitui-
tary gland  in my Physiological Notes, &c. (in
1824),  and stated that this gland reinforced the
ganglial nervous influence endowing the brain by
means of the ganglial nerves distributed to the
cerebral organs—that it was a portion of the gan- 
SUPPLEMENT—Supra-renal
Bodies—Organic Lesions  of.
1567
glial nervous system contributing to the nourish-
ment and functions ofthe brain, and imparting a
unity of development, of permanent  nutrition and
of function, to the double organs composing the cer-
ebral mass.   It appears very probable that simi-
lar offices  are performed by the  supra-renal bod-
ies  as regards the ganglia and ganglial plexuses
of the abdomen ; these bodies contributing to the
functions of the organic nervous or ganglial sys-
tem, as displayed  by  the  abdominal organs —
whether  digestive, assimilative, or  generative.
That both the pituitary body and the  supra-renal
bodies  perform these important functions—im-
portant not only as respects the performance  of
their respective functions, but also as  regards the
life ofthe individual—appears to be  manifest from
the nature and character ofthe nervous communi-
cations existing between them and other parts  of
the ganglial nervous system ; for, instead of de-
scribing these communications merely as branch-
es of nerves detached from other ganglia or parts,
it would be more correct,  taking the size and ap-
pearance of these branches into  consideration, to
describe them as branches sent  from the medul-
lary structure of these bodies, to those ganglia,
plexuses, and nervous trunks, in order to convey
to these the special influences or functions of these
bodies; or, otherwise,  to  reinforce and combine
the influence exerted by these several ganglia and
parts, with which they are anatomically connect-
ed.  That  these bodies are of the  greatest vital
as well as functional importance is  evinced not
only by the consequences following  their struc-
tural lesions, and by the presumed nature of their
functions, but also by  the manner  and the posi-
tions of their lodgments ;  both the pituitary and
the  supra-renal bodies being so  located  as  to
render them, in their  respective situations, far-
ther removed, and  better protected from injury,
and even from structural or other disease, than
any other part of the animal organization.
   10. II.  Structural  Disease of the Supra-
renal Bodies.—Lesions  of the Supra-renal Bod-
ies, and their Associations, <$-c.
   Classif.—IV. Class,  I. Order (see Preface,

   11.  Definit.—General languor and debility,
anamia, feebleness  ofthe  heart's action, remarka-
ble irritability of the stomach, frequent  vomiting,
and pain in the back and loins, often  with a bronzed
or dusky hue ofthe general surface, rapidly increas-
ing exhaustion, emaciation, Sec.
   12. Disease  of the supra-renal bodies usually
commences so gradually  as not to admit of the
patient's knowledge of the exact period at which
he  first began to  experience loss of health or
strength.   It is almost always gradual in its ear-
ly progress, although often rapid in its more ad-
vanced course.  The slowness  or  rapidity of its
progress must, in the present state  of our knowl-
edge, be  attributed to the nature and extent  of
the organic lesion, to the  circumstance  of one or
both bodies being affected, and to the nature and
severity,  local  or  constitutional, of the malady
with which structural change of these bodies is
complicated.
  13. i. Symptoms.—Generally the patient at first
complains of weakness or more  marked debility,
of languor, and of indisposition to bodily and men-
tal exertion.   The appetite is impaired or lost;
the pulse is soft, weak, and often  frequent;  the
whites ofthe eyes are pearly; the body is some-
times more or less emaciated, or, if not emaciated,
leuco-phlegmatic or cachectic, or discoloured, and
generally anaemied.  Uneasiness or pain,  often
severe, is referred to the region of the stomach,
epigastrium,  back, or loins.   Nausea, sickness,
retchings, and frequent  vomitings often occur,
especially as  the prostration, anaemia, and discol-
oration of the skin advance. In some cases, com-
plicated with  disease of other organs, especially
when such disease is acute or disorganizing, the
discoloration  may either be absent or overlooked.
In other cases it is slight, or in  patches, consist-
ing of a murky hue ; but in others it amounts to
a bronzed tint, and is general over the whole sur-
face, but is commonly most marked  on the  face,
neck, superior extremities, penis, and scrotum, in
the flexures  of the axillae  and limbs, around the
umbilicus, &c, varying in deepness from a  dingy
or smoky appearance to a chestnut-brown, or col-
our of a mulatto.   In some cases patches of a
lighter hue occur in various parts ; and in  many
the discolouring may be remarked in some  ofthe
internal  surfaces, the peritoneum, pleura, &c.
   14. With the continuance and progress of dis-
ease, the languor, anaemia, loss of appetite, and
feebleness of the  heart's  action are aggravated.
The discoloration  of skin becomes in some cases
more marked, the  commissures  of the lips  much
darker,  the pulse  smaller  and weaker, vomiting
more frequent and urgent, and pain and weakness
of the back  and loins more complained of.   At
last the patient  sinks and  expires, after a period
which is very indefinite, so that the  disease may
appear almost acute  in some instances, and more
or less  chronic  in others, most probably owing
either to the  severity of the disorganizing lesions
affecting the supra-renal bodies, or to the nature of
the complications characterizing particular  cases.
   15. Although lesions of these bodies are often
uncomplicated with disease of any other organ—
although no lesion or disorder of any important or
vital part can be detected, in many cases, during
the life ofthe patient, lesions of these bodies, and
a peculiar anaemia, being the only or  chief lesions
found after  death, very frequently accompanied
with discoloration—yet they are often associated
with other diseases, chiefly of a constitutional and'
cachectic nature, more especially with general or
partial tuberculosis, with cancer, and with disease
ofthe lungs, &c.
   16. The following table of cases of disease of
the siipra-renal bodies comprises nearly all those
which have been  published up  to this time.  It
is constructed according to that  published by Mr.
Hutchinson ; and to it I have added some recent
cases. 
1568
SUPPLEMENT—Table of Cases of  diseased
No.	References.	Sex und Age.		Occupation. Previous Health, &c.		1 Bronzing of Skin—its Degree Early Symptoms. j or Absence.	
1.	Dr. Addison's Works, p. 9.	Male,	32..		No history. Skin white when in health.	Cough, followed by debil-ity and bronzing of skin.	Colour ot mulatto; scro-turn and penis darkest.
2,	Ibid., p. 12....	Male,	85..	Tide-waiter. Married. Exposed to weather.	Rheumatism eight years previously. Health generally good.	Acute attack of fever, fol-lowed by debility and bronzing of skin.	Dark olive-brown; also in lining of lips.
3.	Ibid., p. 15---	Male,	26..	Carpenter. Married. Intemper-ate.	Very good until three months be-fore the change of colour.	Pain in the back and right leg, followed by debili-ty, wasting, and giddi-ness.	Dark olive-brown, deep-ened in patches.
4.	Ibid., p. 19....	Male,	22..	Stonemason.	No history. Died soon after admis-sion.	Pain in stomach, vomit-ing, tic douloureux.	Face, axillae, and hands of bronzed colour.
5.	Ibid., page 23. (From Dr. Bright's Reports.)	Female, adult.		Not stated..			Complexion very dark...
							
6.	Ibid.,-p. 25....	Male		Barrister. Of middle age.			Surface generally dark; face, neck, and arms covered with deep brown patches.
							
7. 3.	Ibid., p. 30.... Ibid., p. 32....	Female, 60 Female, 53		Not stated.. A servant. Single.	No history. Can-cer of supra-rena! bodies; consecu-tive of cancer of breast. Always thin, but of good health.	Cutaneous eruption four months previously, its cure being followed by stomach symptoms.	Skin of arms, chest, and face of a light-brown colour. Skin generally very dark, with darker patches.
9.	Ibid., p. 35....	Male	53..	Sailor. Mar-ried. Sober.	Very good. A strong muscular man.	Two months previously began to lose appetite and be generally unwell.	Face of a yellow bronzed tint, becoming still darker.
10. 11. 12. 13.	Ibid., p. 3S.... Ibid., p. 39.... Med. Times & Gaz., Dec. 15,1855. (Dr. Burrows.) Ibid., Jan. 19, 1856. (Dr. Gull.)	Female, 28 Male, adult. Male, 24.. Male, 24..		Not stated.. Not stated.. Hawker. Single. Carpenter. Temperate.	Died of cancer ute-ri. Disease of supra-renal bod-ies being consec-utive. Died of cancer of lungs, &c. Had lumbar ab-scess in child-hood.	Those of cancer uteri___ Those of cancer of the thorax. Pain in the back, followed by emaciation and bronzing. Debility, breathlessness on exertion, nausea, &c.	A peculiar dingy appear-ance. Face of a dingy hue, with freckles and brown dis-coloured spots. A dark copper or bronzed colour generally, and lighter patches.
							brown, darker on inside of lips, knees, &c.
14.	Lbid., Jan. 19, 185G. (Mr. Bakewell.)	Male,	23..	Labourer...			
							or bronzed, and darker over the thighs.
15.	Ibid., Feb. 20, 1856. (Dr. Thompson, &c.)	Male,	20..	Baker. Sober	Good.............		
							dark dirty-brown col-our.
16.	Ibid., Feb. 28, 1856. (Dr. Rowe.)	Male,	20..	Xot stated..		Delicate health and bronz-ing of skin.	Skin generally brown,with darker spots.
							
17.	Ibid., March 8, 1856. (Dr. Farre.)	Male,	37..	A publican. Intemper-ate.	A year before had pain in the lum-bar regions, which subsided.	Admitted for delirium tre-mens.	Skin generally of a pecul-iar yellowish brown.
18.	Dr. Addison's Male,		60..	Not stated..			Generally dark and bronzed, with blanched patches.
	Work, p. 29.						
19.	Med. Times & Gaz., p. 233. (Dr. Stock-er.)	Male,	56..	Physician ..	Dyspeptic, but not otherwise ill.	General malaise and irri-tability of stomach, in-creasing debility and emaciation.	Patches of brown colour, which extended; small patches on the face.
 
-renal Bodies and  of Bronzed  Skin.
1569
General Symptoms, Complications,
            Ac.
Excessive  debility,   emacia- 3  yrs
  tion,  demeanour   puerile,
  urine healthy, pain in lum-
  bar region, cough, soreness
  at the epigastrium.

Pinched  anxious expression, 6 mo'i
  vomiting, pulse very fee-
  ble, depression, constipation,
  tenderness  at  epigastrium,
  numbness of extremities.
Thin, pale, and feeble;  faint- 7 mo's
  ing on rising from bed, sick-
  ness and hiccough, pain in
  back,  ang.  curvature   of
  spine, leucothymia,  &c.

Vomiting and pain in  stom- Seve'l
  ach, great debility,  emacia- mon's.
  tion, extreme  prostration,
  &c.
Extreme  debility, vomitings, Not
  emaciation,    abscess    in stated
  breast, &c.
Slight emaciation, great anse- 1 year
  mia, extreme  languor,  ur-
  gent vomiting, pulse very
  compressible.

No history.  Died of ulcerated Not
  cancer, the bronzing being stated.
  remarked at the  post-mor-
  tem inspection.

Emaciated and  feeble, much 4 mo's
  irritability of stomach.
 Dura-
 tion of
Disease,
Mode of Death.
Acute  pericarditis
  and pneumonia.
Not stated.
Sickness  without vomiting, 3 mo's
  weakness and loss of appe-
  tite,  frequent  rigors,  no
  pain, pulse 80, feeble; body
  irritable.
Discoloration of skin not no- Not
  ticed until the post-mortem stated.
  inspection, when disease of
  supra-renal body was fore-
  told.  No history preserved.
No history preserved  .......
                            Not
                            stated.

Irritability of stomach with 8 mo's
  vomiting,  pain across  the
  back, great debility, emaci-
  ation, urine natural, &e.
Nausea, vomiting, great ma- 5 mo's
  laise,  exhaustion,  emacia-
  tion, urine healthy, blood
  loaded with white corpuscles.
Weak and low for a long time, Unkn.
  not much emaciation
Passed into a torpid
  state.
From collapse and
  sinking.
Slight  wandering,
  gradual sinking,
  and drowsiness.
Speedy sinking ..
Inspection after Death.
Not stated.
Died of exhaustion
  in three days aft
  er admission.
Sunk gradually .
Died from cancer.
Died of cancer
Suddenly languid, and  after-
  ward  collapsed, and  died
  after  three days;   tint of
  skin observed for six weeks.

Had also disease of knee-joint,
  and health rather improved
  until within three days of
  death,   lie remained  fat
  and muscular.

He  died in a fortnight from
  delirium tremens.
Anaemic, heart's  action  very
  feeble, irritability of stom-
  ach,  oedema  of upper  ex-
  tremities.
Great debility  and  wasting,
  but no organic disease but
  that  of supra-renal bodies
  indicated.

     III.
6 w'ks
8 mo's
3 w'ks
  or
Not
 tated.
About
6 mo's
Died from exhaus-
  tion   consequent
  upon a purgative.

Sudden exhaustion
From   exhaustion
  caused by a short
  journey.
 ;upra-renal bodies both remarka
  bly indurated  and as large as
  eggs, and  quite  disorganized;
  recent pericarditis and pneumo-
  nia ; no tubercles nor other vis-
  ceral disease.
Both supra-renal bodies contained
  compact  fibrous  concretions ;
  gastric mucous surface inflamed;
  no tubercles; no  other visceral
  disease.
Supra-renal bodies completely de-
  stroyed and converted into stru-
  mous deposits; psoas abscess and
  caries of lumbar  vertebrae; tu-
  bercles  in  lungs ; spleen  en-
  larged.
Supra-renal bodies wasted and de
  stroyed, both weighing only 4:
  grains.  No other disease.

Both supra-renal bodies  were en
  larged, lobulated, and the seat
  of tubercular-like deposits, both
  four  times the natural size; the
  left had suppurated.
Both supra-renal bodies gffeatly
  enlarged,  of irregular surface,
  and  much indurated;  natural
  structure lost;  nucleated cells.
  No other important disease.
Both supra-renal bodies contained
  much cancerous deposit fchrough-
  out their structure.
Cancer of pylorus; left supra-renal
  body destroyed by cancer.
A well-marked case.  No
  chronic lesions but those
  of supra-renal bodies.
The deposits in supra-re-
  nal bodies resembled tu-
  bercle, but there was no
  tubercle  in other  or-
  gans.
The  blood, both before1
  and  after  death,  con-
  tained a great excess of
  white corpuscles.


The disease of supra-renal
  bodies was  an atrophy,
  probably consequent on
  inflammation.
This case was recorded by
  Dr.  Bright  before the
  importance of dissection
  of  supra-renal bodies
  was recognised.
Vomiting had been so ur-
  gent in  this case as to
  suggest the existence of
  malignant disease of the
  stomach.
Collapse.
Diarrhoea, followed
  by succession of
  epileptic     fits,
  vomiting,  &c. ;
  died   on  fourth
  day of these.
Sunk into a typhoid
  state,  with  low
  delirium.
Died  of  debility,
  cancer in medias-
  tinum suspected.

From exhaustion..
Tubercular deposit in one supra-
  renal body ; in the spleen also
  and the  kidneys were degener
  ate.

Right supra-renal body healthy;
  the vein  emerging from the left
  obstructed by cancerous deposit,
  and the organ itself occupied by
  recent extravasation of blood.
One supra-renal body entirely dis
  organized by  cancer, the other
  healthy.
Both supra-renal bodies contained
  pus and bodies resembling hard-
  ened tubercle.  There was  no
  other disease.
Both supra-renal bodies atrophied
  and destroyed, the left contain-
  ed cysts, the right solid concre-
  tions.
Both supra-renal bodies complete-
  ly atrophied, and contained cal-
  careous concretions ; emphyse-
  ma of lungs; fatty degeneration
  of heart.
Each supra-renal body enlarged to
  the size of half a kidney; their
  structure converted into a firm
  tubercular - like matter, and in
  parts softened.
Both supra-renal bodies destroyed,
  containing  gritty,  cheesy, and
  semi-purulent deposit.  No oth
  er disease.
The extent of discolora
  tion of skin was propor
  tioned to that of disease
  of supra-renal body, one
  being sound.
The degree of bronzingap-
  pears to have been pro-
  portioned to that of dis-
  easeof supra-renal body,
  one only being affected.
The degree of bronzing
  was slight, the disease
  of one supra-renal body
  being recent.

One supra-renal body was
  affected, and the bronz-
  ing was slight.
The chain of morbid phe-
  nomena was very com-
  plete in this case.
Both supra-renal bodies were con-
  verted into abscesses, but their
  cortical substance was not whol-
  ly destroyed: circumscribed ab-
  scess in the liver.
So inspection...............
99
No inspection,
 This appears to have been
   idiopathic disease of su-
   pra-renal bodies, no tu-
   bercles being found in
   other organs.
 In this,  as in  case  23, a,
   peculiar   disagreeable
   odour exhaled from the
   patient for three or four
   weeks before death.

In this case the suppura-
  tion  and inflammation
  of supra-renal bodies
  had probably been acutel
  and recent.
The cachexia was precise-,
  ly that of diseased su-
  pra-renal bodies.

The bronzed patches in-j
  dicated  the  patient's
  speedy death when there;
  were not other alarm-!
  ing symptoms.         j 
1570
SUPPLEMENT—Table of Cases  of diseased
No.

20.
25.


25.
29.
31,


32.
33.
Sex and Age.
ibid., Dec. 15,
  1855.   (.Mr.
  Startin.)
Ibid.,  Dec. 29,
  1855.   (Dr.
  Peacock.)

Ibid., Jan. 19.
  1856.   (Dr.
  Burrpwa.)
Ibid., Feb. 23,
  1856.   (Dr.
  Rowe.)
The Associate
  Journ., Jan.
  19,1856. (Dr.
  Budd.)
Ibid.,  Jan. 19,
  1856.   (Dr.
  Budd.)
Med. Times &
  Gaz.,  Feb.
  23,1856. (Dr.
  Thompson.)
Ibid..  Dec. 22,
  1855.   (Dr.
  Rankin.)
Trans, of Path,
  Society,  vol,
  viii.,  p.  325.
  (Dr. Baly.)
Ibid., vol. viii.,
  p. 330.  (Dr.
  Baly.)
Male, 12.
Female, 14
Ibid., vol. viii., Female, 14
  p. 330.  (Dr.
  J. Ogle.)
Occupation.
At   school.
  (Irish.)
At school..
Previous Health, Ac.
Early Symptoms.
Had suffered  from
  abscess  in  the
  neck, and cough.
Female, 28 Married.
           Temperate.
Male, 45.,






Female, 42



        •
Female, 40


Female, 33



Female, 58




Male, 18..






Not stated.
A carter.
 Married.
 Temperate,
Married...





Not stated.


Married...



Married...
Ibid., vol. viii.,
  p. 332.  (Dr.
  J. Ogle.)
Ibid.. vol. viii.,
  p. 333.  (Drs.
  Peacock and
  Bristowe.)

Ibid., vol. viii.,
  p. 337.  (Drs.
  Peacock and
  Bristowe.)
Med. Times &
  Gaz.,   Nov,
 ' 21,     1857.
  (Mr. Wilks.)
Male, 36..


Female, 18
Baker,
Not stated.
Not stated..
Not stated.
Tent-maker.
Healthy.
Loss of appetite, flesh;
  increasing languor and
  debility.
Lassitude, muddy com-
  plexion,  and   slight
  cough.

Menorrhagia and debility
  two years before the dis-
  coloration.
Robust
Good.
Not stated.


Good......
Formerly very stout
  and   of   .large
  frame.


Headache, pains in
  the limbs,  lan-
  guor and debili-
  ty,  followed by
  pain in the loins
Diseased  vertebral
  column.
Incontinence    of
  urine,  scalding,
  containing blood
  and pus.
Emaciation, &c
Had a fall, and se-
  vere pain in the
  right side.
Bronzing of Skin—its Degree
      or Absence.
Dark spots in various re
  gions of body.  At first
  no illness.
A brown tinge  of skin,
 followed by typhoid fe-
 ver, after which bronz-
 ing became more mark-
 ed.
Copper  colour   general,
  and deepest on the face
  and neck.
A  brown  muddy tint,
  deepest  on face, arm,
  and shoulders; no mot-
  tling.
A.  fawny  or  yellowish-
  brown tint, most mark-
  ed on face, arms, thighs,
  and legs; patchy discol-
  oration in parts.
Skin dusky-brown, resem.
  bling that of a mulatto;
  darker  in some parts
  than in others.
Not stated.
Paroxysmal  pain  in the
  abdomen ;    loss   of
  strength; amenorrhcea.

Loss of strength and flesh
As stated, with bronzing
  of the  Bkin;  pain  in
  creased by pressure on
  the loins; vomiting, &c,
Not stated.
Male, 55.. Coppersmith
Female, 18
Young lady.
Good.
Consequent on the urina
  ry disorder; symptoms
  of phthisis, under which
  she sunk.
Symptoms of phthisis.
Fever, with pains in  the
  lower extremities; cede
  ma, &c.
Declined  in  flesh  and
  strength; pains in back
  and limbs.
Delicate, but of full
  habit.
Skin like that of a North
  American Indian; cer-
  tain parts darker than
  others.
Very dark general discol-
  oration ; large  patches
  in mouth.
Skin  became  suddenly
  and generally of a dir-
  ty-brown tinge.

Face  and hands dark-
  brown—" as brown as a
  Japanese;" other parts
  not seen.

Bronzing deep and gen-
  eral.
No bronzing of the skin .





No bronzing of the skin .



No bronzing of the skin ,


No bronzing of the skin
No  discoloration  of the
  skin.
General   debility   and
  chronic   rheumatism ;
  lassitude and sickness.
A  deep bronze tint  of
  skin.
  17.  Mr. Hutchinson has  collected a number
of the cases which  have been recorded, and has
given  a view of the chief symptoms which have
characterized them.  I shall notice these  symp-
toms briefly and in succession, but independently
of his  account of them.—1st. Bronzing of the skin
was observed in the majority of cases of struc-
tural lesion of the supra-renal capsules recorded
by Dr. Addison and some others, and this physi-
cian was inclined to believe that this symptom
was indicative of such lesion.  Several cases have
more recently been observed where lesions of these
capsules have been found without this change of
the colour of the skin, and without any change
whatever.  Several such instances  are  recorded
in the 8th vol. of the Transactions  of the Patho-
logical Society.—2d.  Great debility, without any
evidence of thoracic  or organic disease, loss of
mental energy, faintness, exhaustion, &c, were
very  general sypmtoms.—3d. Irritability of stom-
ach,  nausea,  occasional  or frequent vomitings,
were  also prominently observed.—4th. Pain  in 
Supra-renal Bodies  and of  Bronzed  Skin.
1571
General Symptoms, Complications,
Some  emaciation ;  great and
  increasing  debility ;   op
  pressed   aspect ;    urine
  healthy.

Countenance  expressive   of
  great languor ; emaciation ;
  marked debility;  liability to
  faintings, &c.
Appetite very bad, thirst, great
  debility, pain in  the loins,
  menorrhagia, anxious  ex-
  pression.

No material loss of  health un-
  til within a few weeks  of
  death ;  debilityv loss of ap-
  petite, irritability of stom-
  ach supervened,  failure  of
  memory fo* some months,
  urine normal.
About eight months after the
  first bronzing she began to
  lose flesh and strength ; har-
  assing cough, irritability of
  stomach,  extreme anaemia,
  and debility supervened.
Anaemic and extremely feeble,
  sickness and vomiting.

Anaemic and  feeble, followed
  by discoloration of skin, and
  by a peculiar collapse.

Sinking at pit  of stomach,
  nausea,   loss  of appetite,
  strength, &c. ;  secretions
  healthy, heart's action very
  feeble.
Fever; small, feeble, and quick
  pulse ; severe pain in loins,
  increased by pressure ; fre-
  quent vomiting;  tendency
  to diarrhoea ; abdomen flat,
  empty,  and  tender;  urine
  albuminous; peculiar odour
  of skin.
Disease of  the vertebral col
  umn,  apparently  causing
  death.
Phthisis,  under  which  she
  sunk.
Hectic  and
  phthisis.
symptoms  of
Tumour in left side of abdo-
  men,  emaciation, prostra-
  tion, liver   enlarged,  the
  spine very prominent at the
  last dorsal vertebra, &c.
Emaciation, care-worn  coun-
  tenance; retraction of gums,
  loss of teeth, sordes  on the
  gums, &c. ; general want of
  power, pains in  the  loins,
  &c.; anaemia.
Sickness, feeble pulse;  fits of
  incessant vomiting, return-
  ing after short intervals, for
  seven weeks; emaciation.
 Dura-
 tion of
Disease.
9 mo's
18 m's
7 mo'e
3 yrs.
16 m'
5 w'ks
Not
stated.
12 m's
Not
stated.
Not
stated,
Not
stated
3 mo's
4 mo':
Mode of Death.
Sunk  from  diar
  rhoea;  a succes-
  sion  of  convul
  sions just before
  death.
Suddenly, from an
  epileptic fit.
From    incessant
  vomitings; delir-
  ious before death.
Sunk    gradually
  from exhaustion.
Gradually    sanl
  from exhaustion,

Recovered   under
  the use of tonics,
  the  skin becom-
  ing simply pallid,
Still living........
Exhaustion,  stu-
  por, unconscious
  ness.
Died from scrofu-
  lous deposits and
  vomicae in lungs.

Died from phthisis
Exhaustion.
Exhaustion,
Inspection after Death.
No autopsy,
A chalky concretion found in  the
  medulla oblongata.   The supra
  renal bodies said to be free from
No inspection.
The chief lesion observed was tu-
  bercles in the lungs.  The supra
  renal bodies were not examined.
No autopsy.
No autopsy............


Recovered.............



Living at time of report
Both supra-renal bodies atrophied,
  and their entire structure  de-
  stroyed.  History and inspection
  fully given, with a plate.
Both supra-renal bodies contained
  nodules of firm substance, gray
  and semi-transparent external-
  ly, and yellow and  opaque in
  ternally.  A great part of their
  proper structure unaltered.
Extensive deposits of crude tuber
  cular matter in both supra-renal
  bodies, and in the lungs and left
  kidney.
Extensive  deposit of scrofulous
  matter in one supra-renal body,
  the other not affected.
Cancer of both supra-renal bodies,
  and cancerous deposits in both
  kidneys and  in other parts.
Supra-renal bodies both destroyed,
  their substance being replaced
  by a soft white encephaloid de-
  posit ; similar deposits in  the
  lungs.

Both supra-renal bodies enlarged,
  inflamed, and contained puru-
  lent matter, with gritty matter
  in the right.
Gradually     increasing
  prostration   for  four
  months.
A peculiar and disgusting
  odour a few days before
  death.—See case 16.
Eight months after  the
  change of colour began
  the patient had a fine
  healthy infant.
This case very closely re
  sembled the preceding
  one.
Inflammatory disease of
  supra-renal bodies may
  be conjectured.

The symptoms combine to
  indicate disease of su
  pra-renal bodies.
The  case very  chronic,
  well  marked, and  the
  Bupra-renal bodies most
  completely   disorgan
  ized.  A very interest
  ing case.
Apparently  an  earlier
  stage of the lesions ob-
  served in case No. 28
No  symptoms  but those
  of phthisis mentioned.
No  symptoms excepting
  those of phthisis men-
  tioned.
History, case, and of the
  diseased appearance full
  and interesting.
History and rnorbid ap-
  pearance fully detailed,
No other visceral disease
  observed.
the epigastrium, back, and loins, sometimes acute,
in some instances dull, or an aching merely, was
general.—5th.  Anamia was also  generally pres-
ent, this fluid being impoverished and  abounding
with white corpuscles, the soft solids being flab-
by;—6th.  Feebleness of the heart's action,  a soft,
compressible,  feeble,  and  more  rarely a quick
pulse, were usually observed.—7th. A cachectic,
leuco-phlegmatic,  and unhealthy  appearance  of
the  body, with or without emaciation, were fre-
quently remarked.—8th. A disagreeable  and pe-
culiar odour was exhaled from the body, in some
cases, during life ; and, 9th.  Several nervous and
convulsive symptoms were observed in a few in-
stances.   The  tongue, the bowels, and the urine,
did not present much indication of disorder.  Death
appeared to result chiefly from vital depression or
exhaustion, with more, or less indications of alter-
ation  of the  circulating fluids.   In  some  cases
death  was attributable to the disease with which
the lesion ofthe supra-renal bodies was complicat-
ed, as to cancer, tubercular disease of the  lungs, 
 1572       SUPPLEMENT—Supra-renal B

&c.  The circumstance of one of those bodies only i
bvingdiseased, and the extent to which the struc-
ture of one or both had been destroyed, may be
viewed as modifying or altogether  altering the
symptoms and the final issue.
   18.  ii.  The chief lesions of these bodies which
have been recorded are the following:  (a) Ap-
pearances of  acute inflammation and  its conse-
quences, suppuration, &c.—(b) Atrophy and total
disorganization of their structure.—(c) Calcareous
depositions, or fibro-calcareous concretions, with
or without cysts, some of which  contained a fluid
puriform matter.—(d) A fibrous degeneration, with
great enlargement and induration.—(e) Tubercu-
lar deposits, with great enlargement and loss of
the healthy structure of these bodies.—(/)  De-
posits  of cancerous matter, consecutively of can-
cer in other organs, more or less of the normal
structure of these bodies being still preserved.
Although these structural  lesions were more fre-
quently observed in both supra-renal bodies, yet
one  only was not unfrequently affected, and in a
few cases a portion ofthe healthy structure ofthe
diseased body was preserved. The disease of one
body only, or  the preservation of a portion of the
structure ofthe organ, may rationally be allowed
to modify or more manifestly alter the resulting
phenomena.
   19.  The diagnosis of disease ofthe supra-renal
bodies is very difficult:  1st. As  respects the  cer-
tainty with which this disease may be inferred from
the symptoms present—of which, bronzing ofthe
skin, the persistence  of retchings and vomitings,
the anaemia, and the  weakness and smallness of
the pulse, are the most characteristic; and, 2d.
As regards ascertaining during lifo whether or no
the existing discoloration is to be imputed to dis-
ease of these bodies, or to  one  or  other of the
forms  of Jaundice, which I have described as
Green, and  as Cachectic,  or spurious, Jaundice.
(See § 46-57.) In the  histories of cases of disease
of the supra-renal bodies which  I have perused,
no such diagnosis has been made or suggested ;
and  the appearances  ofthe stools and the states
of the biliary and urinary excretions during life,
and even ofthe biliary apparatus  after death, have
been either insufficiently investigated or entirely
overlooked.
  20.  The prognosis  is most unfavourable, as  it
does not appear that any case has recovered where
the skin had become bronzed or much discoloured.
The prognosis may therefore be ranked in the
same category as the green form of Jaundice de-
scribed in that article.  (Sec <} 46, ct seq.)
I
  Bibliog. and Refer.—T. Wharton, Adenographia sive
Glandularum Descriptio, 18mo.  Amstel., 1659.—Xagel,
Dissert. Sistens Ren. Succent. Mammal. Descript.  Be-
rol., 1S3S ; and Mailer, Archiv, 1336. — C Bergmann,
Dissert, de Glandulis Supra-renalibus, cum Tab.  Gi'.tt.,
1839.—A. Eeker, Der feinere Bau der Nebennieren bcim
Menschen, &c.  Brauns., 1846.—Art. Blutgefrsdriisen in
Wagner's Handw. d. Physiologie, b. iv.  1849.—H.Frei;
in Todd's Cyclop,  of Anat.  Oct., 1849.—H. Gray, on the
Development of the Fuctless Glands, <tc, in Pliilosoph.
Trans., 1852—.<4. KUHker, Mikros. Anat, 2; and Man-
ual of Human Histology, transl. by G. Bush and T. Hux-
ley,  vol. ii., p. 214.—Leydig, Anatomisch-histologiache
Fnters. ub. Fische u. Reptilien, 1S53. — T. Addison, on
the Constitutional  and Local Effects of Disease of the Su-
pra-renal Capsules, 4to.  Lond., 1855, ui*h Plates. (Was
the first to direct attention to Diseases of these Structures.)
— Brown-Sequard, in Archives Com rales de Medecine,
Paris, 1856, p. 395.—Ibid., 1857, p. 374.—Baly, Ogle, Pea-
cock, Bristowe, Wills, Harley, and Hutchinson, in Trans-
actions of the I'athological Society of London, vol. viii.,
8vo.  Lond., p. 325-345.—G.  Harley, on Functions of the
Supra-renal Capsules, etc., in British and For. Med.  Chi-
rurg. Review, &c., Jan., 1S58, p. 204. — Gull, Buirows,
Rowe, Bakeuell, Thompson, Sibley, Farre, Stocker, Pea-
cock, Budd, Rankin, &c, Cases by, in Medical Times and
Gazette from 15th  December, 1S55, until 8th March, 1S56.
—J. Hutchinson, in Ibid., March Sth and 22d, lv56, p.
233 and p. 281.—G. Harley, in British and Foreign Med.
Chirurg. Review, &c, No. xii., Jan., 1858, p. 204;  and
in Lancet, 19th December, 1S57, p. 620.— Wilks in Lan-
cet and in Med. Times and Gaz., 21t?t Nov., 1857. — J.
Copland, in Ibid., 21st Nov., 1857. — [.I dam Martin, in
Ibid., May, 1S58._Edin. Med. Journ., May,  1S5S.—Am.
Journ. Med. Sciences, July, 185S, p. 2-2.]
ies—Bibliography and References.

  21.  The  treatment should be  directed accord-
ing  to  general principles, conformably  with the
phenomena  and with the  complications charac-
terizing individual cases.  These will suggest the
rational indications, and the means by which they
are most  likely to be fulfilled, as far as  this may
be possible.
  [in  the present state  ofthe question, the fol-
lowing conclusions may be  legitimately drawn:
1. Disease  of the supra-renal  capsules  is  not
necessarily associated with bronzing of the skin.
2. Bronzing ofthe skin  maybe produced by oth-
er causes than  supra-renal  capsular disease.   3.
Disease, or even  complete disorganization of the
supra-renal  capsules, may  exist without  giving
rise to any special symptom.  4. Peculiar symp-
toms have been found associated with supra-renal
disease in so many cases as to render it  probable
that the association is more than accidental, and
that under certain unknown conditions a real in-
fluence may be exerted on the economy by a dis-
ease ofthe capsules.   In a case which came un-
der our own observation and treatment recently,
the  supra-renal capsules  were extensively dis-
eased, and one of them disorganized, without any
change of colour  in the skin.] 
INDEX.
t&~ The Numerals denote the First and Second Volumes ;  the figures the number of the page.  The Third or Last
      Volume is indicated by fiejures, the numbers of the pages only.  The Formulae in the Appendix are repre-
      sented by F. followed by the number in figures, and by Ap. and the number of the page also in figures.
AF
Abdomen, auscultation of......   i.
----examination of...........   i.
---inspection of.............   i.
----manual examination of....   i.
---percussion of.............   i.
----various states and appear-         — from di.-eased organs and
  ances of, requiring examina-         structures..................   i. 29
  tion....................... i. 2^1----from the alimentary canal,
Abdominal tumours, feigned... i. 1030 [   pathology of................   i 2S
5 Absorbent  Glands.   See  also      [Aconite, its use in phthisis.....  1268
1|  Lymphatic Glands..........ii. 923---- operations and symptoms
l1----system, diseases of........ii. 918
2 Absorption, following metamor-
4   phosis -and waste of tissues..,
Abortion, Bibliog. and Refer.
 — causes of.................   i
 — causes  depending  on the
  uterus and placenta.........   i
 — causes  depending  on the
  foetus......................   i. 6|  economy....................  i. 28[—   ---operation of..........   448
 — definition of..............   i. 5----on the skin, pathology of..  i. 27|Acro-narcotic poisons, described   474
   • from the lungs, pathology of
— in relation to the causation,
 perpetuation, and removal  of
 disease......................
— of morbid matters in the
  from poisoning by...........415-16
---poisoning by.............   415
-----—- treatment of.........   417
----recommended   in  acute
  rheumatism........  ........   OiT
Acrids, vegetable, operation of,
  in poisoning by..............   391
----treatment of poisoning by.   392
----poisoning by.............   388
Acro-alterant  medicines,  enu-
  merated, &c................  1147
----poisons, described.....'___   447
     diagnosis of..............    i. 9 Abstinence, associated with mor-
----feigned...................i. 1030:  bid agentB..................  i. 32
----occasional exciting causes.    i. 6----bibliography of...........  i. 34
----palliative treatment of....   i. 11 j----feigned..................  i. 30
----pathological causes of.....i. 7, 8----its morbid effects.........  i. 30
----prognosis of..............   i 10'----treatment of its  morbid ef-
---prophylactic treatment of..   i 10   fects......................  i. 34
----remedial treatment of.....   i. 12 Accession of disease to be stud-
---symptoms of..............    i. 8j  ied......................... ii. 31
----treatment of..............   i. 10 Accessory symptoms in insanity ii. 509
Abscess, Bibliog. and Refer....  i. 26;Acephalocysts  described.   See
---chronic..................  i. lSj  also Hydatids...............ii. 293
----chronic, pus in...........  i 18----characters of.............  1534
----consecutive..............  i. 19'----of the liver...............ii. 872
----definition of..............  i. 15] Acetic acid, slow poisoning by..   392
----diffusive, or  in cachectic       Acetum Antihystericum...F. 1. Ap. 5
  habits......................  i. 17 Acetum Camplioratum___F. 2. Ap. 5
---from acute sthenic inflam-       ---Camphora et Ammonise...
  mation.....................  i. 15]                         F. 3. Ap. 5
----of tlie opening of.........  i.  25 Acid, acetic, of poisoning by...   373
----of the prognosis of........  i.  23---- hydrocyanic,  its  use  in
Abscess in the  brain........... i. 262   phthisis....................  1267
---of brain, the parietes of... i. 262|---- ----.  See  Prussic Acid,
 — prussic.   See Prussic Acid,
 poisoning by..............398-405
— sulphuric, its use in phthisis  1267
     lumbal-.  See also Psoitis..    516
 ---of the absorption,  &c,  of
   the contents of..............   i. 24
 ---of the diagnosis of........   i. 22
 ---of the influence of air when
   admitted into...............   L 22
 Abscess ofthe kidney..........ii. 725
 ----chronic, of the kidney..... ii. 726 Acids contained in  urine, de-
 Abscess of the liver, description      I   scribed....................1319-21
   of.......................ii. 849-51, Acids, mineral, appearances aft-
 ---different kinds of.........ii. 867   er poisoning by............. 376-7
 ----directions in which it may      I----slow poisoning by.........   392
   point or open...............ii. S51---■ symptoms of poisoning by. 373-5
 ---external opening of.......ii. 863
 ---regimen and diet in.......ii. 862
 ---symptoms of..........ii. 849-52
 ----treatment of  its  several
   modes of opening..........ii 861-3
 ---treatment of...........ii. S61-3
 Abscess of the spleen described.    892
 ---of the treatment of.......   i. 24
 ----origin of consecutive......   i. 19
 ----parietes of...............   i- 16
----parietes of chronic........   i. 18
----pathology of..............   i- 15
----primary and secondary, of
Acro-sedatives,arrangement and
  enumeration of..............   1147
Action, vascular, to  be allayed
  when increased.............   1140
Actions, morbid, duration of...  i. 682
----vital and vascular, should
  be equalized................   1139
Acute, acceptation of the term..  i. 083
Adhesions, Bibliography.......   i. 44
----of cellular tissue..........   i. 42
Adhesions, morbid, described...   i. 41
----of mucous surfaces........   i. 43
----of opposite surfaces of the
  pericardium................ii. 210
----pathology of..............   i. 40
—— of the pleura, described ...  i. 300
----reparative................   i. 41
----of serous surfaces.........   i. 42
----various, &c...............   i. 43
Adipose tissue, effusion of blood
  into........................   i. 45
----hypertrophy of...........   i. 44
 — its morbid states..........   i. 44
     of tumours in.............   i. 45
  poisoning by...............39S-405
----oxalic, poisoning by.......    378; Adolescence, remarks respecting  i. 50
--------treatment of poisoning       ! Adult age, notices of..........  i. 51
  by.........................    380! Adventitious productions, conse-
  the pancreas.
----pus contained in..........   i. 16j
  ----treatment of poisoning by. 377-8
  Acids, of their use in phthisis ..  1267
  Acidum  Nitro-Hydrochloricum
                           F. 4. Ap. 5
  ---Nitro-Hydrochl. dilut. F. 5. Ap. 5
  Acne, causes of................  i. 36
  ----definition of..............  j. 34
  ----diagnosis of..............  i- 36
  Acne induratii, described.......  i. 35
      treatment of.............  j. 37
      prognosis of..............  i. 36
  Acne punctata, described......  L 36
  ----treatment of.............  i. 38
6'Acne rosacea, described........  i. 35
treatment of.............   L 38
----symptomatic, described ,
i. 547
  quent on inflammation.......  i. 673
----from perverted organic ac-
  tion in their seats...........  i. 678
Adventitious secretions and pro-
  ductions....................  i. 674
Adynamia.   See also Debility..
Adynamic Fever.  See also Ty-
  phoid Fever................L 116S
^Egophony, described..........  i. 203
jEther Phosphoratus. .F. 6 & 7. Ap. 1
^Etiology, or causation of disease  i. 644
Affections of mind, as remedial
  agents......................   1143
  — classification of...........ii. 510
Affections of  the sexual organs
  caused by pregnancy........    498
  — treatment of..............    498
Affections, various  sympathetic,
  during pregnancy........... 501-4
Affusion  of cold  or tepid water
  for insanity.................ii. 606
Affusion  of cold water  on the
  head, <fec, first advised by the
  Author for  poisoning by prus-
  Bic acid.....................   404
                                i. 18 Acne simplex, described.......  i. 35
____termination of............   i- 20----treatment of.............  i. 37]After-pains, defined.....,.....   i. 4f
    progress of...............   i. 201 Acne syphilitica, described.....  i. 36[----symptoms and diagnosis of  i. 4f
Abscess of the vulva...........  14331----treatment of..............  i.
treatment of..............   L 46 
1574          AG                             INDEX.                              AN
Agalactia.   See also Milk, de-      Albuminaria, description of. See
  ficiency or suppression of.___ii. 929!  also Nephritis Cachectica---ii. 736
Agamazooids noticed..........   1517 Albuminous principles  in  nior-
Age, advanced, described......   i. 56   bid growths.................
____.___. divisions of..........   i 51 Alcohol, poisoning by, symptoms
----adult and mature, remarks      |  of..........................
  on.........................   i 51----treatment of poisoning by.
____as disposing to phthisis....   1231;Algiers, climate of, advised for
____ as predisposing to insan-      I  phthisis....................
  ity.........................ii. 55S Alimentary  canal,   absorption
       ___.,____:___*_ .i:..nnnA   :  hag   4Vn».  i.«
                                      from, <fec....................  i 2S
                                        • morbid changes of........ i. 619
                                    Alkalies, &c, advised  for rheu-
                                      matism.....................   690
                                     — poisoning by, symptoms of   3S0
                                     —  ----  appearances   after
                                      death from.................   381
                                    ----slow poisoning by.........   393
                                         of their use in phthisis___  126S
                                    Alkaline  sulphurets,  poisoning
                                      by.........................   43G
----old, described............   i. 56:----treatment of.............   436
Agents, examination of, produc-       lAlmonds, bitter, poisoning by..   403
  ing irritation...............708-10 Alopecia,  described.   See also
     as predisposing to disease..  i. 646
----Bibliography, &c. of......   i. 57
----changes of structure pro-
  duced by...................   i. 52
----declining, described.......   i. 55
----in its generic acceptation..   i. 46
----in its specific acceptation..   i 51
----its first period............
----its several periods arranged
----functional changes  result-
  ing from....................
     Anaemia, symptoms of.........i 221
     ----treatment of............. i. 221
     Anaesthesia from chloroform and
 776!  vapours of aethers............464,5
    I Anaesthesia, described.........    13
 405!----pathology of............:.    13
 407 Anaesthetics, enumeration of...  1147
    'Anasarca, Bibliog. und Refer... i. 731
l-.'T1-;—- consecutive acute.........i. 726
         consequent upon scarlet fe-
53
 hygienic, arrangement of.
• medicinal,  the operations
1144
  Baldness.................ii 162-3
Alopecia, Syphilitic, described..   146S
of..........................   1144 Alterants,  vegetable,  mineral,
---- physical  and  medicinal,
and animal.................   1147
causing insanity..........ii 566-7 Alterations of blood in disease.. i. 227
     their effects on the charac-
  ter of irritation..............ii. 707]
---- therapeutical classification
  of.........................  1144-8
Ageustia, described.... «......     12,-
Ague,  appearances   in  fatal
  ■ of structure connected with
 insanity.................ii. 549-55
— of  structure in  puerperal
 fevers, inquiries respecting.. 579-Sl
— of structure observed after
 nephritis...................ii 727
  cases  of.....................i. 10S9 Alternation  of generation  in
----Bibliog. and Refer., &c... i. 1099  worms......................  1522
Ague-cakes, described.........i. 1089jAlvine  Concretions.   See also
Ague, causes of...............i. 1089 \  Concretions, Intestinal......i 463
                                                                    "  70
                                                                      58
----adynamic states of........i. 1086!Amaurosis, Bibliog. and Refer,  i.
     complicated states of......i 1087
 ---complicated with disease of
  abdominal organs...........i. 10S7
----with disease of respiratory
  organs......................i 10S7
----consequences and termina-
  tions of.....................i 1088
----conversion of one type into
  another.....................i 10S6
----definition of..............i 1085
----diagnosis of..............i 1089
----diet and regimen of.......i 1099
----inferences as to its nature
  i.nd consequences...........i. 1092
----intermissions  and  parox
  ysms of.....................i 1086
----malignant states of.......i. 1087
----masked and anomalous ... i 1088
----means  of cure  during the
•  intermissions.............i. 1094, 6
----nature or proximate cause
  of..........................il091
----paroxysms  and intermis-
  sions of.....................i. 1086
----prognosis of..............i. 1089
----regimen of convalescence
  from........................i 1099
----remedies which prevent the
  paroxysms of................i. 1094
----simple or mild............i 1085
----cerebral complication of... i. 1088
----inflammatory state of.....i 1086
----treatment during the inter-
  missions....................i 1094
----treatment of adynamic... i. 1093
--------of complicated.......i. 1094
--------of, during  the  parox-
  ysm........................i. 1093
--------of inflammatory......i 1093
--------of masked or anoma-
  lous........................i. 1098
     causes of.................  i.
 ---congestive...............  i. 62
----definition of..............  i. 57
----diagnosis of..............  i 65
----from disorganization......  i 63
----efficient causes of.........  i 59
----functional................  i 02
----inflammatory............  i. 63
----from injury..............  i 63
----from lesions of the nerves,
  <&c.........................  i. 64
----from organic changes.....  i. 63
----pathology of..............  i. 59
----prognosis of..............  i 65
----seats of..................  i. 57
----stages, grades,  and  forms
  of..........................  i. 62
  ver.........................   739
----definition of.............. i. 724
Anasarca, description of........ i 724
----from disease of the kidneys i 729
----primary acute and sub-acute i. 725
----primary asthenic.......... i 727
----symptomatic............. j. 727
----treatment of acute general i. 729
--------of primary asthenic .. i. 730
--------of primary sthenic. .. i 729
--------of symptomatic......i 730
Anatomy, general,  of scirrhous
  and other tumours...........   77s
----pathological, of phthisis. .1215-21
Ancients, their opinions of mind
  and vital phenomena........ii. 575
--------of life and organization ii. 575
Ancylostomum, systematic  de-
  scription of the genus........   1514
Ancylostomum duodenale,  sys-
  tematic description of........   1514
----examination of cases after
  death.......................   1515
----pathology of..............   1515
----symptoms of this worm,...   1515
----systematic description of..   1514
----treatment of.............   1530
Andes, elevated localities on the,
  advised for phthisis..........   1278
Anemone, species oif poisoning
  by..........................   388
Aneurism, different forms......i. 132
Aneurism of aorta,  described...   i. 81
----causes of.................   i. 81
----effects produced by.......   i. 83
----of its opening or bursting..   i 81
----symptoms of.............   i. 84
----treatment of..............   i 86
----varieties of...............   i 81
Angina, complicated, treatment
  of..........................   1162
Angina, diffusive, associations or
  complications of.............   1159
     causes of.................   1157
                                ----d-finition of..............  1157
                                Angina, erysipelatous, described 1157-8
                                ----symptoms of..............  1158
symptoms of.............  i. 60!----terminations and prognosis
treatment of congestive...  i 6^   of..........................  H5S
         of functional.........   i. 6G
         of inflammatory......   i. 69
         of organic, &c........   i 69
Amenorrhea, causes of........ii. 964
  — complicated with hysteria
  and epilepsy...............ii 971
  — complicated with  various
  diseases....................ii. 970
  — with vicarious haemorrhage ii 970
----from congenital and organic
  lesion......................ii. 966
  — treatment of..............ii. 967
----diagnosis of..............ii. 964
     functionai...............ii. 964
     pathological states causing ii. 965
     prognosis of..............ii. 964
 — prognosis of complicated .. ii. 971
     regimen and diet for......ii. 966
     treatment of.............ii. 965
     ----of complicated.......ii. 971
     various means advised for ii. 865,6
                           Amentia, described............ii 530
of simple............i. 10931 America, the question of the in-
of the sequelae.......i. 1098|   troduction  of syphilis from,
                             considered..................  1462
                           Ammoniacum, formulae  for pre-
                             scribing, in phthisis.........  1268
                           Amusements  and employments
                             for the insane...............ii. 623
                       275 Anaomin, Bibliog. and Refer.... i. 222
                               causes of................. i 221
----types or varieties of.......i. 10S5
Air, of the influence of, when
  admitted into abscesses......  i 22
---- contaminated  and  close
  states of,  a cause  of scrofula 806, 7
----heated, as a disinfectant..
----respired, states of, as signs
  of disease...................  1092;----complicated..............  i. 221
Air-cells, dilatation of the......ii 901----general, described........  i 220
Air-passages, diseases of the.... i. 296----local, described...........i. 219
Albumen in the urine, tests for.  1335----pathology of..............L 219
----treatment of..............  1162
Angina Membranacea.  See also
  Croup...................... i 519
Angina Pectoris, acute,described  i. 70
----Ribliog. and Refer........  i. 78
----causes of.................  i. 72
----proximate cause of........  i. 73
----chronic, described........  i. 71
----definition of..............  i 71
----diagnosis of..............  L 72
----pathology of..............  i. 71
----prognosis of..............  i 72
----symptoms of..............  i 71
----treatment of.............   i. 75
---•----of, during the intervals  i. 76
--------of, in the paroxysm...  i 75
Angina with  pellicular exuda-
  tion........................  1155
Angina pellicularis, appearances
  of, after death..............  1157
  — description and  termina-
  tions of.....................  1155
  — treatment of.............  1162
Angina plastica, constitutional
  symptoms of................  1156
----definition of..............  1155
     description of...........1155-56
Angina Pharyngea.   See also
  Pharyngitis.................  1153
Angina Tonsillaris.   See also
  Tonsillitis..................1150-2
Angina Trachealis.   See also
  Croup...................... i 519
Angor Pectoris.  See  also An-
  gina Pectoris................  i 70 
AN                             INDEX.                             AS           1575
Animal functions,  sympathetic      lApoplexy, predisposing causes of L 10l!Arsenic  administered  in  ene-
  relations of................  10531----classification of its forms ..   i 97]  mata as a poison............   420
                                         commencing with paralysis  i 95----compounds of, causing pois-
                                         complicated with,  or  ter-        oning......................   417
Animal molecules, injurious ef-
  fects of.....................i. IC6
Anosmia, described............     12
minating in, paralysis.......  i. 93
Anteversion of the uterus......   1391----complicating insanity.....ii. 536
----treatment................   1392----complications of..........  i 104
Anthelmintics,arrangementand       '----its connection with  hemi-
  enumcration of..............   11 ts   plegia......................16,17
   - those advised against Taenia   1549 \----consecutive states of......i. 104
420
Anthrax,  described.
  Carbuncle  .................i. 1251
Antimonial  preparations, pois-
  oning by...................   431
----treatment of poisoning by.   432
Antimonials, of  their  use  in
  phthisis....................  1273
Antimony, chloride of, poisoning
  by.........................   382
--------treatment of.........   382
Antimony - tartate  of  potash,
  poisoning by.-...............   431
Antipathy, defined............  i 78
----treatment of..............  i. 79
Antiseptics,  arrangement  and
  enumeration of.............  1148
----vegetable, mineral, and sa.
  line........................  114S
Anus, abscess of, described.....   650
----contraction of the.........   658
--------treatment...........   658
----excrescences about the....   657
----excoriations and inflamma-
  tion of, in children, treatment
  of..........................   649
----fissures and rhagades of... ii 14S
----fissures of, causes.........   051
                                     consequent on diseases of
                                  the heart...................  i. 105
                                 — definition of..............   i 88
                                 — description of.............   i. 89
                                 — diagnosis of..............   i 99
                                 — distinctions of............   i 89
                                 — exciting causes of.........  i. 102
                                 — its ingravescent form.....   i. 91
                                 — morbid appearances in .. i 92, 96
                                 — morbid relations of........   i 98
                                 — of new-born infants.......  i 119
                                 — operation of its causes.....i 103
                                 — pathological states consti-
                                  tuting..................'....  i 107
                                 — premonitory symptoms of..   i. 89
                                 — preventive treatment of...  i 110
                                 — prognosis of..............  i 100
                                 — remedies advised for......i. 115|
                                 — simple and primary.......   i. 90
                                 — symptoms constituting the
                                  attack......................   i. 90
                                 — treatment of.............  i. 109
                                 -------during the attack....  i 111
                                 -------of the sthenic attack .  i 111
                                 -------of the asthenic attack i 114
                                 -------subsequently to the at-
                                  tack of.....................  i 117
     their symptoms......    6541 Apoplexy, pulmonary..........ii. 911
 ---their treatment......    655----course  and  terminations
 fistula in, described.......    652j  of......................... ii. 911
----treatment of.........    653; Apoplexy of the spinal cord ....  968-9
 of inaction of the.........    645|—   ---prognosis of.........    969
420

421
420
 27
symptoms and treat-
treatment of.
ment of.....................ii 156 Apoplexy of the spleen.
inflammation and excoria-
                                 969
                                 993
|Apostema Cerebri............. i. 262
tions of, in children..........   648'Appearances,  morbid,  of  the
treatment of.
649   blood.......................  1045
itching of the............   649 Appendages, uterine, specific in-
    ■ treatment of.
■ laceration of the.........,
----treatment of........
• mucous discharges from...
----treatment of.........
                                650
                                644
                                644
                                650
                                650
---paralysis of..............   645
--------causes..............   645
--------treatment of.........   645
---prolapse of the, forms of...   655
---treatment of abscess of the   653
---ulceration of.............   652
Anus  and Rectum,  diseases of.
  See also Rectum and Anus...   642
Aorta, aneurism of............  j. 81
---different kinds  of aneurism
  of..........................  i. SI
---symptoms and  signs of an-
  eurism of..................  i 84
---treatment of aneurism of..  i 86
---Bibliog. and  Refer........  i 88
--- constriction  and  oblitera-
  tion of......................  i 88
---its diseases...............  i 79
---inflammation of..........  i. 80
---nervous pulsation of......  i 79
---rupture of, described......  i. 87
Aortitis, causes of.............  i 80
---changes produced hy......  i. 81
  flammation of...............  1379
----treatment of inflammation
  and abscess of..............  1379
----abscess of, in non-puerperal
  states......................  1367
----non-puerperal inflammation
  of..........................  1365
----causes of non-puerperal in-
  flammation of...............  1366
----symptoms of inflammation
  of..........................  1367
----non-puerperal  suppuration
  of..........................  1366
Appendix Caeci,  inflammation,
  (fee. of......................  i 332
Appetite, insatiable............i. 120
----morbid, its causes.........  i. 121
---------definition of.........  i 120
     diagnosis of poisoning by.
----introduced into the vagina,
  as a poison.................
----lesions produced by its prep-
  arations ....................
----operation of,  in  poisoning
  by.........................
----palsy  from...............
----period required to destroy
  life by.....................   422
----poisoning by, and its com-
  pounds .....................417-22
----poisoning by its  external
  application.................   420
----quantity of, required to de-
  stroy life...................   422
----spasms  and  convulsions
  from.......................   418
----symptoms of acute poison-
  ing by .....................   417
---------of slow or chronic poi-
  soning by..................   418
----treatment of poisoning by.   422
----convalescence from.......   423
Arsenical fumes, poisoning by..   420
Arterial system, symptoms fur-  '
  nished by..................1080-7
Arteries, albuminous and puru-
  lent exudations in...........  i. 133
----aneurismal changes of....  i 132
■----atheromatous or fatty mat-
  ter in their coats............i. 133
----Bibliog. and Refer........  i 136
----calcareous deposits in their
  coats.......................  i. 134
----chronic inflammation of...  i 129
----constrictions of...........  i. 132
----their diseases............i 124
---. of the heart, ossification of ii. 225
----inflammation, acute, of....  i 126
—— morbid changes of........  i. 130
----nervous affections of......i 125
----obliteration of............  i. 133
----organization of...........  i. 124
     ossific deposits in.........  i. 134
                                596
                                126
                                127
                                129
                                129
                                130
                                120
                                130
----of their vital properties .
Arteritis, defined............
----causes of..............
----chronic, described......
----complications of.......
----diagnosis of...........
----pathology of...........
     prognosis of.
• symptoms of.............  i 12S
135
135
     treatment of acute
         of chronic...........
Arthritis, rheumatic, symptoms
  of.......................... 007-9
Arts and Employments, Bibliog-
  raphy...................... i. 168
----as causing disease........ i. 162
Arum maculatum, poisoning by   3S9
organic lesions in___i 121 Ascarides, description of.  See,
—------treatment of.........  i 122
---------varieties of..........  i. 120
----vitiated, described........  i 123
---------treatment of.........  i. 124
Appetites, as signs of disease. .1079, SI
Aqua Cosmetica..........F. 8. Ap. 5
---Styptica............F. 9. Ap. 5
----Styptica Cupri et Zinci---
                        F. 10. Ap. 5
Styptica Zinci.
F. 11. Ap. 5
  also, Worms................  1543
----symptoms of.............  1544
----treatment of.............  1571
Ascaris  lumbricoides,   Syno-
  nymes of...................  1544
----systematic description of..  1544
----symptoms produced by....  1545
----prevention of.............  1557
----remedies prescribed for....  1558
----various experiments on...  155S
'.___treatment of'".'.".'.'.'.'.'.'.'.  L SI \----Traumatica Thedenii F. 12. Ap. 5j Ascites.  See Dropsy of abdo-
Aphonia, definition of.........ii 7841----Vanillse............F. 13.^.5   men....................... i. 716
____description of ...........    15, Arachnitis, described.......... l. 2S0|----puerperal,  described...... l ■•■
____functional     ...........  1500 Arachnitis Spinalis, described..   957 Asphyxy,   appearances
after
    hysterical................  15n0JArachnoid of dura mater, lesions _
----pathological'states of... ii. 784, 5.  of..........................  i 255
----structural.................1500
----treatment of..............ii. 783
Aphtha, in last stage of phthisis   1203
----  See also Thrush.........   1167
----treatment of..............   1109
Apoplectic paralysis, lesions pro-
  ducing ............_•........
Apoplexy associated with palsy
____associations  and complica
          of  pia mater,  cysts, tu
      mours, <fcc. of............... i 258
    ----structural changes of......i 25S
    Arachnoid of the spinal cord, in-
      flammation of..............   957
    Armies, protection of, from pesti-
i. i/«/|  lence.......................272, 3
i 2S'Arrangement,  natural,  of dis-
    |  eases affecting the skin.....S68-873
tions of      ..............  i. 104 Arrangements of therapeutical
— Bibliog.'andRefer........ i H8|  agents....................U44-4S
  death...................... i 170
----Bibliog. and Refer........ i 174
----causes of................. i. 169
----defined.................. i. 16S
----general treatment of......i. 172
----of new-born infants....... i. 175
____phenomena characterizing i. 170
---. theory of............... i. 170
____treatment of the, of new-
  born infants................ i. 175
----treatment  of  particular
  kinds of.................... i. 174
----varieties of............... i 171 
1576          AS                              INDEX.                              BL
Assimilating  organs,  morbid      I Auscultation of respiration..... i. 200 Bladder, paralysis of the, de-
  sympathies of...............   1036----of the voice.............. i 202   fined.......................  1297
Associations of disease, their nu-      I Azores, Climate of............ i 414----paralysis of,  from  disease
  merous sources examined. 1036-1055,                                       and injury of the spine ......  1298
Asthenia.  See,  also, Debility..  i. 547|                 B-                  ----causes and forms of paraly-
Asthenic Fever.  See, also, Ty-      'Bacon, poisonous effects of.....   42s   sis of.......................  1297
  phoid Fever................i 1168 Baldness, causes of............ii 163----paralysis of, described---  1297
Asthenic   inflammation,   de-      |----history and pathology of.. ii. 163----treatment of paralysis of..  1299
  scribed.................ii 439-445----partial or limited.........ii 102----phosphatic  urine from dis-
____nature of................ii 456;----general or diffused........ii 162,  eased......................  1333
____treatment of.............ii. 470;----syphilitic, described......  1468----of polypous excrescences  in
Asthma, antispasmodics, <tc, in i 1S9|----treatment of.............ii. 164]  the........................  1312
     appearances after death...  i. ISO Balneum Ioduretum.....F.  14. Ap. 5----spasm of, defined.........  1296
                                 """---Sulphureum........F.  15. Ap. 5'---diagnosis of spasm of.....  1297
                                    ----Potassii Sulphureti.. F.  16. Ap. 5----treatment of spasm of___  1297
                                    ----Potassii Sulphureti et Gela-       ----ulceration of.............  1304
                                      tin«..................F.  17. Ap. 5----urinary, diseases of... .1293-1313
                                    Balsams, of their use in phthisis  1268,----urinary, symptoms  of irri-
                                    Balsamum Astringens F. IS &. 19. Ap. 5|  table.......................  1293
                                    ----Odontalgicum___F. 785. Ap. 29 Blains, described.............. i 326
                                      — Succinatum........F.  20. Ap. 5 Blastemata of morbid  growth,
----Bibliog. and Refer........  i 196
----predisposing causes to.....i 1S5
----change of air  and climate
  for........................i  i. 196
----common or humid........  i 182
----complicated  with  organic
  diseases of heart............  i 1S7
     complications of..........  i Is
----definition of..............  i. 176
----diagnosis of..............  i. 184
----diet and regimen for......  i. 196
----emetics  and  diaphoretics
  for.........................  i 193
— Sulphuris, vel Oleum Sul-      |   described...................   771
 phiiris___............F. 21. Ap. 5 Bleeding, of general and local,
in insanity................ii 603-0
  Spontaneous.   See Haemor-
rhage ......................ii  79
                                         Sulphuris Terebinthinatum
                                                             F. 22. Ap. 5
                                         Terebinthinatum ... F. 23. Ap. 5J
----exciting causes...........  i. 186 Barbiers, remote causes of..... i. 208. Blennorrhagia  virulenta,   de.
----expectorants for..........  i 191 j----defined.................. i. 208J  scribed.....................   1454
----humoral form of..........  i 182[----symptoms of............. i 208; Blindness, feigned.............  i. 130
     indications of treatment...  i 1SS----treatment of............. i 208 Blindness, night  or day, causes
194
188
193
----inhalations for........... i. 191
----mineral waters for........ i 196
----narcotics and anodynes for i. 1S9
----nervous form of.......... i 181
----physiology of............ i 177
----prescriptions for.......... i. 1S9
----prognosis of.............. i 1S4
----proximate cause of....... i. 188
----of the regimenal treatment
  of.......................... i. 195
----spasmodic form of........i. 181
----symptomatic.............i 186
----symptoms of............. i 17S
----terminations of........... i ISO
----of tonics, sulphur, and vari-
  ous other means for......... i
----treatment of the fit.......i
----during the interval....... i
----of symptomatic and compli-
  cated states of.............. i. 195
----varieties of.............. i. ISO
Astringents, of various, in phthi-
  sis .........................  1270
----vegetable, mineral, and sa-
  line........................  1145
Atheromatous or fatty deposits
  in coats of arteries.......... i 133
Atlantic, climate of places in the
  Northern................... i. 414
Atrophy, appearances and states
  of.......................... i. 197
----of the brain.............. i 270
----of the coats of the digestive
  canal....................... i. 625
----of convolutions of the brain i 270
----definition of.............. i 197
----description of.   See, also,
  Tabes......................  1100
----of the heart, characters of. ii. 24*
--------causes of............ii. 248
----•----symptoms  and  treat
  ment of....................ii. 248
----of the liver..............ii 869
----of the mamma...........ii. 933
----of muscles...............ii 996
----of the pancreas...........     7
----physiological pathology of. i 197
----treatment of.............i 199
Atropia, poisoning by.........   448
Attitude  of  body,  signs   and
  symptoms furnished by......  1057
Auditory nerves, deafness from
  affections of.............. i. 187, 8
----treatment of...........ii 988, 9
Auditory passages, deafness from
  various lesions of.........ii. 1S2, 3
----treatment of.............ii. 183
Aura epileptica, remarks on___i 917
Auscultation of the abdomen... i.   5
----Bibliog. and Refer........ i 207
----of the heart..............i 204
----of morbid respiratory sounds i 201
----of the morbid sounds  and
  impulse of the heart.........i 205
Baryta and  its salts, poisonings
and pathology of.........ii 1030-3
  by.........................   432 Blisters and rubefacients, their
----symptoms of.............   432!   use in phthisis..............  1257
----treatment of.............   433 Blood, alterations of, in disease, i 227
Basis of Therapeutics..........  1131.----alterations of, causing hae-
Bath, Turkish, in the treatment      I   morrhage...................ii.  75
  of Syphilis..................  14^->----alterations of, in scarlet fe-
Belladonna, Atropa, poisoning by   44S|   ver........................   741
— appearances of, in pleuritis 317,18
— Bibliog. and liefer........ i 250
— proofs of its changes in dis-
ease........................ i. 231
   causes of changes of...... i 237
     treatment of poisoning by.   449
Belly-ache.  See Colic......... i 420
Belly-ache, dry or West Indian
  colic, treatment of........... i. 439
Beriberi, causes of............ i 209
----defined.................. i 208----changed by the chyle.....i 237
----diagnosis of.............. i 209--------by the food.......... i. 237
----nature of................ i. 210--------by impaired functions
----symptoms   and   morbid      |   of depuration...............i. 238
  change of................... i 209]----changes in, arising from the
----treatment of............. i. 210   nature of food...............i 237
Beverages  advised  for  indiges-      I----changes  of, in  relation  to
  tion..................... ii. 395, 7   special diseases............. i. 231
Bi-chloride of mercury in syphilis  1484----changes of, by the states of
Bile, alterations of the.........ii.   1   vital power................. i 230
     chemical and physiological
  changes of..................ii.   1
----congestion  of the,  in the
  ducts.......................ii. 841
----congestion, symptoms of.. ii. 842
--------treatment of.........ii. 843
     congestion of the, in warm
   ■ chemical analysis of the, in
 scurvy.....................ii. 843
— chemical  constitution  of,
 healthy.................... i 212
— coagulation of............ i 212
— coagulation and appearan.
 cea........................1045,6
climates....................ii. 834----coagulation of, in inflam-
— ducts, spasm of..........ii.   7;  mation.....................ii. 432
— excessive secretion ofthe.. ii. 836----conditions of, complicating
— morbid secretion of.......ii. 637j  disease.....................1048-9
   morbid states of........ii. 837, 8----• congestions of, described .. i. 4117
----treatment of morbid states
  ofthe......................ii. 837
--------of inspissated states of ii   3
----diminished secretion of.... ii. 835
--------treatment of........ii. 836
Biliary  apparatus, appearances
  of, after jaundice............ii. 344
Biliary concretions described... i. 458
----organs, torpor of.........ii 835
—------treatment of........ii 836
Bismuth, sub-nitrate of, poison-
  ing by .....................   3S4
Bitters and tonics in phthisis...  1268
Bladder, abnormities of the ....  1313
----diseases of, Bibliog. <t- Ref.  1313
----inflammation of the urina-
  ry.   See, also, Cystitis......1300-9
----inflammation of the perito-
  neal coat, treatment of.....1311, 12
---irritability of, defined.....  1293
     irritable, causes of........  1293
          ymptoms of......... i
  -------the removal of.......  1142
  ■— considered with  relation to
  the pulse..................i 596,8
  — organic constitution of___  1041
  — the contamination of___1042-50
  — its contamination from ab-
  sorption of morbid matters... i  29
----contamination of, in dis-
  eases.......................i 283
  — contamination of the, di-
  rectly  by  causes of fever ex-
  amined....................i.
  — contamination of, by vege-
  table,  animal,  and morbid
  matters.................... i 244
  — contamination of, its treat-
  ment.......................  1417
  — sources  of  its contamina-
  tion.......................1042-50
     deficiencv of.   See Anaemia i 219
1063
--------diagnosis of.........   1294----depuration of, by the kid
         treatment of.........1294,5
  — malignant and other forma-
  tions of.....................   1312
----symptoms of malignant dis-
  ease of.....................   1312
  — treatment of malignant dis-
  ease........................   1312
  neys and other emunctories,
  necessary to health........i 238-40
  — impaired depuration of, a
  cause of phthisis............  1239
----necessity for the depuration
  of.........................i 137,9
  — determination of, by art .. i 218 
BL
INDEX.
BR          1577
Blood, expectoration  of,  as a
  siSa........................1093,4
----extravasation of, in tuber-
  culated lungs...............  1216
----exuberance  of.........''' j. 214
----indications and signs of a
  Vitiated state of the......... i. 231
----infiltrated into  the  sub-
  stance of the heart..........ii. 250
,----influence  of the  states of,
  on irritability...............ii. 701
----direct influence of the gan-
  glial or the organic nerves on
  the.......................i 244,6
----influence  of  the  organic
  nervous system on.......1046, 54, 5
----influence on the, by muscu-
  lar contractions.............  1020
----local determination of..... i 217
----loss of, in diseases  of  de-
  pressed vital power.......... i. 225
----effects of small but often re-
  peated losses of............. i 224
----remote  effects of large loss
  of.......................... i. 223
----excessive loss  of, in disease i 224
---- excessive loss of, in diseases
  of excitement............... i. 224
----metamorphosis and waste
  of its globules...............1044-5
----mode of avoiding excessive
  loss of, in disease........... i 224
—■.— morbid effects of its loss in
  disease..................... i 224
----morbid effects of its loss in
  health..................... i. 222
----connexion of morbid actions
  and  organic   lesions, with
  states of the................i.
----morbid conditions of, com-
  plicating disease............  1047
----morbid matters in the, caus-
  ing fibrinous concretions in the
  cavities of the heart.........ii. 255
--------signs of.............ii. 256
--------treatment and progno-
  sis of.......................ii. 256
----passage of morbid matters
  into the.................... i 246
----morbid states of the, conse-
  quent upon diseased kidneys
  in scarlet fever.............    733
----morbid  states  of the, to be
  corrected or counteracted... .1140,1
----the effects of morbid states
  of, on the ganglial nerves.. .i. 244,6
----illustrations of its morbid
  states...................... i 240
----prevention of morbid states
  ofthe......................  i 250
----removal of morbid states of,
  by depurants, &c..........i 249,50
----of the organic  nervous in-
  fluence on the..............  i 244
----of its organization........   1041
----signs furnished by........   1087
----states of, in health.......i 211
----of the states of the, in acute
  Bthenic inflammation........ii. 431
----of the  states  of the,  in
  phthisis....................   1209
----of the quantity of, with ref-
  erence to the area of the blood-
  vessels .....................   1046
----states of the, in rheuma-
  tism .......................675,6
----states of, in the vessels___i. 211
----Symptoms of fulness of.... i 215
----therapeutical indications for
  diseased states of............  i. 248
----treatment of  buffy  states
  of..........................i 248
----treatment  of, with loose co-
  agulum ....................  i 248
----treatment of the effects  of _
  large losses of................  i 226
--------of exhaustion  from
  losses of.................... l 226
________of reaction after losses
  0f..........................  i. 226
____urea  and its combinations
  in the, productive of disease i 238-40
____and  its elements  in the
  urine.......................  133E"
Blood or its elements in urine,
  pathological relations of.....  1336
Blood-globules, their presence in
  urine.......................  1336
Blood-letting, best mode of con-
  ducting .................... i. 224
----in fever.................j. 1072
----in inflammations.........ii. 471
----cautions as to, for spasms
  and convulsions.............   931
Blood-vessels, alterations of those
  of tlie heart.................a. 260
----effects of cold on.......... i. 420
  — influence  of   the  organic
  nerves upon.............1040,54,5
  — of want of accord between
  their area and the amount of
  blood in them...............  1046
Blood-vessels,   and lymphatics,
  diseases of, causing dropsy... i 697
Blue-disease described.  See Cy-
  anosis ...................... i 251
----noticed..................ii. 261
Bodies recently dead of certain
  diseases impart   a  dangerous
  poison.....................437-444
Body, signs of disease furnished
  by its surface..............1059,
----position of, influences  the
  pulse..................___   601
Boils, description of...........i 1249
Bolus Anodynus.........F. 24. Ap. 6
----Ante Spasmos......F. 25. Ap. 6
----Arnicae.............F. 26. Ap.
----Bismuthse Comp.....F. 27. Ap. 6
----Cambogiae..........F. 28. Ap. 6
----Camphorae.........F. 29. Ap. 6
----Camphorse Composit.
                       F. 786.  Ap. 29
----Camphorse et Hyoscyami
                       F. 787.  Ap, 29
----Catechu..........F. 788.  Ap. "
----Catechu Thebaicus.. F. 30. Ap. 6
----Ferri...............F. 31. Ap.
---GuaiaciAmmoniati..F. 32. Ap. 6
---Guaiaci Comp.......F. 33. Ap. 6
   - Kino Thebaiacus___F. 34. Ap. 6
---Moschi Compositus. .F. 35. Ap. 6
  ------et Camphorae. F. 789.  Ap. 29
  — Nitro - Camphoratus   cum
  Opio..................F. 36. Ap. 6
  — Rhei Compositus___F. 37. Ap. 6
  — Sedativus..........F. 38. Ap. 6
  — Sudorem ciens......F. 39. Ap. 6
  — Valerianae cum Ferro F. 40. Ap. 6
Bone, formation of new.......ii.  1056
   - necrosis or mortification of ii. 1055
Bones and periosteum, syphilitic
  disease of..................ii. 1471
Bones, caries of...............ii. 1055
  — of the cranium, lesions of
  the..................N......i 509
  — erosion  of...............ii. 1057
  — foreign bodies, &c.......ii. 1060
  — fragility of..............ii. 1057
  — hydatids in.............ii. 1000
  -------prognosis of........ii. 1060
  —■----symptoms of........ii. 1060
  -------treatment of........ii. 1060
  — inflammation  of.  See, also,
  Osteitis...................ii. 1053
  — scrofulous inflammation of ii. 1057
  — organic lesions, non-inflam-
  matory.................... ii. 1057
  — malignant tumour of____ii. 1059
  — symptoms of malignant tu-
  mour of...................ii. 1059
  — softening of.............ii. 1057
  — treatment of softening of.  ii. 1057
----suppuration of..........•  ii. 1055
  — tubercular formations in .  ii. 1059
  — symptoms of tubercular for-_
  mations in.................ii. 1058
  — syphilitic disease of the....  1471
  — tumour of...............ii 1054
  — sanguineous tumours of.. ii. 1058
  — ulceration of............  ii. 1055
Bothriocephali,  systematic  de-
  scription of.................  1526
Bothriocephalus latus, described.
  See, also, Taenia  lata........  1526
----Sj/nonyrnes of............  1526
----treatment of.............  1547
Boyhood, remarks  on.......... i 49
Brain, reflex actions of........    41
----atrophy of the............  i 270
  — Bibliog. and Refer,  to its
  diseases, <fcc.................  i 295
  — physical conditions of the,
  and spinal cord.............    37
  — congestion of, appearances,
  terminations,  and  complica-
  tions .......................  i 27S
  — congestion of, treatment..  i 279
  — concussion of, causing gen-
  eral palsy..................    20
----determination  of blood to,
  treatment of................  i 278
  — ecchymosis of the.........  i 277
----haemorrhage in the.......  i 268
   - hardening of the.........  i. 271
----hypertrophy and atrophy of i 209
----imperfect  development  of
  the........................  i 270
  — induration of, symptoms of i. 273
  — inflammation of, definition  i. 279
  — inflammation of its  mem-
  branes.   See Meningitis.....i 2S0
  — inflammation of the  mem-
  branes and substance of—En-
  cephalitis...................  i. 2S3
  — inflammation  of  its  sub-
  stance .....................  i 261
  — inflammation  of  its  sub-
  stance.   See,  also, Cephalitis
  vel Cerebritis...............  i 282
  — laceration of the..........  i. 277
  — lesions of the, in insanity
                          ii.  549-552
  — lesions of its membranes ..  i 254
  — lesions of the  sinuses and
  vessels of...................  i. 260
  — and  its  membranes, dis-
  eases of....................  i 253
  — the  organization of,  influ-
  encing the mind............ii. 578
  — and organs  of sense, mor-
  bid sympathies of............   1040
  — rupture of the............  i 277
  — softening of...........i. 265,292
  -------its causes...........  i 267
  -------symptoms...........  i 292
  -------treatment...........i. 294
----pulpy softening of........  i. 266
----sphacelation of...........  i. 265
----structural changes of the
  substance of................  i. 261
----suppuration of...........  i 262
----tubercles in the..........  i 273
----tumours in the...........  i. 214
----ulceration of the..........  i 265
----vascular determination to.  i 278
Breast-pang described.........  i. 70
Bronchi,  alterations of their cal-
  ibre........................  i 300
----alterations of  the  fibrous,
  muscular,  and cartilaginous
  structures of................  i 299
----of their mucous membrane  i. 296
----of the secretions of the___i 298
----Bibliog. and Refer, to dis-
  eases of the.................  i 323
----congestion of the.........  i. 301
----treatment of congestion of.  i 302
----dilatation of the..........  i 321
----diseases of the...........  i 296
----haemorrhage from........  i. 299
----inflammation of.  See, also,
  Bronchitis..................  i 302
----perforation from  tubercu-
  losis of the glands of........1221-22
----ulceration of.............  i 321
----treatment of ulceration  of
  the........................  i 321
Bronchial flux, diagnosis of. See
  Bronchorrhoea..............  i 321
Bronchitis, acute, described___i. 302
----diagnosis of acute.........i 308
----prognosis of acute........  i 310
----treatment  of  the   acute
  states of....................  i 311
----acute, morbid appearances
  of..........................  i 308
----asthenic, described.......  i 304
----catarrhal or mild.........i. 303
----chronic, described........i 307
--------the several  means of
  cure for....................i 317 
1578          BR                              INDEX.                              CA
Bronchitis, chronic, diagnosis of i. 308 Caecum, laceration of the.......  L S35:Canccr of the stomach,  symp-
--------treatment of......... i 317 Calculi, biliary, described......1. 45S  toms of........... ........■  ■}"«
                                                                            -----treatment of........1014,16
                                                                             treatment of............. L 340
                                                                             various  means and  pre-
                                                                          scriptions for..............i 341-4
   ■ complications of.......... i 306
—- complicated with pneumo-
 nia.  ........................"• ss,<
— complicating phthisis.....  1211
____its complications, treatment
  of.......:.................. i. 320
____its complicated states, treat-
  ment of.................... i 315
____tlie means of cure of...... i 312
____definition of.............. i. 302
____inhalations for........... i. 313
----treatment of, in the third
 intestinal, origin of....... i. 464,-
 in prostate gland.........   511 ■
 diagnosis of..............   512
■ treatment of.............   512
renal, diagnosis of........  1350----of the womb, forms of, de
         symptoms of.........   1349
  -------symptoms of their pas-
  sage to the bladder..........   1350
  -------treatment of........   1352
  -------treatment  of the pas-
  sage of, to the bladder.......   1352
----vesical, treatment of......   1352
stage of phthisis............  1260----urinary, age and sex as dis-
     prescriptions for.......... i. 311
     regimen and diet for......i 320
----sub-acute, described......i. 306
----prognosis of the  sub-acute
  and chronic................. i 310
----terminations of........... i 305
----true or sthenic........... i. 303
Bronchocele.  Bibliog. and Ref. i 325
----causes  and morbid rela-
  tions of..................... i 323
----defined.................. i 323
----diagnosis of.............. i 324
—— treatment of............. i. 324
Broncho-pneumonia described.. ii. 887
----treatment of.............ii 897
Bronchorrcea defined.......... i. 327
----treatment of............. i 322
Bronze tint  of skin a sign of dis-
  eased supra-renal bodies.....  1570
Brood of Taenia described......  1525
Brucia,  poisoning by..........   414
Bryonia dioica, poisoning by...   3S9
Buboes  of septic pestilence  no-
  ticed .......................   222
Bubo, syphilitic, described.....  1466
----diagnosis of..............  1466
----treatment of.............  1485
----treatment of indolent.....  1485
Bulimia, described............ i 120
Bullae, definition of............i 326
Burial places productive of pes
  tilence and disease..........   106
Burying places, restrictions re-
  specting, advised............   265

                 C.
Cachexia Africana, noticed ... .i 1030
----of  parents  productive  of
  scrofula....................   802
----syphilitic, described......  1471
----verminous, described.....  1540
Cachexy,  defined.............. i. 326
----symptoms of............. i 326
----treatment of............. i 326
----African, causes of.........i 328
--------defined.............. i. 327
--------described........... i. 327
--------treatment of.........i 327
----mercurial, described......   454
Cacodemonia described........ii. 525
Caecum, acute inflammation of. i 331
----symptoms of acute inflam-
  mation  of................... i 332
----treatment of acute inflam-
  mation of................... i 335
----chronic inflammation of the i. 333
----symptoms of chronic inflam-
  mation of................... i. 334
----terminations and complica-
  tions  of chronic inflammation
  of.......................... i. 334
----its diseases............... i 328
----symptoms of its disorders.. i. 330
----treatment of its disordered
  functions...................  i. 331
----prognosis of its diseases ... i 335
----disordered functions of.... i 329
----pathology of its disorders..  i 329
----inflammations of, in con
  nexion with colitis..........ii 665
----causes of its inflammations  i 332
----treatment of other  inflam-
  matory diseases of...........i 336
----inflammation  of its appen-
  dix ........................i 332
----treatment  of inflammation
  of its appendix..............i. 336
----inflammation  of its sur-
  rounding tissues............i. 333
  posing to...................   1345
----urinary, Bibliog. and Ref.   1355
----diagnosis of, in the bladder   1351
----symptoms of, in the bladder   1351
----causes of.................1345,9
  — of  climate,  locality, and
  race, as predisposing to......1346, 7
  — mode of ascertaining their
  composition.................   1340
  — chemical composition of...   1340
  — or concretions in urine, de-
  scribed ....................1339-45
  — urinary, from constitution.
  al and vital conditions.......   1347
  — urinary, diagnosis of......   1351
  — of  diet  and  regimen  as
  causes of...................   1347
  — from disease of urinary pas-
  sages.......................   1347
  — from foreign bodies.......   1347
  — forms of.................   1339
  — of their growth and origin 1348,9
  — habits of living which pre-
  dispose  to..................   1345
  — inferences as to their for.
  mation.....................   1348
  — treatment of, in kidneys ..   1352
----from mal-assimilation, <fec.   1347
  — from  metamorphosis and
  waste of tissues.............   1347
  — origin and growth of......1348,9
  — size and weight of........   1339
  — surface  and structure of,
  described...................   1340
  — symptoms of.............   1351
Calculous concretions, alvine...  i. 463
Calculus,  alternating, described  1343
----ammoniaco-magnesian phos-
  phate, described............   1342
  — carbonate of lime, described  1343
  scribed.....................140'l-5
Cancer-cell, described.........  772,'.'
Cancer uteri, causes of the.....   1 mo
     symptoms of, described ...   1405
     treatment of.............   1407
Cancrum  oris, described.......   1022
Cantharides, poisoning by, symp-
  toms of.....................
  — treatment of.............
Capsules,   supra-renal,  disease
  of.  See, also, supra-renal bod-
450
451
                                1572
Carbonic acid gas,  appearances
  of tlie body from poisoning by 462,3
  — treatment of poisoning by .   463
  — deleterious operation of ...   461
Carbonic  oxide  gas,  poisoning
  by.........................   463
Carbuncle, Bibliog. and Refer.L  1253
----causes of................i  1252
----complicated  with internal
  disease.....................i.  1253
----description and progress of i.  1251
----diagnosis of..............i.  1252
----treatment of.............i  1252
----local treatment of........i  1252
Carbuncles of septic pestilence . 222,3
Carburetted hydrogen gases, poi-
  soning by..................   463
----appearances  after  death,
  from.......................   464
----poisoning by, treatment of  464
Carcinoma,  or  second stage of
  cancer..................... i 338
----of the heart...............ii. 254
----means and prescriptions for i. 340
----of the oesophagus........ii  1047
----of the pancreas...........     9
Carcinomatous tumours  of the
  liver described............ii. 871,2
Cardialgia, symptoms of.......ii. 380
Carditis, causes of.............ii 224
----complications of..........ii 227
----diagnosis of..............ii. 227
—— internal in children.......ii. 233
----internal, symptoms of.....ii. 211
--------treatment of.........ii. 229
                                    progress and duration of.. ii. 228
cystic oxide, described....  1342]Carditis vera, characters of___ii 220
fibrinous, described.......  1343----diagnosis of..............ii 220
 fusible, described.........  1342
■ oxalate of lime, described.  1342
■ structural lesions in......ii. 220
 symptoms of.............ii 223
■ phosphate of lime, described  13421 Cartilage-cell, described.......ii. 773
----urate of ammonia, described  1341
  — uric acid, described.......   1340
  — xanthic, or uric oxide, de-
  scribed.....................   1342
Calomel for worms............   1560
Caltha palustris, poisoning by..    389
Camboge, poisoning by........    391
     for worms................1560-6
Camphor, in cases of insanity .. ii. 613
     when  useful in phthisis ...   1248
     poisoning by.............    408
     ----treatment 6f.........    409
Canal, digestive, morbid changes
  of the......................  L 619
Cancer, Bibliog. and Refer.....  L 344
  — causes of.................  i 339
  — definition of..............  i. 337
  — description of............  i. 337
  — diagnosis of..............  i 338
  — epithelial,  of the  uterus,
  described...................   1404
  — feigned..................i. 1030
  — fungoid, or medullary ofthe
  uterus......................   1402
  — of the liver...............ii 871
  — microscopic diagnosis of...    790
  — prognosis of..............    791
  — question as to its contagion
  considered..................  785,6
  — scirrhous of the uterus___   1404
  — shown to be contagious in
  peculiar  circumstances......    785
  — of the stomach, causes and
  diagnosis of.................   1014
Cascarilla,  when of service  in
  phthisis....................  1269
Catalepsy, definition of........ i. 344
     described................ i 344
     feigned..................i 1030
     remarks on..............    42
     symptoms of............. i. 344
Cataleptic  ecstacy,  description
  of.......................... i.346
Cataleptic and ecstatic fits, Bib-
  liog. and Refer.............i. 349
----causes of................. i 348
----diagnosis of.............. i. 347
----termination of............ i 347
----treatment of............. i 348
Catamenia.   See, also, Menstru-
  ation.......................ii 959
----disordered,  in   connexion
  with rheumatism............   675
Cataphora, described.......... i. 454
Cataplasma Ioduretum...F. 41. Ap. 6
----Sinapeos Fortius ... .F. 42. Ap. 6
----   ----   Mitius.....F. 43. Ap. 6
Catarrh, Bibliog. and Refer. .. i 354
—— causes of................i 350
----complications of..........L 352
----definition of..............i 349
----epidemic.   See Influenza.. ii 4S9
----nature of................ i 352
----prescriptions for..........i. 353
----prognosis of.............. i 351
----symptoms of............. i.350
----treatment of............. i. 352
Catarrhus stomachalis......... i 350 
CA                              INDEX.                               CO           1579
Cathartics,  arrangement  and       Cerebrum, inflammation of the.
  enumeration of.............  1146;  See, also, Cerebritis......... i. 282
Causation of choleric pestilence
  considered..................118-37
----of disease ought to be made
  an object of study...........  1131
Cestoidea,  developmental  his-
  tory of.....................  1521
----sub-order of Platyelmia, de-
  scribed.....................  1519
----ofsuicide..............ii. 636-49 Chalybeates,  of their  use
Causes, the predisposing, to dis-      |   phthisis....................  1269
  ease........................ i 645 Chancre, description of........  1404
.----predisposing to insanity... ii. 555
----productive of insanity.....ii. 561
----recognition and removal of
  all,  requisite to the treatment
  of disease...................   1133
----acting on the several func-
  tions .......................  i. 651
Cautions required in ascertain-
  ing *he causes of vomiting ...   1506
Cavities of the heart, dilatation
  of..........................ii. 244]CharIatanryandimpostures,&c.,
________causes of............ii. 244   retard  therapeutical  knowl-
----of the lungs in phthisis de-         edge.......................
  scribed.....................  1194]Cheese, poisonous effects of ....
----serous, haemorrhage into .. ii. 250]Chelidonium  majus,  poisoning
     gangrenous, treatment of.   1485
----indurated or Hunterian...   14851
----sloughing................   I486
----urethral.................   1486
----varieties of, described___   1485
Changes of climate, diseases ben-
  efited by...................  i 411
----effects of.................  i. 404
Charcoal, when  useful in phthi-
  sis.........................   1268
    • tubercular, in  the lungs,
  their cicatrization...........  1219
----tubercular, in  the lungs,
  healing  processes   of,  de-
  scribed.....................  1219
----and vomicae  of the lungs,
  contents of, may be absorbed.  1219
Celibacy, a cause of phthisis and
•  how........................  1230
Cells,  forms  of,   in  morbid
  growths.................... 772-5
Cellular   tissue,   cedematous,
  hardening  of................ i. 362
    ■ diagnosis and prognosis  of
1130
 428
409
  by
Chest, deformities  of the,  de-
  scribed.....................  i. 367
--------their treatment......i. 368
----examination of the.......  i 365
----inspection of.............  i. 365
----signs furnished by........   10S8
Chicken-pox, conoidal.........  i. 370
----definition of.  See Varicella i 369
----diagnosis of..............  i. 370
----globular, described.......  i 370
----lenticular, described......i. 370
----treatment of.............  i. 371
Childhood, remarks respecting.   i 49
  indurations of..............  i 364 Children, convulsions of....... i. 4S4
---- alterations of.............  i 354'----paralysis of..............  24,5
----Bibliography and Refer...  i. 365---■ acute peritonitis in.......    82
----causes of indurations of ...  i. 364----of phthisis in............  1207
----induration of, definition of.  i. 362----spastic convulsions of..... i. 485
---- pathology of induration of      |----of syphilis in.............  1472
  the........................  i 363;Chin-cough.  See, also, Hooping-
---- treatment  of  indurations         cough......................ii. 273
  of..........................  i. 364 Chlorate of potash, effects of...   452
____ causes  of diffusive inflam-        Chlorides,  several  advised  in
  mation of..................  i. 356  scrofula....................   832
                                    | Chlorine and the chlorides, pois
                                 735:  oningby.:.................   451
                                    1--------treatment of.........   451
  fusive inflammation of.......i 360 Chloroform and chloric ether, of
 — diagnosis and complications       I  their anaesthetic effects......   464
  of diffusive inflammation of..  L 358, Chlorosis, Ribliog. and Refer... i. 375
 — diffusive inflammation  of,        ----causes of................i. 370
  definition  of................  i 355----definition of............. i. 371
 — morbid changes from diffu-        ----diagnosis of.............. i 372
  sive inflammation of.........  i 357----history and symptoms---i. 372
 ___ pathological inferences  as       ]----means prescribed for......i 374
  to diffusive inflammation of..  i. 359,----pathology of............. i 373
   diffusive inflammation of,
complicating scarlet fever ...
   curative  treatment of dif-
                                    ----prognosis of.............. i 373
                                    ----treatment of............. i 374
                                    Cholera, autumnal, definition of i. 375
                                    ----Bibliog. and Refer.......i 382
                                    ----  causes and  pathological
                                      states of.................... i. 379
                                    ----diagnosis of, and corrosive
                                      poisons.....................   366
                                    ----diagnosis between, and pes-
                                      tilential cholera............. i. 379
                                    ----history and symptoms of.. i. 375
                                    ----medicines prescribed for .. i 3S1
Cephalitis, definition of........  i. 282]----treatment of............. i 380
____symptoms of.............  i. 2S2 Cholera biliosa, causes and states _
Cerebellum, lesions of, occasion-         of.......................... i- 375
  ing paralysis...............     37----defined..................1-375
Cerebral congestion, described .  i. 278,— symptoms of............. ;. 377
---- prognosis  of diffusive in-
  flammation of the...........  i. 360
---- prophylactic treatment of
  diffusive inflammation of ....  i 360
---- symptoms of diffusive in-
  flammation of...............  i 356
----terminations of diffusive in-
  flammation of...............  i. 357
---- treatment of  diffusive in-
  flammation of...............  i 360
Cephalagia, described. See, also,
  Headache................ii 167-81
    ■ diseases, the relations of, to
  cachectic nephritis..........ii. 745
----functions, treatment of their
  disorders in fever........... i. 1081
----organs, connexions subsist-
  ing between, and the mind. ii. 5S7,90
Cerebral plethora, causes  and
  symptoms of................ }• 273
Cerebritis, description of......i 261
----general and partial....... i 282
Cerebro-spinal  affections con-
  nected with gastro-enteritis.. ii 30
____  fluid  in  connexion  with
  palsy.....................•    3S
----meningitis, symptoms  and    ^
  appearances of..............   9«>S
Cholera flatulenta, causes of...  i. 377
----defined and described.....  i. 377
Cholera   spasmodica,  causes,
  symptoms, &c, of...........  i. 378
----defined and described.....i. 378
Choleric  fever of infants, causes
  and symptoms of............i. 382
----of infants defined.........  i. 382
----prophylactic and regimenal
  means for..................  j- 384
----treatment of.............  i 383
Cholocystitis, defined..........   ii. 6
Chorea, affections resembling..  i. 390
----appearances after death...  i 3SS
----Bibliog. and Refer.......j. 396
   - the  causes of.,...........  i 389
Chorea, complications and term-
  inations of..................  i 387
----defined..................  i 387
  — indications of cure in .---  i 392
  — diagnosis and prognosis of.  i 388
  — history of medicines, rec-
  ommended for.its cure.......  i. 392
  — history and symptoms of..  i. 387
  — nature of................  i. 3S9
  — prescriptions for..........  i. 395
  — in connection  with rheu-
  matism ....................   674
  — treatment of.............  i 392
  — treatment advised  by the
  author.....................  i 393
  — treatment of complicated
  and  irregular states.........  i 395
  — torsk and cod-liver  oil first
  advised for, by the author...  i 393
Choi'oid plexus, changes in ....  i 259
Choroiditis, symptoms and treat-
  ment of....................i. 1020
Chronic, acceptation of the word i. 683
Chylifaction, disorders of......i. 622
Chymifaction, disorders  of.___  i. 622
Cicuta virosa, poisoning  by___    465
Cinchona, of its use in phthisis.   1269
Circulation affected by muscular
  contractions................   1112
  — conditions of, complicating
  disease....................1049, 50
  — influence of  the   organic
  nervous system  on the.....1040-52
Circumcision,  sanitary  import-
  ance of this rite.............    486
Circumstances of life as predis-
  posing to disease............  i. 647
  — modifying the form, dura-
  tion, and termination of dis-
  ease .......................  i. 687
Cirrhosis of the liver..........ii. 869
Classification of the affections
  and manifestations of mind ..  ii. 512
  — of infectious agents.......ii. 402
  — of diseases of the skin___868-874
  — of disorders of the mind. ii. 510-13
  — of haemorrhages..........   ii. 79
  — of lunatics required.......ii. 624
  — of states of insanity, by the
  author.....................ii. 512
  —. of therapeutical agents ... 1144-8
  — of poisons...............  4S2-3
  — synopsis of...............    510
  — of healthy and morbid sym-
  pathies ...................1029,30
Climacteric decay, causes of...  i. 397
----definition of.............  i. 396
----symptoms of.............  i. 396
----treatment of.............  i. 397
----disease, Bibliog. and Refer, i. 39S
Climate, in the North Atlantic . i. 414
----Ribliog. and Refer........ i. 418
---- as regards  the causation
  and cure of diseases......... i 404
----of change from a cold or a
  temperate to a warm........ i. 409
----eflects produced by change
  of.......................... i. 409
----of change from a warm to a
  cold or temperate........... i. 410
----as regards the food of man i. 407
---- in relation to preventing
  diseases.................... i. 404
---- the  elements of, or condi-
  tions constituting...........  i. 39S
----of certain places in England i 411
----as influencing the food and
  varieties of the species.......  i 407
----changes of, as a means of
  cure.......................  i. 409
----general view of........... i 401
---- and localities disposing to
  phthisis...................1232-37
----the physical relations  of...  i 398
----as a remedial agent......i 411
----and season, influence of, on
  insanity....................ii. 559
----as a therapeutical agent ..   1132
----in relation to the varieties
  of the human species........  i 404
Clothing proper for the insane .  ii. 594
Coagulation and appearances of
  the blood..................1045, 6
Coal-gas, poisoning by.........   463 
1580          CO                              INDEX.                               CO
Coal-gas,  poisoning  by, treat-       I Coma, diagnosis, duration, and       Congestion, treatment of ..... .  i 470
  mcnt of....................   464  tenuinations...............  i. 454 Conium, symptoms of poisoning
Coast, south of Kngiand, climate       ----pathology of.............  i. 4.r>r>   by.........................    405
  0f               ..........i. 412----profundum, described.....  i 454----use of, in phthisis........   1269
Coeciiln's Indicus, poisoning by.   414----prognosis of..............  i. 455 Conjunctiva,  inflammation of.
Colchicum  autumnale,  poison-       ----somnolentum, described ..  i 454   See, also, Conjunctivitis.....i. 9S6
  m„ by        ..............   423----symptomatic.............  i 455 Conjunctivitis, symptoms of ...  i 9S7
__ __'treatment of.........   424----treatment of.............  i 457----diagnosis of..............  i 987
Cold Bibliog. and l.efer....... i. 425,----varieties and symptoms of.  i 453----tenuinations of...........  i 9*7
____'causation of disease by___i. 422'----various states of, treatment      !----treatment of.............  i. 9s7
____as causing  and curing dis-     .  I  of..........................  i. 457 Connexion  of gastro - enteritis
  eases...................... i 419 Coma vigil described..........  i 453,   with cerebro-spinal affections,   ii. 30
                                                                            - subsisting between the mind
changes after death from..  i. 422
Communications  between  the
Complications of  disease from
  morbid state of blood........   1049
----of diseases, their sources or
  causes examined............   1033
      circumstances  favouring
  the effects of................ i 422
---- counteraction  of its ill ef-
  fects....................... i. 423
----death by.......*......... i. 420
----effects produced by....... i 419
----effects of, in various states
  of the system............... i 421
----effects of, on the brain, or-
  gans of sense, &c............ i. 421
----physiological and patholog-
  ical effects of............... i. 419]Composition, chemical,  of urin-
----prevention of its ill effects, i 423
----the remedial action of .... i 423
----stage in fevers...........i 1046
----treatment of its ill effects.. i 423
Cold ingesta, treatment of their
  bad effects.................. i 423
Colic and ileus,  Bibliog.  and
  sides of the heart described .. ii. 260]   and cerebral organs.........ii. 573
----symptoms of.............ii. 261 Consecutive causes of diseases..  i. 657
Compartments of the heart, signs      [Consensus nervorum, noticed ..  1027
  of their hypertrophy.........ii. 241 Conserva Acetosellae.....F. 46. Ap. 6
   of, from lesions of the heart  1050
   of scarlet fever, treatment
of.....................  ...759,61
Consistence,  alterations  of,
  the heart...................ii. 249
--------treatment of.........ii 250
Constipation, Bibliog. and Refer,  i 479
  Refer......................  i 44S
Colic, definition of............  i 426 —
----the diagnosis and prognosis
  of..........................  i 436
----divisions of its species___i 426
----after parturition.........   i 45
----remarks on its pathology..  i 435
                                         causes of................. i 472
                                      — consequences and termina-
                                       tions of..................... j. 474
                                     ----definition of............. i. 471
  ary calculi.........'.........   1340----duration, <fec............. i. 471
----mode of ascertaining the..   1340----lesions occasioning.......i. 473
Concretions, biliary, Bibliog. and      I----means and prescriptions for i 475
  Refer......................  i 463'-— pathology of............. i 471
--------causes of............i. 461----during pregnancy........   502
--------composition and situa-      i---------treatment of.........   502
  tion of.....................  i. 459'----prescriptions for.......... i. 475
definition of.........  i. 45S ■
description of........  i. 45S ■
      from  morbid  secretion
  treatment of................  i 438
----species of, described......i. 426
----treatment of.............  i. 436
----bilious, pathology of......  i. 429
----bilious, treatment........  i 437
Colic, complicated states of___i 434
.----complicated, treatment of.  i 446
----  from  injurious  ingesta,
  treatment of................  i 437
---- from obstruction, descrip-
  tion of.....................  i. 432
----from obstruction, treatment
  of..........................  i.442
----simple, defined...........  i 427'
----treatment of its simple or
  functional form.............  i. 436,
----sympathetic or symptomat-
  ic forms of..................  i 434]
----sj-mptomatic, treatment of  i. 446,
Colic, lead, definition of.......  i. 430
                                         prognosis of.............. i 475
                                         synopsis of its treatment.. i. 478
      — diagnosis and progno-      |----treatment of............. i 475
  sis of.......................  i. 462----treatment of obstinate___i 476
--------lesions produced by ..  i 460----prolonged, treatment of... i 476
      — symptoms of.........  i. 459 Constitution and  habit of body
         symptoms of their pas-      |   as predisposing  to disease___i 647
 sage.......................  i 460.Constitution, effects of irritation
-------treatment of the pas-         upon.....................ii. 706,7
 sage of.....................  i 462----prevailing epidemic, should
-------treatment of........  i 462J  be studied..................  1133
— calcareous, expectoration of  1094 Constrained positions cause dis-
— expectorated in phthisis ..   12191  ease....................... i 144
— fatty, noticed............  i. 466 Constriction of aorta..........  i 88
— feigning of...............i 1036----of arteries................ i 132
— fibrinous, in the cavities of      Consumption, pulmonary,  diet
 the  heart...................  i 255  advised in..................  1284
— heterogeneous............  i 466----means of prevention advised
   ■ intestinal,  Bibliog.   and       \  for.........................  1250
 Refer......................  i. 467
--------causes of............  i. 465
-------definition of.........  i. 463
-------local effects of.......i. 465
-------origin and composition
 of..........................  i. 464
-------symptoms of........  i 465
-------treatment of........i 466
    in the pancreas
     pathology of............. i. 430;----in tuberculated lungs, their
----remedies advised for......i 439;  formation..................   1219
----symptoms of............. i 430,----urinary.  See, also, Calculi,
   treatment of............. i. 439|
   treatment of the sequelae
of.......................... L 442]
urinary...................1339-49
   or calculi in urine described
                           1339-45
Colica biliosa, described.......  i. 428[Concussion ofthe brain.
----cibaria, described........i. 427
----constricta, treatment of...  i. 442
----hepatica, described.......  i. 428
----saturnina, pathology of...  i 430
Colitis, acute, symptoms of___ii. 666
----chronic, symptoms of.....ii 666
Colloid, or glue-like substance,
  noticed.....................  i. 676
Colloid, or gum-cancer, or glue-
  cancer, described...........    779
Colon, Bibliog. and Refer.....i 453
----its diseases..............  i. 449
----flatulent distension of.___  i. 449
----faecal collections in.......i 449
—— inflammation of. See, also,
  Colitis....................ii.  665-7
----. over-distension of........  i 450
----torpor of, defined.........  i. 449
--------effects of.. v.........  i 450
---------treatment...........  i 451
----unnatural positions of.....  i 452
Colour of the blood, changes in.   1045
20
                                    Conditions or states, pathologic-
                                      al, must be studied in all cases  1133
                                    ----requisite for  paracentesis
                                      thoracis....................   332
                                    Condylomata, described.......  1467
                                    Confectio Menthse Viridis.F. 44. Ap. 6
                                    ----Sennae Comp........F. 45. Ap. 6
                                    Confinement, causing disease .. i 13'
                                    Congestion, the  accession and
                                      causes of................... i. 468
                                    ----appearances of  congested
                                      parts....................... i 469
                                    ----Ribliog. and Refer........ i 471
                                    ----of blood..................i. 467
                                    ----of blood the removal of ...  1142
                                    ----of the brain, symptoms and
                                      causes of................... i 278
                                    ----of the bronchi............ i. 301
                                    ----consequences and termina-
                                      tions of.................... i 469
                                    ----doctrine of, in  fever exam-
                                      ined .......................i. 1062
     changes of, in the skin.. 1059, Go—:— of the mamma...........ii. 933
Column, spinal, diseases of.....    933'----ofthe venous sinuses of the
Coma, Bibliog. and Refer...... i 45m  vertebrae, effects of..........    40
----complicating scarlet fever.    7361----symptoms of............. i 469
Coma, definition of............ i 4531----textures most liable to____i 470
----remarks on  the remedies
   used in....................1267-77
---- pulmonary, the treatment
   of.........................1240-67
----treatment  advised  for by
   authors...................1240-50
----treatment  advised when it
   is threatened...............  1252
----treatment of its usual form  1252
----  tubercular.    See,  also,
   Phthisis.................1188-1285
Contagion.  See, also, Infection, ii. 401
----means which protect from, ii 417
---- manner in which the  sys-
   tem is invaded by it.........ii. 414
----morbid impression made by ii. 416
Contamination of blood,  sources
   of.........................1047-50
■---------and  structures  from
   absorption of morbid matters,  i 28
----of circulating fluids,  sources
   of........................1042-50
----syphilitic,  description  and
   diagnosis of................  1471
Contamination consequent upon
   phlebitis, treatment of.......  1450
Contaminations,    occasioning
   puerperal diseases...........53S-40
Contiguity and proximity of po-
   sition a cause  of sympathy...  1037
Continuity of surface a cause of
   sympathy...............1033, 1037
Contractility, cerebro-spinal, de-
   scribed.....................ii. 694
----  insensible  organic,  de-
   scribed.....................ii. 694
  — sensible organic, described ii. 694
    various grades of, described ii 694
Contractions of the cavities and
  orifices of the heart.........ii. 249
  — treatment of.............jj. 249
----of muscles,  effects of on the
  circulation.................  1112 
CO
INDEX.
DE          1581
 Contractions of muscles, effects
  of, on the blood.............  1113
 Contra-indications  of cure,  re-
  marks on...................  1113
 Convalescence from fever, symp-
  toms and stages............i 1048
 ----  ----  contingencies   and
  treatment of................i. 1083
 Convulsions, Bibliog. and Refer, i 505
 ----exciting causes of........ i. 491
 ----remote and efficient causes
  of......................... i. 490
 ----acute or spastic, of children i 4S5
 ----of children, diet  and  regi-
  men for.................... i. 501
 .----prevention of............ i. 500
 ----treatment of.............i. 49S
 -—■ treatment of symptomatic, i 499
 ----chronic, described........ i 483
 ----complications of..........i 488
 ----complicating scarlet fever.   736
 ----consequences and termina-
  tions of.................... i 489
 ----definition of.............i. 479
 ----diagnosis of.............. i. 489
 ----duration and recurrence of i 484
 ---- from exhaustion, haemor-
  rhage, &c, treatment of.___i. 495
 ----forms of.,............... i. 481
 ----general, described........ i 483
 ----general, indications of cure
  of.......................... i 492
 ----infantile, description of... i. 434
 ----their duration and recur-
  rence ...................... i 485
 .---the premonitory signs.....i. 485
 ----the treatment of......... i 498
 ----from irritation, treatment of i 495
 ----local, described.......... i. 482
 ----various means advised for. i 496
 ----modifications of.......... i 484
 ----pathology of.........:... i 492
 ----partial, described......... i 482
 ----during pregnancy........   504
 ----prevention  of the  parox-      j
  ysms of.................... i 495;
 ----puerperal................ i. 486
 ----modifications of puerperal, i. 487
 ----puerperal, prevention of .. i 504
 ----puerperal, remedies advised
  far......................... i 503
 ----puerperal, the premonitory
  symptoms.................. i 486
 ----puerperal, treatment of... i 502
 --------regimen for.......... i 498
 --------symptoms of......... i. 4S7
 ----remedies for.............. i. 503
 ----symptomatic states of.....i 4S7
 ----tonic, described.......... i 483
 --------treatment of......... i 492
 Convulsive disorders resembling
  chorea..................... i 390
 Copper, poisoning by its prepa-
  rations, &c..................   8S5
 ----treatment...............   385
 ----compounds  and  prepara-
  tions of, poisoning by........   433
 Copper vessels, poisoning by...   433
 Cord, spinal, causes of its dis-
  eases ...................... 935-8
 Cornea, inflammation of.  See,
  also, Corneitis...............i 1013
 Comeitis acutus, described.....i 1014
 ----scrofulous, described......i. 1014
 ----sub-acutus et chronicus, de-
  scribed .....................i 1014
 Corrodents, mineral and vegeta-
  ble.........................  1145
 Corrosive  sublimate, of its u-e in
  syphilis.................... _ 1486
 Costiveness of bowels.......... i 471
 Cough, Bibliog. and Refer.---i 508
 ----causes of................. i 506
 ----d finition of.............. i 506
 ----dry, described........;  • ■  • i 506
 ----humid, described......... i 507
 ----remedies for.............. i- 507
 ----as a symptom of phthisis ..  1199
 ----idiopathic, treatment of... i. 507
----symptomatic, treatment of i 507
----treatment   of,  in  second
  stage of phthisis.............  125S
Countenance,  signs of disease
  furnished by...............1057,59
Cow-pox, complications of......   1419iCysticercus cellulosa, symptoms
----definai and described.  See,         produced by................   1530
  also, Vaccination............   14141----tenuicollis, systematic and
----inoculated...............   1417   general description of........   1532
----protective influence of___   1421,----various species of, noticed .   1525
«---regular—inoculated.......   1414iCystine, indications  of, cure for
     irregular or anomalous___   1415----the origin of.............
1327
1327
1326
1302
1303

1304
     pathological relations of...
Cystitis, acute, description of..
----duration  and terminations
  of..........................
----suppuration and gangrene
  from.......................
---------treatment of........   1310
---- appearances  after  death
  from.......................   1306
----causes of.................   1307
----chronic, described........   1304
---------terminations of......   1304
---------treatment of.........   1311
----complications of..........1305,6
----diagnosis of..............   1306
----primary seat of...........   1300
----prognosis of.............   1307
----synonymes of, and definition   1300
----treatment of.............   1310
----true seat of..............   1302
Cysts or vesicles, described .... ii. 295
----compound, described......ii 296
----description of,  containing
  hydatids...................ii. 293
----in the heart..............ii. 253
----in the liver..............ii. 872
Cytoblastema, of morbid growth
  described...................    771
D.
----nature of................   1416
----inferences respecting.....   1417
----recurrent................   1416
Cramps, as signs of disease___   1066
Cranial bones, diseases of the ..  i. 509
Cranioscopy or  phrenology, re-
  marks on, in relation to in-
  sanity.....................57S-584
Cranium, Billing, and Refer...  i 511
   - lesions of its bones........  i 509
----lesions of the envelopes of
  the........................  i 50S
Creosote, of its use in phthisis..   1269
Cretinism, Bibliog.  and Refer..  i 513
----causes of.................  i 512
----definition of..............  i 511
----description of............  i 511
----treatment of.............  i. 512
Crisis, Ribliog. and Refer.____i 519
----causes of.................  i. 516
----defined and described.....i. 513
----haemorrhagic.............  i 515
----manifestations of.........  i. 513
----pathological  remarks  re-
  specting....................  i. 513
----stage of, in fevers.........i 1047
Critical days, remarks on......i. 518
Croton Tiglium, poisoning by ..    389
Croup,  acutely inflammatory,
  described...................  i 523
----Bibliog. and Refer........  i 546'Daphne Gnidium and D. Meze-
----causes of.................  i 528]  reum, poisoning by..........   390
----complicated with exanthe-       .Day-blindness.  See,  also,  He-
  matous fevers...............  i. 5261  meralopia..................ii 1029
----complications of..........  i. 525 Deafness, Bibliog. and Refer. .. ii. 192
----curative treatment.......  i. 534 Deafness and dumbness........ii. 190
----definition of.............  i. 519, Deafness  from diseases of the
----diagnosis of..............  i. 527  Eustachian tube...........ii. 185,9
----diet and regimen in.......  i. 546!----treatment of.............ii. 1S6
----history of................  i 520 Deafness  from affection of the
----humid and spasmodic forms,       |  external ear................ii. 182
  treatment of................  i 538---------treatment of.........ii. 183
----modifications of..........  i 523----and deaf dumbness, feigned i. 1031
----mucous or bronchial......i. 524----from  lesions  of the tym-
----nature of.................  i. 532j  panitic cavity...............ii. 1S5
----pathological conclusions...  i. 533---------of local remedies for ii. 190,2
----pathology of.............  i. 530----from  various  pathological
----prophylactic treatment___i. 546,  states ofthe auditory organ.. ii. 183
----remarks on remedies recom-       ]---------treatment of........ii. 184
  mended for.................  i 540---------of the remedies  ad-
----remedies advised for___i 534,40:  vised for..................ii. 190-2
----sequelae of, treatment for       '----from  diseases  of  the tym-
  the........................  i 540]  panitic membranes..........ii. 182
----spasmodic, described......  i. 524 Debility of associated organs ... i 552
----stage-s of, described.......  i. 521----Bibliog. and Refer........i 560
----terminations and prognosis  i. 527]----a cause of phthisis........  1239
----treatment of.............  i. 534----of the cerebro-spinal  sys-
----treatment  of  consecutive       I  tem........................ i. 553
  and complicated............  i 539----of the circulating systems, i. 552
____usual form of.............  i 521----consecutive or secondary.. i. 550
Crystals in morbid growths___    775----consecutive, treatment of . i. 558
Cucumis Colocynthis, poisoning       ----consequences and termina-
  lly .........................    3891  tions of..................... i 555
Cupreous poisoning, diagnosis of   433----of convalescence, treatment
----treatmentof.............    434]  of.......................... i. 559
Cupreous poisons, operation of..    434----complicated, described---i. 551
____appearances from.........    434----complicated, treatment of. i. 558
Curvatures  of  the spine  de-       !----definition ot..............i. 547
  scribed.....................938-40----diagnosis of.............. i. 555
____treatment of.............  940,4----special effects of.......... i. 551
Cuticle, affections of the.......    863----from exhaustion.......... i 551
Cyanosis, cause of.............  i. 253]----feigned, noticed..........i 1031
____defined..................  i- 251----of the general system...  . i. 554
____lesions in................  i- 252----sympathetic............. i 550
____symptoms, &<-., of........  i 251----of the muscular system ... i 553
____treatment of.......•......  i 253----of the organic nervous sys-
Cynanche  pharyngea.  See, al-       |  tem........................ i 552
  so,  Pharyngitis.............   1153----of various organs, treatment
Cynanche  tonsillaris.  See, al-       |  of.......................... i. 55S
  so, Tonsillitis...............1150,3----pathological conditions of..  i. 05S
Cynanche trachealis.   See, also,       '----pathological relations of... i. 555
  Croup......................  i 519----causes and states of primary i. 54S
Cysticercal stage of Taenia de-       ;----treatment of primary.....i. 556
  scribed.....................   1524----regimen and diet of.......  i 500
Cysticercus celiulosn., described.   1528----of respiratory and assimila-
----identity of with Taenia so-       '  ting functions..............  i 553
  Hum.......................   1528----of sexual organs..........  i. 553 
1582          DE
INDEX.
DI
                                                             their      'Diaphragm,  inflammation  of.
                                                             .....ii. 519]   See Diaphragmitis...........
                                                             .....ii 533----inflammation of, defined ..
                                                             .....ii. 552----seat of inflammation of....
                                                            ......ii. 533----organic lesions of.........
Decoctum Althsess.......F. 47. Ap. 6----described..........'......ii 530-----paralysis of..............
___Arctii Lappae.......F. 4S. Ap. 6----forms and states of.......n. 531----rupture of................
____________Comp.....F. 49. Ap. 6]----treatment of.............ii 602----spasms of................
___et   infusum  Beccabungae       Demonomania, description of... ii. 524 Diaphragmitis, appearances aft-
                        F. 50. Ap. 6,----treatment of.............ii. 599|   er death....................
Debility, characteristic signs of       Delusions   in   insanity,
  general..................... i 554   sources...............
---states and manifestations of i 547 Dementia, causes of.....
---treatment of............. i 55G|----diagnosis  of........
Decay, climacteric............ i 396----prognosis of.
— Calumba? Composit. . F. 51. Ap. 6
— Cacuminum  Pini  Compos-
 itum..................F. 52. Ap. 6
— Cinchonae  Compositum
                       F. 53. Ap. 6
-------Aperiens.......F. 53. Ap. 6
-------et Rhei........F. 55. Ap. 6
-------et Serpentariae. F. 56. Ap. 6
— Cydoniae Compositum F. 57. Ap. 6
— Deobstruens........F. 58. Ap. 7
— Depurans..........F. 59. Ap. 7
— Dulcamarse.........F. 60. Ap. 7
------Comp..........F. 61. Ap. 7
Demulcents,  enumeration  and
  arrangement of.............1145-6 ■
Dengue.   See, also, Scarlatina
  rheumatica.................   721
Denticola hominis, described...  1520 •
Dentition, difficult, Bibliog. and
  Refer......................  i 5S3
— causes of.................
— in connexion with rheuma-
 tism .......................
— complications of..........
— prognosis of..............
— symptoms................
— tei-minations of...........
defined.................. i 580---treatment of,
— pathological relations of dif-
 ficult....................... i 580
— treatment of............. i 581
— the  treatment  of  sympa-
 thetic disorders of........... i. 582
Filicis Compositum. .F. 02. Ap. 7iDeobstruents, recommended for
Gallae..............F. 6.'!. Ap. 7|  dropsy..................... i 709
     Gentianse Comp.....F. 64. Ap. 7
 ---Guaiaci et Dulcamara?
  Comp.................F. 65. Ap. 7
---Helenii Comp.......F. 66. Ap. 7
---Inuhe Comp........F. 67. Ap. 7
---Pectorale Elsneri___F. 68. Ap. 7
---Punicse Granati.....F. 69. Ap. 7
---Quassise Compos.....F. 70. Ap. 7
---Santonici...........F. 71. Ap. 7
---Sarzae Compos......F. 72. Ap. 7
---Secalis Cornuti......F. 73. Ap. 7
---Senegas.............F. 74. Ap. 7
---Scoparii Cacuminum F. 75. Ap. 1
■---Taraxaci  Comp.....F. 76. Ap. 7
--------Comp. Stollii..  .F. 77. Ap. 7
----Tormentillae........F. 7S. Ap. 7
Decrepitude, described.........  i 56
Degeneration of structure of the
  heart, partially into fat___ii. 250,2
----causes of.................ii. 251
■---■ treatment of.............ii 252
Deglutition, difficult, described, i 501
----difficult.   See,  also, Dys-
  phagy...................... i. 561
----as a sign of disease.......  1079
Delirium, Bibliog. and Refer... i 571
----defined.................. i. 565
---diagnosis  of.............. i 567
----from exhausted nervous in-
  fluence ..................... i. 568
----from exhausted vital power
  and excited vascular action .. i 568
----from inflammatory action in
  the brain, or its membranes.. i 568
     vegetable, mineral, and an-
  imal.......................  1147
Deposits of blue and black mat-
  ters in urine................  1335
----calculous, of uric acid, and
  its combinations............  1325
----earthy and ossific, in  the
  heart and pericardium.......ii. 252----complicated, treatment of'.
----signs of..................ii. 252----in the dark races
---organic, in the urine......  1335 —   — treatment of.
Diarrhoea,   appearances  after
  death from.................
----associations  or  complica-
  tions of.....................
----Bibliog. and Refer........
---bilious, described.........
----treatment of bilious.......
----chronic, feigned..........i
----chronic mucous, treatment
  of..........................
----of children, medicines pre-
  scribed for..................
---in children, when weaning
     colliquative, treatment of .
 1.599
 i. 699
 i. 599
 i601
 i. 602
 i. 601
 i 602

 L600
 i. 599

  675
 i 600
 i 600
 i 600
 i. 600
 i 001

 i 007

 i 606
 i. 619
 i 603
 i 610
. 1031
     phosphatic, in urine, patho-
  logical relations of..........1332,4
----in  urine, therapeutical re-
  lations of...................1334, 5
----of uric acid, and its combi-
  nations, diagnosis of.........1322,4
----treatment of.............1325, 6
----urinary, of their formation 1321,2
Depression.   See, also, Debility i. 547
----lateral, of the ribs........ i 367
----of the ribs, treatment of... i 368
Depurants  advised  in morbid
  states ofthe blood........... i 249
----arrangement and enumera-
  tion of.....................  1146
Depuration  of blood, necessity
  for promoting...............1137,9
---by the emunctories, requi-
  site to health............... i 23S
----functions of, on the states
  of the blood................. i 243
----means of, for morbid states
  of the blood................. i 248
                                                                            • definition of,
                                                                            ■ diagnosis of..............
                                                                             with discharge of unaltered
                                                                             ;esta.....................
                                                                             duration and termination of
                                                                         — idiopathic, described......
                                                                        ----treatment of idiopathic___
                                                                        ----in  infants  and children,
                                                                          treatment of................
                                                                        ----inflammatory............
                                                                        ----treatment of inflammatory
                                                                        ----lienteric, treatment of___
                                                                        ----mucous, or catarrhal......
                                                                        ---- treatment of mucous......
                                                                        ---during pregnancy........
                                                                        --------treatment of.........
                                                                        ----prognosis of..............
                                                                        ----puerperal, described......
                                                                        --------treatment of.........
                                                                        ----regimen and diet for......
                                                                        ----relations of..............
                                                                        ----remedies for, recommended
                                                                          by authors..................
                                                                        ----symptoms of.............
                                                                        ---symptomatic, described...
                                                                        ---treatment of idiopathic....
                                                                        ----treatment of symptomatic.
                                                                        ----treatment  of,   in  second
                                                                          stage of phthisis............
                                                                        ----treatment of, in third stage
                                                                          of phthisis..................
                                                                        ----from ulceration of mucous
                                                                          follicles.....................
                                                                     . _ ----with ulceration, treatment
----with tremor, described___i. 57l]Determining   or   consecutive         of..........................
--------the causes of........i 572   causes of disease............ i. 657 •---varieties of, described.....
--------the different states of i 572piabetes, Bibliog. and Refer. .. i. 598 Diathesis   and other  circum-
--------distinctions of forms of i 572----causes of................. i 5S8   stances of a patient should be
—■-----symptoms of........ i 573----complications of.......... i 5S6   studied.....................
-------- modifications of their       ----indications of cure for.....i. 596 Diathesis and temperament dis-
  symptoms.................. i 574----definition of.............. i. 583   posing to phthisis...........
Delirium Tremens.  See, also,       ----diet  and regimen for......i 597 Dibothrium latum,  described.
  Delirium with tremor........ i. 571----duration of............... i. 586!  See, also, Taenia lata........
----Bibliog. and Ref er........ i. 5S0----organic changes.......... i. 5S6 Diet, different kinds of, required
----the  diagnosis of.......... i 574----prognosis of.............. i. 587.  in different climates.........
----pathology of............. i 575----proximate cause of........ i. 588----recommended  in  indiges-
---prognosis of.............. i 575----remedies prescribed for ... i 596   tion....................ii
----remedies recommended  for i 57S!----symptoms of............. i. 5841----after parturition ....'.....
■---treatment................ i 576----terminations of........... i. 586 Diffusive inflammation of cellu-
--------ofitsstages......... i 576----treatment of............. i 592|   lar tissue...................
-------°l it* first form......i 576---treatment proposed by the      ;Digestion, states of, in phthisis.
     ----of its second form.... 1. 577   author..................... i 595Digestive  canal,  alterations of
Delivery, of convalescence after   535----treatment of, proposed  by         situation ...
---deviations from the natural      |  writers..................... i. 592'____anaemiaof"...........
  course  of convalescence after. 536,7 Diabetes mellitus described___i. 583'----appearances simulating dial
---feigned, noticed..........i 1031 Diagnosis of diseases........1056-10991   ease............
-— hamorrhage during.......ii 130 Diaphoretics,  arrangement and       ----atrophy of its tissues......
Delusions, description  and clas-      |  enumeration of.............  1140____Bibliog. and Refer
  sification of, in  insanity---ii 502,5 Diaphragm, Bibliog. and Refer. i 602'----changes of capacity of the
                                   ii Derivation, means of producing i 218
    ■ lesions in fatal cases......i 56S' Derivatives in cases of insanity, ii. 615
 ---pathology of.............. i. 568!----of their use in phthisis___  1276
---phenomena of............i 566 Descent of the uterus..........  13S7
----prognosis of.............. i 569]----symptoms of.............  1389
----treatment of, recommend-       |----treatment of.............  1389
  ed by authors............... i. 570 Desire for food and drink, disor-
---treatment of, in third stage       |  dered states of.............. i 621
  of phthisis..................  1509 Despondency during pregnancy   504
----treatment  of its  several       |----treatment of.............   504
  states...................... i 569 Destruction of organized parts.. i 679
i 611

i. 614
i 606
i. 616
i 616
i 606
i 615
i. 602
i. 609

i605
i. 607
i. 603
i. 609

i. 614
i 604
i.610
i. 613
i604
i. 611
  502
  502
i 609
i 605
i. 613
i 618
i605

i616
i.602
i. 603
i. 609
i. 610

 1258

 1260

L 005

i. 612
i. 603
 1132

 1225

 1521

i407

393-7
  538

i. 356
 1202

i637
i. 624

i. 619
i 625
i. 640
i. 637 
DI                              INDEX.                               DR           1583
Digestive canal, change of situa-      'Disease, often followed by drop-       ]
  tion or positions of.......... i. 639|   sies........................  i 684i
Dreaming, of the phenomena of
     remarks respecting.
----congenital lesions of the ..  i. 639----produced by infection.....ii. 410 prink, desire of, as a sign of di
   disorders of secretion  and      '----local and functional, inci-
excretion...................  i 623]   dental to the puerperal states 532-71
S76
 41
1079
advised in fevers.........i. 1082
----enlargement of its follicles i 627----the metastasis of.........i. 686 Drink and food, as causing di:
   formations   in,   resultin;
from morbid nutrition in the
----functional disorders ofthe. i. 621----its duration should always
----hyperemia of............ i 624'  be considered...............  1132
----hypertrophy of its tissues.. i. 626---- favoured by temperature
—. general doctrine of.......i 65S   ease....................... i 653
   • division of, into stages .... i 681lDrinks and  beverages  for indi
----lesions of its tissues.......  i 624
----morbid appearances of....  i. 619!
----morbid formations in......i. 636!
----morbid secretions in the ..  i. 634
----morbid sensibility of......i. 623
----obliteration  or strangula-
  tion of......................  i. 6391
----perforations of............i 632]
----softening of its coats......  i 629
----ulceration of.............  i 630
----symptoms furnished by ...   1075
Digestive mucous surface, treat-
  ment of its diseased states in
  fevers......................i 1078
Digestive organs, diseased, from
  causes acting on the......... i. 653
----morbid sympathies of, with
  brain, &e...................i. 1040
----the relation  of  these dis-
  eases to cachectic nephritis... ii. 745
Digestive  tube,   intro - suscep-
  tions of...'.................. i 638
----complicated   productions,
  &c......................... i 636
----morbid productions in.....i 636
Digitalis,  appearances   after
  death from..................   395
----cumulative effect of.......   394
----grades of poisoning by .... 393,4
----symptoms of poisoning by.   393
----treatment of poisoning by.   395
 and humidity...............  i 049
— of the fluids and solids orig-
 inate  in altered conditions of
 vital power.................  i 666
— functional and organic, re-
 marks as to the terms.......  i 683
— of  grades of morbid action
 in.........................  i 6S1
---influence of light and sun-
 shine on....................  i 650
---Pathogeny  of,  discussed ..
                          i. 65S-666
--- its  pathogeny  must  be
 studied.....................   1133
—- preliminary remarks re-
 specting....................  i. 641
    to be resisted  by opposing
  gestion...................ii 395-S
Dropsy of abdomen, appearances
  in fatal cases............... i 718
  — Bibliog. and Refer........ i. 723
  — causes of................. i. 716
----definition of............. i. 716
----diagnosis of.............. i 719
----different  forms  and states
  of.......................... i 716
—- pathology of............. i 716
——• the prognosis of.......... i 720
----puerperal, described...... i. 722
--------treatment of......... i. 723
----treatment of............. i. 720
--------of its acute states___i. 720
--------of  its  symptomatic
  states...................... i 721
Dropsy, acute, active, or inflam-
  matory, or sthenic..........i. 694
     causes of................ i 694
vital and nervous power,
   the successions of.........i. 684
— terminations of........... i 683
— types and forms of....... i. 6S2
— resulting from morbid con-
 ditions of the blood..........1047, 8
— poisoning may occur or be
 produced during............   365
—  prevention   of  domestic
 causes of...................   263
—• puerperal, severally consid-
 ered ......................541-594
— relations of.............. i 684
   . in relation to climate.....i. 404
1142----progress of............... i. 695
----use of, in phthisis........   1269----in relation to races.......i. 404
Dilatation  ofthe cavities  and       Diseases, secondary syhpilitic. .1466-9
  orifices of the heart..........ii 244 —- tertiary syphilitic........1469-71
----signs and symptoms of . .ii 245,6 Disguised or lurking gout......  ii 43
__:_ treatment of.............ii. 240 Disinfectants, the necessity of
Discharges, excessive, to be re-         employing..................   277
  strained....................   1139'----notices of................  1148
----haemorrhoidal, described .. ii 147 Disinfection,  means for........ii. 419
________treatment of........ii. 152 Disorders of  the organic  func-
DLsease, aetiology of........i. 644-658
 — associations and complica-
  tions of,  their sources exam-
  ined ......................1036-55
 — Bibliog. and Refer........  i. 6SS
 — blue, notice of............ii. 251
    ■ of the causation and doc-
  tions  in  connection  with in-
  sanity......................ii 537
----symptomatic of indigestion ii. 380
Displacement of the heart.....ii. 262
--------causes of............ii. 262
----of the ovarium...........ii. 1066
     of the uterus.............   138
trine of.....................  i 641 Dissolvents, alkaline, saline, <fcc.  1145
                                  j Distoma, characters of........  1536
                                      ■ diagnosis of..............  1537
                                       prognosis of..............  1537
                                                                  1536
   • from causes acting on the
  functions...................  i 651
----from causes affecting the
  respiratory organs...........  i 652]----systematic description---
----effect of, on the pulse.....602, 3] Distomum haematobium,  action
---exciting causes of........  i 651 j  of, on the liver..._---;._.....  1538
----predisposing causes of ....  i 645
----the  general  predisposing
 causes to...................  i 649
—- specific causes of.........  i 656
— circumstances influencing
 its character and  tendencies
 ought to be studied..........   1132
— circumstances  modifying
 the form, duration, and term-
 inations of..................  i 687
— with reference to climate..  i 411
— consecutive and determin-
 ing causes of...............  i 657
     alterations produced by, on
  the urinary organs and blad-
  der........................  1538
----characters of.............  1537
----symptoms produced by....  1538
----systematic description of..  1537
----treatment of.............  1557
Distomum hepaticum, action of,
  on the liver.................  1538
----characters of.............  1537
----diagnosis of..............  1537
----prognosis of..............  1538
----systematic description of..  1537
----defined..................  i 6441----treatment of.............  1557
____doctrine of...............  i 642iDistomum heterophyes, descnp
----benefited by change of cli-
tion of.....................   I538
 mate           .............  i- 408 Distomum lanceolatum, system-
— caused by cold...........  i 422   atic description of.  .........  1538
from causes acting on the
Distomum ophthalmobium, char-
digestive organs.............i-653   actersof....................  *-°™
   *______",.™ .rfino- on nr.       Diuretics advised for dropsy ... l. Til
 ---from causes acting on or-
  gans of sense............... i- C54----arrangement and enumera-
— the complications of......i. 684   tion of ..  .......• •.....■ - - •  "46
____endemic, sources of.......i 868---- remarks  on  the  several
     pn.-ilom c        ......... i- s^'l  kinds of, advised for dropsy.i. 711-14
~ ex nthematous'........... i 974 Doctrine, general, of disease... i 658
  _Wnin" of     ..........i 1029 Doctrines,  unsound  and  spe-
____those usual'ly'feigned...i 1030-8   cious    retard  therapeutical
____observed in the foetus.....1.1238'  knowledge.................  1129
     acute, treatment of........  i. 702
----acute, in the head, stages
  and forms of................  i. 753
Dropsy of Amnion, definition of  i. 724
  ------pathology of.........i. 724
  ------treatment of........i. 72-1
  — appearances observed after
  death from.................  i. 691
  — appearances of the fluids ef-
  fused in ....................  i. 692
  — asthenic or passive.......  i. 696
  -------treatment...........  i. 703
  — Bibliog. and Refer.......i. 715
  —. causes of.................  i 091
Dropsy of cellular tissue defined.
  See, also, Anasarca.........  i 724
  — of the cellular  tissue  de-
  scribed.....................  i 724
----partial, of cellular  tissues
  described...................  i 724
Dropsy  of the  cavities  of  the
  chest.......................  i 731
  — complicated with pulmon-
  ary disease, treatment of....  i. 704
  — congej^tal, noticed.......  i. 740
  — Bibliog. and Refer.......  i 743
  — causes of.................  i 742
  — treatment of.............  i 742
  —• of spinal membranes.  See,
  also, Hydrops spinae.........i. 741
Dropsy, definition of...........  i. 689
----deobstruents advised for..  i 709
----the diseases most frequent-
  ly occasioning..............i. 693
----from disease of the absorb-
  ent system, treatment of ....  i. 704
----from diseases of the  blood-
  vessels .....................  i. 697
----from disease ofthe heart..  i. 697
--------treatment of........  i 703
----from disease of the kidneys i. 700
--------treatment of........  i 705
---- from disease  of the liver
  and spleen..................  i. 699
----as a sign of disease  of the
  liver.......................ii. 699
---- from disease  of the liver
  and spleen, treatment of.....  i. 704
----diuretics advised for......  i 711
----divisions of, into active and
  passive.....................  i 690
Dropsy,  encysted, Bibliog. and
  Refer......................  i 751
--------definition of.........  i 743
--------causes of............  i. 743
________of the kidneys.......  i. 750
—1.___. of the liver..........  i 750
________prognosis of.........  i. 744
.-------_ situations of.........  i. 744
----.----. treatment of........i. 744
.________of the womb.........  i.  749
________of the Fallopian tubes i. 749
----feigned..................i 1031
____in the head.  See, also, Hy-
  drocephalus  ................  i. 752 
1.1S4
DR
INDEX.
EC
Dropsy in the head, acute......i. 752
----historical view of opinions
  as to the pathology of....... i 6S9
----idiopathic or primary, treat-
  mcnt of.................... i ™-
____iodine and its preparations
  first recommended for, by the
  author..................... i. 709
____ lesions of the viscera ob-
  served after................i 692
____medicines recommended for i. 703
Dropsy, ovarian, causes of.....i 740
----of the ovarium.   See, also,
  Hydrops ovarii.  Definition of i. 745
---------diagnosis............ i 747
---------pathology of.........i. 745
---------symptoms  and prog-
  ress ........................ i. 746
---------prognosis of......... i 747
--------. treatment of......... i. 747
.---------various means of cure i 74S
----pathology of.............i 6S9
----  chief  pathological  states
  causing.................... i 693
Dropsy of the pericardium. See,
  also, Hydrops pericardii.....i 732
----Bibliog. and Refer.......j. 735
----the causes of.............i 734
----d finition of............. i. 732-------------.......
     diagnosis of.............. i. 7341---  various   complications,
 ---pathology of............. i
 ---treatment of.............i. 734
 Dropsy  of  the  peritoneum de-
   scribed.  See Dropsy of abdo-
   men ....................... i 716
 Dropsy of pleural cavities.  See,
   also, Hydrothorax...........i. 736
 ---primary or idiopathic.....i. 694
 ---prognosis of.............. i. 701
 ---purgatives advised for___i 710
 ---refrigerants  and antiphlo-
   gistic remedies for........... i. 706
 --- remedies advised for the
   treatment of................ i 707
 ---sub-acute................ i 695
 -------treatment of........ i. 702
 --- symptomatic or  consecu-
   tive........................ i. 697
 -------treatment of........ i. 703
•---treatment of............. i 701
 ---state of the urine in......i. 701
 --- from  uterine and ovarian
   disease, treatment of........ i. 706
Dysentery, associated with  in-       (Dysentery, tonics in...........  i- 838
  testinal worms..............i 812!---treatment of various states
  — the asthenic forms of.....i 802    and  contingent  alterations
  ______causes of............ i 802,   from......................  J. 831
  ______contagious or infec-       ,---of the type of............l 809
  t j01ia...............'........ i. 804----various  consequences and
____ _11 various' remedies'for . i 826;  alterations from, treatment of L 832
_________symptoms of........ i 805 Dysmenorrhoea, complications of ii. 974
_________treatment of......... i 825----treatment of congestive and
____astringents in............ i. S3T'  inflammatory...............ii 975
---- Bibliog. and Refer........ i 843----definition of.............ii 972
____bilious adynamic, described i 806----description of............ii. 972
----. camphor in.............. i 840----diagnosis of..............ii. 973
____chronic, complications of.. i. 814,----irritable or neuralgic.....ii. 972
_________symptoms of......... i 813'----treatment of neuralgic---ii 974
_________treatment of......... i 829]----obstructive..............ii 973
____ complications of chronic,       ----treatment of obstructive .. ii. 975
  treatment of................ i 830----pathology of.............ii. 974
---------with jaundice....... i 812----prognosis of..............ii. 974
_________with disease  of  the       ----treatment of.............ii. 974
  liver....................... i. 810----treatment in the intervals, ii 975
---------with rheumatism____i. 813 Dyspepsia, description of.   See
---------with  scurvy......... i. 812!  also Indigestion.............ii 377
---------with diseased spleen . i. 811 Dysphagia, definition of.......  i 501
---------with splenic and peri-       pysphagy, Bibliog. and Refer. .  i. 565
  odic diseases, treatment of... i 827:----complications of..........  i 562
---- descriptions  of complica-       !----diagnosis of..............  i 563
■  tions of acute and chronic.. i. 810-27----idiopathic, described.....1. 561
         their treatment......i. 827!---------treatment of.........  i. 561
                                      — paralytic, or symptomatic
                                      of lesions of the brain  or me-
                                      dulla oblongata, &c..........  i. 562
                                      — symptomatic and compli-
                                      cated ......................  i 562
                                      — symptomatic of spasm, flat-
                                      ulence, &c..................  i. 562
                                      — treatment of the compli-
                                      cated and symptomatic states
                                      of.........................  i 563
                                      — treatment of idiopathic and
                                      simple states of.............  i. 563
---- various forms  of,  copse-      ;---------symptoms of........ i 799
  quent on scarlet fever ...".. .739^11,----
  treatment of................ i. 827
----in the dark races......... i. 807
----in dark races, treatment of i. 827 •
----definitions of............. i. 797
----diagnosis of.............. i 817 ■
----diaphoretics  in........... i. 837]
----diet and regimen for...... i. 843 ■
----emollients and demulcents      I
  in......................... i 835
----epidemic, history of...... i. 816 •
----evacuants for............ i 834
----external derivation for ... i 837 Dyspnoea  and  cough  during
----feigned..................i 103li  pregnancy.................   503
----forms  and  symptoms  of      .Dysuria described.............  1353
  asthenic.................... i 805|
----• hepatic, described........ i. 810:                 *'-'•
----.----treatment of........ i. 827 Ear, deafness from various le-
----histoiy of................ i 797
----history of epidemics of.. .i 806, 9
----hyper-acute,  symptoms, &c. i. 801
---------treatment of........ i. 825
----inflammatory form.......i. 799
         ■ causes of............ i. 799
   intestinal haemorrhage, <fec,
treatment of................  i. 832
— ipecacuanha for..........  i 839
— lesions consequent upon...  i 816
—  malignant or  putrid  de-
scribed......................  i 805
— of mercurials in..........  i. 838
   methods of cure and reme-
  quent
----various remedial means ad-
  vised for................... i 714
Drunkenness, Bibliog. and Ref. i 791
----definition and consequences
  of.......................... i 782
----pathology of.............i 784
----prognosis of.............. i 789
----symptoms and signs of.... i 7821  dies advised for by authors.i. 833-43]Earache, defined and described, i 846
----prophylactic treatment of. i 790----nervo-adynamic or typhoid,       ----causes of .,................ i. 846
----treatment of............. i. 789   described.................. i. 805----treatment of............. i 846
Dumbness and deafness.......ii. 1S2]---- of  the operation  of the       [Ecchymosis of the brain....... i. 277
                                      causes of.................i 819, 20,Echinococci, a-tiology of.......  1520
sions of.....................ii 182
— diseases of the............i 844
— diseases of, consequent upon
scarlet fever................   741
— acute inflammation of.  See
also Otitis..................i. 847
—  inflammation of,  Bibliog.
and Refer..................  i 853
— nervous affection ofthe ...  i 845
— noises in the.............  i 844
—----causes of............  i 845
-------treatment of.........  i S45
— inflammation ofthe.......i 847
—  disease  of,  complicating
scarlet  fever................   734
Duodenitis, consequences of.... i 794
----treatment of.............i 796
Duodenum, Bibliog. and  Refer, i 797
Duodenum, the diseases of.....i. 792
---functional disorders of.... i. 792
---their treatment.......... i 793
---inflammation of.  See, also,
  Duodenitis................. i. 793
--- acute inflammation of, its
  symptoms..................i 794
--- inflammation  of,  remarks
  on......................... i 793
---ulceration and perforation
  of.......................... i. 795
Dura mater, structural changes
  of.......................... i 254
---symptoms of its lesions ... i. 257
     tumours in............... i. 255
    of the  pathological  condi-
 tions constituting the several
 forms of..................i 820-23
— pathological inferences re-
 specting.................... i 819
— prescriptions for.......... i. 841
— prophylactic treatment of. i 843
— relapse of................ i. 823
---remedies recommended for
                          i S33-43
— rhubarb in............... i 839
— scorbutic, described......i 812
------causes of............ i. 812
—- —— symptoms of........ L 812
------treatment of.....».. i. 828
— seat and forms of......... i 797
    the several forms of...... i 798
     prognosis of..............  1526
 — systematic and general de-
  scription of..................  1523
Echinococcus altricipariens,char-
  acters of....................  1524
---diagnosis of..............  1525
---prognosis of..............  1525
---scolex of, described.......  1529
---systematic description of..  1529
Echinococcus scolicipariens, de-
  scription of.................  1523
---mature taenia of..........  1523
---scolex of, described........  1523
---structure of................  1524
 —.symptoms of.............  1524
     synonymes  of............  1523
     systematic description of..  1523
----of spinal cord, alterations of   960----its simple states.......... i 799 Eclampsia.   See  aby Convul-
---------inflammation of.....   957----sthenic, acute form....... i 799 j   sions........................ i 485
Dynamic states of vital action.. i 659,-------------treatment of---i 823(Ecstasy, cataleptic, definition of i. 346
Dysentery, acute, described.... i 799--------------remedial means      i----treatment of............. i. 34S
---------treatment of........i 823|  for........................ i. 824]Ecthyma, acute............... i 835
----anodynes in............. i 835----sub-acute, describod...... i. 813----causes of................ i. 854
----antiseptics in............ i 840'----treatment of............. i. 829
----appearances after death... i. 816----terebinthinates in........ i S40
---- aromatics and  absorbents      ----the terminations and prog-
  for......................... i 838!   nosis of.................... i. 814
• definition of.............. i. 853
• diagnosis of.............. i. 854
• chronic.................. i. 853
■ treatment of............. i S55 
EC
INDEX.
EN          1585
230
Eczema, acute................  i. S56 Emphysema, intrinsic......... i 864 Endocarditis, treatment of rheu-
----Bibliog. and Refer........i. S60|----lesions causing........... i. 865;  matic or arthritic...........ii
----causes ot................  j. S5S;----of the lungs........  .....ii 900 Endo-metritis,  description  of.
----^nl?n?,c. ••••,•.............  j- S50!----treatment of............. i S66i  See, also, Metritis, internal..  1371
----definition of.............  j. $56:----vesicular, of the lungs___ii. 901'----treatment of.............  1379
----diagnosis  of..............  i. SSSpmplastrum Ammoniae. .F. 107. Ap. 7'Enema   Aloes  et  Asafoetida?
----prognosis of..............  j. S5S----Anodynum Fortius.F. 108. Ap. l\  Comp................F. 130. Ap. 9
  — specific form of...........  j. 857----Antimonii Potassio-Tartra-       |----Antiliystericum___F. 131. Ap. 9
 ---syphilitic................ i. 857
 ---treatment of............. i. 859
 Education, effects of, on insanity ii. 559
 ----physical.................i 860
 Effects,  arrangement  of medi
   cincs according to their special  1145
 Effusion from chronic pleurisy .   309
 ---from chronic pleuritis, signs
   of its absorption............   311
 Eggs of taenia described.......  1278
 Egypt, climate  of, advised  for
   phthisis...................1277,81
 Electuarium Alkalinum - ferra
   turn..................F. 79. Ap. 7
 ---Anthelminticum... .F. 80. Ap. 7
 ---Antispasmodicum. ..F. 81. Ap. 1
 ---Aperiens___F.  82 and 83. Ap. 7
 ---Arnicae Compo3.....F. 84. Ap.
 ---Becliicum..........F. S5. Ap.
 ---Cinchome Aperiens. .F. SO. Ap. 7
 ---Cinchona; Comp.___F. 87. Ap. 1
 ---Cinchona? cum Ferro F. SS. Ap
 ---Deobstruens F. 89, 790.  Ap.  8, 30
 ---Febrifugum........F. 90. Ap. 8
 ---Febrifug. Hoffmanni F. 91. Ap. 8
 ---Febrif. Trillei-i......F. 92. Ap. 8
 ---Ferri Ammonio-Chlo-
   ridi Composit..........F. 93. Ap. 8
 ---  Ferri  Potassio-Tar-
   trate.................F. 94 Ap, 8
 ---Ferri Sesqui-Oxidi F. 791.  Ap. 29
 ---Nitri Camphoratum.F. 95. Ap. 8
 ---Purgans...........F. 96. Ap. 8
 ---Scillae Composit.___F. 97. Ap. S
 ---Senna? Composit.....F. 9S. Ap. 8
 ---Terebinthinae.......F. 99. Ap. 8
 ---Terebinthinatum ..F. 100. Ap. 8
 ---Valeriana* Composit. F. 101. Ap. 8
 ---Vermifugum.......F. 102. Ap. 8
 Elephantia, Bibliog. and Refer.. i 863
 ---causes of................ i. 860
 ---diagnosis of..............i. 863
 ---pathology of............-. i 8G1
 ----symptoms, &c............i 861
 ---treatment of............. i 863
 Elephantiasis, Arabian........ i 860
 Elevation, high above the ocean,
   considered  with relation  to
   phthisis....................   1277
 Hixir Aloes Compositum F. 103. Ap. 8
 ---Pectoralis Wedellii.F. 104 Ap. 8
 --- Proprietatis  Rhubarbari
   num.................F. 105. Ap. 8
 ---Rohorans..........F. 100. Ap. 8
 Emaciation, feigned...........i  1031
 ---as a sign of disease.......   1064
 ---as a sign of phthisis......   1202
 Embrocations, rubefacient, those
   advised for phthisis.........   1257
 Embryo of taenia, described....   1523
 Emetics, enumeration of.......   1146
 ---in cases of insanity.......ii. 607
 ---of their use in phthisis....   1270
 ---in scarlet fever...........    764
 ---choice of, for spasm.......    931
 ---choice of, to produce vom-
   iting.......................   1500
 Emigrations of intestinal worms
   described..................1516-1S
 Emmcnagogues,    arrangement
   and enumeration of ... .■.....   1147
 Emotions  and desires  predis-
   posing to phthisis...........   1230
 ---of mind, as causing and in-
   fluencing disease, to be studied
 ---should  be directed  or ex-
  cited so as to  promote recov-
  ery ........................
 ---the  moral, as  exciting in-
  sanity......................»• 5G2
 Emphysema, Ribliog.andRefer. i. 867
 ---definition of.............. )■ 863
---diagnosis and prognosis ... i. 866
---extrinsic................. i 865
----interlobular  and sub-pleu-
  ral.........................ii-904.
     Ill
  tis..................F. 792. Ap. 39i----Antispasmodicum
----Anticolicum.......V. 109. Ap. 8                    F. 132, 133. Ap. 9
---Antiliystericum---F. 110. Ap. 8---Asafcetidse.........F. 134. Ap. 9
---Aromaticum Comp. F. 111. Ap. 8---Asafoetidae et Terebinthinae
---Belladonna;........F. 112. A p. 8                        F. 135. Ap. 9
---Camphorae........F. 113. Ap. 8-------Composit.....F. 136. Ap. 9
---Defensivum.......F. 114. Ap. 8,---Belladonna?........F. 137. Ap. 9
---Deobstruens.......F. 115. Ap. 8---Camphorse Comp. .. F. 13S. Ap. 9
---Picis..............F. 116. Ap. S---Camphoratum.....F. 139. Ap. 9
---Resolvens.........F. 117. Ap. s!---Catharticum.......F. 140. Ap. 9
---Roborans..........F. 118. Ap. S|---Colocynthidis Compos.
  — Rubefaciens.......F. 119. Ap. Si                       F. 141. Ap. 9
    Stibiatum.........F. 120. Ap. 8]---Commune........F. 794. Ap. 30
Employments  and amusements
  fbr the insane...............ii. 623;
Employments causing disease .. i 137]
     regimen, &c., favouring the
---Contra Spasmos___F. 142. Ap. 9
---Emolliens......... F. 14Li. Ap. 9
 — Emollio-Aperiens.. .F. 144. Ap. 9
    Ipecacuanha;.....1\T.)5. Ap. 30
occurrence of phthisis........  1128----Opiatum..........F. 145. Ap. 9
1132
1143
  Emprosthotonos, defined.......  1101
  Empyema, described..........   313
  ----diagnosis of..............   324
  ----operation advised for......332-5
  ----perforations caused by....   322
  ----signs and symptoms of....   313
  ----treatment of.............   331
  ----with ulceration and perfor-
    ation of the pleura..........   313
  Emulsio Amygdalo-Camphorata
                        F. 121. Ap. 9
  ---Anticatarrhalis___F. 122. Ap. 9
  ---Camphorata.......F. 123. Ap. 9
  ---Camphorata Anodyna
                        F. 124. Ap. 9
  -------Comp.........F. 125. Ap. 9
  ---Nitro-Camphorata . F. 126. Ap. 9
  ---Pectoralis.........F. 127. Ap. 9
  ---Pro Tussi.........F. 128.  Ap. 9
  ---Sedativa..........F. 129.  Ap. 9
  Encephalitis, described........  i 261
      causes of.................  i 2S5
      definition of.............  i. 2S3
      diagnosis of..............  i 285
      regimen for..............  i. 292
  ----states,  forms,  and compli-
    cations of...................i. 280
   — symptoms of.............  i 284
   — terminations and  prognosis
    of..........................  i 286
   — treatment of its acute states i. 287
   — several means  of treatment
    of acute....................i. 289
   — treatment of its complica-
    tions.......................  i 289
   — treatment of its sequelae...  i. 292
   — treatment of its sub-acute
    and chronic states..........  i. 291
   — treatment of its unfavour-
    able and anomalous states__i 290
  Encephalocele,  described......i 277
  Encephaloma, structure of.....    77S
  Endemic diseases, causes of....  i 80S
   — influences  and  diseases....  i 807
   — influences,  Bibliog.   and
   Refer......................  i S77
   ------means of counteract-
   ing ........................i S76
   ------diet and regimen dur-
   ing exposure to.............  i S77
  ________. diseases produced by.  i S70
  __----effects of............i S70
  --------operation  of, on  the
    system.....................  i 814
  --------prevention of........i. 874
  ________sources of...........i SGS
  Endocarditis, alterations caused
   by.........................ii. 209
  ----in children...............ii. 233
  ----complicated with  rheuma-
   tism........................__  673
  ----remedies advised for......ii. 229
  ----successive lesions caused by ii. 209
  ----symptoms of the first stage ii. 209
  ----of the   eecond and  third
   stages......................ii. 210
  ----treatment  of acute.......ii 2291
  --------. of chronic...........ii. 230|
100
     Saponis...........F. 146. Ap. 9
     Sedativum.........F. 147. Ap. 9
  ------Camphoratum F. 148. Ap. %
 ---Terebinthinatum.. .F. 149. Ap. 9
 ---Terebinthina?......F. 150. Ap. 9
 ---Terebinthino-Camphora-
   tum.................F. 151. Ap. 9
 ---Thebaicum........F. 152. Ap. 9
 ---Vermifugum......F. 153. Ap. 9
 Energy, nervous, to be restored
   or supported................1135-7
 England, climate of certain parts
   of.......................... i. 411
 England, the south and south-
   west coasts of, their climate.. i. 412
 Enteritis, acute, description of. ii. 659
 ----acute  follicular,  remedies
   prescribed for...............ii. 660
 ----in children...............ii 682
 ----acute follicular,  treatment
   of..........................ii. 681
  ------for children.......... ii 682
  — appearances  after  death
   from the acute form.........ii. 675
  — indirect causes of.......ii. 67S, 9
  — caused by medicinal sub-
   stances ..................... ii 677
  — causes, exciting,  of........ii. 676
  — causes, predisposing, of.... ii. 676
  — appearances  after  death
   from chronic................ii. 676
  — chronic  follicular,   treat-
   ment of....................ii. 682
  — complications  or  associa-
   tions of.....................ii 670
 ----complications  of, in chil-
   dren .......................ii. 670
  — indications of cure in.....ii 679
  — diagnosis of............ii. 671-3
  — diagnosis of its  complica-
   tions .......................ii. 673
  — diagnosis between, and per-
   itonitis.................___    91
 ----diagnosis between,and pois-
   oning ......................    372
  — follicular, consequent on fe-
  vers*......................  . ii. 663
  ------acute in children.....ii. 663
 --------chronic, in children.. ii. 664
 ----several forms of, described
                           ii.  659-70
 ----glandular, described......ii. 661
 ----glandular   or   follicular,
  symptoms of..............ii. 002-3
 ----lesions consequent upon... ii 074
 Enteritis phlegmonodea, or in-
  flammation of all the coats of
  the small intestines.........ii. 604
----phlegmonoid, treatment of ii. 6-0
----poisonous causes of.......ii C7■<
 ---pseudo-membraneous,  de-
  scribed ..................... ii 669
----pseudo-membraneous, t; eat-
  mentof....................ii. 6S3
  — favourable terminations of ii 673
  — terminations of...........ii 673
  — unfavourable  terminations
  of..........................ii 673 
1586          EN
INDEX.
EX
Enteritis, treatment of........ii 679|Epilepsy, description of........ i 904
----treatment during convales-       ----diagnosis of.............. I. J1J
  cence from..................ii. 084----from disorders of the diges-
____causing ulceration of intes-       I  tive organs................. i 913
  tines.....................ii. 674-6----from disorders of the gener-
Entero-colitisi' follicular, treat-         ative organs................ i. 913
  ment  of....................ii 681----external means advised for l. 936
Entozoa.  See, also, Worms___   1514----feigned..................i 1031
____human, described........   1514----imperfect seizures of......i 900
____genesis of............___   1515.----the intervals between the
____remarks respecting....... i. 679  fits......................... i 907
____in  veins.................   1317]----treatment of, in the inter-
Ephelis, definition of.......... i. 878!  vals....................*---i 921
____diffused.................. i. 878----nature of................ i 917
____lenticular................i. 87*----associated with palsy.....    29
____symptomatic  ............ i. S79----phenomena   constituting
----treatment of.............i. 879 j  the fit...................... i. 905
Ephemera, Bibliog. and Refer.. i. 1137
----causes of.................i. 1136
----described ..;.............i 1136
----diagnosis of..............i 1136
----symptoms of.............i 1136
----treatment of.............i. 1137
Ephemera, puerperal, symptoms
  and treatment of............    548
Ephemeral fever defined.  See,
  also, Ephemera.............i. 1136
Epian, description of..........   1475
tpidemic  catarrh.   See  Influ-
  enza .......................ii 489
----constitutions, the general,
  should be studied...........   1134
Epidemic  diseases.   See, also,
  Epidemics..................  i 879
----the causes of...........i 880-88
----Bibliog. and Refer........  i 895
----causes.................i 880-SS
----conclusions as to their caus-
  ation .......................  i. 8S7
----their occasional  connexion
  with epizooties..............  i 8S3
----notices of some  epidemic
  constitutions of authors......i. 891
----historical notices of some..  i 891
----general inferences respect-
  ing.........................  i 894
----the influence of infection in
  their  causation.............  i. 8S6
----the opinions of the non-in-
  fectionists respecting, contro-
  verted......................  i 889
----justly viewed as pestilences    105
----the precursors of.........  i 888
Epigastrium, alterations of sen-
  sibility at the...............  i 897
----concussions and contusions
  of..........................  i. 902
--------symptoms of........  i. 902
--------treatment of.........i 903
---- distention,   tumefaction,
  &c, at the.................  i. 897
----examination of the states of i 897
----pulsation at the, causes of.  i 898
Epiglottis, inflammation and ul-
  ceration of..................ii 791
Epilepsy,  from affection of the
  spinal cord.................i. 912
----appearances   after  death
  from.......................  i. 915
----asthenic, or adynamic, de-
  scribed .....................  i. 911
----Bibliog. and Refer........i. 940
----exciting causes of........i. 909
----predisposing causes of.....i 908
----from cardiac  disease......i 912
----classes of remedies advised
  by authors for..............  i 927
----complications of..........i 914
----various complications of...  i. 915
----treatment of complicated..  i 926
----complicated with apoplexy i 914
----treatment of the apoplectic
  complication of..............  i 926
----complicated with insanity,  i 914
----treatment of, complicated
  with  insanity...............  i 926
----complicated with paralysis i 914
----treatment of paralytic com-
  plications...................  i. 926
----consequences and termina-
  tions  of.....................  i 907
----and  convulsions, complica-
  ting insanity................ii 535
i— definition of..............  i 904
     the  stages of phenomena
  constituting the fit.......... i 905
----premonitory symptoms of.. i. 904
----prognosis of.............. i 920
----regimen and diet for......i 940
----remarks  on remedies  for,
  commended by authors ... .1. 927-40
----remedies advised  for  the
  symptomatic varieties of.....i 923
----remedies  advised  for, by
  authors,  with practical  re-
  marks....................i. 927-39
  — sanguineous, or sthenic, de-
  scribed ..................... i. 911
  — simple, or idiopathic...... i 911
  — spinalis, described........i 912
  — sympathetic, described___i 912
  — treatment of the fit....... i 920
  — treatment of cerebral.....i 922
----treatment of the symptom-
  atic forms.................. i 923
  — varieties of.............. L 910
  — various modes of treatment
  advised by authors........i 927-39
Epistaxis, Bibliog. and Refer... ii 88
     causes of................. ii. 89
     complicating scarlet fever.   734
     pathology of ..,........... ii.
  — phenomena of............ ii. SS
----prognosis of.............. ii. 90
----treatment of............. ii 90
----treatment after the attack ii. 92
----local treatment of........ ii. 91
Epithelial cell, described.......   773
Epithelium in urine...........  1337
Epizooties,  sometimes  precede
  epidemics.................. i 8S3
Erectile tissue, lesions of....... i. 942
----Bibliog. and Refer........i. 942
Erethism, described........... i 942
----mercurial  ...............   454
----symptoms of............. i 943
----treatment of............. i. 943
Ergotism, description.......... i 943
----how produced............ i 943
Erotomania,  description of.___ii. 516
----treatment of.............ii 595
Errhines, enumeration of......  1146
Eructations as a sign of disease.  1081
Eruption,  miliary.   See,  also,
  Miliaria....................ii. 992
----herpetic, description of.... ii 207
----pustular, described.......   611
----scaly, the pathology of....   526
--------treatment of.........   520
Eruptions,  syphilitic, described.  1407
----squamous, pathology of....   520
--------treatment of.........526-31
Eruptive and other fevers, their
  relations to cachectic nephri-
  tis .........................ii. 748
Erysipelas, Bibliog. and Refer., i 970
----exciting causes of......... i 953
----predisposing causes of.___i 953
----with cephalic affection .... i 950
----treatment  of the  cephalic
  complication...............i 962, 3
----treatment of cephalic  com-
  plication with turpentine, case i. 963
----complicated, described___i. 948
----complicated, treatment of
  the......................... i. 960
----definition of.............. i 944
  — description of............ i 944
  — of depletions, tonics, stim-
  ulants, and antiseptics for ... i. 964
  — diagnosis of.............. i. 952
Erysipelas, division of its forms i. 946
----epidemic................. i 954
----of the face............... i 945
____with gastro-bilious disorder L 950
____treatment of gastro-bilious t 963
----of infants, described......L 968
_— in infants  and  children,
  treatment of................ i 966
  — infection of ....;......... L 953
  — lesions in fatal cases of.... L 952
  — modifications of the consti-
  tutional disturbance of......i 946
  — modifications of  the  local
  affection....................i. 946
  — nature of................ i 967
  — cedematous, described.....i 948
  — treatment of cedematous .. i 960
  — treatment of various  com-
  plications of................ i 963
  — phlegmonous, description of i 948
  — treatment of phlegmonoid. i. 961
  — prognosis of.............. i. 952
  — its connexion with puerpe-
  ral fevers................... 582,8
  — regimen and diet for...... i 970
  — complicating scarlet fever.   736
  — simple or mild, described.. i 947
  — treatment of simple or mild i 959
  — extending to the throat and
  larynx..................... i 945
  — extending  to  the throat,
  pharynx, &c, treatment of .. i 963
  — treatment of............. i 958
  — treatment of diffusive and
  suppurative................i. 960-2
  — local treatment of........i 964
  — various local means of treat-
  ment....................... i 965
  — its varieties, arrangement
  of.......................... i. 947
Erythema, causes of........... i 973
----chronic.................. i. 973
----definition of..............i 971
     description of............. i. 973
     diagnosis of..............i. 973
     primary or idiopathic.....L 972
     symptomatic............. i 972
     treatment of.............i. 973
Ether, poisoning by inhaling...   407
Euphorbia officinarum,  poison-
  ing by.....................   390
Europe, dates of the first appear-
  ance of syphilis  in various
  parts of....................  1459
Eustachian tube,  &c, deafness
  from diseases of.............ii 185
  — treatment of.............ii. 186
Evacuants,  arrangement   and
  enumeration of..............  1146
Evacuations, alvine, with respect
  to the biliary secretion.......1084,6
  ------signs furnished by..  .1084,6
----intestinal, assigns of disease  1081
Examination of the urine, mode
  of conducting...............1321,2
  — of the abdomen...........   i 1
Exanthemata, general notice of
  the......................... i. 974
----causing phthisis..........  1239
Excavations in the  lungs, de-
  scribed.....................  1218
----matters contained in them  1218
----parietes of, described.....  1218
Excitants, enumeration and ar-
  rangement of...............  1147
----nervous and muscular....  1147
Excitement, consequences  and
  terminations of............. i. 664
----excessive, should be  mod-
  erated  .....................  1140
----indirect.................. i. 663
----intensity and duration of.. i. 664
----primary forms of......... i 660
----primary, of the  several or-
  gans ...................... i. 660
----and  reaction, states of.... i 059
----secondary or consecutive.. i 663
Excrescences, fungous or warty,
  described...................   7S0
Excretion, definition of........ i. 975
----excessive, should be  mod-
  erated ......................  1139
  — of fatty matters.......... i. 973
  — necessity for promoting .. .1137-9 
EX                             INDEX.                              FE           1587
Excretion,  the promotion of in
  fever.......................i. 1077
----of urine, diseased.........  1353
Excretions, Bibliog. and Refer, i. 982
----biliary, described......... i. 982
.----the exhaled.............. i 975
----faecal, &c................. i. 980
----morbid, <fec...............i 978
.----natural, described........i 975
----the secreted.............. i 977
----and secretions during the
  puerperal states.............   536
----urinary.................. i 9S0
Exhalations from putrid animal
  matters, poisoning by.......   444
----and   secretions,   morbid
  states of.................... i 669
----and secretion, the simpler
  alterations  of............... i 667
----transformations of........ i 670
Exhaustion, described......... i 551
----the prevention and remov-
  al of.......................  1142
Existences, invisible but organ-
  ized, causing pestilences.....   252
Exostosis, described..........ii. 1054
Expectorants, arrangement and
  enumeration of.............  1147
Expectoration, appearances, &c,
  of.......................... i. 982
----bloody................... i. 983
■ purulent.
Fainting, diagnosis of.........i 1027
----defined..................i 1024
----description of............i. 1025
----feigned..................i. 1032
----pathological  inferences re-
  specting....................i. 1026
----treatment of.............i. 1027
----Bibliog. and Refer........i 1028
Fat, deposit  of, in the heart's
  structure in obese persons ... ii. 997
----or oil in the urine........   1337
Fatty degeneration of the sub-
  stance of the heart........ii  250-2
----treatment of.............ii. 252
-—of the liver..............ii 870
----of the pancreas...........
----or  adipocerous  degenera-
  tion of muscles..............ii 997
----formations in the uterus ..   1402
----matters in coats of arteries  i. 133
----principles of morbid growths   777
Fatuity, description of...*>..... ii. 533
----treatment of.............ii 002
Fauces, organic lesions of, treat
  ment of....................   1165
Favus.  See also Tinea capitis.. 1173-5
----treatment of.............   1173
Feigned diseases, account of. i 1030-38
----Bibliog. and Refer........i. 1038
Feigning disease..............i 1029
     objects of................i. 1029
----various states of.........i 982,4
----states of, as  signs  of dis-
  ease .......................1092-4
----states of, in the various dis-
  eases of the respiratory organs  1094
----as a symptom of phthisis..   1200
Extractum   Aloes   Alkalinum
  Composit.............F. 154.  Ap. 9
----Dulcamarae........F. 155.  Ap. 9
----Hellebori Nigri Backeri
                      F. 156. Ap. 10
Exudation, fibrinous, expector-
  ation of.....................   1094
----inflammatory, described...  ii 436
----in pleuritis, organization of   321
Eye, diseases of the...........  i 984
----diseases  of, Bibliog.  and
  Refer....................i  1023,4
----inflammations of the.  See,
  also, Ophthalmia............  i 985
----gouty inflammation of the
  intwnal tissues of...........i 1020
----inflammation  of anterior
  chamber of.................i 1015
--------symptoms and termin-
  ations of....................i 1015
--------treatment of.........i 1010
----inflammation of the choroid
  coat of.....................i 1020
--------treatment of.........i. 1020
----inflammation of the exter-
  nal tissues..................  i
--------ofthe globe of......i 1022
--------symptoms of........i 1022
----internal  inflammation  of,
  after fevers.................i 1021
----symptoms and treatment of i 1021
----inflammation of its internal
  tissues.....................i 1019
--------of the iris.  See, also,
  Iritis.......................i 1016
--------ofthe  retina of......i 1019
--------of the whole organ.. .i 1022
----symptoms furnished by the
                            106S, 70
Eyelids and eye, syphilitic affec.
  tionsof.....................  1469

                 F.
Face,  paralysis  of  the  muscles
  of..........................
----signs  of disease furnished
  by the.....................
----syphilitic affections of the.
Fiecation, disorder of.......... i. 622
----obstructions  to  the func-
  tions of....................  1082
Faeces, obstructions to the evac
  uationof...................  J0**-
Fainting, causes of........... .L lu-o
----consequences and termina-
  tions of..............
i 984 Females, gonorrhcea of........  1455
1057
1407
     state  of, at far-advanced
  pregnancy..................   532
Fever, means of preventing the
  accession of.................i. 1070
  — removal  of  predominant
  states of morbid action in... .i 1078
  — seats  of alterations found
  after death from............i 1050
  — appearances  after  death
  from.......................i 1050
  — arrest of, at its commence-
  ment.......................i. 1071
----Bibliog. and Refer........i. 1083
  — of blood-letting in........i. 1072
  — means of resisting the ex
  citing causes of.............i. 1069
  — proximate cause of........i. 1053
  — author's  views as  to the
  proximate cause of..........i 1060
  — remote causes of..........i. 1053
  — nature ofthe morbid changes
  observed after death from ... i. 1050
  — classification of its types .. i 1048
  — the removal of congestion
  and local determinations of
  blood in....................i 1078
  — doctrine  of contamination
  of the blood in, by its cause,
  examined..................i. 1059
  —■ of convalescence from.....i. 10S3
  — general course of.........i 1045
  — indications of cure in.....i. 1071
  — definition of..........___i 1038
----general description of..... i 1041
  — diagnosis of..............i. 1044
  — inflammation ofthe eye aft
  er.........................i 1021
  — symptoms and treatment of i. 1021
  — food and drink in.........i 1082
  — the forms or types of......i 1048
----management and regimen
  of patients in...............i 1082
----milk, noticed.............   536
  — produced by the primary
  affection  of organic nervous
  system.....................l 1061
----doctrine of the primary af-
  fection of the  nervous  system_
  in, examined.............• • i- 1061
____connexion of gastro-enteric
  disorder with...............   ii.  31
----the pathology of.......i 1053-09
----general inference respect-_
  ing the pathology of.........i 1069
----opinions of the ancients as
  to the pathology of........i 1053, 5
----opinions of the moderns as
  to the pathology of.......i 1056-60
----opinions of the older  writ-
  ers on the pathology of---i 1055-6
----prognosis of..............\- 1051
Fever, means for promoting the'
  secretions  and   excretions
  in.......................i- 1077-S
----the promotion of the secre-
  tions and excretions a thera-
  peutical principle in.........i 1077
----of relapses of.............i 10S3
----stages of the course of.... i 1045
----cold stage of.............i 1040
----stage of decline...........i. 1048
----stage of crisis'............i 1047
----stage of excitement.......i 1040
----the formation  or precurso-
  ry stage of.................i 1045
----stage  of invasion.........i 1046
----the precursory or incuba-
  tive stage..................i. 1045
----stage of reaction..........i 1047
----terminations of...........i 1049
----curative treatment of.....i 1071
----general treatment of......i 1069
----prophylactic treatment of. i. 1069
----the types or forms of......i 104S
----the types of, classified___i. 1048
----means of moderating  ex-
  cessive vascular action in... .i. 1072
----of vascular depletion in.. .i. 1072
----general view of..........i. 1040
----of supporting vital power
  in.........................i 1070
Fever, adynamic  See, also, Ty-_
  phoid fever.................i 110?
  — ardent, fevers comprised
  under......................i 1136
  — bilio-gastric, definition of.. i 1150
----bilio-gastric, description of i 1150
  — congestive or synochoid pu-
  erperal. ....................567-70
----the congestive, doctrine of,
  examined..................i. 1060
Fever, continued, arrangements
  of, by authors............i 112-8-32
  — classifications of.......i. 1128-32
  —  remarks on the classifica-
  tion of..................i 1129,32
  — continued, definition of ... i 1123
  —  circumstances influencing
  the prognosis...............i 1135
  — prognostic symptoms of i 1132-36
  — ephemeral, after parturi-
  tion........................    548
----feigned..................i 1032
----gastric, after parturition,
  symptoms and treatment of..    543
Fever, gastro - bilious, Bibliog.
  and Refer..................i 1155
----gastro-bilious, causes of... i 1153
----means of cure for.........i 1153
----description of............i. 1150
----diagnosis of..............i 1152
—■- duration  and termination
  of.........................i 1152
----prognosis of..............i 1153
----treatment of.............i 1153
Fever, hectic, defined.   See also
  Hectic Fever...............i 1123
----hectic, varieties of.....i. 1124,5
Fever, idiopathic,  characters of i. 1040
--------description of its phe-
  nomena ..................i 1040,1
Fever, inflammatory or ardent,
  Bibliog. and Refer..........i. 1150
----  ----  appearances  after
  death from.................i 1141
----defined..................i 1137
---■ doctrines of, examined... .i. 1061
----forms of.................i 1137
----treatment of.............i 1145
--------during excitement.. .i 1146
--------during exhaustion... i. 1147
----mild form of.............i 1137
--------complications of.....i. 1138
----severe...................i 1139
--------causes of............i 1142
--------duration of..........i. 1142
________history of...........i 1140
--------nature of...........i 1143
________terminations and prog-
  nosis.......................i 1141
Fever, intermittent.   See, also,
  Ague......................i- 10-5
____intestinal, after parturition,
  symptoms and treatment....    54S
i. 10251____of refrigerants in.........i 1075.----low nervous..............i. 1151 
1588          FE                               INDEX.                              GA
Fever, malignant puerperal, ap-      iFevers, defined...............i HOOTood of the parents may cause
  pearances after death from .. 575-8----described.   See, also,  Re-        scrofula_in the offspring....   803
— appearances after  death      |   mittents...................i. 1100----and drink, as causing dis-
  from, as  described by several      IFibrous tissue,  alterations of.. .i. 1230;  ease............... • • ■ ■ • • • • l ood
  writers        .....■ •.......   678----Bibliog. and Refer........i 1233----of the young  in relation to
____of the states of the blood in   574----inflammation of..........i 1233  scrofula.................... 804,6
____causes of................   570 Filaments and fibres of morbid        — poisons,   symptoms   and
----inflammatory puerperal... 565-7
----pathological inquiries  re-
  specting puerperal..........   579
  growths described...........    775   treatment of................  425, 9
Filarise, systematic description      |Fool's-parsley, poisoning by---    474
  0f..........................  1542; Formations, parasitical and oth-
                                      ers, may be thrown off by pro-
                                      moting organic, nervous, and
                                      vital power.................   1142
____of the prominent states of. 572^4 Filaria Medinensis, history and
____symptoms and states of... 570-5,  localities of.................   1543
____of certain symptoms of.... 572-4----preventive treatment of...   1560
Fever, mucous, appearances aft-       ----symptoms and diagnosis of   1542 Formative period in infectious
  er death from...............i 1157:----systematic description of..   1542|  diseases..................ii. 411,3
----Bibliog. and Refer........i. 115S----synonymes of............   1543 Forms   and  modifications  of
causes of................i. 1157----treatment, curative, of.
defined..................i. 1156 Fingers and nails, alterations of,
15601
— diagnosis of..............i. 1156]
—• duration, termination, and
 prognosis...................i. 1157|
  phthisis....................1203-8
Fotus Conii............F. 796. Ap. 30
phthisis.................  1202 Fragility of bones............ii. 105
France, climate of certain parts
  of.......................... i. 413
                                     — and nails, signs of disease
                                      furnished by................   1067
     symptoms of.............i. 1156'Fish-diet inlndigestion........ii. 394]Freckles, described............ i. S7S
.___treatment of.............i 1157 Fish poisons, sources of........    426'Fumigation, of its use in phthisis  1270
Fever, rhenmatic.   See,  also,       ,----symptoms of.............    425 Functional conditions consequent
  Rheumatism................   664----treatment  of.............    427;  on age.....................  i. 53
----scarlet, pathological infer-       i Fish-skin disease described. See,
  ences respecting............   7511  also, Ichthyosis.............ii. 360
____severe or complicated con-       Fistula,  gastro-colic, diagnosis
  tinned.....................i. 1163|  of..........................   150S
----simple continued.........i 1162 j----gastro-intestinal, diagnosis
Fever, sweating, malignant  or       |  of.........................   1404
  complicated................i 1160jFistula in ano,  described......    052
----Bibliog. and Refer.......i 1102----complicating phthisis.....   1214
----causes of.................i 11611 Fistula, renal, remarks  on.....ii 763
----definition of.............i 1158 Flaccidity of soft solids as a sign
----diagnosis of..............i 1160]  of disease..................   1064
----histoiy of................i. 115^ Flatulence in connexion with in-
----prognosis of..............i 1160|  digestion...................ii. 382
     symptoms of.............i. 1159, Flatulency, Bi bliog. and Refer, i 123S
                                    ----of bowels,  treatment of .. .i 1237
                                    ----definition of..............i 1234
                                    ----of the intestines, symptoms
                                      and effects of...............i 1236
                                    ----of the stomach, causes and
                                      phenomena of..............i. 1235
                                    ----as a symptom............   10S1
                                    ----of stomach, treatment of. .i 1237
                                    ----symptomatic disorders con-
                                      sequent on.................i 1235
                                    ----treatment of.............i. 1237
                                    Flesh-meats in indigestion.....ii. 394
                                    Flexions of the uterus.........   1390
                                    ----treatment of.............   1393
     treatment of.............i. 1101
Fever, symptomatic, characters
  of..........................i 1044
Fever, synochoid, defined.  See,
  also, Synochoid fever........i. 1102
---- typhoid.   See,  also, Ty-
  phoid fever.................i 1108
Fever, typhus.  See, also, Ty-
  phus.......................
Fever  yellow.   See Pestilence
  haemagastric...............
Fevers,  malignant  puerperal,
  symptoms and causes of.....570-8
     origins  and symptoms  of
11S1

 152
synochoid puerperal.........   507 Flooding, during delivery,  ex-
Fevers,  periodic.   See  Agues
  and Intermittents...........i 1085
Fevers, puerperal, arrangement
ternal......................ii 132
   internal.................ii 132
   remedies advised for......ii. 130
Function,  impaired  or  lost,
  should be restored..........  1142
Functions and mechanism ofthe
  spinal cord.................    43
Fungi, poisonous,  symptoms of
  poisoning by............... 475-6
----appearances in fatal cases.   476
Fungo-haematoid tumour of  the
  liver.......................ii. 872
Fungo-haematoid disease of  the
  pancreas...................    10
Fungoid disease, complications
  of..........................i.1245
----description of............i. 1243
----Ribliog. and Refer.......i. 1249
----causes of.................i. 1246
----definition of..............i. 1243
----diagnosis of..............i. 1245
----origin of.................i. 1247
----prognosis of..............i. 1247
----progress and duration of. .i 1245
----treatment of.............i. 124S
Furuncle, Bibliog. and Refer...i. 1253
----asthenic, described.......i. 1250
---------treatment of........i. 1251
----sthenic, described........i 1250
---------treatment of.........i 1250
Furuncular eruptions, defined. .fc 124!)
Fusiform cells, described......   774

                 G.
                                                                      Gall-bladder, of calculi in.....i. 459
of their forms and states.....552-4---- during labour, treatment      I----diseases of...............   ii 1
    ■ author's  arrangement  of
  their forms and states.......   553
----exciting causes of........   555
----predisposing causes of ....   555
----commencing before deliv-
  ery ........................   570
----diagnosis of their  several
  states...................... 581-3
----their connexions with epi-
  demic and endemic diseases . 561,2
----their connexion with  ery-
  sipelas .....................559-01
----infectious, nature of......556-9
----author's  inferences as  to
  the prevention of...........   561
----pathological inferences re-
  specting ...................   584
  of..........................ii. 136'.
----treatment subsequently to ii 138]-
---- after  delivery, treatment
  of..........................ii. 138.
Fluid, the cerebro-spinal, in con-       ].
  nexion with palsy...........     3S -
Fluids, the circulating, contam-       i.
  ination of.................1041-50
----effused in dropsy,  charac-
  ters of.....................  i. 692
Foetus.  Bibliog. and Refer, to
  diseases of..................i 1242 •
     death of the, causes of____i. 1239'.
   excessive distention of___   ii. 4
--------diagnosis of.........   ii. 5
-------pathology of........   ii 5
--------treatment of.........   ii. 0
— inaction of the...........   ii 2
— complications of torpor of .   ii 3
— andMucts, causes of their
 torpor.....................   ii 4
— diseases  of, Bibliog. and
 Refer......................   ii 8
— accumulations of bile in...   ii 2
-------symptoms of........   ii 3
   inflammation of, defined ..   ii 6
----death of, from syphilis---   1481'---------alterations caused by.   ii 6
----diseases causing death of . i.  1239'---------symptoms of........   ii. 6
 — diseases observed in the.. .i  1238'---------treatment...........   ii. 8
     small-pox in the..........   895'----torpor of.................   ii. 2
                                         ----treatment...........   ii. 4
                                         ducts, disease of..........   ii 1
                                         ----inaction of the.......   ii. 2
   literary notices of........ 550-2!----syphilis in the...........1480-1
— periods of commencement.   509----syphilitic, infected from one
— periods of occurrence from       I  or both parents.............14S0-1
parturition............_.---   534 Fomites, of infection by.......ii. 408
     prognosis of their different
  forms...................... 583,4
----synonymes and definitions
  of..........................   549
----treatment of.............5S5-93
----their types and forms de-
  scribed ..................... 562—4
Fevers, putro-adynamic, treat-
  ment of, in..............i 1211-14
----treatment of their complica-
  tions .......................i  1214
----treatment of their modifica-
  tions.......................i  1213
Fevers, remittent, Bibliog. and
  Refer......................i.  1121
                                    ---------spasm of............   ii. 3
                                    --------spasm, &c, of.......   ii 7
                                    Gall-stones.  See, also, Concre-
                                      tions  biliary..............i. 458-63
                                    ----notices of................ii 6,7
                                    ----passage of, resembles poi-
                                      soning by corrosive poisons ..    371
  — m fever.................i. 10S2 Ganglia, agency  of, in sympa-
----kinds of, advised for indi-      |   thies.........,............1030-33
  gestion---...............ii. 393,7 Ganglial  nervous  system,  re-
----of man in  relation to cli-         fleeted actions of the........     40
  ma.te......I--,-;----:••.•••• '• 407----system, its influence on the
—- in respect of the varieties of      I   blood and circulation.       1041-50
  the species................. i. 407 Ganglial neuralgia.........  ii  1013
     its influence in disposing to      ^Gangrene, from various physical
                                      nf--ents.....................  h. 15
Fomentum Camphoratum
                      F. 157. Ap. 10
Food, changes in the blood pro-
  duced by................... i 237
---desire of, &c, as a sign of
  disease.....................  10S0
phthisis....................   12361 
GA
INDEX.
GO          1589
Gangrene, from diseased or de-
iGast.odynia, diagnosis of......   99SGlos.sitis, complicated and symp
    See, also, painful affections
 of the stomach..............
— prognosis of..............
— various remedies for......
998-
  composed animal matters___ ii 17
----from fibrinous  and ossific
  formations in arteries....... ii. 13
----Bibliog.  and Refer.......[ ii. 28
----of cellular tissue......... ii. 10'----symptoms of.............   99S
----from obstructed circulation ii. 12]----synonymes and definition ot  997
----from intense cold......... ii. 1GI----treatment of.............   999
----constitutional symptoms of ii. 19;Gastro-enteric disease.........  ii. 29
----constitutional treatment of ii. 23]----Bibliography and Refer...  ii. 34
----indications of cure of.....» ii. 22;----in connexion with fevers..  ii. 31
----definition of.............  ii. 9!----■----with affections of the
----from vital exhaustion..... ii. 121   genito-urinary organs.......  ii. 33
----of fibrous tissues......... ii. 11 ]---------with gout...........  ii. 33
----from disease of the heart.. ii. 14---------with hepatic affections  ii. 32
----from excessive heat...... ii. 10---------with  mesenteric dis-
----Hospital, description of... ii. ISi   ease........................  ii. 33
--------treatment  of........ii. 24, 6----in its relation to diseases of
----from inflammation of inter-      j   the skin....................  ii. 33
  nal coats of arteries......... ii. 13 —— therapeutical indications in  ii. 34
----of the integuments....... ii. 10 Gastro-enteritis, described.....  ii. 29
----of the lungs..............ii. 907----morbid relations of.......  ii. 30
----of mucous membranes___ ii. 11----connected with cerebro-spi-
----from extremes of tempera-      |   nal affections...............  ii. 30
  ture....................... ii. 16---------with disorders of the
----from lesion of nerves..... ii. 15!   respiratory organs..........  ii. 30
----from obstruction of arteries ii. 13----in relation to increased vas
----from obstruction of veins.. ii. 14;   cular action................  ii. 31
----pathological relations of ..  ii. 9]----asthenic, complicating scar-
----of the phenomena connect-      |   let fever....................   735
  ed with.................... ii. 10 Gastro-intestinal  canal, morbid
----from poisons............. ii. 171   changes of..................  i 619
----from animal poisons...... ii. 19 Generation,  alternation  of,  in
---- symptoms caused by the      |   worms.....................   15
  several pathological states of ii. 19-22----of worms, circumstances fa-
---- treatment of  the several      I   vouring....................   1520
  pathological states of........ ii. 22---------considered..........   1520
----termination of........... ii. II1---------means preventing the   1551
----treatment of............. ii. 22 Genc-is of worms.............   1420
----local treatment of........ ii. 20 Genito-urinary organs, their dis-
----regimen and diet for...... ii. 27]   orders in connexion with gas-
----complicating scarlet fever.   736'   tro-enteric disorder..........  ii. 33
----of serous membranes..... ii 11 Giddiness, described.  See, also,
Gangrenous ergotism.......... ii. 171   Vertigo....................   1495
Gargarisma  Acidi  Hydrochlo-      [Girlhood, remarks on..........   i. 49
  rici.................F. 15S. Ap. 10 Glanders, Bibliog. and Refer...  ii. 37
----Acidi Hydrochlorici Com-      ----causes of.................  ii. 34
  posit................F. 159. Ap. 10----acute farcy in  the human
---Antisepticum.....F. 160. Ap. 10,  subject.....................  ii. 35
---Astringens .......F. 161. Ap. 10----chronic farcy.............  ii. 35
---Astringens Zobellii             ]---.----forms  of.............  ii. 35
                      F. 162. Ap. 10--------definition of.........  ii. 34
---Bi-boratis Sodae.. .F. 163. Ap. 10--------description of........  ii. 34
---Catechu Thebaiacum            ;----associated with acute farcy  ii. 35
                      F. 174. Ap. 10--------nature of............  ii. 36
---Capsici..........F. 797. Ap. 30]--------prevention of........  ii. 36
---Commune........F. 105. Ap. 10,--------prognosis of.........  ii. 36
---Potassae Nitratis F. 166, 7. Ap. 10----simple acute, in the human
---cum Soda; Chlorinata            J   subject.....................  ii 35
                      F. 798.  Ap. 30---.----appearances after death
---Stimulans........F. 799.  Ap. 30,   from.......................  ii. 35
---Zinci Sulphatis___F. SOU  Ap. 30,--------treatment of.........  ii. 36
Garrisons and camps, protection      ;Glands, bronchial,  tuberculosis
  of, from pestilence.......... 272-3   of..........................1221,2
Gastric affections, feigned.....i 1032--------tuberculosis of, in chil-
Gastritis, acute or phlegmonous 10021   dren.......................
----acute or severe states of,      ]----enlarged intestinal, notices
  described...................1003-5;   of..........................
--------treatment of.........  1007----lymphatic.  See, also, Lym-
--------appearances after death      |   phatics, &c.................ii. 923
  from.......................  1005'----disease of, from absorption
        ■ causes of............  1000
----chronic, described........  1005
--------intentions of cure in .  100S
--------definition  and  syno-
  nymes of...................  1000
--------description of........  1001
--------diagnosis of.........  1006
--------diagnosis between and
  peritonitis..................    91
--------diagnosis between and
  poisoning...................   372
--------forms and states.....  1001
----mild forms of.............  1002
---------treatment of.........  1007
--------prognosis of.........  1007
--------seats and varieties of.  1001
----sub-acute form described..  1003
---------treatment of.........  1007
----sub-acute   and   chronic,
  treatment of...............•  100S
----treatment   of  pain   and
  spasm in...................  100S
Gastrodynia, causes of.........   998
  of morbid matters...........ii. 920
----mesenteric, diseases of the.
  See, also, Mesenteric disease . ii. 983
----Peyer's, ulceration of.....ii 676
----diseases of, consequent upon
  Bcarlet fever................   739
----affections of the sebaceous
  glands of the skin...........   867
Gleet, treatment advised for ...  145S
Globules of the blood, their met-
  amorphosis and waste.......1043-5
Glossitis, acute,  course  and ter-
  mination of.................  1177
  -------described...........  1177
  _______treatment of.........  1179
  — asthenic acute, described .  1177
  _______course  and  termina-
  tions of.....................  117S
  -------treatment of.........  1180
  -------causes of............  1178
  — chronic  superficial,   de-
  scribed .....................  1179
  -------treatment of.........  1181
      tomatic....................  1178
             treatment of.........  1181
998----partial, described.........  1179
999]---------and superficial, treat-
      ment of....................  H81
    ---------prognosis of the forms
      of......... ................  1179
    —*- sthenic acute, treatment of  1180
    ----superficial, noticed.......  1178
    Glottis, oedema of the..........ii 789
    ----spasm of.   See, also, Lar-
      ynx, spasm of............ ii 777-84
    ----hysterical spasm of.......ii 784
    ----treatment of.............ii 784
    Goitre,  described.   See  Bron-
      chocele..................... i 323
    Gold,  poisoning  by the hydro-
      chlorate, chloride, and iodide of   3S5
      — treatment of.............   380
    Gonorrhoea, antiquity of.......1458,9
    ----complications of..........  1455
    --------their treatment......  1457
    ----diagnosis between and leu-
      corrhcea .................ii. 818,23
    ----in males, described.......  1454
    ----regimen and diet for......* 1457
    ----remedies advised for......  1450
    ----symptoms  of rheumatism,
      connected with.............   672
    ----secondary effects of.......  1455
    ----synoni/nies&nddefinition of  1454
    ----a distinct  disease from sy-
      philis ......................  1460
    ----treatment of.............  1455
    ---------in females...........  1456
    ---------in males............  1456
    ----abortive treatment of, dis-
      approved ...................  1456
      — treatment of first stage of.  1456
      -------of the second stage of  1456
      -------of its third, or chronic,
      stage.......................  1457
      — of the vulva..............  1431
    Gonorrhoeal ophthalmia.   See,
      also, Ophthalmia, gonorrhoeal i 1002
    Gout,  acute, diagnosis of......., ii 44
    --------- history of...........  ii. 3S
    -------------of the regular pa-
      roxysm of..................  ii. 38
    ---------prognosis of.........  ii. 45
    ---------the sequelae of.......  ii. 40
    ---------treatment of.........  ii. 53
    ---------empirical treatment of ii 00
    ----anomalous, or affections  of-
      ten  preceding...............  ii. 42
    ----atonic or masked.........  ii 43
    ----author's opinion  as  to  the
      pathology of................  ii. 49
    ----Bibliog. and Refer........  ii. 70
    ----causes of.................  ii 40
    ----exciting causes of.........  ii. 47
    ----predisposing causes of.....  ii. 40
    ----chronic, described........  ii. 40
    ---------concomitants and con-
      sequences of................  ii. 41
    —-------diagnosis of..........  ii. 45
    ---------prognosis of.........  ii. 40
    ---------treatment of.........  ii. 61
    --------local treatment of....  ii. 02
    ----definition of..............  ii. 37
    ----disguised or lurking......  ii. 43
    ----remedies  prescribed  for a
      fit of.......................  ii. 54
    ----local treatment of the fit. ii. .>, 9
    ----treatment  of, after the fit.  ii. 5'.)
    ----its connexion with gastro-
      enteric disorder.............  ii. 47
    ----of irregular..............  ii. 46
    ---------various tenns used for ii. 41
    --------treatment of........ii. 63,4
    ----of  mineral and  thermal
      waters in...................  ii. 66
    ----retrocedent or displaced ...  ii. 42
    ---------treatment of.........  ii 63
    ----opinions of authors on  the
      pathology of..............ii. 48,52
      — pathological states consti-
      tuting ......................  ii. 48
      — prevention of.............  ii. 67
      — treatment of, advised by the
      ancients....................  ii. 52
      — treatment  of, misplaced...  ii. 64
      — treatment of the partxysm of ii. 54
1222

 784 
1590          GR
INDEX.
HA
Grades of morbid action....... i 681,H8ematemesis pathological infer
Grain, spoilt, &c, injurious ef-
  fects of.....................
Granular cell, compound,  de-
  scribed .....................
Gravel  in the  urine,  appear-
  ances of....................   1339
________defined and explained   1339
Greasy degeneration of the sub-
  stance of the heart........ii  250,1
—— signs and symptoms of.... ii 251
Green-sickness, described......i 371
Growths.  See, also, Tumours..    768
----cancerous, kinds of, degen-
  eration of...................    786
----cancroid and non-cancroid,
  described...................769-87
----cartilaginous cancroid, de-
  scribed.....................    7S2
--------diagnosis  of.........    781
----epithelial   cancroid,   de-
  scribed.....................779,80
--------diagnosis  of.........    791
----fatty-cancroid............    783
----fibrous-cancroid, described    780
--------diagnosis  of.........    791
----confervoid,  or  fungoid,  in
  urine......................   1339
----cystic, described.........    780
----degeneration of cancerous
  and cancroid...............    7S6
—.— mechanical and vital effects
  produced by................    783
----enlargement of, from blood-
  vessels .....................    7S7
----fibro-nucleated, described.    779
   |   ences as to.................ii. 113
476----pathology of..............ii. 109
   ----pathognomonic  symptoms
774   of..........................U.112
   i----primary, or  simple,  de-
      scribed..................... ii 109
    ----prognosis of..............ii. 114
   ----regimen for..............ii 117
   ----from disease of viscera con-
      nected with the stomach.....ii. 110
   ----from disease of the vessels
      of the stomach..............ii 111
   ----succedaneous, or vicarious, ii. 110
   ----premonitory symptoms of.. ii 112
   ----treatment  of,  during  the
      attack...................ii 115-16
   --------after the attack......ii. 116
   Ha?mato - cathartics,  enumera-
      tion of......................   1147
   Haemato-globuline, the metamor-
      phosis and waste of..........   1044
   Haematosin in urine...........   1336
   Haematuria, Bibliog.  and Refer, ii. 127
   ----causes of.................ii. 123
   ----means of cure for.........ii. 127
   ----definition of.............ii. 122
   ----description of............ii. 123
   ----diagnosis of..............ii 125
   ----pathological states causing ii 124
   ----prognosis of..............ii. 125
   ----regimen and diet for......ii 127
   ----symptoms of.............ii. 123
   ----treatment of.............ii. 125
   Haemoptysis, appearances after
      death from.................  ii. 97
----malignant, defined.......    769
—— morbid, chemical composi-
  tion of......................    776
--------elements of..........  770-0
—-------mineral and  pigment-
  al principles of..............    777
----non-cancerous,  may  they
  be transformed  into cancer-
  ous?.......................  787,8
--------pathological  relations
  of..........................    787
----non-malignant, described. 769-S7
----of primary and secondary.    7S9
----scirrhous and other morbid,
  general anatomy of.........    778
--------Bibliog. and Refer, to 796,7
-------- diagnosis of.........789,91
--------pathological  relations
  of..........................  784,9
        ■ prognosis of.........    791
----Bibliog. and Refer........ii. 107
----exciting causes of........ ii 98
----predisposing causes of..... ii 98
----complications  or  associa-
  tions of..................ii 99-101
----diverse means of cure for ii. 103-7
----definition of.............. ii. 95
----diagnosis of..............ii. 101
----causes of its frequency .... ii 96
----seat of the haemorrhage in. ii. 98
----of inhalation for the cure of ii. 107
----pathological relations of... ii 99
----the prevention of.........ii. 106
----prognosis of..............ii. 101
----regimen  during and after
  the attack..................ii 107
----premonitory signs of...... ii 96
     progress and course of___ ii. 96
     complicating phthisis.....  1211
     as  a symptom of phthisis..  1197
    ■ tubercular, described.....    783!----symptoms of.............  ii 96
Guaiacum, of its use in syphilis   1487]----treatment  for the  attack
Gummata, tubercular syphilitic   1470J  of........................ii  102-7
Gums, signs of disease furnished       ]----history of its treatment... ii. 102
  by.........................   1075 Haemorrhage, Bibliog. and Refer,  ii. 86
Gums, of various  medicinal, in       j----alterations of the blood in .  ii. 75
  phthisis....................   1271;----exciting causes of.........  ii. 78
Gutta Indurata,described......   i. 35—-— remote causes of..........  ii 77
----Rosacea, described........   i. 35]----classification of its forms by
GutttB Acetatis Morphias F. 168. Ap. 10]  the author..................  ii 79
----JEtheris..........F. 801. Ap. 30 —    — of its varieties by vari
          Terebinthinatae
                      F. 169. Ap. 10
----^Etherise Absinthii F. 802. Ap. 30
----Anodynes........F. 170. Ap. 10
---Antiloimicae......F. 171. Ap. 10
---Antispasmodics; .. F. 803. Ap. 30
---contra Spasmos. .F. 172,3. Ap. 10
 ---Nervinae.........F. 174. Ap. 10
---Odontalgic*......F. 804. Ap. 30

                 II.
Habits of life and profession, as
  predisposing to disease.......  i. 647
Haemagastric  Pestilence.   See,
  al-o,  Pestilence,  Haemagas-
  tric.......................152-217
ii;i'maphannaca,  enumeration
  of..........................   1147
Haematemesis, appearances after
  death from.................ii 113
----Bibliog. and Refer........ii 118----treatment  of, from inter-
----of black matter..........ii. Ill  rupted circulation...........  ii.  82
---exciting causes of.........ii 1121----feigned, notices of........i. 1032
----predisposing causes of..... ii. 111!----intestinal, appearances aft-
----definition ot..............ii. 108  er death by.................ii. 121
----diagnosis of..............ii. 114--------Bibliog. and l.efer.  .. ii. 122
----from organic lesions___ii 110,11---------remote causes of.....ii. 122
 ous authors................. ii. 79
— definition of............. ii. 72
— diagnosis of.............. ii. 79
— its relations to irritation .. ii 75
— of the influence of organic,
 nervous, or vital power on ... ii. 73
— prognosis of.............. ii. 79
— prophylaxis of............ ii. 85
— regimen and diet for...... ii. 85
— with reference to its seats, ii 87j
— symptoms attending...... ii. 78!
— symptoms preceding...... ii. 78
— into areolar and other struc-      I
 tures.......................ii. 143
— in the brain.............. i 268
*— from the serous membranes      j
 of brain and spinal cord.....ii. 142
— into shut cavities.........ii. 142'
— into serous  cavities, Bibli-
 og. and Refer...............ii. 143
Haemorrhage, intestinal, defini-
  tion of..................... ii IIS
  -------diagnosis of.........U. 121
  _______pathological states caus-
  ing ........................ ii 118
  -------prognosis of.........ii 121
  -------regimen and diet for. ii 122
  -------symptoms of........Ii. 121
  -------treatment of.........ii 121
  — from the liver............ii 843
  — as   indicative  of diseased
  liver.......................ii 874
  — from mouth and throat___ ii. 94
  -------symptoms  and  diag-
  nosis.......................  ii 94
  -------treatment of......... ii 95
  -------Bibliog.  and Refer. .. ii 95
----nasal, description of causes,
  and treatment of..........ii. S3-93
  -------definition of.  See, al-
  so, Epistaxis................ ii 88
----from the oesophagus......ii. 1049
     into the pericardium......ii 142
     into the peritoneum......ii. 143
  — from physical causes, treat-
  ment of....................  ii. SO
----into the pleura...........ii. 142
----from  the  respiratory or-
  gans.  See, also, Haemoptysis ii 95
----from the skin............  ii. s7
--------Bibliog.  and Refer. ..  ii 88
--------causes and history of.  ii. 87
--------phenomena and treat-
  mentof.....................  ii. S3
----in  the spleen.............    993
----from the stomach, defined.
  See, also, Hsematemesis......ii 10S
----changes in the tissues, the
  seats  of..................... ii 74
----from the urinary organs.
  See, also, Haematuria........ii. 122
----uterine, Bibliog. and Refer, ii. 141
--------during delivery......ii. 132
  -------internal, after  deliv-
  ery ........................ii. 132
  -------after  sixth month  of
  pregnancy..................ii 131
  -------prognosis............ii. 132
  -------in the puerperal state
                           ii. 130-133
  -------remedies advised for
                          ii 13S, 141
  -------treatment of........ii 133
  — from the uterus, described.
  See, also, Menorrhagia......ii 127
----changes in the vascular sys-
  tem causing................ ii 74
----treatment  of, from lesions
  of  vital  power  and vascular
  action....................ii 80-82
Haemorrhagic Congestion of the
  Mamma....................ii 933
Haemorrhoidal complaints, clas-
  sification of.................ii. 149
----discharges  described......ii. 147
---------treatment of.........ii. 152
----tumours described......ii. 145,7
'--------treatment of.........ii. 153
Haemorrhoids, Bibliog. and Ref-
  erences.....................ii 15S
----with fissures and rhagades
  of anus.....................ii 148
----with ulceration of anus ... ii. 149
----causes of.................ii 150
----various complications of... ii. 148
----treatment  of the complica-
  tions  of...................ii. 156,7
----constitutional treatment  of ii. 152
----definition of..............ii 144
----diagnosis of..............ii 150
----of the propriety of arresting
  the discharge of.............ii 152
----pathology of.............ii 145
----prognosis of..............ii. 151
----regimen and prophylaxis of ii 168
----remarks respecting........ii 144
----suppressed,  re - establish-
  ment of....................ii 158
----symptoms and character of ii. 145
----treatment of.............ii. 152
Hair, alterations of the........ii. 159
----alterations and loss of, Bib-
  liog. and Refer..............ii 164
—— effects of syphilis upon___  146S 
HA                              INDEX.                              HE           1591
nan*, effects of removing the... ii 159 Headache, arthritic,  treatment      Heart, prognosis of its diseases, ii. 201
----of excess of...............ii. 160]  of..........................ii 177----seat and anatomical char-
----felting or matting of......ii. 161----congestive...............a 169|  acters of its diseases.........ii. 198
----its growth in unusual situ----------causes  and symptoms      ----  of  the  natural  sounds of
  ations......................ii. 160  of..........................ii 170  the........................ii. 195
----loss and want of........a 162-41--------treatment of........ii 175----  of  the  morbid  sounds of
----loss of colour of...........ii 161----dyspeptic or bilious.....ii 171-21  the___-...................ii 195
 --------treatment of.........ii 162:---------causes  of............ii. 172----structure of the..........ii 193
    . morbid states of..........ii. 161!—    —treatment of.........ii. 176]----structural lesions ofthe, de-
----preternatural colour of.... ii. 162
----trichomatose, definition of. ii. 164
,--------causes of............ii. 165
--------treatment of.........ii. 166
--------Bibliog. and Refer. .. ii. 167
Hands, chronic rheumatism of.    669
Haustus  Acidi Nitrici et Opii
                    F. 175, 6. Ap. 10
---Anodynus........F. 177. Ap. 10
---Contra Emesin___F. 178. Ap. 10
---Anti-Emeticus___F. 179. Ap. 10
---Aperiens.........F. ISO. Ap. 10
---Aperiens ex Jalapa et Aloe
                      F. 181. Ap. 10
— Aperiens ex Scammonia
                      F. 182. Ap. 10
---Arsenicalis.......F. 806. Ap. 30
---Astringens.......F. 183. Ap. 10
---Balsam Peruviani.F. 807. Ap. 30
---Belladonnae et Cinchonas
                      F. 80a Ap. 30
---Boracicus........F. 184. Ap. 10
---cum Calumba et Ferro
                       F. 185.  Ap. 10
---Camphorae Comp.. F. 186. Ap. 10
---Carminativus.....F. 187. Ap. 10
---Chlorinae.........F. 805. Ap. 30
---Colchici..........F. 188. Ap. 10
---cum Colchico.....F. l->9. Ap. 10
---Conn............F. 190. Ap. 11
---Conii et Hyoscyami F. 191. Ap. 11
---Deobstruens et Roborans
                       F. 192. Ap. 11
---Diaphoreticus.....F. 193. Ap. 11
---Diaphoreticus.....F. 809. Ap. 30
---Diureticus........F. 194. Ap. 11
---Diureticus .. .F. 195, 6, 7. Ap. 11
---Emeticus excitans.F. 198. Ap. 11
---Emmenagogus... .F. 810. Ap. 30
---Guaiaci Comp.....F. 199. Ap. 11
---Hyoscyami et Anisi F. 811. Ap. 30
---Infusi Cinchonas cum Acido
  Hydrochlorico.......F. 200. Ap. 11
---Infusi  Cusparias' Composi-
  tus.................F. 201. Ap. 11
---Infusi Uvae Ursi Alkalinus
                      F. 202. Ap. 11
---Infusi  Uvae Ursi Composi-
  tus.................F.203. Ap. 11
---cum Iodinio......F. 204. Ap. 11
---Laxans..........F. 205. Ap. 11
---Nervinus.........F. 812. Ap. 30
---Pectoralis........F. 813. Ap. 30
---cum Plumbi Acetate
                      F. 206. Ap. 11
---Quassiae et Ferri. .F. 814. Ap. 30
---Quinae et Zinci... .F. 207. Ap. 11
---Salinus...........F. 815. Ap. 30
-------Aromaticus . .F. 816. Ap. 30
-------Demulcens.. .F. 817. Ap. 30
-------Sedativus___F. 818. Ap. 30
---Sedativus........F. 208. Ap. 11
-— Sedativus........F. 819. Ap. 30
-------Emolliens___F. 209. Ap. 11
-------cum Magnesia F. 820. Ap. 30
------■ et Refrigerans F. 821. Ap. 30
---contra Spasmos  F. 210,11. Ap. 11
--- contra  Spasmos  cum  Pi-
  lula Camphorae......F. 212. Ap. 11
---Stimulans........F. 213. Ap. 11
---Stomachicus......F. 214. Ap. 11
---Stomachicus  Aperiens
                      F. 215. Ap. 11
---Terebinthinatus Aperien3
                      F. 216. Ap. 11
---Tonicns Alkalinus F. 822. Ap. 30
---cum Uva Ursi___F. 217. Ap. 11
Headache, Bibliog. and Refer. . ii 181
----definition of.............}]• 101
----pathology of.............ij. 107
----prognosis of..............ii- 175
____remedies recommended for
                           ii.  178-81
  — from vascular determina
  tion........................ii. 170
--------symptoms of........ii 170
----intermittent.............ii 173
----nervous, symptoms of .... ii 169
--------treatment of........ii 175
----from organic lesions......ii. 172
----from organic or cerebral le-
  sions, treatment of..........ii 177
----partial and neuralgic.....ii. 174
----pericranial, treatment of.. ii 177
----from disease of the perios-
  teum and cranial bones.....ii 172
----plethoric or inflammatory,
  treatment of................ii. 176
----rheumatic, described.....ii. 173
--------treatment of........ii 177
----topical remedies for......ii. 180
----varieties depending on path-
  ological states..............ii. 169
----diagnosis of the pathologic-
  al varieties.................ii 174
---- various forms, treatment
  of..........................a 178
Headaches, during pregnancy .   503
-------treatment of........   504
---rheumatic, notices of.....   673
Health, defined............... i 644
Hearing, impaired or lost......ii. 182
----symptoms furnished by...  1071
Heart, actions of the..........ii. 194
----arrangement of its diseases ii. 200
----auscultation of........... i 204
--------morbid sounds of___i 205
----Bibliog. and Refer, to the
  diseases of.................ii. 203
----causes of its diseases......ii 197
---- communications  between
  the sides of the.............ii. 260
---- complication  of  its  dis-
  eases.......................ii 201
----course, duration, and term-
  ination of its diseases.......ii 201
----dimensions and weight of,
  in health and disease.......ii. 194
----disease of, causing dropsy, i 607
----lesions of, their influence
  in complicating disease.....ii 1050
  — alterations of its blood-ves-
  sels........................ii 260
  — alterations of its  consist-
  ence .......................ii. 249
  -------treatment of........ii. 250
  — atrophy of the...........ii. 195
  -------its characters.......ii 248
  -------its causes...........ii. 248
  -------symptoms and treat-
  ment of....................ii. 248
  — carcinoma, &c, in the___ii. 254
  — contractions of the cavities
  and orifices of..............ii 249
  -------treatment of........ii 249
----cysts and hydatids in the . ii. 253
     dilatation of its cavities... ii. 244
     ----of its orifices........ii. 244
-------------treatment of.... ii. 246
--------causes producing dila-
  tation of the  cavities and ori-
  fices of.....................ii 244
---------signs and symptoms
  of..........................ii 245
_________progress, termination,
  and prognosis of............ii. 246
____lesions of the orifices of ... ii 212
---- lesions producing  rupture
  of the......................ii. 258
____lesions of the valves of the  ii 213
----local signs of its diseases.. ii 199
----intimate  nature  of its  le-
  sions.......................ii. 198
----nature of its diseases.....ii 200
----states of, affecting the pulse   598
     morbid sympathies of.....  1038
  fined.......................ii. 235
----symptoms and signs  fur-
  nished by..................  10S6
----general symptoms of its dis-
  eases  ......................ii. 199
----symptoms of disease of the
  valves of.................ii. 212-13
----treatment of its diseases., ii 202
----treatment of organic  dis-
  eases of....................ii. 203
----general view of diseases of
  the........................ii.197
----increased action ofthe.  See,
  also, Palpitation............ii. 204
----impaired action of the  .... ii 203
--------treatment of........ii. 204
----irregular action of the .... ii. 203
  -------treatment of........ii 204
  — dilatation of  the cavities
  and orifices of, when caused
  by diseased valves........ii. 244,6
  -------treatment of........ii. 246
  — displacement of the.......ii 262
  -------causes of............ii. 262
  — endocarditis, treatment of. ii. 229
  — fatty degeneration of, signs
  and symptoms of............ii. 251
  -------described...........ii 250
  -------treatment of........jx. 252
  — fibrinous concretions in the
  cavities of the..............ii 255
  -------from internal  cardi-
  tis.........................ii. 255
  -------from morbid matters
  in the blood................ii 255
  —  malignant  formations  in
  the......................a 253,54
  — functional disorders ofthe . ii. 203
  -------Ribliog. and Refer. .. ii. 206
  — gangrene of the..........ii. 221
  — hypertrophy of the... .ii 195,235
  -------description of.......ii. 236
  -------nature and causes of. ii. 237
  -------complications of.....a 238
  -------diagnosis and  symp-  '
  toms.......................ii. 240
  -------influence of, on the ce-
  rebral circulation...........a 239
  -----------on the pulmonary
  circulation.................a 240
  -------prognosis and termina-
  tions of....................a 242
  — hypertrophy of the com-
  partments, signs of..........ii 241
  -------treatment of.......ii. 242,3
  — treatment of  hypertrophy
  from diseased valves........ii. 243
  — induration of............a 250
  — indurations,  cartilaginous
  and osseous^of the structure
  of..........................a 222
  — infiltration of  blood in the
  structure of................ii 250
  -------of serum in the struc-
  ture of.....................ii. 250
  — inflammations of the.  See,
  also, Carditis...............ii. 208
---------Bibliog. and Refer.,
  &.C.........................ii. 234
  -------exciting causes of.... ii. 225
  -------predisposing causes .. ii 224
  — inflammation  of, in chil-
  dren.......................a 233
----complications of its inflam-
  mations ....................ii 227
----diagnosis of inflammations
  of..........................a227
  — inflammations  of, duration
  and termination...........ii. 228,9
  — inflammation of the endo-
  cardium.  See, also, Endocar-
  ditis .......................a 209
                                                                         inflammations  of,  then-
treatment of.............ii- 175]----pathological* causes  of its      j  prognosis.................ii. 22S, 9
arthritic, or gouty........a 1731   diseases....................a 1981--------their relapses.....a 230,31 
1592          HE                              INDEX.                              HY
Heart, inflammation of the sub-       [Hemiplegia, chronic, treatment
  stance of the.  See, also, Car-         of............  ............
  ditis vera...................ii. 220]----intermittent,  noticed.....
____treatment of inflammations       'ilemiplegic paralysis, treatment
  of.......................ii. 229-331  of.......  ..................     45]
_________of  inflammatory dis-       ! Hemlock dropwort, poisoning by   476
  easei- of the.................ii 202 Hemlock, symptoms of poison-      ]
________of inflammations of, in       [  ing by.....................   465!
  children....................ii 234 Henbane, diagnosis of poisoning
____neuralgic or painful  affec-       |  by.........................    466
  tions of  the.................ii. 206Hepatalgia, description of.....ii. 838
________causes of............ii. 2(17 Hepatic diseases,  causes of, in
________diagnosis of.........ii. 2i 17   different climates...........ii. 830
--------treatment of........ii 207
----obesity of the............ii. 250
--------treatment of........ii 252
----cedema of, described......ii. 250
____osseous and  cartilaginous
  formations in the...........a 222
---- palpitations of, after par-
  turition ....................   540
--------during pregnancy ...   503
----percussion of the region of
  the........................a 197
----perforation of one of its cav-
  ities .......................ii 222
----polypous formations in the
  cavities of the..............ii. 254
----ruptures of the...........ii. 257
---------seat and history of... ii. 257
----rupture of the valves of... ii. 259
--------causes of............a 259
--------symptoms and diagno-
  sis of. ......................ii. 200
----partial rupture of.........ii. 259
---- inflammatory softening of
  the........................ii. 221
----different kinds of softening
  of..........................ii. 221
----symptoms of inflammatory
  softening of................ii 224
----non-inflammatory or chron-
  ic softening of the...........ii. 249
--------symptoms of........ii. 249
----tubercles in the..........ii. 252
----tumours of various kinds in ii. 253
----ulceration of the.........ii 222
----unnatural positions of .... ii. 262
--------causes of............ii. 262
Heart-affections, feigned.......i 1032
Heart and pericardium, adven-
                                  Hooping-cough, external means
                                    advised for.................ii. 290
                                  ----plans and means of cure ad-
                                    vised for.................ii 283-90
                                  ----opinions as  to  the  nature
                                    and seat of...............a 279-82
                                  ----prognosis of..............a 283
                                  [----synonymes of.   See, also,
                                    Pertussis...................ii. 273
                                  ----treatment of.............ii 284
                                  ----specific modes of treatment
                                    advised by authors..........ii. 2S6
                                  ----complicated with  abdom-
                                    inal disorders...............ii 275
                                  ---------with inflammatory ir-
                                    ritation of the brain, or of its
                                    membranes.................ii. 277
                                  ---------with bronchitis......ii 276
                                  ----description of complicated. ii. 275
                                  ----treatment of complicated.. ii. 285
                                  --------of the bronchitic com-
                                    plication ...................ii 285
                                  ----complicated with cerebral
                                    disease.....................ii 275
                                  --------treatment...........a 2S5
                                  ----complicated with intestinal
                                    disorder....................ii. 277
                                  ----with phthisis.............ii. 277
                                  ----with pneumonia..........a 270
                                  ----treatment of,  complicated
                                    with pneumonia or pleuritis. .a 2*5
                                  ----description of simple......ii. 273
                                  ----treatment of simple.......a 2S4
                                  ----various complications, treat-
                                    ment of....................ii 286
                                  Hordeolum, described.........i 1250
and sub-acute..'...........ii. 845-7[Hospital gangrene, described .. ii. 18
  ■ seats and forms of......ii. 844-5t----treatment of............ii. 24,26
   termination in absccs___a 849;Iluman  species, the  relations of
     feigned..................i 1033
----their connexion with gas-
  troenteric affections........  ii 32
----influence of races on......ii. 833
Hepatic  functions, sympathies
  of..........................   103G
Hepatic ileus, described.......i. 42S
Hepatitis, of blood-letting for .. ii. 855
----complications of..........ii. 853
--------with dysentery, <fcc... ii. 853
---------with fevers..........ii. 853
---------with gastritis.......a 854
----consequences and termina-
  tions of..................ii  849-53
----definition of......'.......ii. 844
----diagnosis of..............ii. 853
----use of mercurials in.....a 855-8
----relations of, &c...........ii 844
----relations as to climate and
  constitution................ii 844
----prognosis in acute and sub-
  acute ......................a 854
    • seats and symptoms of acute
. treatment of, in Europeans
climate to the varieties of___i 404
in warm climates...........ii. 859lHydatidic cysts, description of. ii. 293
       • of acute and sub-acute
                          ii. 855-64
-------ofthe complications of
 acute......................ii 860
   • chronic  seats  and  symp-
 toms of....................ii 848 -
-------prognosis in.........ii. 855 -
-------treatment of........ii. 864 -
— chronic, of the nitro-muri-  /     j-
 atic acids in................a 865 ■
Hydatids, Lilliog. and Refer. . a 297
----in bones................ii 1059
----remote   and  immediate
  causes of...................ii 296
     definition of..............ii. 292
                                                                             in the heart..............ii. 253
                                                                             of the liver..............ii 872
                                                                             seats of..................ii. 296
                                                                             symptoms of.............ii 297
                                                                            ■ treatment of.............ii. 297"
  titious formations in the.....ii. 252 Hereditary predisposition to in-      \----in the urine..............  1338
 -------signs of.............ii. 2521  sanity......................ii. 555 Hydrencephalocele,  or  watery
 — Bibliog. and Refer......ii. 202-7----predispositions  to  disease,      I   hernia of the brain.......... i 277
 — diseases ofthe...........ii. 193   described.................i. 645-51 Hydrocephalus, definition of... i 752
 — introductory remarks on       I Hernia cerebri, described......i. 277----acutus, appearances after
  their diseases...............ii. 1931----of the ovarium..........ii. 1000!   death...................... i 750
Heartburn, described.........ii. 3S0iHerpes circinatus, description of ii. 2(58--------duration of.......... i. 756
Heartburn,  &c,  during  preg-
  nancy .....................   502
--------treatment of........   502
llent, its injurious effects, when
  excessive..................   409
Hectic fever, Bibliog. and Refer, i 1128
----causes of................i. 1124
----defined..................i 1123
----description of............i 1123
----nature, &c, of...........i 1126
causes of............i 760
exciting causes of___i 761
predisposing causes of i 760
definition of......... i. 752
diagnosis of........i 757,9
                                             described...........ii 20t>
                                    ----labialis, described........a 268
                                    ----phlyctrenoides,  description
                                      of.........................ii. 207
                                    ----preputialis, described.....ii. 26S
                                    ----zoster, description of.....ii 267|—    ---forms and stages of..  i. 753
                                    Herpetic eruptions, Bibliog. and       '---------history of...........  i 753
                                      Ref it......................ii. 271--------literary history of its
                                    ----causes of................ii. 269|  treatment..................  i 763
                                 ._. ----definition of.............ii. 267,---------indications and means
     pathological causes of... i 1124-51----diagnosis of..............ii. 269  of cure............... .....i. 764
----prognosis of..............i 1125'----treatment of.............ii. 270----■---- medicines and means
----regimen and diet in......i 1128(Hiccough, causes of...........ii 271 j  recommended for..........i  704-8
----treatment of.............i. 1127:----diagnosis and prognosis of. ii. 272---------pathological inferences  i. 702
--------ofthe several varieties       '----Bibliog. and Refer........ii. 272---------pathological  opinions
  of.........................i 1127----definition of.............ii. 271'  respecting..................  i. 701
----varieties of............j. 1124,5
Hellebore and Veratria, poison-
  soning by..................   424
     treatment of.............ii  272 ■
Hip-joint, chronic rheumatism       I
  of.........................067-9
treatment of........   425jHippomane Mancinella, poison-       ----
Helmintha, general description
  of.........................1520-30
Hemeralopia, description of .. .ii. 1032
 ---treatment of............ii. 1033
    - synonymes and phenomena
390-
       prognosis of.........  L 759
       prophylactic treat-
ment of....................  i 769
   ----treatment of........i. 763
   hyper-acute, described....  i. 756
       treatment of........  i. 70S
                                      ing by
                                    History of early appearances of
                                      venereal diseases..........1459-63!----sub-acute, description of..  i 757
                                     — literaiy,  of venereal dis-      !--------appearances after death i. 757
                                      eases.....................1459-63,---------treatment of........  i 76S
  of.........................ii._ 1029 I lome-sickness, described.....ii 1033 j----chronic, appearances after
Hemicrania, described........a 174 Honey,  poisonous,  symptoms      ;  death......................  j. 773
Hemiplegia,  accession  of,  de-
  scribed.....................
 — its  connexion  with  apo-
  plexy ......................
 — description of............
 — diagnosis of..............
 — states and sources of......
 — consequent upon inflamma-
  tory Boftening, treatment of..
  |   caused by..................   430'
lGjHooping-cough,  Bibliog.  and
     Refer................".___ii. 291,2
16'----causes of................ii 2S3
16|----definition of.............ii. 273;_____
      ■ diagnosis of..............ii. 282!
17----appearances observed in fa-      .
  1   tal cases of.................ii. 278:
46----literary history of........ii. 273,-
 Bibliog. and Refer. ..  i. 7S0
• causes of............  i 771
• definition of.........  i 771
■ duration of..........  i 773
 indications of treat-
 ment of....................  i 775
-------diverse remedies and
 means advised for.........i. 775-80
-------prognosis of.........  i 774 
HY
INDEX.
IN           1593
1144

 561
466
Hydrocephalus,  chronic,  regi-
  men and prophyluctic treat-
  ment of .................... i 780
--------symptoms of........ i. 772
--------varieties of.......... i 771
----congenital, described.....i. 740
Hydrocyanic  acid,  its  use in
  phthisis....................  126
Hydromet ni, described........i. 749
Hydrophobia.   See,  also,  Ra
  bies........................618-42
Hydro-pleurisy, described.....i 736
Hydro-pleuritis, described.....i 736
Hydrops, definition of.  See, also,
  Dropsy...,................. i 689
----Abdominis, described..... i 710
----Ovarii.   See, also, Dropsy,
  Ovarian.................... i. 745
----Saccatus.   See, also, Drop-
  By, encysted................ i. 743
----Spina;, described......... i. 741
--------pathology of.........i. 741
----Tubalis.................. i. 749
Hydrorachis, described........ i. 740
Hydrothorax, appearances after
  death from................. i 737
----acute and sub-acute......i 736
----Bibliog. and Refer........i 739
----diagnosis of.............. i 737
----description of............ i 736
----remedies and prescriptions
  advised for................. i 739
----symptomatic or complicated i 737
----treatment of.............i. 738
Hygienic  agents, arrangement
  of..........................
----inferences, as regards the
  infection of puerperal fevers .
Hyoscyamus, diagnosis of pois-
  oning by...................
Hypertrophy, causes and origin, ii. 299
—- characters of.............ii 300
----description of............ii. 298
----effects of.................ii. 300
----nature of................ii. 299
----treatment of.............ii. 300
----Bibliog. and Refer........ii. 300
----varieties of..............ii. 298
Hypertrophy of the brain.....i. 269
----of the heart, causes and na-
  ture of....................ii. 237-8
--------its influence on  the
  cerebral circulation.........a 239
--------on the pulmonic circu-
  lation ......................ii. 240
--------complications of.....a 238
--------defined.............a 235
--------diagnosis and symp-
  toms of.....................ii. 240
--------prognosis  and term-
  inations of..................ii. 242
--------treatment of.......ii. 242-4
--------treatment of, from dis-
  eased valves................ii. 243
----of the liver.............ii 867-8
----of the mamma...........ii. 933
----of the muscles...........ii. 996
----of the pancreas...........     8
----of adipose tissue..........  i 44
----of the tissues of the digest-
  ive canal................... i. 626
----of the body of the uterus.
----of the neck of the uteru3..  1367
--------treatment of........1383-4
Hypnotics, enumeration of.....  1147
----poisoning by............ .460-74
Hypochondriacal monomania .. ii. 521
Hypochondriasis,  Ribliog.  and
  Refer.......................ii. 313
----exciting causes of.........ii. 305
----predisposing causes of..... ii. 305
----complications of..........ii. 302
----definition of..............ii 300
----degrees or grades of.......ii. 301
----description and history of. ii 301
----diagnosis of..............ii 304
----duration and progress of... ii 303
----medicinal treatment of.... ii 309
----pathology of..............ii. 30G
----during pregnancy........   504
________treatment of.........   504
----prognosis of..............ii 307
    , regimen advised for.......ii. 308
Hypochondriasis,    restorative      [Beus, Bibliog. and Refer....... i 44S
  means advised for...........ii. 311!----definition of.............. i 432
----structural changes observ-      I----diagnosis of.............. i 434
  ed after death from.........ii. 303----history and symptoms of.. i 433
----terminations of...........ii 303]----from intussusception of the
----its treatment, and author's         bowels..................... i- 434
  indications and intentions for ii 308----remarks on its pathology.. i 435
. modes of treatment advised
----the prognosis of..........i 436
  by other authors............ii. 312----remedies recommended for  i. 443
Hysteralgia, notices of........ii. 1013
----after parturition..........    546
--------,. treatment of.........    54GI
Hysteria, Bibliog. and Refer. .. ii. 340] Imbecility, causes of...........a 627
----causes of.................ii. 325----pathological causes of.....ii. 628
----exciting causes of.........ii. 327----described................ii. 625
----predisposing causes of.....ii. 325----treatment of.............ii 628
    treatment of.............  i 442
— treatment of convalescence
 from.......................  i 446
     complications of..........ii. 323
     definition of..............ii. 314
  — diagnosis of..............a 324
----duration of...............a 323
----feigned..................i. 1033
----anomalous forms of.......ii 317
----irregular forms of.........a 317
----milder and more regular
  forms of....................ii. 314
----more severe forms of.. .ii 315-16
----local manifestations of  ii. 317-322
----relations to various nervous
  complaints..............ii. 317-322
----paroxysm or fit of described ii. 314
----painful affections of___ii. 318-20
----complicated with palsy....    32
----after parturition..........   546
--------treatment of.........   547
----pathology of..............ii. 327
---• pathological opinions as to  ii. 328
----pathological inferences___ii. 329
----regimen and diet  of.......ii. 329
----■ sympathetic phenomena of ii. 329
---. terminations of...........ii. 328
----treatment of.............ii. 330
--------of the digestive func-
  tions in.....................ii. 333
--------especially in the  in-
  tervals .....................a 331
--------of  the irregular  and
  complicated forms of.........ii. 333
--------of nervous states in .. ii 332
--------prophylactic.........ii. 338
--------of the  seizure........ii. 331
--------of the  vascular states  ii. 332
Hysteric affections.  See, also,
  Hysteria...................ii 314
Hysterical  affections complicat-
  ing insanity................ii. 536
----affections,  treatment  of
  various..................ii. 334-37
—-pains, etc., treatment of
                            ii. 333-36
----paralysis described.......ii. 321
Hysteritis, symptoms of in preg-
Impetiginous affections  describ-
  ed.   See, also, Impetigo......ii. 363
Impetigo, Bibliog. and Refer... ii. 369
■---• causes of.................ii. 367
----definition of..............ii. 363
----diagnosis of..............ii 366
----prognosis of..............ii. 367
----treatment of.........ii. 367, 369
----local treatment of........ii. 36S
----complicata, described.....ii. 365
----eczematosa, described.....ii. 365
----erysipelatodes............a 366
----favosa, described.........ii 365
----figurata, described........ii. 364
----simplex, described........ii. 364
----sparsa, described.........ii. 365
Impotence, Bibliog. and Refer.. ii. 376
----causes of..............ii. 370-74
----caused by functional  dis-
  order.......................ii. 370
--------by mental influences. a 370
--------by organic lesions.... ii. 371
----definition of..............ii. 369
—- in the female. See Sterility,
  causes of....................ii. 373
----pathology of..........ii. 370-373
----treatment of.............a 374
Incendiarism, a form of partial
  insanity....................ii. 517
Incoherency, description of.....ii. 530
Incubation of infectious  agents . ii. 411
----stage of, in fevers........i 1045
Indications of cure, remarks on.  1133
----for a recourse to emetics...  1505
----for treating fevers........i 1071
----of infection...............ii. 413
Indigestion, Bibliog. and Refer, ii. 398
----exciting causes of.........ii. 384
----predisposing causes of.....ii. 383
----consequences of...........ii. 382
----treatment  of   the * conse-
  quences of..................a 392
----definition   of.   See,  also,
  Dyspepsia...................ii 377
    diet and regimen for......ii. 393
nancy......................   500----disorders symptomatic of.. ii. 331
       treatment of.........   500----drinks and beverages in
. puerperal, described......   565
■----course and termination
..........................   565
----i. treatment of.........   5S5
     Iatropha Curcas, poisoning by ..
1374 Ichorous  pus, its expectoration
       as a sign of disease..........
     Ichthyosis, anatomical changes
                         ii. 395-398
— pathology of..........ii. 386-388
— remedies advised for .. ii. 389-392
— of certain symptoms of.... ii. 380
— treatment of symptomatic
 affections of.............ii.  392, 393
— terminations of.......ii.  382, 383
— acute....................ii. 378
-------states,  treatment  of
 the........................ii. 390
— chronic..................ii. 379
constituting................ii 361--------states,
treatment  of
 Bibliog. and Refer........ii. 363
 causes of.................ii 362 ■
• definition of..............ji 361
 description of.............ji 360 ■
the........................ii. 391
— chronic, of the evacuations
during......................ii 380
   inflammatory, described... ii. 379
____remedies advised for... ii 309-12 Ileus, appearances in, after death i 433
____diagnosis of..............ii- 301--------states of, treatment of
____forms of..................«• 360   the.........................ii. 390
____treatment of..............ii. 302----complicating phthisis.....   1213
Idiotcy, causes of..............ii. 627----simple asthenic,..........ii. 378
____complications of..........ii. 627!----treatment of the more simple
----description of.............ii. 6251  states of....................ii. 390
____feigned..................i- 1033----• ofthe urine of............ii. 381
____associated with palsy......    30!----from vascular irritation... ii. 379
____pathology of..............ii. 628----of the digestive  and asso-
----treatment of..............ii. 628   ciated viscera, during........ii. 381
Beo-colitis of hot countries.....ii. 667 Induration of structures, patholo-
----acute, symptoms of.......ii. 667,  gy of.......................ii. 400
—- chronic, symptoms of......ii. 66S----treatment of.............ii 400
     sub-acute, symptoms of ... ii. 008 Induration of the brain........i. 271
. causes of................. i 272 
1594          IN                               INDEX.                               IN
 Induration, etc.. of  the  heart's
   structure...................ii. 250
 Induration,  thickening,  etc,
   from inflammation..........ii. 43S
 ----ofthe  liver...............a 869
 ----of the pancreas...........     8
 ____of neck of uterus, described  1367
 ________treatment of.........  1383
 Infancy, described............  i. 47
 ----the diseases of............  i 47
 ----its first epoch............  i. 47
 ----its second period..........  i 48
 Infants, apoplexy of new-born.. i 119
 ----asphyxy of new-born, treat-
   ment of.................... i 175
 ----choleric fever of..........i 382
 ----convulsions in............i 484
 ----paralysis of..............24, 25
 Infected, importance of separat-
   ing the healthy from........a 41
 Infected localities, restrictions
   respecting..................   274
 Infection, agents producing___a 404
 ----agents for  preventing  or
   counteracting...........ii 417, 418
 ----alterations of  the  tissues
   consequent upon............ii. 416
 ----by animal effluvia........ii 406
 ----Bibliog. and Refer___ii 423, 426
 ----shown  to  be the cause of
   choleric pestilence..........118-131
 ----circumstances favouring or
   retarding...................ii. 413
 ----circumstances which favour ii. 416
 ----circumstances proving___a 407
 ----classification of agents caus-
   ing ........................a 402
 ----ofthe duration ofthe power
   of,"by an infectious disease... a 418
 ----effects of, or diseases caused
   by.........................a 410
 ----by specific emanations.... ii 407
 ,----by means of food.........a 405
 ----indications and symptoms
   of..........................a 413
 ----manner in which the system
   is invaded by it.............ii 414
 ----means  which protect from, a 417
 ----media or means conveying
                          ii. 40S-410
 ----medical means  required to
   prevent the development of.. a 422
 ----moral aids against........ii. 421
----morbid impressi«D made by a 416
----the necroscopic poison, pro-
   ductive of..................   441
----pathological relations of... a 401
----of the period elapsing from,
   until disease is developed .ii 411-413
 ----periods elapsing between its
  production and the impression
   of its causes................ii. 411
 ----of its precursory period.... a 411
----of phthisis, considered....  1228
 ----precautions  against,  de-
   scribed .....................ii 420
----proofs of.................a 407
----ofthe prevention of, in puer-
  peral diseases...............   594
----a chief cause of puerperal
   fevers..................}. .555-561
----by self-contaminating agents
  or morbid matters...........ii. 406
 ----sources of, noticed........a 404
 ----transmission of........ii.  408-10
 ----treatment when symptoms
  of, first appear..............a 422
Infectious diseases may be ag-
  gravated by superadded causes a 411
 Infectious nature of haemagastric
   pestilence demonstrated---171-192
 Inferences, pathological, respect-
--------. as to puerperal fevers   579
--------respecting scarlet fever   751
--------as to the origin, propa-  •
  gation, varieties, and patholo-
  gy of syphilis...............  1481
Inflammation, of absorption in
  the seat of..................a 469
----Bibliog. and Refer.___ii. 4S7-4S9
---- of the states  of the blood
  in the capillaries of the seats
  of..........................a469
Inflammation,  the  capillaries
  and blood early affected in ii 463, 4
----exciting causes of.....ii 450^52
----causes,  mental, constitu-
  tional, etc...................a 449
----constitutional  and  predis-
  posing causes of.............ii 44S
----specific causes of..........ii 452
----diffusive, of cellular tissues i 355
----considerations which should
  guide the treatment of.......ii 470
----definition of..............ii 426
----diet and regimen of.......a 486
----causing induration, thick-
  ening, etc...................ii. 438
----in relation to irritation.... ii 702
----local means of cure.___a 480-82
----diagnosis of changes  after
  death......................ii 447
----diagnosis between, and va-
  rious other diseases........ii. 446, 7
----external  means of  treat-
  ment ....................ii. 477-80
----modifications  and varieties
  of..........................a 438
----modifications  of, by struc-
  ture ........................ii 445
----opinions of its nature, .ii. 457-462
----the organic nervous endow-
  ment  of the part primarily
  affected in..............a 462-464
----pathology of..........a  462-469
----of the phenomena constitut-
  ing ........................a 426
----prognosis of..............a 455
----circumstances  influencing
  the prognosis of.............a 455
----various  remedies  advised
  for.....................a  473-482
----of reparation  of the conse-
  quences of...................a 469
----different states of capillary
  tone in the same seat of......ii. 468
----causing suppuration......a 437
----theory or nature of___a  456-457
----various grades  and states
  of, treatment of.............ii. 485
----causing ulceration........ii 438
----of the venous circulation in
  the seat of..................ii. 468
----the development  of  new
  vessels in...................a 464
----acute sthenic appearances
  after death.................a 430
--------of the coagulation of
  the blood...................a 432
--------changes ofthe blood in a 431
--------remarks  on the char-
  acters of................a 426, 430
--------local characters of.... a 426
--------constitutional  symp-
  toms of.....................a 430
----asthenic, local characters of a 439
--------complications of......ii 443
--------. consequences of......ii 443
--------the basis of indications
  of cure of...................ii. 482
--------local means  advised
  for.....................ii. 484, 485
--------means to mitigate ur-
  gent symptoms..............a 484
--------nature of the states of
                          a 405, 467
--------progress and duration
  of..........................a442
--------depurating and  sup-
  porting remedies advised for  a 484
--------the remedies advised
  for supporting vital resistance
  to the extension of..........a 483
---.----constitutional  symp-
  toms of.................a 440-442
--------terminations of......a 443
--------principles of treatment
  of......................ii 482,483
--------the necessity  of sup-
  porting vital power..........ii. 483
----chronic, local signs.......a 434
---■----constitutional   symp-
  toms .......................ii. 434
----specific Ftates of..........ii. 453
--------treatment of the.....ii. 4S6
----sthenic, complications of .. ii. 435
--------consequences of......a 435
 Inflammation, sthenic,  exuda-
   tion caused by..............ii. 436
 ________means of cure of. .a 470-4 S2
 ________nature of the forms of a 462
 ________progress and duration
   of..........................a 434
 --------softening caused by.. ii 437
 --------terminations of......a 435
 --------indications  of  treat-
   ment of....................ii 470
 ----of the uterine appendages
   after parturition............   566
 --------course  and termina-
   tions .......................   568
 Inflammations, consecutive,  de-
   scribed .....................a 463
 ----from absorbed morbid mat-
   ters ........................a 453
 ----from morbid matters circu-
   lating in the blood...........a 453
 ----secondary, described......a 453
 --------causes  and modes of
   their production.........a 453, 454
 Influences, mental, remedial...   1144
 ----of the mutual, exerted  by
   the mind on organization, and
   by the latter on the former... a 5S7
 Influenza, appearances in fatal
   cases.......................ii. 496
 ----Bibliog. and Refer........ii 499
 ----remote causes of..........a 496
 ----complications of..........ii 492
 ----definition of..............ii 489
 ---diagnosis of..............ii. 495
 ---history of................ii. 489
 ---nature of.................ii. 498
 ---prognosis and duration of.. ii. 495
 ---remedies advised for......ii. 498
 ---sequelae of................ii 495
 ---symptoms of..............ii 492
 ---treatment of..............ii 498
 ---complicated with bronchi-
   tis .........................a 493
 --------with  disease  of the
   heart or pericardium.........a 494
 --------with  diseases  of the
   lungs......................a 493
 --------with pneumonia......a 493
 ----treatment of its  complica-
   tions .......................a 498
 Infusoria, notices of...........  1519
 Infusum Amarum......F.  218. Ap. 11
     Angelicas Comp.. .F.  219. Ap. 12
     Angelicas sylvestris
                      F.  823. Ap. 31
     Anisi Comp.......F.  824. Ap. 31
     Anthemidis Comp. F.  220. Ap. 12
     ArmoraciaeComp..F.  221. Ap. 12
     Arnicse...........F.  222. Ap. 12
 ---Arnicae Comp.....F.  223. Ap. 12
 ---Artemisiae vulgaris
   Comp...............F.  224 Ap. 12
 ---Barberis.........F.  225. Ap. 12
 ----Calami aromatici .F.  226. Ap. 12
 ----Calami aromatici Comp.
                      F.  227. Ap. 12
----Caryophylli Comp. F.  228. Ap. 12
 ----Cinchonae cum Quinae Sul-
   phate ...............F.  229. Ap. 12
 ---Conn............F.  230. Ap. 12
 ---Diosmas crenatae ..F.  230. Ap. 12
 ----Gallae............F. 825. Ap. 31
 ----Gentianae Alkalinum Comp.
                      F. 232. Ap. 12
 ----Guaiaci Comp.___F.  233. Ap. 12
 ---Glechomas  hederaceae cum
   Acido Hydrocyanico.. F.  234. Ap. 12
 ---Juniperi..........F. 235. Ap. 12
 ---et Mistura Juniperi F.  236. Ap. 12
 ----Marrubii.........F.  237. Ap. 12
 ---Melissae Comp.___F.  238. Ap. 12
 ----Menthae et Caryophylli
                      F.  239. Ap. 12
     Menthae  Comp. .F. 240,1. Ap. 12
     Menyanthidis.....F.  242. Ap. 12
----Millefolii  Comp___F.  243. Ap. 12
----Pectorale.......F. 244,5. Ap. 12
 ---Quassias Comp.___F.  246. Ap. 12
 ---Quassias  cum Aqua
   Calcis..............F. 247. Ap. 13
---Rhatanias........F.  248. Ap. 13
---Rhei.............F. 249. Ap. 13
---Rhei Alkalinum F. 250,1. Ap. 13
---Rhei Comp........F. 252. Ap. 13 
IN
INDEX.
IN          1595
Infusum Rosae et Aurantii Com-
  positum .............F. 253. Ap. 13
----Rut83 Comp.......F. 254. Ap. 13
----Salvias  Comp......F. 255. Ap. 13
----Sambuci  cum Antim. Tar-
  tarizat..............F. 256. Ap. 13
----Santonicas Seminum Comp.
                      F. 257. Ap. 13
----Sarzas Alkalinum.. F. 258. Ap. 13
----Senegas et Serpentarias
  Comp...............F. 259. Ap. 13
----Sennae  Comp......F. 260. Ap. 13
----Sennae cum Manna F. 261. Ap. 13
----Serpentariae.......F. 826. Ap. 31
---. Serpentarias Comp. F. 262. Ap. 13
----et Haustus Scoparii Compo-
  situm...............F. 263. Ap. 13
----Spigeliae Comp___F. 264 Ap. 13
----Tiliae Comp.......F. 265. Ap. 13
----et Mistura Tonico-Aperiens
                      F. 266. Ap. 13
----Turionum Pini Abietis
                      F. 827. Ap. 31
----Uvae Ursi.........F. 267. Ap. 13
----Valerianae........F. 268. Ap. 13
----Valerianae  Comp.. F. 269. Ap. 13
----Valerianic  et  Serpentarias
  Comp...............F. 270. Ap. 13
----Zingiberis........F. 271. Ap. 13
Inhalation for the cure of haemop-
  tysis .......................a 107
----in the treatment of chronic
  bronchitis.................i 318-20
----substances advised for .... i. 319
----of its use in phthisis......  1275
InjectioAcetiPyroligneiF. 272. Ap. 13
----Argenti Nitratis. ..F. 273. Ap. 13
----Astringens.......F. 274 Ap. 13
----Astringens.......F. 828. Ap. 31
----Boracica.........F. 275. Ap. 14
----Zinci  Acetatis   Composi
  ta..................F. 276. Ap. 14
Inland climates in disease.....i 417
--------in  tubercular  con-
  sumption ................1254,1281
Inoculation  of putrid animal
  matters, effects of...........   445
--------treatment of.........   445
----of small-pox.............905-10
--------reasons against and in
  favourof................... 907-9
----is it indispensable  to  the
  production of rabies ?........   629
----of  syphilis, modes of per-
  forming ....................  1489
--------as a means of preven-
  tion and cure...............  1489
----of a specific virus, the com-
  mon cause of rabies..........   627
Inquiries as to the pathology of
  puerperal  fevers............579-81
Insane,  selection of  attendants
  on the......................ii. 625
Insane patients, their classifica-
  tion ........................a 624
----employments  and amuse-
  ments for...................a 623
----visits of friends to the.....a 624
    ■ of the seclusion of the .... a 591
Insanity,  delusions in, sources
  of.......................a 519-21
----duration of..............ii. 538
----false perceptions in.......ii. 502
----fatal terminations of......a 543
----feigned..................i. 1033
--------how to be detected.. .i 1033
----of the forms of...........a 513
----hereditary predisposition to ii. 555
----intellectual, treatment of . a 620
----during or after lactation .. ii 628
----lesions causing a fatal issue
  in.......................ii 543,47
--------of the brain in___ii. 549-51
--------observed in the head
  in.......................ii. 549-53
--------of  structure in cases
  of.......................a 549-55
--------of the abdominal vis.
  cera in.....................a 554
--------of the  thoracic viscera
  in.........................ii 653
----the  moral  emotions  and
  passions as causes of........ii 662
----mortality in lunatics.....ii 547
----organic functions, states of,
  in.........................ii. 508
----in relation to phrenology ii 578-84
----the physiological pathology
  of.......................ii. 573-90
----prognosis of..............a 537
----circumstances influencing
  the prognosis of..........a 538,40
----proportions of recurrence of ii. 543
----regimen and diet for......ii. 594
----relapses and recurrences of ii. 542
----the prevention of,  and of
  relapses....................ii. 595
----caused by religious appre
  hensions and impressions .. ii.  563-6
----religious consolation in ... ii. 622
----remedies advised for ... ii. 603-19
----review of remedies advised
  for.........................ii. 603
----signs and symptoms of.... a 502
----symptoms furnished by the
  locomotive  organs in........ii 507
--------moral, intellectual, and
  instinctive, in..............a 505
----  ---- indicating  recovery
  from.......................ii 541
--------of,  furnished by  the
  sensibility..................a 502
----in relation to social and po-
  litical conditions and commo-
  tions .......................ii 572
----terminations of...........a 637
----general  remarks- on  the
  treatment of................a 590
----treatment of, review of the ii. 590
--------of convalescence from a 594
--------of,  should be based on
  a knowledge of the causes ... a 593
--------of  the specific  forms
  of..........................
--------moral, during  conva-
  lescence from...............a 622
----from partial disorder of the
  understanding..............ii. 519
Insania Gravidarum, described, ii 628----demonomaniacal, causes of,
----treatment of.............ii 633|  described...................a 524
                                       chronic, described........ii. 530
                                       complicated............ii 533-7
                                   --------treatment of........ii 603
                                   --------with apoplexy.......a 536
                                   _____________treatment of.... ii 603
                                   --------with epilepsy........a 535
                                   _____________treatment of___ii. 603
                                   ________with  hysterical  and
                                     cataleptic affections.........ii 536
                                .__________with paralysis.......    30
— of bleeding in...........ii 603^4]--------with general paraly- _
— of general and local bleed-         sis............. ........... u. 5d4
,ng in"....................ii 603-61-------------treatment of....ii. 603
----Lactantium, described .... a 630
--------treatment of.........ii 635
----post partum, described___ii 629
--------treatment of.........ii 633
Insanity, accessary symptoms in ii 509
----arrangements of the states
  of.......................ii 510-12
----author'3 classification of its
  Btates......................ii 513
----Bibliog. and Refer........ii. 655
----causes...............U- 655i 573
----causes and modes of fatal _
  terminations of.............ii- 843
----exciting or productive causes
  of..........................jj-^1
----physical causes of........?J* S2S
----causes predisposing to---ii. 555
    . definition of.............il 500
connate, defined..........ii 625
connected with vertigo.... ii. 535
after delivery............ii. 629
----treatment of........ii 633
demonomaniacal, noticed . ii 524
fatuoup, treatment of.....ii 602
general, described........a 526
    treatment of........a 599
remarks on its definition.. a 500----homicidal, described......a 517
delusions in..............ii- 503'--------treatment of........a 590
Insanity, idiotic, described.....ii 626
----incoherent, description of.. ii. 530
--------treatment of........a 602
----with  propensity to intox- _
  ication, noticed.............ii 517
  — maniacal.   See,  also,  Ma-
  nia ........................ii. 526
  -------remedies  advised for
                          ii 599-602
  ------treatment of.....ii. 599-602
----melancholic, treatment of. ii 596
----milder forms of..........ii. 513
----misanthropic, noticed.....ii. 526
  — monomaniacal, forms of ii 519-25
  ------treatment of.......ii. 595-7
  — moral, the several states
  of.......................a 513-17
  ------treatment of........a 595
  — the moral treatment of.... a 619
----organic functions, disorder.?
  of, connected with..........ii. 536
  — associated with general pa-
  ralysis .....................ii. 534
----partial forms of..........a 513
     partial disorder of intellect
     .........................ii. 519
 -------general view of......a 519
--------treatment of........ii. 595
----during pregnancy........ii 628
--------treatment of........a 633
----puerperal, causes of......ii. 631
--------defined..............ii. 628
--------treatment of........ii. 633
--------diagnosis of.........a 630
--------treatment of........ii. 633
--------pathology of.........ii. 633
--------remedies advised for. ii. 634
--------prognosis of.........ii. 631
--------regimen and diet in.. ii. 635
--------treatment of........ii. 633
----senile, described.........ii. 516
----suicidal,  described.   See,
  also, Suicide................ii. 636
--------causes and occasions of a 636
----theomaniacal, described .. a 524
----treatment of general......ii. 599
----various  predispositions to
                           a 555-61
Insects, poisonous, notices of...   481
Insomnia, partial, noticed.....   879
----treatment of.............   880
Inspection  of abdomen........   i. 1
Integuments, syphilitic disease
  of the......................  1467
Intellect, connate deficiency of. a 625
Intemperance in food and drink,
  as predisposing to disease.... i. 649
Intermarriages, when frequent,
  cause scrofula..............   803
Intermissions of ague, described i. 1086
----treatment during.......i. 1094,6
Batermittents,  chronic or ob-
  scure, described.............i 1113
----regimen in...............i 1115
----treatment of.............i 1115
--------advised by Dr. Ste-
  vens .......................i. 1109
---------when they change
  their type..................i 1109
Intestinal haemorrhage........a IIS
Intestines,  diseases of, Bibliog.
  and Refer..................ii 689
----carcinoma of.............a 687
----contraction or constriction
  of, with thickening.........ii 687
----haemorrhage from.....a 118-22
----causes of inflammation of. a 676
----large, inflammation of.  See,
  Colitis.....................ii 665
----small, inflammation of their
  glands.....................ii 661
  — inflammation ofthe mucous
  cent of small.  See, also, Muco-
  Enteritis...................ii. 659
  ------treatment of........a 679
----pseudo - membraneous  in-
  flammation of..............a 669
  __small, inflammation of.  See,
  also, Enteritis..............a 658
  — inflammation of all the coats
  ofthe small.................ii 664
  — inflammation of both small
  and large, or ileo-colitis.....a 667
  ------in hot countries......a 667 
1596          IN                               INDEX.                               KI
Intestines,  lesions of, diagnosis
  of.........................    369
---------diagnosis of, by pois-
  ons ........................  371,3
----paralysis of, the symptoms
  of  ........................ii. 6S6
________treatment of........a 6S6
____  disease  of,  complicating
  phthisis....................  _ 1213
----rupture of the............ii 6S7
----scirrhus of a portion of.... a 6S7
____symptoms of scirrhus, &c,
  of.........................ii 6S7
----treatment of scirrhus, &c.. ii. 6SS
----softening  of the  mucous
  coat of the.................ii 68S
--------causes of............ii. 68S
--------diagnosis of.........ii. 688
--------nature of...........ii. 689
---------symptoms of........ii. 688
----•----treatment of........ii 689
----spasm of, its causes___'... ii 6S5
--------remarks on..........ii. 684
---------symptoms of........ii. 684
--------treatment of........ii. 685
----thickening of the.........ii. 6S7
----ulceration of............ii. 674, 6
Intoxicating agents productive
  of insanity.................ii. 568
Intoxication, defined.   See, also,
  Drunkenness...............  i 782
----diagnosis of..............  i 789
Intro-susceptions ofthe digestive
  canal......................  i 63S
--------. ileus caused by......i. 434
Invagination  of the  digestive
  tube.......................  i 63S
----of intestines causing ileus . i. 434
Invasion, stage of, in fevers .. .i. 1046
Inversion of the  uterus, symp-
  toms and diagnosis..........   1394
--------treatment of........   1395
Invisible  organized existences
  causing pestilences (?).......    252
Involution of litems described. .   1394
Iodides, of their use in phthisis  1270
Iodidum Hydrargyri.. .F. 277. Ap. 14
----Plumbi..........F. 27S. Ap. 14
Iodine and Bromine, poisoning
  by.........................    382
Iodine and its compounds, pois-
  oning by...................    452
--------symptoms caused by .    352
---------treatment of poison-
  ing by.....................    352
----preparations of, advised for
  scrofula....................   831
---------advised for  constitu-
  tional syphilis..............   1483
---------first  prescribed for
  syphilis by the author.......   1483
Ipecacuanha, poisoning by.....    410
--------treatment of........    410
Iris, inflammation of.   See, also,
  Iritis.......................i 1016
Iritis, definition and description
  of..........................i 1016
----idiopathic, description of. .i 1016
'--------terminations and diag-
  nosis of....................i 1017
--------treatment of........i ISIS
----  sympathetic,  description
  and forms of................i. 1018
--------diagnosis and  treat-
  ment of....................i. 1018
-—-----varieties............i 1018
Iron, preparations of, for scrof-
  ula ........................    832
Irritability, Bibliog. and Refer.. ii 696
----of the influence ofthe blood
  upon.......................a 695
----conditions requisite to the
  healthy manifestation of.....if. 694
----definition of.............ii. 690
----the dependence and source
  of.......................ii. 690-93
----connexion of, with ganglial
  nervous influence...........1032-3
----of the grades of..........ii. 693
----various grades of, described a 603
----insensible organic contrac-
  tility, its lowest grade.......a 694
■----depends upon the organic
  nervou3 system.............a 694
Irritability, relation of,  to the      I                  j
  nervous systems............1032-3]                   "    .....
____the sources of it shown___a 090 Jaundice from  arrest of biliary
----of the uterus, noticed.....  1301'   secretion...................ii. 348
Irritant and alterant poisons...   447----Bibliog. and Refer........ii 359
Irritants,   mineral,  vegetable,      ;----from biliary exuberance .. ii. 340
  and  animal.................  1144V---------treatment  of........ii. 353
Irritation,  examination  of the      !----cnchectic................ii. 351
  agents producing.........ii. 707-10----from calculi in the ducts .. ii. 348
----Bibliog. and Refer........ii 716---------treatment  of........ii. 355
----its effects on the blood____ii. 703----exciting causes  of.........ii. 344
----exciting causes of.......ii. 708-9----predisposing causes of----ii. 343
____of the cause  of the perio-      ----remote causes of..........ii. 352
  dicity or recurrence of its  ef-      .----complicated..............ii. 349
  fects.......................ii. 707----from  compression  of the
----constitutional, effects of .. ii. 700;   ducts by tumoure...........ii. 348
____.----treatment of........ii. 711---------treatment  of.........ii. 355
----definition of..............ii 696----from congestion of liver... ii. 346
----duration of..............a 707---------treatment  of.........ii. 354
----effects of, may be either di-      j—- definition  of.............ii. 341
  rect  or reflected.............ii. 700----from disease of the ducts
----the influence of its agents or         and gall-bladder............ii. 347
  causes on the states of.......ii. 707---------treatment  of........ii. 355
----limitation  and  extension      ----from disease of the duode-
  of..........................a 697   num.......................ii. 348
----manifestation of its  effects, a 70G----distinctions of, by authors, ii. 351
----means applicable to the seat      |----duration of..............ii. 342
  of..........................ii. 712----feigned..................i. 1033
----sources and causes of, occa-      |-—■ forms and states of.......ii. 343
  sioning neuralgia........ii  1015-18----green or black...........ii. 349
  — in relation to morbid nutri-      |---------treatment  of........a 355
  tion........................a 702----from hepatitis and hepatic
  — pathological  relations  of         abscess.....................a 346
                          ii. 697-702---------treatment  of........ii. 353
  — physiological  relations  of      |----infantile,  described.......ii. 350
                          ii. 698-700----from  structural lesions of
  — relation  of the  cerebro-      I   the liver...................ii. 346
  spinal nervous system  to.....ii 698---------treatment  of........ii. 354
  — relation of, to haemorrhage      ----morbid appearances in.... ii. 344
  and  serous effusion..........ii 702----in organic diseases of the
  -------to the states of inflam-      j   liver.......................ii. 874
  mation.....................ii. 702----pathological relations  of... ii 346
  -------to irritability........a 696---------causes of............ii. 343
  -------to  the nervous sys-      I-----precursory symptoms  of... ii. 341
  tems.......................ii. 697----during pregnancy........   502
  — preliminary remarks on... ii 696:----prognosis of..............ii. 352
     its  indirect  or  reflected      ----of remedies recommended
  for, by authors............a 366,9
  — spurious, described.......ii. 351
  -------treatment of........ii. 355
  — symptoms of.............ii. 341
  — termination of............a 342
----from torpor of the liver, de-
  scribed.....................ii. 347
  -------treatment of........ii. 354
  — traumatic,  described......ii. 350
          treatment of........a 355
  transmission...............ii. 60S
----of predisposition to.......ii. 707 •
----of the propagation of.....ii 703 ■
----of the reflection of........a 704 ■
----regimen and diet in......ii. 716 •
----sensation, intellectual ex-
  ertion, and moral  emotions,
  as causes of................ii. 709 -
----sympathetic, causing retch-
  ing and vomiting............   150S -
----terminations of..........ii. 706] Jealousies  and contentions re-
----its direct transmissions ... ii. 698   tard therapeutical knowledge  1131
----treated  by  anti-spasmod-       Jews,  introduction  of syphilis
  ics.........................ii 7131  into Europe ascribed to......1461-2
---------by alteratives and de-      ' Joints, chronic rheumatism of..   667
  obstruents..................ii. 714:----nodosities of the.......... 668-9
---------by depurants.......ii. 714----and ligaments, signs of dis-
--------by derivatives.......a 712]  ease furnished by..........1066-67
—;-----by general or constitu-      |----syphilitic disease  of.......  1471
  tional means...............ii. 711---- disease of, caused by urea
         by local means......ii. 711   and its  combinations in the
---------by sedatives, narcot-
  ics, &c.....................ii. 713
--------by tonics, &c.........ii. 713
----treatment of, with reference
  to removal of the causes of... ii 710
----indications of treatment .. ii. 710
  blood....................i 238,40
Julepus Sedativus.....F. 279. Ap. 14

                 K.
Kamala-powder,  recommended
   gainst worms..............  1555
----varieties of reflected---ii. 704-5! Kidney, abscess or suppuration
----continued and periodic  ef-      |   of..........................ii. 725
  fects of.....................ii. 700 Kidneys, affections of the nerves
----morbid, should be allayed.  1141   of the......................ii. 779
----spinal, described......... 945,6----affection of, consequent on
--------treatment of........948-51   scarlet fever................ 737-9
----reactive or sympathetic... ii. 705----alterations of their  blood-
----simple or direct..........ii. 703   vessels.....................ji. 770
Ischuria, described---........  1353----alterations observed after
Issues  and setons advised  for         inflammation of the........ ii 727
T Phthi.8,1,8.......••■••■........  1270----anaemia of the............ii. 766
Itch, Bibhog. and  Refer.......ii. 721!----atrophy of the...........ii 766
----causes of................ii. 718----Bibliog. and Refer.......ii. 771
----complications of..........ii. 717!----cachectic  inflammation of
----definition of..............ii. 716]   the, description of.        ii 736-41
----description of............a Tlzl---------the  stages and  'form's
----diagnosis of..............ii. 71s   of organic lesions in.......ii. 741-4
      n-ation of..............ii. 71s — congestion or hypera;mia of ii. 766
                              }}• ll'l----" cyBtfS simple serous,  in the ii. 767
                                         the diseases of...........ii 721
treatment of.
forms or varieties of......ii 717 
KI
INDEX.
LI          1597
Kidneys,  diseases of the, caus-
  ing dropsy.................. i. 700
----disease of the, causing ana-
  sarca ...................... j. 732
----displacement of, symptoms
  and treatment of...........ii. 771
----dropsy from disease of the,
  treatment.................. i. 705
----encysted dropsy of....... i 750
----fatty deposits in the......ii. 707
----granular deposits in the .. ii. 767
----granular disease  of  tlie.
  See, also, Nephritis, Cachectic ii. 736
----of haemorrhage in, or from
  the........................ii 765
----hydatids in the...........ii. 708
----hypertrophy of the.......ii 706
----inflammation of, described
  and defined.  See, also,  Ne-
  phritis ..................... ii 722
----inflammation of the  pelvis
  and calices of.  See, also, Pye-
  litis ........................ii 757
----inflammation of the struc-
  ture,  pelvis, and calices  of.
  See, also, Pyelo-Nephritis.... ii. 762
----inflammation of the tissued
  surrounding the............ii 763
----influence of  inflammation
  of, in causing other disease-!  . ii 732
----lesions in the  pelvis,  cal-
  ices, and ureters of the......ii 770
----organic lesions of the.....ii. 705
----morbid  condition  of, in
  scarlet fever................   733
----morbid secretions  in  the
  substance of the............a 767
----morbid  sympathies   be-
  tween, and other organs.....  1037
----softening and induration of ii 707
----depuration by, requisite to
  health....................i 238,40
----tubercles in the..........ii 709
----unnatural situations of the a 771
----various morbid deposits in
  the, described...........ii 767-69
Kousso, methods of treating tae-
  nia by .....................  1554
[Laryngitis, asthenic acute, com-       iLepriasi^,  classification  of the
1  plicated states of............a 789|  forms of....................   520
----asthenic, complicating scar-       ----definition and synonymes.
  let fever....................    734  See, also, Psoriasis..........   519
----catarrhal, described......ii. 7st>----pathology of.............   526
----chronic, described........ii. 790 ]----treatment of............. 520-9
---------causes  of............a 790i---- regimen and diet in......   531
--------complicated with chron-      [---- syphilitica...............   524
  ic diease of the lungs........ii. 791! Leprosy, appearances after death
               with tracheitis.. ii. 791 i  from.......................ii. 809
Laburnum, poisoning by......   476
Laceration of the brain........ i. 277
Lactation, Bibliog. and Refer.  . ii 776
----influence of menstruation
  and pregnancy on...........ii. 773
----slighter disorders of.......ii. 772
----undue or improper........ii. 774
--------treatment of........ii. 774
----termination of the period,
  remarks on.................ii. 770
Lacteal system noticed........a 918
Lactiferous  tubes,  chronic in-
  flammation of the...........ii. 932
----symptoms and treatment of
  inflammation of.............ii 932
Lameness, feigned............i. 1034
Laryngeal  suffocation,  descrip-
  tion of...................ii. 777-83
Laryngismus  Stridulus.   See,
  also, Larynx, spasms of......ii. 777
Laryngitis, definition of.......ii. 7S6
----causes of acute...........u. 795
----acute,   complicated   with
  pharyngitis, <fcc.............ii. 788
----description of the several
  states and varieties of ... .ii 786-91
----diagnosis of the acute.....ii. 793
--------of the  chronic.......ii. 794
----. ----  of the  complicated
  forms......................ii. 794
----prognosis of acute........ii. 795
--------of chronic...........ii 795
----treatment of acute asthenic ii 799
--------of the  asthenic  com-
  plicated states..............ii. 799
----appearances  after  death __
  from acute sthenic..........ji- 792
——. sthenic acute,  described... ij. 786
---------treatment of.........ii. 796
_____________of the complicated  _
  states of.     ...............»• "'•>
 --------inhalations, <fec, for.. ii. S00
 --------local means for.. ii. 800, 1, 2
 --------topical means advised
  for.......................a 800-1
 --------appearances after.... ii 792
----primary chronic, described
                            ii. 790-1
         treatment of.........ii. 799
 ---complicated and  consecu-
  tive chronic.................ii. 791
----consecutive or complicated
  asthenic....................ii 7S9
----consecutive or complicated
  sthenic.....................ii. 788
Larynx,  closure of, by enlarged
  thymus gland...............ii. 779
----hysterical spasm of.......ii 784
---------treatment...........ii. 784
----inflammation  of.   See,  al-
  so, Laryngitis..............ii. 78C
----nervous  and  sympathetic
  affections of the.............ii 770
----paralysis of, definition. See,
  also, Aphonia...............ii. 784
----paralytic states of.........ii 784
----spasm of, in adults........ii. 783
---------sources of...........ii. 7S3
---------treatment of.........ii. 784
---------causes of............ii. 77S
----spasm of, in children, syno-
  nymes of...................ii. 777
--------definition and symp-
  toms of.....................ii. 777
---------diagnosis............ii. 77S
---------indications of cure for ii. 782
------— nature of the........ii. 788
 --------pathology of.........ii. 778
---------treatment...........ii. 782
----stridulous suffocation of, in
  children....................ii. 777
----prognosis  of stridulous  af-
  fections of the...............ii. 782
----syphilitic ulceration of....   1469
Larynx  and  trachea,  Bibliog.
  and Refer..................ii. 807
---------diseases of...........ii. 770
---------foreign bodies in the . ii. 803
----.----■----diagnosis of... ii. 804,5
--------.----prognosis of.....ii. 806
 —.---------treatment of.... ii. S06
---------disease of, complica-
  ting phthisis................  1212
 --------of tumours compress-
  ing the.....................ii. 806
--------.----diagnosis.......ii. 807
Laughing and weeping, as symp-
  toms .......................  1095
Laurel water, <fec, poisoning by   403
Lead, appearances  after  death
                                          injurious effects of........ i 1
                                       — modus  operandi  of poisons
                                       of..........................   398
                                       — palsy from, described.....    26
                                       — poisoning by acetate of.__   395
                                       -------by carbonate of......   390
                                     ---------by the iodide of......   397
                                       _______by the oxides of.....   397
                                       _______by its  preparations,
                                       treatment of................   398
                                       — prevention of its  injurious
                                       effects.......... ........... j. 161
                                     Lead-colic described........... i. 430
                                     ---------treatment of......... i 439
                                     ---------its sequelae.......... i. 442
                                     Lepra, definition and synonymes.
                                       See, also,  Leprosy...........a 807
                                     ----Alphoides, described......   523
                                     ----Anassthesiaca, described .. ii 809
                                     ----Judaica, noticed..........ii. 810
                                     ----Nigricans................   524
—^syphilitic chronic.........ii. 79l|----Taurica, noticed..........a 809
____     treatment of.........ii S03|----Vulgaris, described.......   523
____asthenic acute............ii- 7S9,LepriasIs, Bibliog. and Refer. ..   531
                                  ----Bibliog. and Refer........ii. 815
                                  ----causes of..............ii. S12, 13
                                  ----definition and  synonymes.
                                     See, also, Lepra.............ii. 807
                                  ----description of............ii 808
                                  ----diagnosis of..............ii 811
                                  ----Jewish, noticed...........ii. 810
                                  ----maladie3 allied to.........ii. 809
                                  ----treatment of.............ii 813
                                  ----tubercular.  See, also, Le-
                                     pra  ........................ii. S07
                                  Lesions, congenital and organic,
                                     causing amenorrhoea......ii. 9G6,7
                                  --------treatment of.........ii 967
                                  ----organic,  their  connexion
                                     with states of the blood...... i. 680
                                  --------causing vomitings ...  1507
                                  ----of  structure  found  after
                                     phthisis...................1215-21
                                  ----of viscera after dropsy___i 092
                                  Lethargy described............ i. 453
                                  Leucorrhcea, Bibliog. and Refer, ii. 820
                                  ----■ definition of..............ii. 810
                                  ----diagnosis between, and gon-
                                     orrhcea.................ii. 818, 823
                                  ----synonymes of...........'. ii. 816
                                  ----oris et cervicis uteri.......a 820
                                  ---------cause3 and symptoms
                                     of...........................ii 820
                                  ---------treatment of.........a 820
                                  ----in  connexion  with  preg-
                                     nancy......................   498
                                  ---------treatment of.........   498
                                  ----uterine, acute............ii. 822
                                  ---------chronic and sub-acute ii. 822
                                  ---------diagnosis of..........ii. 823
                                  ----•----nature of............ii. 824
                                  ---------terminations of......ii. S24
                                  --------treatment of........ii. 824
                                  ----■----regimen and diet___ii. 825
                                   ----vagina?, causes of.........ii. 81S
                                  —------local means of cure for ii. 819
                                  ---------acute,  diagnosis of ... ii. 818
                                  -------------symptoms of.... ii. 81S
                                  -------------treatment of___ii. 819
                                  ---------chronic diagnosis of.. ii. 818
                                  --------•----symptoms of.... ii. 818
                                  ---------treatment of.........ii. 819
                                  ----vulvae, description of......ii. 817
                                  ---------treatment of.........ii. 817
                                  Lichen, Bibliog.  ani Refer..... a 829
                                  ----causes of.................ii. S2S
                                  ----definition of.............ii. S26
                                  ----description  of its  several
                                     varieties....................ii 826
                                  ----diagnosis  of..............ii. 82S
                                  ----treatment of.............ii. S2S
                                  ----islandicus,  of its  use  in
                                     phthisis....................  1270
from.".".....................   397|Lientery, description of........ i. 005
Life, neglect of the doctrine of,
  retarding the progress of ther-
  apeutics ....................  H29
----powers of, to be closely ob-
  served .....................  1134
—------should be supported. .1135, 7
Light and  sunshine, as causing
  disease..................... i. 050
Lime, oxalate of, in urine.   See,
  also, Oxaluria..............  1328
Linctus Acidi Hydrochlo-
  rici.................F. 2S0.  Ap. 14
----Boracicus.........F. 281.  Ap. 14
----Camphoraceus ... ,F. 282.  Ap. 14
----Chlorureti Calcis .. F. 2S3.  Ap. 14
----Demulcens.....F. 2S4, 5.  Ap. 14
----Demulcens et Ape-
  riens  ...............F. 2S5.  Ap. 14
----Emolliens (Brendellii)
                      F. 287.  Ap. 14
----cum Ipecacuanha. F. 2s9.  Ap. 31
----Myrrhae et Ipecacuanhae
                      F. 288.  Ap. 14
----Oleosus.......F. 289, 90.  Ap. 14 
1598          LI
INDEX.
LY
Linctu? Opiatus.......F. 291. Ap. 14 Liver, hydatids in the.........ii S72
----Opiatus cum Scilla F. 292. Ap. 14----impaired action of the .... ij. 835
____Pectoralis........F. 293. Ap. 14--------treatment of.........u. bib
___Potassa? Nitratis . .F. 294. Ap. 14]---treatment of morbid secre-
---Refrigerans.......F. 630. Ap. 31   tionofbile.................ii. 838
___Terebinthina?.....F. 831. Ap. 31---induration of the.........n. boy
Linimentum AmmoniaecumOleo       !---inflammation of the.  See,  _
  Terebinthinae........F. 295. Ap. 14   also, Hepatitis..............ii. S44
.___Ammoniae  et Terebinthinae-------of its substance......a 845
  Comp...............F. 296. Ap. 14-------of its surfaces........a 847
___Anodynum.....F. 297, 8. Ap. 14---influences  producing dis-
___Camphorae Fortius F. 299. Ap. 141  eases of the...............ii  830-4
    . CantharidumComp.F. 300. Ap. 14,-------of diet, regimen, etc.,
___Febrifugum.......F. 301. Ap. 14
___Iodinii...........F. 302. Ap. 14
---Opiatum.........F. 832. Ap. 31
---Pliosphoratum---F. 303. Ap. 14
---Py rethri.........F. 304. Ap. 14
---Rubefaciens......F. 305. Ap. 14
---Saponis et Camphorae Com-
  positum.............F. 306. Ap. 14
  on the......................ii. 831
  ------of other  diseases on
  the functions and diseases of
  the.......................ii-  832,3
  ______of races on diseases of
  the........................U- 833
____of iodide of potassium in or-
  ganic diseases of the.........ii 875
----contra Spasmos ... F. 307. Ap. 14----melanosis of the..........ii 872
     Stimulan3........F. 30S. Ap. 14
----Sulphuro-Saponaceum
                      F. 309. Ap. 14
---Tabaci...........F. 310. Ap. 15
---Terebinthinae Compos-
  itum................F. 311. Ap. 15
---Terebinthino-Phosphora-
  tum................F. 312. Ap. 15
---Thebaiacum Compos-
  itum................F. 313. Ap. 15
---Volatile..........F. 314. Ap. 15
Lips and mouth, signs of disease
  furnished by................  1058
Liquor Acetatis Morphiae F. 315. Ap. 15
---Antimonii Potassio-Tartra-
  tis..................F. 316. Ap. 15
---Balsamico-Aromaticus
                      F. 317. Ap. 15
---Bi-boratis Sodas Compositus
                      F. 318. Ap. 15
---Calcii Chloridi___F. 319. Ap. 15
----Camphorae ^Ethereus
                      F. 320. Ap. 15
---Ferri Oxygenati. .F. 32L Ap. 15
---Hydrargyri Bichloridi
                      F. 322. Ap. 15
---Potassii Iodidi___F. 323. Ap. 15
---Potassii Iodidi Ioduretus
                      F. 324 Ap. 15
---Morphiae  Citratis. .F. 325. Ap. 15
.---Plumbi Acetatis Dilutus
                      F. 320. Ap. 15
■----Potassa? Chloratis.F. 327. Ap. 15
■---Potassii Iodidi Ioduretus
  C'uncentratus........F. 328. Ap. 15
----Potassii Iodidi Ioduretus
  Dilutus.............F. 329. Ap. 15
----Zinci Acetatis___F. 330. Ap. 15
Lithic acid, source and quantity
  of..........................  1319
Liver, abscess  of the...........a 849
____morbid sympathies between
  the, and other organs........   1051
----neuralgic states of the .... a 838
----means of cure advised for
  organic diseases of.........ii 875,6
----of organic lesions of the... ii 866
--------consequent on inflam-
  mation .....................a 866
--------from  impairment  of
  vital power, and  depravation
  of the blood.................a 870
----organic  diseases of the, di-
  agnosis of..................a 873
--------indications of cure for ii. 875
--------treatment of.........a 875
----pathological causes of its
  diseases.................a 830-33
----portal congestion of the ... a 840
----lesions  of,  complicating
  phthisis....................   1214
----regimen  and diet for dis-
  eases of the.................a 876
----scirrhus of the...........a 871
----sanguineous congestion of
  the, symptoms of............ii 842
--------treatment of........ii. 843
----softening of the structure
  of the......................ii. 866
----suppuration of the........a 867
----influence of high ranges of
  temperature on the..........a 830
----torpor of the.............ii 835
--------treatment of.........ii 836
----treatment  of  the several
  modes  in which abscess ofthe,
  may open.................a 861-4
----tubercles in the..........ii. 870
----malignant tumours ofthe ii 871,2
----venous congestion of the .. ii. 840
----and  spleen, treatment  of
  dropsy caused by disease of..  L 704
        treatment of.......a 861-4 Living, habits of,  disposing  to
-------of the different kinds      I   urinary calculi..............  1345
 of..........................ii 867 Lobelia inflata, poisoning by...   445
— increased action ofthe___ii. 8361 Localities, considered with refer-
— Bibliog. and Refer.......a S77   ence to the cure of disease ... i. 411
— cancer of the.............ii. S7ll----infected,  restrictions   re-
    causes of its diseases ... ii. 830-34   specting....................   275
----chronic  inflammation  of,
  treatment of..............ii 864-6
----of the circulation in the.. a 839,40
—^— cirrhosis of the...........a 809
----influence of climate on the a 830
----congestion, partial, of the . ii. 839
----consequences and termina-
  tions of inflammation of... a 849-66
----serous cysts in the........ii. 872
----the diseases of the........ii. 829
----disease of, causing dropsy, i 699
----encysted dropsy of........i. 750
----enlargement of the.......ii. 852
--------described..........a 867, 9
--------diagnosis of.........a 852
----fatty disorganization of... ii. 870
----functional disorders of the. a 834
----fungo-haematoid tumour of
  the........................ii 872
     inland, considered in rela-
  tion to phthisi3.............1277,8
Lochia, states of, after delivery.   537
----morbid states of, means ad-
  vised for...................   53S
Locomotive organs, disorder of,
  in insanity.................ii 507
Lolium  temulentum, poisoning
  by.........................   477
Loquelee defectus, described....   1500
Lotio Acidi Hydrocyanici
                      F. 331. Ap. 15
---AcidiHydrocyanici F. 833. Ap. 31
----Acidi Nitro-Hydrochlorici
                      F. 834 Ap. 31
---Antiphlogistica .. .F. 332. Ap. 15
----Antipsorica.......F. 333. Ap. 15
---Boracica.........F. 334 Ap. 15
                                        Evaporans........F. 336. Ap. 15
----of gangrene of the........ii. 8071----Evaporans Astringens
----causes  of hepatic  disease                             F. 336. Ap. 15
  in  Europeans in  hot coun-       !----Flava............F. 337. Ap. 15
  tries.....................a 830-34 — Hydrargyri Camphorata
----haemorrhage of the.......a 8431                      F. 338. Ap. 15
Lotio Sedativa.........F. 339. Ap. 15
----Terebinthinae  et  Campho-
  rae .................F. 340. Ap. 15
____Terebinthinata ... F. 341. Ap. 15
Lue3 jEthiopica, described.....  1473
____Venerea, nature  and cure
  of.   See, also, Syphilis.......  1454
Lumbago, description of.......   671
----diagnosis of, from nephritis a 729
----feigned..................i 1036
Lumbricus teres described. See,
  also, Worms................  1545
----symptoms of.............  1646
----treatment of.............  1659
Lungs, perforating abscess ofthe a 907
----of absorption from........  i 27
----atrophy of...............a 907
----Bibliog. .and Refer, to their
  diseases....................a 912
----collapse of the............
----concretions in tuberculated,
  their formation.............  1219
----dilatation of the air cells .. ii 901
----diseases ofthe............ii. 878
----emphysema of, described a 900,1
----vesicular emphysema of... ii 901
--------causes of............a 902
--------progress and prognosis
  of..........................a 903
--------treatment of.........a 905
--------symptoms and diagno-
  sis of. ......................a 902
----fungo-haematoid disease of
  the........................a 910
----gangrene of the..........ii 907
--------symptoms of.........ii. 909
--------treatment of.........ii 909
---haemorrhage into  the.....a 911
----hypertrophy of...........ii 906
----inflammation of the.  See,
  also, Pneumonia............ii. 873
--------complicating phthisis.  1212
----intercurrent and secondary
  inflammation of, in phthisis ..  1215
----lesions  of  the,  associated
  with tubercles.............1216,17
----inter-lobular and subpleural
  emphysema of the...........a 904
--------symptoms and diag-
  nosis of.....................ii. 904
--------treatment of.........ii. 906
----malignant structures of the ii. 910
----melanosis of..............ii 910
----morbid sympathies of.___  1038
---spurious melanosis of.....a 911
----oedema of described......ii 905
--------symptoms of........a 906
--------treatment of.........ii 906
----pulmonary haemorrhage... a 911
----tubercles of the.  See Tu-
  bercular Consumption.......  1188
----seats of tubercles  in the...  1215
----distribution of tubercles in
  the........................  1215
Lupus, Bibliog.  and Refer......a 917
----causes  of.................ii. 916
----means  of cure advised for. ii. 916
----definition and synon. of... a 913
----diagnosis of..............ii 915
----treatment of.............a 916
----local treatment of........ii. 917
---- phagedenicus, described... a 914
----superficialis, described.... ii. 914
Lymphadenitis.   See,  also,  In-
  flammation   of   Lymphatic
  Glands.....................a 923
Lymphangitis,  appearances  on
  dissection..................ii 920
----causes  of.................a 919
----description of acute.......a 919
   -----of chronic...........ii. 920
   - indications of cure........ii. 921
----definition of.............ii. 918
----prognosis and terminations
  of..........................a920
----treatment of.............ii. 921
Lymphatic glands, consequences
  of their diseases.............ii. 927
----enlargement of...........ii 925
----inflammation of..........ii. 923
--------causes of............ii 924
--------treatment of.........ii. 925
----specific inflammation of... ii. 924
--------treatment of.........a 926 
LY                             INDEX.                              ME           1599
Lymphatic glands, symptoms of      |Man, the influence of climate on I. 404'Measures, preservative against
  acute inflammation of.......ii. 923 Mania, causes of..............ii. 530]  pestilence........•.....• • • •261-77
     symptoms of  chronic in-
  flammation of...............ii 924
----malignant diseases of the.. ii. 927
----morbid deposits in......a 926,7
----pestilential disease of... ■.. ii. 926
----scrofulous enlargement of. ii. 925
----structural lesions of.......ii 925
----tubercular deposits in.....ii 926
Lymphatic system, signs of dis-
  ease mrnished by...........   1088
Lymphatic and lacteal systems, ii. 918
----Bibliog. and Refer........ii. 928
Lymphatics,  constriction  and
  obliteration of..............ii. 922
----disease of, causing dropsy.  i 697
—— Inflammation of.  See Lym-
  phangitis ...................a 918
----structural lesions of.......ii 921
----malignant diseases of.....a 922
----varicose states of.........a 921

                 M.
 course and duration of.... a 529 Meats, poisonous, various kinds
. diagnosis of..............ii. 529   of..........................427,8
• illusions and delusions of.. ii. 5291 Mechanism and functions ofthe
■ medical treatment of___a 600, 2   spinal cord.................    43
• prognosis  of..............ii. 529 Mediastinitis, course andtermin-
. regimen and diet in......ii 599   ations of....................ii. 952
     remedies advised for . .ii 599-602
     treatment of.............ii. 599
  — acute, described..........a 526
----chronic, or protracted states
  of..........................ii528
----puerperalis, described.....ii. 628
----sub-acute, states of.......a 527
Manifestations  of  disease, ar-
  rangements of..............a 1059
----of mind,  classification  of
                          ii. 512-513
Marasmus, description of.  See,
  also, Tabes.................  1100
Masticatories, enumeration of..  1146
Mastodynia, symptoms and treat
  ment of....................   604
Madeira, climate of...........i. 414 Mastoitis, symptoms and treat-
Madness, description of........ii. 526
Madrid colic, treatment of......i 439
Maggot-pimple described.......   i.  36
Maladies,  epidemic, considered
  pestilential.................   105
Malaria, means of counteracting  L 876
      See, also, Endemic Influ-
  ment of..................a 930-31
Masturbation, described.
  also, pollution, voluntary ... .485-90
----a productive cause of in-
  sanity......................ii. 568
     of phthisis...............   1230
     signs of..................    486
  ences......................i. 867 Materialism, modern, in  rela-
----ofthe prevention ofthe gen-       |  tion to insanity.............ii 576
  eration of...................  i 874 Meadow-saffron, poisoning by ..    424
----treatment  and  regimen       |----treatment of.............    424
  when exposed to............  i. 877i Means of cure, recommendations
 Male-Fern, aethereal oil  of, for
   treating taenia..............   1551
 ----extract of, for treating tae
   nia........................   1551
 ----formulae of, for treating tas-
   nia  ........................   1550
 ----methods with, for treating
   taenia......................   1549
 —— and   pomegranate - bark
   combined, for treating taenia .   1553
 Malignant characters in measles ii. 942
 Malignant  formations   in  the
   heart.....................a 253,4
 Malignant puerperal fever, his-
   tory, course, and termination
   of..........................570-80
 .---remarks  on several means
   of cure.....................590-93
 ---pathological doctrine of... 579-84
 ----treatment of.............588-93
 Mamma, adipose tumour of the  ii 934
 ----atrophy of the............a 933
 ----Bibliog. and Refer, to its
   diseases....................a 938
 ----cartilaginous or osseous tu-
   mour of the.................ii 936
 r— cystic  and  hydatidic tu-
   mours of the................a 936
 --------diagnosis of.........a 938
 ----diseases ofthe............a 928
 ----functional and painful af-
   fections of the..............ii. 929
 ----haemorrhagic congestion of
   the........................ii 933
 ----hypertrophy of the........ii 933
 --------treatment of........ii 934
 ----inflammation of the.   See,
   also, Mastoitis..............ii. 930
 ----acute inflammation of  .... ii 931
 --------causes of............ii. 931
 ----.----treatment of........ii. 931
 ----chronic inflammation of... ii. 932
 --------treatment of........a 932
 ----organic lesions of the.....a 933
 ----painful affections of the ... a 929
 --------diagnosis of.........ii 929
 --------treatment of.........ij. 930
 ----painful tumour of the.....ii. 935
 --------treatment of.........ii. 930
 ----scrofulous tumours of.....ii. 934
 ----painful puerperal affections
  of..........................   504
 --------treatment of.........   504
 ----states of, after parturition    536
Mammary tumour, chronic, de-
  scribed ....................ij- 934
____treatment of.............ii 935
     to their adoption.........  1133
  — should be employed appro-
  priately  to inferred patholog-
  ical states..................1133,5
  — should be  selected  with
  Btrict reference to their known
  operation...................  1134
  — advised for phthisis by au-
  thors......................1240-50
Means,  external, advised  for
  phthisis....................1276,7
  — various, advised for phthisis  1275
Measles, appearances  in  fatal
  cases of..................ii 945,46
----Bibliog. and Refer........a 951
     causes of.................ii. 947
     description of............ii. 938
     diagnosis of..............ii 946
---history of................ii 939
     modifications of..........ii 940
     period of precursory fever . ii 939
     prognosis of..............ii. 947
---regular form of...........ii 939
  — sequelae..................ii. 943
  — stage of desquamation .... ii 940
  -------of eruption of........ii 939
  -------of florescence of......ii. 940
  — synon. and definition of... ii. 938
  — terminations of...........ii 943
  -------in death............ii. 945
  -------in other diseases .. ii. 943, 44
  — tissues most uniformly af-
  fected in...................ii 940
  — treatment of.............a 949
  -------of its  several  types
  and states...............ii. 949, 51
  — complications of, treatment
  advised  for................a 950-1
  — without  catarrhal  symp
  toms.......................ii 943
----without the eruption......ii. 943
  — with gastric and bilious dis
  order.......................a 941
  — in connexion with hoopinL
  cough......................ii 943
----with  inflammatory compli-
  cations .....................a 940
----inflammatory states of the,
  treatment of................ii 949
 — with intestinal affection... ii 941
 — of certain irregularities of. ii. 942
 — with nervous disorder.....ii. 942
 — with malignant characters a 942
 — nervous  and   malignant
  forms, treatment of..........ii 950
 — symptoms  of the  various      I.
  sequelae of..................a 9441.
  — definition  and  symptoms
  of........................a 951,2
 ----treatment of.............ii. 952
 Mediastinum, abscess in the ... ii. 952
 --------treatment of.........ii. 953
 ----Bibliog. and Refer........ii 953
 ----inflammation of..........ii. 951
 ----organic lesions of the......a 953
 Medicines, the actions of, consid-
  ered .......................  1144
 ----alterative and irritant___  1147
 ----the channels through which
  they act...................1144-45
 ----classified according to then-
  special action...............1144-8
 ----recommended for dropsy .. i. 706
 ----general effects of.........  1145
 ----modes of their exhibition..  1144
 ----irritating and depressing..  1147
 ----those calculated to  protect
  from pestilence.............   276
 ----remarks on those advised
  in phthisis.................1267-77
 ----physiological action of.. .1143-48
 ----several, advised for scrofu-
  la and tuberculosis.......... 830-7
 ----wrong estimates of their ef-
  ficacy   retard   therapeutical
  knowledge..................  1130
 Medulla oblongata, state of, aft-
  er rabies...................   624
  — spinalis,  different columns
  of, influence the sensitive and
  motive powers..............    43
 Melaena,  Bibliog.  and Refer.... ii. 955
 ----definition and synon......ii. 953
  — described................ii. 120
  — diagnosis of..............ii 954
  — forms of.................a 954
  — pathological  states  occa-
  sioning.....................a 120
  — prognosis................ii 954
  — sources of................ii. 954
  — treatment of.............ii. 954
  — varieties of..............ii. 120
 Melancholia, causes of.........ii 523
  — characters of.............ii. 521
  — delusions in..............ii. 522
  — diagnosis of..............ii. 523
  — hygienic and medical treat-
  ment of................a 597, 599
  — visceral disorders in......ii. 523
 Melancholic monomania.......ii. 521
 Melanosis, anatomical relations
  of..........................ii. 956
 ----Bibliog. and Refer........ii. 959
  — causes of.................a 957
  — chemical and physical con-
  stitution of.................ii 957
  — definition of..............ii. 955
  — forms of true.............ii. 955
  — liquiform................ii. 956
  — of the liver...............ii. 872
  — of the lungs..............ii. 910
  — origin and nature of......ii. 957
  — progress of...............a 957
  — seat of...................ii. 955
  — symptoms and diagnosis of ii. 957
  — treatment of.............ii. 953
  — punctiform..............ii 956
  — spurious, described.......ii. 958
  — stratiform...............ii 956
  — tuberiform...............ii. 956
 Membranes of brain, lesions of.  i 254
  — examination of...........ii. 959
  — serous and synovial.......    858
  — of spinal  cord,  causes of
  their diseases...............935-38
  ------inflammation of.  See,
  also, Rachialgitis............    956
Meningitis, defined............i. 280
  — duration, organic changes,
  <&c.........................  i 282
  — symptoms of acute........i. 2S0
  — symptoms of chronic......i 281
  — cerebro-spinal, described..    958 
1600          ME                              INDEX.                              MI
Meningitis, spinalis definitionot  957 Mercurials, phv.-iological action of  457 Miliary fever described........ i 1153
-----1_ diagnosis of,"from my-      ---in syphilis...............  1483 Milk, deficiency or suppression
  elitis                ........   903---various affections caused by   455   ofthe......................U. J At
____H prognosis of  ........   903----of death from small doses of   457----excessive secretion of.....n. 774
________treatment  of compli-     I----for inflammation.........u. 474-------- treatment of.........n. 774
  cations of...................   905----intolerance of............   455---suppression of the........ii 775
________acutus, appearance af-     |----of their use in phthisis___  1-71--------treatment of........a 775
  ter death...................   95S----resistance of their operation   450 Milk-fever, described..........ii. 773
____________described.......   95S----poisoning by.............453-59----treatment of.............ii 774
____________treatment of....   964----treatment of acute poison-       Milk, poisonous, noticed.......   430
________chronicus, described. 959,60]   ing by.....................   458 Mind, intellectual affections  of,
.____________treatment of___   965--------of chronic poisoning by   459]  as remedial agents..........  1141
--------associated with cere-     '----certain, advised for scrofula   832 j----moral affections of, as  re-
  bral meningitis.............   95S Mercury, in  the treatment  of       j  medial agents...............  1144
Menorrhagia, Bibliog. and Ref. ii. 141
.--- causes of................ii. 97S
----exciting causes of.........ii. 12S
----predisposing causes of.....a 12S
----at the cessation of the cata-
  menia......................a 129
---definitic not..............a 127
----diagnosis of..............ii. 077
----congestive...............ii. 977
----diagnosis of..............ii 129   tions
----haemorrhagic.............a 977----of its use in constitutional
----diagnosis between, and abor-     j   syphilis....................  1484
  tion........................ii. 97S--------in primary syphilis ..  14S1
        • between, and organic       Mesenteric disease, appearances
syphilis....................14S4-5----sensual  affections of, as
— bi-chloride of, poisoning by   3S0'   remedial agents.............  1144
------symptoms and appeal-      ----influencing the  organiza-
ances after death from......  3S6,7,   tion of the brain.........a 587-590
______treatment for.......    3S7----of the  connexion of,  and
— in cases of insanity.......a 009]   the nervous system......a 5S4-5S8
— preparations of,  their op-      I----emotions of, their influences
eration and effects..........453-59|   on the pulse................   603
   poisoning  by  its prepara-      ----its emotions ought to be di-
380
  uterine disease..............ii. 97S
----treatment of.........a 133, 979
----acute haemorrhagic, or in-
  flammatory................. ii 977
----during  pregnancy, treat-
  ment of....................a 134
----after sixth month........ii 131
    ■ previously to sixth month, ii. 131
 after death.................ii 9SS
— Bibliog.  and Refer........ii 991
— complications of..........ii. 9S0
— diagnosis of..............a 987
-------between, and various
 other diseases.............a 9S7,8
-------between, and infantile
 remittent fever.............a 987
----prognosis of..............a 97S----exciting causes of........a 9S5i
    ■ remedies advised for. .ii. 138, 140----predisposing causes of.___ii. 984
                                         consequences of..........ii. 9S7
                                     rected and excited so as to aid
                                     recovery....................  1143
                                   ----exertion and exhaustion of,
                                     a cause of phthisis..........  1230
                                   ----manifestations of their ori-
                                     gin and relations........ii. W-530
                                   ----and organization  in  rela-
                                     tion to insanity.............a 573
                                   Mineral acids,  acrid vapours, ef-
                                     fects of..................... i 166
                                   ----molecules,  productive  of
                                     disease..................... i 154
                                   ----waters and baths for rheu-
                                     matism.....................   C95
                                   ----advised for scrofula.......   835
                                   Misanthropic  monomania,   de-
                                     scribed.....................a 526
                                   Mistura Acetatis Morphias
                                                         F. 342. Ap. 15
                                   ----Acidi Boracici___F. 343. Ap. 15
                                   ----Acidi Hydrocyanici Com-
                                     posita ..............F. 344. Ap. 16
                                   ----Acidi Hydrochlorici F. 345. Ap. 16
                                   ----Acidi Nitrici Composita
                                                         F. 346. Ap. 16
                                   ----Alkalina Anodyna F. 347. Ap. 16
                                   ■---Alkalina Anodyna F. 835. Ap. 31
                                   ----Alkalina Cardiaca F. 34S. Ap. 16
                                   ---Aloes et  Guaiaci  Compos-
                                     ita..................F. 349. Ap. 16
                                   ----Ammoniaci Composita
                                                       F. 350-1. Ap. 16
                                   ----Ammoniaci et Conii
                                                         F. 836. Ap. 31
                                   ----Ammonias Hydrochloratis
                                                         F. 352. Ap. 16
                                   ----Anodyna.........F. 353. Ap. 16
                                   ----Anodyna.........F. 837. Ap. 31
globules of the blood.........1043-5----Anodyna (Infantilis) F. 354. Ap. 16
------of the  tissues during       ----Anodyna Acetosa .F. 355. Ap. 16
disease................i. 27, 671-80!----Anodyna cum Zinco F. 356. .1;;. 16
     indication of cure in......a
  — in connexion with gastro-
  enteritis....................  a 33
----nature of................ii. 988
----prognosis of..............ii. 988
----regimen and diet for......ii. 991
----remedies advised for... .ii 9S9, 1
----stages and duration of . .ii 985, 0
----symptoms of.............ii. 9S5
----synon. and definition of .. ii. 9S3
----treatment of.............ii. 9S9
----acute, described..........ii. 984
----chronic, described........ii. 984
Mesentery and its gland3......ii. 983
----acute inflammation of..... ii. 983
----chronic inflammation of... a 983
----consequences of inflamma-
  tion of......................a 983
---treatment of inflammation
  of..........................a 983
Metamorphoses of tissues.......i 671
----symptoms and progress of. ii 129
----treatment of..............a 979
--------of organic...........a 9S0
--------of passive or chronic . ii. 980
---. puerperal................ii. 130
----true, or the discharge being
  natural.....................ii. 970
--------treatment of.........ii. 979
Menses,  absent and retained.
  See, also, Amenorrhoea......a 903
----inflammation of cervix ute-
  ri after cessation of..........   1370
---and menstruation........a 959
----suppression of the........ii. 968
——----prognosis of.........ii. 969
.--------treatment of.........a 969
Menstrual period, of the first ap-
  pearance of..............-... ii 960
—— management of the.......a 962
Menstruation, absent  and  re-
  tained......................a 963
----Bibliog. and Refer......ii 982, 3
----the final cessation of......a 902|Metamorphosis and waste of the
--------medical management
  of..........................ii. 903
--------symptoms indicating, ii. 962
----duration ofthe function of ii. 962 Metastasis of diseases..........  i 6S6----Anti-Cardialgiaca.F. 838. Ap. 31
     difficult.   See,  also, Dy
  menorrhoea.................ii 972
---excessive.   See, also, Men-
  orrhagia....................a 976
----irregular, and its complica
  tions.......................a 9S0
-------treatment of.........a 981
----of certain irregularities of. ii. 980
----offensive, described.......ii. 981
--------treatment of.........a 982
----phenomena of............a 959
----suppressed, described.....ii 968
--------diagnosis of.........a 968
---treatment   of  acute  sup-
  pressed.....................a 969
--------chronic suppressed... a 970
Mentagra.  See, also, Sycosis ..  1024
Mentai manifestations, in insan-
  ity.........................a 505
     different forms of.........  i. 6S7
----of rheumatism...........  073,5
Metritis, definition of/.........   13S4
---complications,  &c, of.___   1385
----treatment of.............   13S7
----acute, described..........   1379
--------seat and symptoms of  1379
--------treatment of.........   13S0
----chronic, treatment of.....   1385
----internal, description of....   1365
---puerperal, described......    565
--------course and termination    056
---non-puerperal, described ..   1371
--------diagnosis  and  prog-
  nosis of....................   1373
  — sub-acute and chronic, di-
  agnosis, &c.................   1374
  ------and chronic non-puer-
  peral, symptoms of..........   1373
    ■ as symptoms of disease ...  1075 Metro-phlebitis,  treatment   of
Mercurial cachexy, described, <fcc.  4541   puerperal..................   5S7
---disease, described........453-50 Miliaria, Bibliog. and Refer.... a 993
---erethism, described.......   454'----definition of..............a 992
---fever, noticed............   454----diagnosis of..............ii. 993
----disease,  fumes  productive      j----prognosis of..............ii. 993
  of..........................   453!----symptoms of.............ii. 992
---palsy, noticed............ i 154'----treatment of.............a 993
---purging, noticed..........   454 Miliary eruption.  See, also, Mi-
---salivation, diagnosis of.... 456-7!   liaria......................a 992
     Anti-Dysenterica
                    F. 839-40. Ap. 31
----Anti-Emesis......F. 357. Ap. 16
----Anti-Icterica......F. 841. Ap. 31
----Antiphlogistica. F. : 5<4). Ap. 16
----Antiseptica.......F. 360. Ap. 16
----Aperiens.........F. 361. Ap. 16
----Aperiens Salina.. .F. 302. Ap. 16
----Aromatica........F. 303. Ap. 16
----Arsenicalis.......F. 364 A]). 16
----Arsen. cum Opio.. F. 365. Ap. 16
----Asafoetida?.......F. 366. Ap. 16
----Asafcetidae Composita
                      F. 367. Ap. 16
----Asafcetidae et Conii F. M2. Ap. 31
----Asafcetidas et Valerianae
                      F. 36S. Ap. 16
----Balsami Peruviani F. 369. Ap. 16
----Balsami Peruviani Compos-
  ita..................F. 8-13. Ap. 31
----Balsami Tolutani .1". 370. Ap. 16
----Bechica..........F. 371. Ap. 16
----Belladonna?.......F. 844. Ap. 31
----Camphorae.......F. 372. Ap. 16
----Camphorae Ammoniata
                      F. 845. Ap. 31
----Camphorae Composita
                      F. 373. Ap. 16
----Camphorata___F. 374-5. Ap. 16 
MI
INDEX.
NE          1601
Mistura Cardiaca......F. 846. A p.
---Carminativa......F. 37e! Ap.
---Carminativa Deobstruens
     „  ,.             F. 377. Ap.
---Cathartica.......F. 378. Ap.
— Cathartica Ammonica
                      F. 379. Ap.
---Chloratis Potasses et Sodae
                      F. 847. Ap.
---Cinchona?........F. 380. Ap.
---Cinchona? cum Acido
                      F. 848. Ap.
---Cinchonae et Acidi Sulphu-
  rici.................F. 849. Ap.
---Cinchona? Alkalina F. 381. Ap.
---Cinchonas Aperiens F. 382. Ap.
---Copaibas.........F. 850. Ap.
_— Conii Composita .. F. 383. Ap.
---Cydonias Infusi Composita
                      F. 851. Ap.
---Creta? Comp......F. 384 Ap.
---Decocti Cinchonae. F. 852. Ap.
---Decocti Cinchonas Ammo-
  niata...............F. 385. Ap.
---Decocti Cinchonae Compos-
  ita...............F. 386,7. Ap.
---Decocti Cinchonas cum Ace-
  to Pyroligneo........F. 38S. Ap.
---Decocti Genistae.. F. 853. Ap.
---Demulcens.......F. 389. Ap.
---Deobstruens___F. 390-2. Ap.
■---Diaphoretica.....F. 393. Ap.
---Diaphoretica.....F. 854. Ap.
---Diaphoretica Anodyna
                      F. 394 Ap.
---Diaphoretica Anodyna
                      F. 855. Ap.
---cum Digitale Kerm.  Miner.
                      F. 856. Ap.
---Digitalis et Colchici Comp.
                      F. 395. Ap.
---Diosmas crenatae . .F. 396. Ap.
---Diuretica F. 397,8, 9,400. Ap.
---Emetica excitans F. 402,3. Ap.
---Expectorans......F. 404. Ap.
---Expectorans......F. 857. Ap.
---Febrifuga......F. 405,7. Ap.
---Febrifuga (Peysson) F. 408. Ap.
---Febrifuga Nervina. F. 409. Ap.
---Guaiaca Ammoniata F. 410. Ap.
---Guaiaca Comp. ... F. 411. Ap.
---cum Hydrargyri Bichlorido
                      F. 412. Ap.
---Hydrochlor. Ammonias
                      F. 864. Ap.
---contra Hydropem .F. S59. Ap.
---Infusi Anthemidis Compos-
  ita .................F. 860. Ap.
---Infusi Calumbas et Hyoscy-
  ami ................F. 861. Ap.
---Infusi Calumbas Composita
                      F. 862. Ap.
---Infusi Cuspariae Composita
                      F. 413. Ap'.
---Infusi Salicis Composita
                      F. 414. Ap.
---Infusi Senegas Composita
                      F. 415. Ap.
---Infusi Serpentarias Compos-
  ita...............F. 416,7. Ap.
---Infusi Uva? Ursi . .F. 418. Ap.
---Infusi Uvae Ursi Composita
                      F. 419. Ap.
---Infusi Valerianae. .F. 863. Ap.
---Laxans..........F. 420. Ap.
---Mucilaginis Anodyna
                      F. 421. Ap.
---Myrrha?..........F. 422. Ap.
■---NYrvina........F. 423,4 Ap.
---Oleosa...........F. 425. Ap.
---Pectorali3......F. 426, 7. Ap.
---Phosphorata......F. 428. Ap.
---cum Potassii Iodido  et Aci-
  do Hydrocyanico___F. 853. Ap.
---Purgans......F. 429, 30. Ap.
---Refrigerans.......F. 431. Ap.
---Resolven3........F. 432. Ap.
---Rhei Comp.......F. 433. Ap.
---Rhodii Comp. . .F. 434, 5. Ap.
---Salina............F. 436. Ap.
—— Salina Antiseptica
                 F. 437, 8, 9. Ap.
---Salina Febrifuga F.  440,1. Ap.
___Salina Sedativa...F. 865. Ap.
     III.
31 Mistura Sedativa......F. 442. Ap. 18
17,---Sedativa.........F. 866. Ap. 32
   ---cum Soda? Biborate F. 867. Ap. 32
17---cum  Soda? Potassio-Tar-
17   trate...............F. 86S. Ap. 32J
   ---Stomachica___F. 869,70. Ap. 32
17---Strychnia?........F. 443. Ap. 19
   ---contra Tenesmum.F. 871. Ap. 32
31---Terebinthinas  Venetae
17   (Clossius)............f. 444. Ap. 19
   ---Tonica.........F. 445, 6. Ap. 19
31---Tonico-Aperiens . .F. 872. Ap. 32
   ----Tonico - Deobstruens
31                       F. 873. Ap. 32
17---Vermifuga.......F. 447. Ap. 19
17---Vinosa...........F. 448. Ap. 19
31---Zinci Composita . .F. 874 Ap. 32
17---Zinci Opiata......F. 875. Ap. 32
   Mode3 of exhibiting medicines..  1144
31---of  treatment  advised  for
17   phthisis by  authors.........1266-77
31 Moisture, as predisposing to dis
     ease....................... L 649
17 Molecules, animal,  injurious ef-
     fects of.....................i 166
17---means of preventing inju-
     rious  effects  from  mineral,
17   vegetable, and animal....... L 168
31 Momordica Elaterium, poisoning
17   by.........................   391
17 J Monkshood, poisoning by......   415
17]--------treatment of........   417
311 Monomania,   demoniacal,   de-
     scribed.....................ii 524
17---misanthropic.............ii. 526
   ----hypochondriacal.........a 521
31 —-------treatment of........ii. 596
   ----melancholic, described.... ii. 521
31--------treatment of........ii. 596
   Monostoma, synonymes of.....  1517
17l----systematic description of..  1517
17iMoors and Jews, of the intro-
17   duction  of  syphilis  into Eu-
17]   rope by....................  1465
IS Moral treatment of insanity___a 619
32 Morbid action,  principal  states
18:   of, described................ i. 658
18! Morbid actions, their connexion
18|   with states  of the blood......L
18j----the  removal  of  predomi-
18;   nant, in fever..............i. 1078
   Morbid appearances in the heads
181   of the insane.............ii. 549-53
   Morbid secretions susceptible of
32   organization................ i 677
32  "
   Morbus Gallicus, described.  See,
     also, Syphilis___...........  1459
32----Niger of the ancients, .ii. Ill, 118
   ----Venereus, described.   See,
32   also, Syphilis...............  1464
   Morphia, opium, and their prep-
32   arations, operation and effects
     of.........................   467
18----and its salts, poisoning by   470
   -------------treatment oi....   472
IS Mortality, rate of, in the insane ii. 545
   --------in ha?magastric pesti-
18   lence......................   167
   --------in plague...........   254
IS Motion, paralysis of,  described .    13
18,Motor and sensitive  powers, in-
   |  fluenced by different columns
18;  of the spinal medulla........    38
32 Mouth, haemorrhage  from......  ii. 94
18----inflammation of the.   See,
     also, Stomatitis.............  1018
18----symptom3  furnished  by
18*  the........................  1075
18 Muco-cystitis, consequences and
18   terminations of.............  1301
18;----diagnosis of..............  1300
18----synonymes and definition
   I  of.........................  1300
32----acute, described..........  1301
181--------treatment  of........  1308
18!----chronic, described........  1301
18'--------treatment of.......1309-10
lS^Iuco-enteritis, description of, in
18|  children....................ii. 660
18,----treatment of.............ii. 679
   |----acute, symptoms of.......ii. 659
18i.--------treatment of........ii. 679
18—------in children..........ii. 6S0
321----chronic, symptoms  of..... ii. 660
 101
 Muco - enteritis, chronic,  treat-
  ment of....................a 680
 --------in children..........a 0S0
 Mucous surfaces, syphilitic affec-
  tions of....................   1409
 Mucus, expectoration  of, as a
  symptom...................   1092
 ----in urine, appearances of ..   1337
 Muscles, adipocerous or fatty de-
  generation of............■... a 997
 ----alterations of their consist-
  ence .......................ii. 996
 ----motion and sensation of... ii 993
 ----their structure.........ii. 996,8
 ----atrophy of...............ii. 996
 ----Bibliog. and Refer, to___ii. 99S
 ----changes of colour of......ii. 996
 ----effects of cold on......... i 420
 ----of the contractility of.___v. 993
 ----causes  affecting  the con-
  tractility of.................ii. 993
 ----division of...............ii. 993
 ----morbid contractions of.... ii. 996
 ----gangrene of..............ii. 996
 ----hardening of.............ii. 996
 ----hypertrophy of...........ii. 996
 ----inflammation of..........ii. 995
 --------causes of............ii 995
 --------consequences of......ii. 995
 --------symptoms of........ii. 995
 --------treatment of........ii 996
 ----lesions of their sensibility . ii. 995
 ----softening of..............ii. 995
 ----suppuration of...........ii. 995
 Muscular motion, signs of dis-
  ease furnished by...........1065-6
 ----structure, diseases of. See,
  also, Muscles...............a 993
 Mushrooms,  poisonous,  opera-
  tions and effects of.......... 474,6
 ----appearances in fatal cases.   476
 ----treatment of.............   476
 Myalgia, described.   See, also,
  Muscles, pain of............ii. 995
 Myelitis, described.   See, also,
  Inflammation  of the  Spinal
  Cord.......................   961
 ----appearances  after death
  from.......................   962
 ----complications of..........   963
 ----diagnosis of..............   963
 --------between, and spinal
  meningitis.................   963
 ----prognosis of..............963—1
 ----acutus, described........ 961,2
 --------treatment...........   964
 ----chronicus, described......   959
 --------treatment of........   964
 Myomalaxia,  or   softening   of
  Muscles....................ji. 997
 Myositis.  See Muscles, inflam-
  mation of the...............ii. 905

                 N.
 Nails, affections of the.........   808
 Narcotic and irritant poisons...   474
 Narcotics, enumeration of.....   H47
 ----in cases of insanity.......ii. 610
 ----of the operation of........   460
 ----poisoning by.............460-74
 Nausea during pregnancy.....   501
 ----treatment of.............   501
 ----as a symptom............   1080
 Neck, rheumatism of the......   072
 Necroscopic poison, appearances
  after death from............   440
 ----indications  and means  of
  cure for its effects........... 443,4
 ----diagnosis of its operation .   439
 ----cases of disease caused by 438,43
 ----diseases which impart this
  poison..................... 437,9
■----nature  of  the distemper
  caused by.................. 441-3
----effects, &c, of, described. .437-41
 ----inferences as to the nature
  of its effects................ 441,3
----predisposing causes to  in-
  fection by..................   441
----symptoms produced by ...   43S
----treatment of the  effects
  caused by.................. 443,4
Necrosis, causes of............ii. 1055
     or mortification of bone  .. a 1055 
1602          NE
INDEX.
(ES
Necrosis, symptoms of........ii 1056 Nervous centres, conditions of,
Nematelmia, definition of......  1537
Nemat. lidea, definition oi......  1537
Nephxuluiii,  description   and
  cause- ot...................ii- ^"
----treatment of.............a 770
____notices of................a 1013
Nephritis,   appearances   after
  death from.................ii. 727
----causes exciting, concurring
  with,  and predisposing to.... a 722
----consecutive or symptomat-
  ic states of.................a 730
--------of the  absorption of
  purulent or sanious matters.. a 731
--------of disease of the blad-
  der, prostate  gland, and ure-
  thra .......................a 732
--------of paraplegia........ii 732
--------of scarlet fever and
  other eruptive fevers........ii 731
--------of typhoid fevers___ii. 731
----consequences and tenuina-
  tions of.....................ii. 725
---■ complications of..........ii 733
----definition of.............ii. ""
----description of............a
                                  Night-blindness, treatment of..ii 1031
occasioning paralysis".".".. • • • •  36-40 Nipple, inflammation of the .... ji 930
— influence,  organic, on  the      [----causes of................il *J0
states of the blood ./........  i 243----treatment of......... a 930
— system, in connexion with      .Nitric  and  muriatic acids  in
mma                    a 5S4-90]  hepatic diseases...........u.  S65,6
       disorders  of, during      Nodosities of joints, rheumatic
                                  ■  and gouty..................667-69
                                  Noli me tangere, described . .a 914-16
                                  Noma, description of..........   1022
                                  .---- of the vulva.............   1433
                                  Nose,  signs of disease furnished
                                    by.........................   1058
                                  ----syphilitic  disease   of  its
                                    bones......................   1469
503
  pregnancy.................
Neuralgia, alteratives and deob-
  struents advised for........ii. 1022
----Bibliog. and Refer. ... .ii. 1028,9
----exciting causes of........a 1015
----predisposing causes of... .ii. 1015
----general character of......ii 1000
----complications............ii. 101
— diagnosis between, and the
 passage of a calculus........a 729
-------between rheumatism
 and lumbago...............a 729
-------of its  more simple
 state-......................a 72S
— in the female............a 725
— prognosis of..............ii. 733
— consecutive and complicated
 states of.................a 730-32
— modified states of........ii 729
-------and consecutive, treat-
 ment of....................ii. 735
— description of simple acute ii. 723
-------of sub-acute.........ii 724
— sub - acute   and  chronic,
 treatment of................ii. 734
— arthritica, symptoms of... ii 729
— asthenic, described.......a 730
— cachectica, appearances aft-
 er death from...............ii. 741
-------exciting causes of.__ii. 753
-------remote causes of.....ii. 752
-------consequences of... ii. 737-41
-------complications and re-
 lations of................ii. 744-50
-------treatment of its various
 complications.............ii 755,6
-------definitions ot........ii. 736
-------synonymes of........ii 736
-------description of........a 736
---.----diagnosis of.........ii 744
-------duration of..........ii. 741
-------medicines advised for ii 753
-------nature of............a 750
-------relations to other dis-
 eases....................a 744-50
-------treatment of........ii. 753
-------acute, symptoms of... ii. 730
-------chronic.............ii 737
---■---•----causes of.......ii. 753
---gouty,  appearances  after
 death from.................ii 730
---in the gouty diathesis .... a 729
---treatment of  gouty  and
 rheumatic..................ii 735
---rheumatic, remarks on.... ii. 730
---treatment of primary and
 simple.....................ii. 734
   ----intentions of cure for.....ii. 1021
   ----definition oi.............jj. 1006
   ----diagnosis of.............ii. 1014
   ----evacuants, emetics, and pur-
     gatives for..............ii 1021,22
   ---. of the extremities........ii 1011
   ----facial, described.........ii. 1008
   --------division of..........ii 1009
   --------symptoms of........ii 100S
   --------duration of.........ii 1009
22'----appearances in fatal cases a 1019
       feigned..................i. 1034
. femoral or crural........ii 1012
 frontal..................ii 1009
----syphilitic affections of.___  1409
----and palate, syphilitic ulcer-
  ations of the................  1469
Nostalgia, Bibliog. and Refer, .a 1034
----causation of.............a 1033
----appearances in fatal case? ii 1034
----diagnosis between real and
  feigned....................ii 1034
----symptoms of.............ii. 1034
----synonymes and definition
  of.........................a 1033
----treatment of.............ii 1034
Nostomania.  See, also, Nostal-
  gia........................a 1034
----ofthe ganglia............ii. 1013, Nostrils, haemorrhage from .. .a 83-90
   in gouty, hypochondriacal,
 and hysterical persons......ii. 1014
— infra-orbital, described ... a 1009
—- sources and causes of irri-
 tation  producing,  particular-
 ized ....................ii 1015-18
— ofthe liver...............ii 838,
— local mean3 for..........ii. 1026
   • various medicines advised
Nubia, the climate of, advised
  for phthisis.................   1278
Nuclei, naked, of morbid growths   771
Nutrition,  metamorphosed  or
  transformed................ i 671
---- ofthe body as a sign of dis-
  ease .......................  1064
----transformations of........ii. 671
Nux vomica, poisoning by.....   411
for......................ii 1022-6 Nyctalopia, synonymes and phe-
1009
  nomena of..................i 1029
Nyctalopia  and  hemeralopia,
  Bibliog. and Refer..........a 1033
O.
— mental.................a
— of muscular and membra-
 neous parts................ii. 1012
-------diagnosis between, and
 rheumatism................ii 1012
— nature of................ii. 1019 Obesity, amount of, notices of. .ii. 1036
— of the neck and trunk___ii. 1010----Bibliog. and Refer.......ii 1039
— of nerves of association a 1013,14----causes of................a 1036
— ofthe cervical nerves___ii 1010|----characters of............a 1035
— of the intercostal nerves., ii. lOlOj----ofthe  chemical  doctrine
— of lumbar nerves........a 1011   of......................a 1037,38
    special notices of.........ii 10071----of the heart..............ii 250
    paroxysms of, described  . .a 1006----partial and general......a 1035
                                        pathology of.............a 1037
— duration and return of the
 paroxysms of..............ii. 1007
   ■ pathological causes of.. ii 1015,16
- synonymes and definition, ii 1035
 treatment of............a 1038
                                        differences  between,  and
                                      rheumatism................    677
                                    ----sciatica, described........a 1012
                                    ----terminations and prognosis
                                      of.........................a 1018
                                    ----treatment of.............a 1021
                                    ----of the tongue, described...   1176
                                    --------treatment of.........   1176
                                    ----of the viscera............a 1013
                                    ----uteri, causes of...........   1362
                                    --------described............   1362
                                    --------diagnosis  and  prog-
                                      nosis of.....................   1362
                                    --------treatment of.........   1364
                                    Neuralgic  affections.  See, also,
                                      Neuralgia..................a 1006
                                    ----various  remedies  advised
                                      for.....................ii. 1022-2G
                                    —— treatment of............ii. 1021
        - of secondary........a 735,Neuritis, causes of............ii. 1004
Nerves, Bibliog. and Refer.. .a 1005, 6----definition of.............ii 1001
----of the periosteum........ii 1013 Obliteration of arterie3........i 133
     diseases of...............ii. 998
----effects of cold on.........i 420
----ganglial, agency of, in the
  several  healthy and  morbid
  eympathic3.................1031-3
----the organic or ganglial, their
  direct effect on the blood___i 243,6
----inflammation of, described.
  See, also, Neuritis..........a 1001
----lesions  of sensibility, and
  function of.................a 1005
----structural changes of.....a 998
----tumours of the........ii 1003,4
Nervous affections  resembling
  chorea, described...........i 390
--------from mercurials.....   454
     prognosis of.............a 1004
     treatment of............H. 1005
     varieties of..............ii 1002
 — acute, described.........ii. 1001
----symptoms of chronic.....a 1002|
Neuroma, description of.......ii 1003
----diagnosis of.............a 1003'
----treatment of.............a 1005;
New-born infants, apoplexy of..  i 119
     of the  canal of portion of
  intestines..................  i. 638
----of vena cava.............   1442
Obstipation.   See, also, Consti-
  pation .....................i 471
Odontalgia, forms of..........a 1009
Odour ofthe breath  as a sign of
  disease................."....   1092
(Edema, description of........  i. 724
----treatment of.............  i. 72S
----of the glottis, described...  i. 7S9
----of the heart..............ii. 250
----of the lungs, described .... ii. 905
----synonymes and definition ii 1039
----active, described.........ii 1040
--------diagnosis of.........a 1040
----passive, described........a 1039
--------appearance3   after
  death......................a 1039
----treatment of.............ii 1040
CEsophagitis, causes of........ii. 1043
----definition of.............ii. 1042
----prognosis of.............a 1047
----in children, treatment of .a 104S
----acute, symptoms of......ii. 1043
--------terminations of.....a 1044
  -------treatment of........ii. 1048
     chronic and sub-acute... .ii. 1045
     ----treatment of........ii. 1049
     complicated, treatment of. a 1048
Nice, climate of, noticed.......  i 413 (F.^ophagus, Bibliog. and Ref ,t. ii 1052
Night-blindness.  See, also, Nye-       |----diseases of the.....       a 1041
  taloPia.....................ii 1029----foreign bodies in the.!.!.ii 1052
----causes of................ii 1030;--------treatment of........a 1052
  — pathological states  of..... ii. 1031----structural changes of... ii. 1041,2
phenomena of............ii. 1030 ■
gangrene of.............ji 1044
■ prognosis of.............a 10311---hemorrhage from........a 1049 
CES                              INDEX.                              PA          1603
(Esophagus, haemorrhage from,      [Ophthalmia, scrofulous,  symp
  treatment of...............ii. 1050
----inflammation of the.  See      j.
  CEsophagitis...............ii. 1042
----organic lesions of......a 1041,2 ■
----paralysis of the..........a 105l|
        ■ diagnosis of.........ii. 105F-
toms and progress of........L 1006
------terminations and diag-
nosis of..................i 1006,7
------treatment  and regi-
men .....................i. 1007,8
            local, of........i 1009
--------treatment of........a 1052!----sclerotica,  diagnosis   and
----perforations of the.......ii. 1042  prognosis of................i. loll
----scirrhus of the...........ii. 1047--------symptoms and termin-
----spasm of the.............ii 1050|  ations of....................i 1010
--------causes of...........ii. 1050--------treatment of........i. 1011
--------symptoms of........a 1050]-------------local, of........i 1011
--------treatment of........ii. 1051----universalis, description of. i 1022
----stricture of the..........ii. 1045--------terminations and diag-
----stricture and ulceration of,         nosis of....................i 1022
  treatment of...............ii. 1049---------treatment of.........i. 1022
----permanent stricture of, diag-      |----variolous, described.......i 1009
  nosis of....................ii. 1046 ■---------treatment of.........i 1009
----suppuration of...........ii. 1044 Opisthotonos, defined..........  1101
----thickening and  induration       Opium and its preparations, ap-
  of.........................ii 1045|  pearances after death  from
 398
1271
834
   . symptoms of thickening . .ii 1045
----fibro-cartilaginous tumours
  of.........................a 1045
----ulceration of the.........ii. 1040
--------symptoms of........ii 1047
Oil of bitter almonds, poisoning
  by.........................
----cod-liver, its use in phthisis
--------advised  for scrofula
  and tuberculosis............
----male-fern,  for  the  treat-
  ment of taenia..............  1551
Oils,   empyreumatic,  poisoning
  by.........................   474
----of their use in phthisis....  1271
Old-age, described............  i 56
Oleum Camphora?.....F. 449. Ap. 19
Omentitis, description of.......    75
Onychia, syphilitic, described ..  1469
Ophthalmia, Bibliog. and Refer.
  to........................i 1023,4
----causes of................ i. 985
  poisoning by................   471
----antidotes for.............   472
----its modes of operation ....   471
----morphia, and their prepara-
  tions, operation and effects of   467
----and opiates,  their use  in
  phthisis....................   1271
----poisoning by,  diagnosis of.   469
--------treatment of........   472
--------. cold affusion for.....   472
--------and by its  prepara
  tions, symptoms  of..........   467
--------appearances after death
  from.......................   471
----smoking, effects of.......   468
Organic functions, disorders of,
  connected with insanity.....ii. 536
----states of, in insanity......ii 508
---- nervous system, influence
  on the  blood................ i. 243
--------influence exerted on
  the secretions by the........ i. 667
definition of.............. i. 985[--------or vital power, its in-
----forms of................. i 986
----feigned..................i 1035
----arthritica externa........i 1012
----arthritica  interna,  symp-
  toms and treatment of.......i. 1021
----erysipelatous.............i. 1010
----exanthematous, causes and
  forms of....................i 1009
--------treatment of.........i. 1009
----gonorrhoeal,  symptoms  of
  acute......................i 1002
--------causes of............i 1003
--------diagnosis  and  prog-
  nosis of.....................i. 1002
--------treatment of........i. 1003
    symptoms and treatment of
  fluence on haemorrhage......  ii. 73
---- or ganglial nervous  sys-
  tem, its influence in associat-
  ing or complicating disorders
                         1030,47,49
---------its influence  on  the
  blood and circulation___1030,47,49
----nervous system, primarily
  affected by the efficient causes
  of fever....................i.  1061
--------the source  of irrita-
  bility.....................ii. 691, 3
Organization of the brain, influ-
  encing the mind..........ii. 587, 8
----and mind, in relation to in
  sanity.....................ii 573
  the mild....................i. 1005]Organized parts, destruction of.  i. 079
----interna, definition of......i 1015 Organs,  diseased,   absorption
----of  internal   parts,  de-      j   from.......................   i 29
  scribed..................i. 1015,22..----ha?morrhage into the struc
----of the internal coats, de-      |   ture of.....................ii. 143
  scribed.....................i 1019-----of  reproduction,  sympa-
----intermittent.............i 1023]   thies with..................   1053
    • morbillous...............i. 1010:----of respiration,  diseases of,
  causing phthisis............  1233
----of  sense,  morbid  sympa-
  thies of....................  1040
Orifices of the  heart, dilatation
  of..........................ii.  244
---------causes of............ii.  244
Osseous formations in the heart ii.  222
Osseous  system,  Bibliog.  and
  Refer......................ij. 10G0
----diseases of...............ii. 1053
Ossification of arteries  of  the
  heart......................ii-  200 Palate, Bibliog. and Refer.
Ossific deposits in arteries.....i.  134]----inflammation of the .
     transformations..........  i  673]--------causes of.
Otalgia.  See, also, Earache ... i. 846
Otitis, causes of............... i 851
----defined.  See, also, Ear, In-
  flammation of.............. i 847
----acutus, defined........... j. 847
--------symptoms of........ i. 847
--------terminations and con-
  sequences of................ i. 848
--------treatment of........ i 851
----chronic, consequences and
  lesions from..............i. 849,50
--------described........... i. 849
--------treatment of........ i 852
----external, symptoms...... i 847
   - internal, symptoms.......i 848
Otorrhcea,   consequences  and
  structural changes from.. .i 849,50
----purulent, described....... i 849
Ovaria,   abscess  of,  treatment
  of.........................a  1064
  — Bibliog. and Refer, to___ii  1007
  — diseases of the...........ii.  1061
  — effusions, &c, into the___ii.  1063
  — functional disorders of the. ii.  1061
  — inflammation.   See, also,
  Ovaritis...................ii  1001
----inflammation of, after par-
  turition ....................   566
  — organic lesions of........ii  1064
  — symptoms of organic lesions
  ofthe......................ii  1064
  — treatment of organic dis-
  eases of the................ii.  1065
  — rheumatism of...........   675
  — scirrhus of the...........ii.  1065
  — suppuration of...........ii.  1063
  — encysted and other tumOura
  ofthe......................ii.  1065
  — malignant and  other  tu-
  mours ofthe...............ii.  1065
Ovarian dropsy, described.....i 745
Ovaritis, cases  of.............ii.  1062
  — causes of................ii.  1062
  — definition and synonymes. a  1061
  — symptoms of............a  1062
  — terminations  and  conse-
  quences of.................ii.  1063
  — treatment  of.............ii.  1063
  — puerperal, notices of......   566
Ovarium, of extirpation of the.ii  1006
   - hernia or displacement of. ii.  1066
Oxalic acid, poisoning by......   378
   - treatment of.............   330
Oxaluria, causes of............   1330
  — characters  of urine  con-
  taining oxalate of lime......   1328
  — source of................   1329
  — symptoms attending......   1330
  — treatment of.............   1330
Oxyuris, systematic description
  of the genus................   1519
----vermicularis, systematic de-
  scription of.................   1539
  -------diagnosis of.........   1521
  -------locality of...........   1520
  -------symptoms of........   1520
  — ■----various remedies for .   1536
  -------treatment of........1535-6
Ozoena, definition of..........ii.  1007
   - causes and progress of___ii.  1007
   - prognosis of.............a  1067
   - treatment of............a  1067
---purulent.................  i 988
--------of infants...........  i 988
------------causes of.......i. 988
------------symptoiM   and
  progres3 of..................  i. 989
------------terminations and
  prognosis of................  i. 989
------------treatment of....  i 990
------— in adnlts............  i. 991
------------causes of.......i 992
------------contagion of....  i. 992
------------symptoms   and
  prognosi3 of.................  i 994
------------terminations and
  diagnosis of.................  i 995 Osteitis, causes of............ii 1054--------symptoms of........
------------treatment of___i 996:----local causes of...........a 1054--------treatment of........
_________________local......i 998'----consequences and termina-      I----relaxation of the.........
____________various means of      \  tions of....................ii 1054]----ulceration of the.........
  cure.......................  i 998----definition of.............ii. 10531----syphilitic ulcerations ofthe
____pustular','" symptoms  and       I----symptoms of............ii. 1054jPalatitis, complications of
  treatment of..............i- 1005,6]----seat and anatomical changes
Pain or aching in the region of
  the liver indicative of organic
  disease of..................ii 873
----as a symptom of disease ..  1074
----kinds of, as symptoms ....
     as a symptom of phthisis..
----rheumatica, symptoms and
  treatment of.............>• l01-\-»
____scarlatinous..............i. 1010 Osteomalacia, described.
of.........................ii. 1053----prognosis of.
                               1074
                               1201
                                  3
                                  1
                                  1
                                  2
                                  3
                                  1
                                  3
                               1469
                                  2
----description of............   1, 2
treatment of.............ii. 10561
treatment of.
.ii. 1057]Palpitations, causes of..
      3
      3
.. ii. 204
____scrofulous causes of......i 1006 Osteosarcoma, described......u, 1059'----course and duration of.... ii. 205 
1604          PA
INDEX.
PE
Palpitations, diagnosis of......ii 205 Paracentesis  thoracis, for em-
----treatment of............ii. 205, 0   pyema.....................
____definition of.............a 204----manner of performing ....
____a3 ?i(rn3 of disease........  10S0; Paralysis, consequences of.....
____treatment of hysterical ... ii 206]----definitions of.............
     Bibliog. and Refer........ii. 200;----diagnosis of,
____of the heart, during preg-
  nancy  .....................   603
________treatment of........   503
Palsy, associated with apoplexy    29
____associations and complica-
  tions of....................    29
----Bibliog. and Refer........    54
----blood-letting for..........    50
____physical conditions of the
  brain in....................    37
----predisposing causes of....    35
____from arsenic.............    27
----cerebro-spinal fluid in con-
  nexion with................    38
----external means of cure ad-
  vised for...................    52
----disorders preceding and at-
  tending ....................    27
----associated with epilepsy ..    29
----of evacuants and  altera-
  tives for....................    50
----general history of........    27
----complicated with disease of
  the heart...................    31
--------with hysteria.......    32
--------with inflammation of
  the brain...................    30
---------with insanity, descrip-
  tion of.....................    30
----complications of, their treat-
  ment ......................    48
----from lead, described......    26
----of the lower  half of the body.
  See, also, Paraplegia........    28
----from mercury............    27
----mineral waters advised for    52
----from narcotics...........    27
----shown to  arise  from two
  distinct conditions ofthe nerv-
  ous centres.................   36-9
----on the pathology of.......    36
----remote causes of.........    34
----topics connected with the
  pathology of................  36-41
----pathological  states  occa-
  sioning.....................
  -------diagnosis ofthe......
  — physical agents producing.
  — prognosis of.............     s-i
  — appreciation and appropria-
  tion of remedies for.........  50,3
  — terminations of...........     33
for.
 regimen and diet for.
 with rheumatism.........
 shaking, described.......
• of the sphincters.........
 states  of the  sphincters

. of stimulants, tonics,  <fcc,
     i Parents, disorders of, predispos-
  331   ing to phthisis.............1226-28
333^ 5;----habits of living  of, pvedis-
   33]   posing to phthisis...........1227,8
   12____transmission   of  phthisis
   32   from.......................1225,6
      Parietes of abscess, described... 10-17
      ----of abscesses of  the brain,
        described................... i. 262
      Parotid gland, diseases of......    55
      ----functional disorder of.....    65
      ----inflammation of.   See, also,
        Parotitis...................    66
           suppuration of,
___treatment of various com-       Parotids, Bibliog. and Refer. ..
 plications of................  4S-50----chronic enlargement of ...
___agitans, described........     25]----organic lesions of the.....
_______treatment of.........     48 ——• affection of, consequent on
___in connexion with apoplexy   i. 93  scarlet fever................
___passing into apoplexy.....   i. 95 Parotitis, causes of............
___of the urinary bladder___1297,9----definition of.............
________treatment of.........   1299'----metastasis of, noticed.....
— in children, treatment of..     48----states or varieties of......
— associated with  disease of
 the cranial and vertebral bones     30
— of the facial muscles......     14
— local forms of............     13
— general, described........     20
--------states and sources of 20,21,2
--------associated with insan-
 ity.........................ii. 534
--------pathological states pro-
 ducing....................20, 21, 2
  55
  57
  57
10S5
       ■ symptoms of, described    23
    ----treatment of.........    47
— complicated with hysteria,
 treatment of................
— complicated with idiocy ...
— infantile, forms of........
— of infants and children....
— complicating  insanity, de-
 scribed.....................ii. 534
---complicated with insanity,
 treatment of................
--------with disease ofthe kid-
 neys .......................
---local or partial treatment of
---of motion, described......
--------treatment of........
---particular muscles........
---of the oesophagus........ii
---from poisons, descriptions of
--------treatment of........
---of the rectum and anus ...
--------symptoms and  treat-
 ment of....................
   ■ complicated with rheuma-
  49
  30
  25
24,5
  49

  31
  45
  13
  45
  14
1051
  26
  4S
 045

 045
----symptoms of.............
----treatment of.............
----chronic, treatment of.....
----endemic and epidemic___
----epidemic, treatment of___
----scrofulous, treatment of...
Paroxysms of ague described...
--------treatment of.........i. 1093
----of epilepsy, description of.. i 905
--------duration of.......... i 906
----of hysteria, described ..ii 314,15
Parturiency, changes during, oc-  .   -
  casioning disease............  " 632
----changes subsequent to, caus-
  ingdisease..................   534
Parturient process independent
  of the cerebro-spinal nervous
  influence...................
Parturifacients, enumerated ...
Parturition, not dependent upon
  the cerebro-spinal  nervous in-
  fluence .....................
----changes consequent upon,
  favouring diseose...........
----of convalescence after___
----the management of conva-
  lescence after...............
----inflammation of the cervix
  uteri after..................  1365
----sinking, &c., after........   647
--------treatment of.........   547
----treatment of therseveral de-
  viations   from  the  natural
  course of convalescence from
 633
1143
533
534
535
537
537
11
11
----premonitory symptoms of.
----treatment of.............
----of the urinary bladder___
Pancreas, suppuration and ab-
  scess of....................
----symptoms of abscess of ...
----increased action of the___
----atrophy of the...........
----Bibliog. and Refer........
----chronic and  organic dis-
  eases of the, treatment of....
----concretions in the........
----diseases ofthe............
----fatty degeneration of.....
----functional disorders of___
----fungc-ha?matoid  disease of
----gangrene of.............
----hypertrophy of...........
----induration  of............
----inflammation of.   See, also,
  Pancreatitis................
----organic lesions of, non-in-
  flammatory.................
----symptoms  of organic dis-
  eases of....................
----scirrhus and carcinoma of.
----softening of the..........
----torpor of the.............
Pancreatitis,   definition  and      I.
  symptoms of acute..........      5
----causes of................      fil
----complications of..........      5
----chronic, notices of........      6|
----terminations of...........      5i
----treatment of.............      7i
P.ipvdfp, syphilitic, noticed.....   14671
tism.......................   074 Passions of the mirld eausing in-
 of sensation, described....
-----treatment of......
• of the sense of smell...
■ of one side of the body.
■ sympathetic effects of..
■ of the sense of taste
12|   sanity..........-.:■..........a 662
45J----and sentiments as causing
12'   disease.....................  i 655
                                    16! Pathogeny of disease must be
                                    40   studied.....................  1133
0----of tlie sense of taste......     12'Pathological  conditions  consti-
4]----ofthetongue.............  11701  tuting gout................. ii. 4S
• treatment of........  1176 Pathology of disease........... i 658
    — of the sense of touch
    — complicated  with  disease
    of the urinary organs, treat-
 si  ment of....................
 41 Paralytic apoplexy, lesions pro-
 9
 4
10
 6
13
49
  ducing
Paralyzed parts, temperature of
Paraplegia, consequences of....
     description of............
     diagnosis of..............
     lesions occasioning........
     symptoms of.............     18; Pellagra, Bibliog. and Refer
     terminations of...........  1«-19----causes of................
     treatment of.............     401----diagnosis of.............
     causing   affections  of  the      ----appearances of fatal cases
  urinary organs..............     19!----history of.
        necessity for its study.....   1133
        of apoplexy..............  i. 107
     — of fever, general inferences
     respecting..................i. 1069
     -------old and modern opin-
97   ions of the.............i. 1053-1069
2^----of insanity...........ii 573-678
18 Patients,  prejudices,  &c,  of,
17   retard therapeutical knowl-
32;   edge.......................   1131
1^ Pectoriloquy, described........  i. 204
                                     04
                                     62
                                     02
                                     61
                                     59
■ puerperal, noticed........    547'-
     ■ treatment of.........    547 ■
prognosis of..
symptoms of.
8 Parasites, animal, definition of.  1514'----srnnn. and definit.
        the origin of.........  1515---- treatment of
— human,  first  class of,  no-       ----Asturian, description of..,
 ticed.......................  1519 Pemphigus, Bibliog. and Refer.
-------second  class of,  de----- complications'of..........  66,66
 scribed.....................  1520----description of.............     64
-------or intestinal.  See, al-       ----diagnosis of..............     67
 so, Worms..................  1514----prognosis of..............     67
— to be thrown off by promo-       ----synon. and definit........     C4
 ting organic nervous power ..  1142----treatment of."............     C8 
PE
INDEX.
PE           1605
Pemphigus, local treatment of..     69 Peritoneum, substances foreign      Pertussis,elefinitionot.  See,also,
----acute, symptoms of.......     64  to it found within the.......   102 i  Hooping-Cough.............ii. 273
----chronic, symptoms of.....     60----tubercles and scrofulous tu-      Peru,  climate  of,  as  respects
Perceptions, false, in insanity.. ii 5021  mours of....................   101|  phthisis....................  1233
Percussion of abdomen........    i. 4----appearances after death...    84; Perverted states of vital power,  i 605
Perforation of one of the cavities       i----causes of.................    93 Pestilence, of its  arrest,  when
 82'-
1001
  ofthe heart................ii. 222----in children, forms and symp-
----ulceration, and rupture of      ]  toms of.....................
  the oesophagus.............ii. 1040.--------treatment of........'.
Perforations of the  digestive      ----structural changes conse-
  tube.......................  i 632!  quent upon.................  84-89
----consequent upon epyema..   313 Peritonitis, chronic tubercular,
----of vagina................   1430
Pericascal  tissue,  inflammation
  of.......................... i. 333
Pericarditis, adhesions of the op-
  posite surfaces of pericardium ii. 216
----causes of.................ii. 224
----characters of.............ii 214
----in children...............ii. 234
--------causes of............ii. 234
----complications  of..........a 227
----diagnosis of...........ii. 21G, 17
--------of its complications .. ii. 227
----prognosis of..............ii. 228
----progress and duration of.. ii. 228
----complicated with rheuma-
  tism .......................   673
---signs and symptoms of .a 216-20
---structural  lesions  in  the
  acute......................ii. 214
--------. in chronic...........ii. 215
Pericardium, adhesions between
  its surfaces.................ii. 210
----of the diseases of.........ii. 193
----ossific formations in tlie... ii 252
----haemorrhage into.........ii. 142
----inflammation  of the.  See,
  also, Pericarditis............ii. 214
----causes of its inflammation, ii 224
----morbid sounds  from  dis
  eases ofthe.................ii. 217
Pericranium, lesions of the..... i. 254
----syphilitic  disease of.......  1471
Perinseum, laceration of the....   542
----prevention and treatment.   542
Peri-nephritis, consequences and
  terminations of..............ii. 703
----description of............a 763
Periodic fevers.  See Agues and
  Intermittents...............  1085
Periodicity, characteristic of the
  effects of irritation..........a 706
Periosteitis,  successive   altera-
  tions during................
----associations of............
----Bibliog. and Refer........
----causes of.................
---definition of.............
---diagnosis  of..............
---suppuration from.........
---suppurative, treatment of.
---treatment of.............
---acute, symptoms of.......
---chronic, symptoms of.....
-------treatment of.........
---specific, &c, treatment of.
Periosteum, inflammation  of.
  See, also, Periosteitis........
---affection of, in rheumatism
---and  bones, syphilitic dis-
  ease of.....................  1471
---syphilitic disease of....... 1471
Peripneumonia. See, also, Pneu-
  monia......................a 878
---notha,  or Asthenic  Bron-
  chitis ...................... i. 304
Peritoneum, Bibliog.  and Refer.  105
----diseases of the............    73
----encysted dropsy  of the__. i. 749
----haemorrhage into.........ii. 143
----inflammation of.   See, also,
  Peritonitis..................
----inflammation of, associated
  with inflammation of the vis-
  cera it invests..............
----organic  lesions  of, _ conse-
  quent on its inflammation....
----malignant formations in ..
----non-inflammatory, organic
  lesions of................... ^JiT*
_________causes of............   104
                                    introduced or prevailing.....   271
                                    — maladies  comprised under
                                    this term...................   105
                                    — measures against, when in-
                                    troduced into a town or camp   271
                                 '---------when  it  appears  in
described...................    80]   transports, ships of war, &c. .   273
  complications of..........  83,4--------when introduced among
 69
671
----complicated  with  inflam
  mations of viscera invested by
  the peritoneum ....  ........
----treatment of its complica-
  tions.......................
-------------with inflamma-
  tions of abdominal organs ...
----management  of convales-
  cence from.................
----diagnosis of..............
---------between, and gastritis,
  and enteritis...............
---------from paracentesis ab-
  dominis ....................
----prognosis of..............
----progress, duration, and ter-
  minations of acute and chron-
  ic, in children..............   82,3
----in  connection with  rheu-
  matism ....................
  — complicating scarlet fever .
----synonymes and definition
  of..........................
  — in    synochoid  puerperal
  fever.......................
  — terminating in adhesions..
  -------in effusion..........
  — fatally...................
  — indications of treatment for
  — acute, description of......
  -------in children..........
  -------modifications of.....
----terminations  of acute gen-
  eral .......................
  — acute, appearances after ..
  -------exudations from.....   S5, 0
  -------false membranes, and
  morbid formations from......  56, 7
  -------remedial  means  ad-
  vised for...................    95
  -------symptoms of........    73
  -------treatment of........    95
  — chronic, in children
84'
9S,9

 100
  91

  91

  77
  93
075
736

 73

568
 77
 77
 7S
 95
 73
 S2
 76

 77
 84
84
84-89
  101
        . described...........78,81
  -------literary history of___    78
  -------lesions caused by___    87
  -------symptoms of........    80
  —----terminations and con-
  sequences of................    81
  -------tubercular, in children    83
  -------treatment of........    98
  -------lesions constituting..    87
  — asthenic acute, lesions con-
  sequent upon...............    87
  -------treatment of........    97
  — general,  description of___    75
  -------asthenic, described...    76
  ------------from perforation
  of the digestive canal........    76
  ------------course of.......    76
  — haemorrhagic, described...    77
  — latent, noticed...........    77
  — omentalis, described......    75
----partial,  symptoms  of its
  several forms...............    74
  — treatment of.............    98
         chronic
  troops, armies, or in garrison.   272
----prevention of foreign.....207-71
--------by quarantine.......207-70
----promoted by want of venti-
  lation ......................   266
----its chief source commented
  on.........................   106
----choleric,    Bibliog.    and
  Refer, to................... 151,2
---------conclusions  as  to its
  causation and propagation ...   134
---------causes and nature of 118-1D4
---------diagnostic  characters
  of..........................   110
--------convalescence   from,
  treatment of................   149
--------definitions of........   107
---------description of........   Ill
---------modus operandi of its
  exciting cause..............   134
--------synopsis of  the forms
  and stages of...............   139
--------grades  and stages of
  with reference to treatment..   137
---------shown to be propagat-
  ed by infection............118-134
--------proofs  of its infectious
  nature....................118-134
---------morbid  appearances
  after death from...........114,115
--------consecutive    pheno-
  mena of....................   113
--------progress and mortal-
  ity of.......................   109
---------relations of, &c......   134
------— introductory remarks
  re-pecting..................   107
--------various  remedies ad-
  vised for ..................143-148
--------fully developed symp-
  toms of.....................   112
---------invading and prelim-
  inary symptoms of..........   Ill
-------- prognostic  symptoms
  of.........................t   114
---------synonymes..........   107
---------treatment of........   137
-------------adopted by the
  author.....................   142
-------------notices of modes
  of, adopted  in different coun-
  tries  ......................139-142
------------- of  the   severer
  grades of...................   145
-------------of  the third or
  most intense grade of........   146
-------------of its invasion ..   137
-------------of  the   mildest
  forms and earlier periods___   143
-------------of  the advanced
  stages......................   145
-------------of  the  stage of
  collapse....................   148
---------turpentine,  &c, ad-
  vised for...................
----glandular.   See Pestilence,
  Septic.
puerperal, described......   564 Pestilence, ha?magastric, of anti-
147

217
_________course  and  termina-
  tions of....................564,5
---------treatment of........   585
Perspiration, changes  in, as to
  amount and quantity........ 863-4
----states of,  as signs  of  dis-
  ease........................1062-4
----morbid states of..........   864
----state of, in rheumatism ...   677
----and sweats, in phthisis---   1203
symptoms of........ 103,4:----treatment^  of,  in
___.____treatment of.........    1041  stage of phthisis
second
       septics for..................   209
       -------appearances after death
       from.......................   160
       -------Bibliog. and Refer. . .215,17
       -------of blood-letting in___   207
       -------exciting causes of....   169
       -------predisposing causes of 168,9
       -------remarks  on   various
       means of cure.............207-211
       -------definition of.........   152
       -------description of........   154
1258--------diagnosis of.........   102 
1606          PE                              INDEX.                               PH
Pestilence, hsemagastric,  diag-      Pestilence, septic, historical no-      iPhlebitis, view of treatment ad-
  nosis 0? from its course, dura-      ,  tices of....................218-221   vised for  ....          ......  14«
  tion, and termination........ 162-5--------oleum terebinthinae ad-      ----of the  brachial veins......  1441
______]_______between, and re-      '  vised for...................   257----of the  crural veins.....      1441
  mittent or periodic fevers....   146--------of the origin of......241-44----poisoned, or asthenic,  de-
_________description of its mild----------period of crisis of----   225   scribed.....................  144U
  reform....  ..............   154-------------of decrement of..   225----sthenic, symptoms of....    1439
___1_________treatment of....   203-------------of eruption of...   224---------—— of the  stage of
________description  of its se--------------of incubation of.   224:   infection of.................  1439
  vererforms.................   154-------------of invasion of...   225-------------of its local stage   1439
_____________treatment of____   204---------prognosis of.........220, 3----suppurative, described---  1440
________pathological inferences---------protection  furnished      i----puerperal, treatment of... 587, S
  asto.......................200-3  byanattackof.............   241----uterine, notice of.........  1440
_________external  means  ad-_________influence  of  race in---------consecutive affections
  visedfor....................   210  predisposing to.............   251   of..........................   570
_________of mercurials in.....   207---------remedies advised for . 256,9---------in the  puerperal state    56S
_________modifications   of its      '_________modes of sepulture pre-      I---------symptoms of........   569
  characters  ................. 155-7  disposing to.................   250---------terminations of......   570
_________rate of mortality in..   107---------symptoms of........   221 Phlegmasia alba dolens, syno-
_________nature of............   199---------simonymesoi........   217'   nymes of...................   279
_________infectious  nature of,      ]---------treatment of.........   225----dolens,  appearances after
  demonstrated..............174-192-------------convalescence from  259   death......................   2S3
---------originof...........195,199 Pestilence,  typhoid, symptoms      |----Bibliog. and Refer........   291
_________questions as to the ori-      I  consecutive upon............113-14----causes of.................   284
  gin of, investigated.......... 195-9 Pestilences, remedial means and      |----indications  of cure in.....   2i5
_________prognosis of.........   105  medicines against...........   276----definition of..............   280
_________of quarantine against   269 Pestilences, &c., arrangement of      |----description  of............   2^1
_________sequelae of...........   15S:  protective means from......   261----history of................   280
_________source of............   193----the prevention of.........   262----means advised for........    289
_________of its several stages ..   15S----prevention  of, as regards      j----nature of................    2S6
---------division  of its course      I  burying-places..............   265j----pathological inferences re-
  into stages.................   15S----prevention   of  domestic      ]   specting....................    287
_________treatment  of its ad-      |  causes of...................   263----puerperal states of........   281
  vanced stages...............   206,----prevention ofthe generation      j----unconnected with the pucr-
-------------of convalescence      |  of..........................   263   peral states.................   2S5
  from.......................   211----protection from, by means       ----remedial measures advised
_____________of its early stages   204:  which will resist their infection   276   for.........................  2SS.9
---------synonymes..........   152---------Bibliography and Ref-      |----symptoms characterizing .   281
---------of tonics and antisep-      |  erences.....................   279----terminations of...........   283
  tics in......................   208---------of the community from   261----treatment of.............287,9
---------treatment of........   203---------of  individuals,  famil-      ; Phosphates in urine,  diagnosis
--------------by various means      [  ies, &c,  from...............   274|   of.........................1330,31
                             207-211---------by seclusion, during..   275---------pathological relations
-------------advised  by  Dr.      j----regimen and diet, physical      I   of.........................1330-34
  Stevens....................   210  and moral, against..........   270 Phosphorus, poisoning by......    3S3
---------of turpentine in.....206-8----restrictions on persons from       ----appearances after.........    3S4
Pestilence,  septic,  arguments      |  seats of....................   275----treatment of.............    384
  used by the anti-infectionists  244-7 Pestilential cholera.  See, also,      .Phrenitis,  or Periphrenitis, de-
--------appearances after death      I  Pestilence, choleric..........   107J   scribed.....................i 2S0
  from.......................   225 Petechiae of plague, described ..   223 Phrenology, examination of, in
---------modified attacks of ..   223 Phallorrhcea   virulenta,    de-      !   relation to insanity......a 578-584
---------Bibliog. and Refer. .. 200,1  scribed.....................  1454 Phthisis, complicated  with  ab-
---------carbuncles and buboes      Pharyngitis, causes of.........  11531   dominal  disease, treatment of  1266
  of.......................... 222, 3----definition of.............  1153----beverages advised for.....  1285
---------causes of............   228----description of............  1154----Bibliog. and Refer.......12^5,7
---------conclusions as to ita      ----terminations of...........  1154----of the states of the blood in  1209
  causes and propagation......   252----asthenic, complicating scar-      '----complicated with bronchitis  1211
---------local causes predispos-      :  let fever....................   734----the succession of  morbid
  ing to......................   249----chronic, description of ....  1155j   phenomena in the causation of  1240
---------caused and propagated      ; Pharynx, inflammation of.   See,       ----caused by previous disease
  by contagion..............22S-249J  also,  Pharyngitis............  1153   of respiratory  organs........  1238
---------definitions of........   218----inflammation  and organic      ]----causes of, described......1223-39
---------diagnosis of.........   220  lesions, treatment of.........  1165----causes of................1238,9
---------diet and regimen in..   259----and parts adjoining affected       ----classification of its causes .  1224
---------duration of..........   225  in scarlet fever.............   734----causes of, acting during and
---------of invisible organized      ----tumours and foreign bodies      |   after puberty...............  1229
  existences in causing........   251  in the......................  1165----general results  from  the
--------most  intense, or first      !----syphUitic ulceration of....  1469   concurrent operation of several
  form of.....................   221 Phenomena, morbid, procession         of its causes................  1240
--------Ie3s intense, or second      I  of.......................... i 081----causes of,  appertaining to
  form or grade of............   221 Phlebitis,  alterations produced      i   the parent..................  1225
---------less severe forms of ..   223i  by.........................  1437----numerouspredisposingcauses
---------of its generation  de      '----causes of................  1437]   of, described...............1223-39
  novo.......................   241 —— definition of.............  1437'----causes of, acting chiefly be-
---------grades or states of...   221----diagnosis of..............  1442   fore puberty................1228,9
---------the hypothesis  of in-      ----appearances  of, on dissec-      ----description  of cavities  and
  sect life, as a cause of........   251  tion........................  1442   vomicae in the lungs in......  1218
---------circumstances  predis-      ----duration of..............  1441----in children, states of lungsin  122"
  posing to, and counteracting,      [----ofthe extension of........  1440!----circumstances  and  influ-
  the infection of.............24S-51----different pathological con-      |   ences aiding to occasion____1230-39
--------local and other means      I  ditions of...................  1440----complications of, described
  for.........................   259----pathological inferences  re-      !                              1211-15
--------modifications of......   223:  specting....................  1442---------treatment of........  1203
--------rate of mortality from   254----prognosis of..............  1441----cough, as a symptom of...  1199
--------nature of...........   254----remedies  advised for the      '---------treatment of.........  1264
---------its infectious  nature      |  local stage of................  1445----description  of...........1191-96
  discussed...................228-49----regimen advised for......  1446'----external means of cure for 1276-7
--------proofs of its infectious      ----seats of..................  1441----diet advised for..........1284,5
  nature.....................228-50----treatment of.............  1442----diagnostic signs and symp-
---------proofs  furnished  by      '---------advised by the author  1444   toms of..................1197-1203
  contemporary writers of its in---------preventive, of........  1444----states  of digestion in.....  1202
  fectious nature..............235-5"---------advised for the first or      ----duration of..............   1222
---------objections  of non-in-        local stages of..............  1445----climate  of  Egypt  advised
  fectionists answered.........244-4S---------of second Btage of....  1446!   for......................1277-81, 4 
PH                             INDEX.                              PI          1607*
1205

1214
1215
Phthisis, emaciation a sign of..  1202
---expectoration in.........1200,1
---fingers and  nails,  appear-
  ances of, in.................  1202
---complicated with fistula in
  ano........................  1214
---forms and modifications of 1203-9
---the common form of... .1191-1190
-------its treatment........  1252
---fumigations advised for...  1276
---complicated with haemopty-
  sis.........................  121l!
-------treatment of.........1263, 4
---of haemoptysis as a symp-
  tom of......................  1197
---in infants and children....  1207
-------treatment of........  1203
---of infection from.........  1228
___intercurrent  or secondary
  inflammation of lungs in.....  1215
---of  inhalation in its treat-
  ment.......................  1275
---complicated with disease of
  the intestines...............  1213
_______of larynx and trachea  1212
_______with  laryngeal  and
  tracheal affections, treatment
  of.........................
-------with  lesions  of the
  liver.......................
-------with  lesions  of the
  lungs......................
---tubercular and other lesions
  found after deatli from .. .1215-1222
---remarks on the means ad-
  vised for.................... 1207
---mineral waters in the treat-
  ment of....................1274,5
---origin, &c, of, considered.  1190
-------in the scrofulous dia
  thesis......................  1190
---pain as a symptom of.....  1201
---parents, diseases of, caus-
  ing ........................1225-8
-------habits of, causing___1227, 8
---pathological anatomy of. .1215-21
---perspirations and sweats in  1203
---complicated with pleuritis.  1213
-------with  pneumonia.....  1212
-----------treatment of....  1264
---the means of prevention ad
  vised for...................1250,1
---conditional means  of pre-
  vention ....................  1251
---efficient means of  preven
  tion........................  1251
---states of the pulse in......  1202
---in the dark race3........1208, 63
---in different races and coun-
  tries.......................  1233
---quick respiration a symp-
  tomof......................  1200
---of  seasons and climates as
  respects....................1232, 6
---of  the spirometer   in  the
  diagnosis of.................  1197
Phthisis, its first stage, of bleed
  ing in, and when required...,
-------of chalybeates in ...,
-------change  of uir, voyag
  ing in......................
-------described...........  1191
-------of terebinthinate em-
  brocations in...............  1257
-------of external medication
  in.........................1256,7
-------food and regimen in..  1253
.-------of inhalation of medi-
  cated vapours in............  1257
_______internal medical means
  advised in..................1254, 6
_______of issues,  setons,  &c..  1257
_______physical signs of.....1192,4
-------treatment of.........1252-7
___________medical........1254-6
___its second stage, described 1194,6
_______ diet and regimen in..  1260
_______means advised for the 1258-9
_______physical signs of.....  1192
_______treatment of.........  1^57
___its third stage described.... 1196
_______several medicines ad
  vised for......• • -.- •••:-•• -..J?6}
_______means advised for.. .1200,1
1354
1255
1253
Phthisis, its third stage, treat-
  ment of....................1260,1
-----------intercurrent  af-
  fections in..................1260,1
-----------of diarrhoea in..  1260
---complicated with disease of
  the stomach................  1213
---synon. and definit oi ...'.  1188
---temperaments  and consti-
  tutions  in  which it origin-
  ates.......................1190-91
---of the transmission of.....  1225
---treatment of............1240-63
-------historical sketch  of,
  advised by authors.........1240-50
-------advised  when  it  is
  threatened.................  1252
---healing processes of tuber-
  cles in.....................  1219
---of a winter residence for ..  1254
---acute  or  rapid  form,  its
  treatment..................  1262
---consecutively  acute,  de-
  scribed .....................  1206
-------treatment of........  1262
---primary acute or rapid, de-
  scribed.....................1204,5
-------lesions  of  structure
  after.......................  1200
---bronchial  glandular,  de-
  scribed....................1221, 22
-------in children..........  1222
---bronchial and tracheal com-
  plications of, treatment of...  1204
---dyspeptic, noticed........  1211
---latent form, described___1203, 4
-------its treatment......i .1261, 2
---protracted, description of.. 1200, 7
-------treatment of........  1203
---pulmonalis, described,  &c.
  See, also, Phthisis........11SS-1277
Phymosis, treatment of........  1485
Physical conditions constituting
  a climate................... i. 398
---relations of climate....... i. 398
  — causes of insanity........ii. 555
  — disorders causing  insani-
  ty........................ii. 555-7
Physicians, in what they retard
  therapeutical knowledge.....  1130
Physiological  pathology of  in-
  sanity ....................ii. 573-8
Pia mater, morbid structure of. i 258
---tubercles in the.......... i. 259
---of spinal  cord, inflamma-
  tion of.....................   957
Pian,   described.   See,  also,
  Yaws......................  1475
Piles,   described.    See,  also,
  Haemorrhoids...............ii. 144
Pilula? Alkalinae.......F.  876. Ap. 32
---Aloes cum Ferro.. F.  450. Ap. 19
---Aloes  cum Ferro Compo-
  sita? ................F.  451. Ap. 19
---Aloe3  cum Ferro Compo-
  sita?................F.  877. Ap. 32
---Aloes et  Ferri___F.  452. Ap. 19
---Aloes et Moschi Composi-
  ta?..................F. 453. Ap. 19
---Aloes et Scammonise Com-
  posita? ..............F.  454. Ap. 19
---Alterative?.....F. 455, 0. Ap. 19
---Ammoniaci CompositaB
                      F.  457. Ap. 19
---Ammonias  et Anthemi-
  dis.................F.  453. Ap. 19
---Ammonio-SulphatisCupri
  Comp...............F.  459. Ap. 19
---Anodyna?........F.  400. Ap. 19
_______.............F.  878. Ap. 33
---Anodyno-Alterativa?
                      F.  879. Ap. 33
---Anodyno-Aperientes
                      F.  402. Ap. 18
---Antimonii Alteratives
                      F.  404 Ap. 18
---Antimonii et Guaiaci
  Comp...............F.  465. Ap. 20
---Antimonii  Oxysulphure-
  tiComp...........F. 466, 7. Ap. 20
---Antispasmodica?.. F.  468. Ap. 20
---Antispasmodicas  Pierqui-
  nii.................F.  469. Ap. 20
---Aperientes.......F.  8S0. Ap. 33
Pilulas Aperientes Composites
                      F. 470. Ap. 20
  — Aperientes Alterative?
                      F. 471. Ap. 20
  — Aperientes cum Hyoscy-
  amo................F. 881. Ap. 33
  — Argenti Nitratis et Bella-
  donna?..............F. 472. Ap. 20
---Argenti Nitratis Compo-
  sita? ................F. 473. Ap. 20
  — Argenti Nitratis et Gen-
  tiana?...............F. 474 Ap. 20
  — Argenti Nitratis Opiatae
                      F. 475. Ap. 20
---Arsenicales.....F. 470, 7. Ap. 20
  — Arsenitis Ferri ... F. 478. Ap. 20
  — Asafcetidae cum Cincho-
  na .................F. 479. Ap. 20
---Asafcetidae Composita?
                      F. 480. Ap. 20
  —Asafcetidae cum Felle
                      F. 481. Ap. 20
  — Asafostidas et Valeriana?
  Comp...............F. 482. Ap. 20
  — Astringentfls.....F. 483. Ap. 20
  ------.............F. 882. Ap. 33
  — Balsamas Comp. . .F. 434. Ap. 20
  — Balsamica?.....F. 485,6. Ap. 20
  — Balsamica? Camphorata?
                      F. 487. Ap. 20
  — Belladonnas......F. 488. Ap. 20
  — Belladonnae Extracti et
  Cinchonas...........F. 883. Ap. 33
  — Benzoini et Terebinthinae
  Comp...............F. 489. Ap. 20
  — Bismuthi.........F. 490. Ap. 20
  — Brucea?..........F. 491. Ap. 20
  — Calcii Chloridi et Conii
                      F. 904. Ap. 33
  — Cambogiae, Aloes, et Am-
  moniaci.............F. 885. Ap. 33
---Cambogiae Composites
                      F. 492. Ap. 20
  — Camphoras et Ammoniaci
                      F. 8S5. Ap. 33
  — Camphorae et Antimonii
  Thebaiacas..........F. 493. Ap. 20
  — Camphorae Composites
                      F. 494. Ap. 20
  — Camphorae et Ipecacuan-
  has.................F. 495. Ap. 20
  —. Camphoras  et  Nitri
                      F. 496. Ap. 20
  — Camphorae et Opii F. 886. Ap. 33
  — Camphorae et Quinines
                      F. 887. Ap. 33
  — Castorei Thebaiacas
                      F. 497. Ap. 20
  — Catharticae.....F. 498,9. Ap. 21
  — Chalybeatas......F. 888. Ap. 33
  — Colocynthidis Composites
                      F. 500. Ap. 21
  — Colocynthidis  extr. et
  Hyoscyami..........F. S90. Ap. 33
  — Colocynthidis  cum  Hy-
  drargyro............F. 501. Ap. 21
  — Colocynthidis  cum Sul-
  phure...............F.889. Ap. 33
---Cupri Sulphatis cum Opio
                      F. 502. Ap. 21
---Deobstruentes..F. 503-10. Ap. 21
-------...........F.891-2. Ap. 33
---Biniodidi Hydrargyri
                      F. 511. Ap. 21
---Diaphoretics.....F. 512. Ap. 21
---Diaphoreticae Sedativa?
                      F. 513. Ap. 21
---Digitalis et Camphoras
  Comp...............F.514. Ap. 21
---Digitalis  et  Myrrhae
  Composita!..........F. 515. Ap. 21
---Diuretica?........F. 516. Ap. 21
---Diureticae  Alterativae
                      F. 517. Ap. 21
---Diureticae  Antispasmod-
  icas.................F.893. Ap.33
---Diureticae  cum Hydrar-
  gyro................F. 894. Ap. 33
---Dulcamara? et Antimonii
                      F. 518. Ap. 21
---Emmenagogae  ... .F. 519. A p. 21
---Expectorantes___F. 895. Ap. 33
---Extr. Gentianae et Hu-
  muli Comp..........F. 520. Ap. 21 
1*608          PI                              INDEX.                               PN
Pilula? Ferri Ammonio-Chloridi
                    F. 521,2. Al).
---Ferri Aperientes F. 523,4 Ap.
---Gentiana? et Aloes F. 896. Ap.
---Guaiaci et Aconiti. F. 897. Ap.
---Guaiaci  Compositae
                  F. 525, 6,7. Ap.
___Guaiaci  et  Antimonii
  CompositaB..........F. 52a Ap.
___Hellebori et Aloes Com-
  positae ..............F. 529. Ap.
---Humuli Comp.....F. 898. Ap.
---Hydrargyri  Anodynae
                      F. 530. Ap.
---Hydrargyri  Bichloridi
                      F. 531. Ap.
---Hydrargyri Compositae
                      F. 899. Ap.
---Hydrargyri Phosphatis
  Comp...............F. 532. Ap.
---Hydrargyri  et  Scillae
                      F. 533. Ap.
---Hydrargyri Chloridi Com-
  positae, seu Pilulas Plumme-
  ri..................F. 534 Ap.
—— IpecacuanhsB Compositae
                      F. 900. Ap.
---Ferri Iodidi......F. 535. Ap.
---Kino Compositas.. F. 536. Ap.
---Morphias cum Digitale
                      F. 537. Ap.
---Morphiae et Ferri Sulpha-
  tis..................F. 901. Ap.
---Myrrhas et Balsami Com-
  positae ..............F. 538. Ap.
---MorphiaB Hydrochloratis
                      F. 902. Ap.
---Moschi Composites F. 903. Ap.
---Nervinae (Stoll.)  . .F. 539. Ap.
---Nervinas.......F. 905,6. Ap.
---Nervinae Antimoniatae
                      F. 540. Ap.
---Nucis vomicae ... .F. 541. Ap.
---Nucis Vomicae et Aloes
                      F. 907. Ap.
----Nucis Vomicae Compo-
  sitas................F. 542. Ap.
---cum Oleo Crotonis F. 543. Ap,
---Plumbi Acetatis et Digi-
  talis ................F. 544 Ap.
---Plumbi Acetatis  et  Col-
  chici...............F. 545. Ap.
---Plumbi Acetatis .. F. 546. Ap.
---Purgantes........F. 547. Ap.
---Rhei Resolventes . F. 548. Ap.
---Rhei Balsamica?  . .F. 549. Ap.
---Sarza? Composites. F. 908. Ap.
---Scammonias......F. 550. Ap.
---Scillae Compositas . F. 551. Ap.
---Scillae et Galbani Com-
  posita; ..............F. 909. Ap.
---Scillas cum  Ipecacuanha
                      F. 659. Ap.
---Sedativa?___F. 553,4, 5. Ap.
---Sesqui - sulphureti Anti-
  monii...............F. 912. Ap.
---Soda? cum Rheo et Hyo-
  scyamo.............F. 910. Ap.
---Sodae  Sesqui - carbonatis
  cum Hyoscyamo.....F. 556. Ap.
---Stahlii...........F. 557. Ap.
---Stomachica?
           F. 558,9, 60, 1, 2. Ap.
---Stomachica?......F. 911. Ap.
---Stomachicas Aperientes
                      F. 563. Ap.
---Stramonii........F. 564 Ap.
---Strychniae........F. 565. Ap.
---Styracis  Compositae
                      F. 566. Ap.
---Sudorificas......F. 567,8. Ap.
---Sulphatis Strychnias
                      F. 569. Ap.
---Terebinthinatae.. .F. 570. Ap.
---Terebinthinatas et Cam-
  phoras cum  Opio.....F. 571. Ap.
---ThebaiacaB  Compositae
                      F. 913. Ap.
---Tonicas...........F. 914. Ap.
---Tonicas Aperientes
                    F. 572-6. Ap.
---Tonicee cum Cupro F. 577. Ap.
---Tonicee cum Sulphate
  Zinci...............F. 57a Ap.
Pilulas Tonico-Emmenagogas         I Pleuritis of both sides..........   308
                      F. 579. Ap. 22____complicated with bronchitis   315
___Uva? Ursi ct Rhei .f! 580. Ap. 22----causes of, exciting........   293
---Uva? Ursi et Sodas. F. 531. Ap. 22--------pathological.........   „99
___Valeriana? Composita?           I----changes of structure consti-
                      F. 582. Ap. 221   tuting......................   299
____Valeriana? et Zinci F. 583. Ap. 23--------successive structural,
----Zinci et Myrrhas. .F. 534 Ap. 23]   during....................318-323
___Zinci cum Myrrha et          '----i° children,  lesions conse-
  Ipecacuanha........F. 5S5. Ap. 23'   quent on...................   323
----Zinci Sulphatis Com-          j----complications of..........314-16
  posita?............F. 586,7. Ap. 23--------treatment of.........   335
Pilularum Anodynarum Mas-        I----cure, means of, advised for 327,9
  sa..................F. 401. Ap. 23|----description of............   299
Pitting from small-pox, preven-      ----diagnosis of..............   323
  tion of.....................916,17]--------between effusion from,
   Pityriasis, Bibliog. and Refer. .    290
   ---general, described........    293
   ----causes of................    295
22----complications of..........    295
   ----course and progress of ....    294
   ---definition and synonymes.    291
   ----diagnosis of..............    294
   ---mineral waters advised for    290
   ----prognosis  of.............    294
   ---varieties of, described___291,3
   ---treatment of it3 local vari-
     eties.......................    295
   ---capitis, described.........    292
   ---palmaris, described.......    293
   ---treatment of general......    296
   Plague.   See,  also, Pestilence,
     Septic......................    219
   ---Bibliog. and Refer........  260,1
   ----conclusions respecting  the
     causes and propagation of ...    252
   ---caused and  propagated by
     contagion..................230-248,
   ---nature of................    254
   ---treatment of.............    265]
   Platyelmia, first order of Worms,
     described...................   162l]
   Plethora,  causes of............i 215
   ----treatment'of.............i. 210'
   ----general..................  L 214
   ---local....................  j. 216
   Pleura, Bibliog. and Refer.___    340
   ---diseases ofthe............    297
   ---effusions into............    337
   --------consequent  upon in
     flammation.................319-22
   ---cancerous formations in...    338
   ---cartilaginous  and  osseous
     formations in the...........    337
   ---tubercular formations in the    338
   ----gangrene of, noticed......    337
   ---gaseous fluids in..........    337
   ----haemorrhages into... .337; a 142
   ----inflammation of.  See, also,
     Pleuritis....................    297
   ---the diverse organic changes
     during inflammation of the . 318-322
   ----symptoms  and  signs  of
     structural changes of the ....    338
   ----structural changes  of, not
     resulting from inflammation .  336,8
   ---treatment of organic lesions
     ofthe......................    339
   ---ulceration and perforation
     of..........................    337
   Pleurisy.   See, also, Pleuritis ..    297
   ---associated with pneumonia    326
   ---in children, diagnosis.....    323
   ---complications of.........314-316
   ---diagnosis  from  condensa-
     tion of lung.................    324
   --------from pleurodynia ....    323
   --------from tuberculous  dis-
     ease of lung................    324
   ---in dark races............    316
   ---chronic, described........    308
   --------recovery with contrac-
     tion of side.................311,13
   --------treatment of........    331
   ----circumscribed............    307
   ---double, described.........    308
   --------treatment of........    331
   ---dry,  description of........    304
   --------physical conditions of    305
   ---partial, described.........    307
   ---. symptoms of sthenic acute    300
   Pleuritis,   appearance  of  the
     blood in....................    317
   ----analysis of the blood in  ...    317
  and Hydrothorax...........    326
  — complicated with exanthe-
  matous and other fevers.....    315
  ------with scarlet fever___    736
  ------with hepatitis.......    315
  — the friction sounds of.....    305
  — in infants and children ...    316
  ------complications of.....    317
  ------treatment of.........    336
  — pathological anatomy of .318-323
  — complicated-with peritonitis    315
  ------with phthisis........  1213
  ------with tubercular  con-
  sumption...................    315
  ------with  pneumonia —
  pleuro-pneumonia...........    314
  ------with chronic tubercu-
  lar pneumonia..............    315
  — physical signs of..........301-3
  — prognosis of..............    325
  —. treatment of, in the dark
  races.......................    335
----regimen and diet in......    336
----in connection with rheuma-
  tism .......................    674
---- signs and symptoms of....    300
----states and varieties of.....    298
----synon and definit. of......    297
----treatment advised for, by
  author....................329,330
--------history of its........327,9
Pleuritis, acute sthenic, consec-
  utive changes in............    304
--------conclusions  as to.....    306
--------symptoms of.........    300
---. —— terminations of......    304
-------. treatment of........327,9
---asthenic, described.......    306
--------treatment of.........    330
----cachectic, described......    306
----chronic, described........    308
--------effusions in..........    309
-------■ signs of absorption of
  effusion....................    314
---.---• physical signs of.....    310
--------symptoms of.........    309
--------terminations of......    314
--------treatment of.........    331
---circumscribed, treatment of   331
----diaphragmatic, described..    307
---latent, described.........    306
--------treatment of.........    330
---. mediastinal, noticed......    307
---partial, described.........    307
--------with effusion........    307
Pleurodynia.   See, also, Neural-
  gia of intercostal nerves.....a 1010
----causes of.................    341
----causes predisposing to ....    300
---. definition and synon. of...    340
----description of.............    341
----diagnosis of..............    341
---treatment of...............    342
Pleuro-pneumonia, properly  so
  called......................    326
---described................a  888
----states of, described.......    326
----symptoms of.............ii  S88
----treatment of.............ii  898
Pleurosthotonoe, defined.......  1101
Plica Polonica,  described......a  164
     causes of.................ii  165
     treatment of.....;.......ii  166
---Bibliog. and Refer........a  167
Pneumathorax,  Bibliog.   and
  Refer.......................    346
  — causes of.................    843
  — consecutivo effects of......    343 
PN                              INDEX.                              PO           1609
Pneumathorax, definition of___   342
----pathology of..............   342
----prognosis of..............   345
----symptoms and signs of___   343
----physical signs of..........   344
---treatment of.............   345
Pneumonia, of abscess from ii. 882-895
----in the aged, treatment of.. ii. 896
----of bleeding in............ii 893
----complicated  with  bronchi-
  tis.   See, also, Broncho-pneu-
  monia......................ii. SS7
---causes of.................ii. 890
----in children, treatment of.. ii. 899
---complications of..........ii. 830
---complicating phthisis.....  1212
________pleuritis.............ii 8SS
----definition of..............ii. 878
---physical diagnosis of.... ii. 8S4,6
___of diaphoretics, and  other
  means  of cure for...........a 895
---diet and regimen in......ii. S99
----duration of...............ii 892
---forms of, noticed.........ii. 879
----of mercury and opium in.. ii 894
---prognosis of..............a $92
---several stages of..........a 881
___in  the dark races,  treat-
  ment of....................ii. 899
---treatment ofthe third stage
  of..........................ii 895
----structural  changes in the
  several stages of...........ii 881, 2
---of tartarized antimony in.. a 894
----terminations of...........ii. 892
---circumstances influencing
  the treatment of............ii. 895
----treatment of complicated.. ii. 897
----varieties of...............ii
Pneumonia, primary acute,  de-
  scribed .....................ii. 879
----diagnosis of simple acute.ii. 883,4
----acute sthenic, described... a 879
--------treatment of.........ii.
----asthenic or congestive .... ii.
--------means of cure for.. .a 896, 7
--------physical signs of.....ii ""
--------complicating   scarlet
  fever.......................   736
--------terminations of......a 887
--------treatment of.........ii. 896
----chronic, description of.....a 900
--------treatment of........a 900
----complicated, the treatment
  of..........................a 897
 ----of endemic..............ii. 891
 ----of epidemic..............ii. 891
 ---nervous or typhoid........ii. 886
 ---sthenic or pure...........ii 879
 Pneumonitis.  See Pneumonia.
                            a 878-S3
 ---chronic, described........ii. 900
 --------treatment of.........a 900
 Poison, counteraction of the op-
   eration of...................  307
 ----imbibed from recently dead
   bodies.....................437-444
 ---of resisting the progressive
   effect  of, and the tendency to
   death  from.................  308
 —— necroscopic,  definition  of.
359
373
415
309
405
407

400
380
381
436
Poisoning, matters requiring at-
  tention on suspicions of......
----general principles of treat-
  ment of....................   306
  — by acetic acid............   373
  ------treatment of........   373
  ------appearances after death
  from.......................
  — by aconite, aconitina, &c..
----by acrid and corrosive pois-
  ons, symptoms  and diagnosis
  of..........................
---by alcohol, symptoms of ..
  ------treatment of........
  ------appearances after death
  from.......................
----by alkalies, symptoms of..
    ----treatment of........
    by alkaline sulphurets ....
    ----treatment of........   436
    by the specie3 of anemone.   388
----by   animal  food, appear-
  ances after death from.......   429
----by putrid animal matter ..   444
----by exhalations from putrid
  animal matters.............   444
--------treatment of.........   445
----by  animal  meats,  treat-
  ment of....................   431
----by animal substances.....428,9
----by  diseased animal  sub-
  stances.....................   429
--------symptoms produced by   429
—-----treatment of.........
----by antimonial preparations
--------treatment of.........
--------appearances after death
  from.......................
----by  chloride  of antimony,
  symptoms of...............   382
--------treatment of........   382
--------appearances after death
  from.......................
----by external applications ..
----by applications to the  sur-
  face, denuded of its cuticle...
----by the external application
  of arsenic...................
  — by administering arsenic in
  enemata...................
  — by arsenic, diagnosis of...
  ------lesions produced by  ..
  ------treatment of........
  ------of convalescence from
  ------introduced  into  the
  vagina.....................   420
  ------acute form of........   417
  ------chronic or  slow form
  of.........................   418
  — by arsenical fumes.......   420
  — by Arum maculatum.....   389
  — by baryta and its salts....   432
  ------treatment of........   433
  — by belladonna, appearances
  after death.................   448
  -------diagnosis of.........   449
  — by sub-nitrate of bismuth,
  treatment of................   385
  — by bitter apple...........   389
  — by bromine..............   383
     by brucia................   414
  See, also, Necroscopic poison.437-444----by bryony
--------nature and source of.437-443,----by Caltha palustris.......   389
Poisoned,   appearances   after      |----by camboge..............   391
  death, of having been.......302-5----by camphor..............   408
----circumstances  and symp---------treatment of........   409
  toms indicating having been.358,60----by cantharides---.......   450
---diagnosis  by chemical ex
  periments, of having been ...  364,5
Poisoning  has  been referred to
  acute diseases ofthe digestive
  organs.....................    366
----circumstances under which
  it may occur or be produced
  during disease..............365,6
----diagnosis  of, during disease 365,6
         treatment of ..'......   451
--------appearances after death,
  from.......................   451
  — by carbonic acid gas, symp-
  toms of....................   461
  ------treatment of........   463
  __by an admixture of carbon-
  ic acid  and sulphurous acid
  gases......................   462
general.............   361--------treatment of........   463
________by  post-mortem  re-
  BO&rcli   ...".•••••••••••"•■"   oo*
____of the duration of.........   361
____modes in  which  it  takes
  place..............v • ■ V'
____time   of death  after  first
  symptoms of................   361
----by carburetted hydrogen
 gas........................   463
-------treatment of........   464
-------appearances after death
 from.......................   464
— by celandine
— by chlorine and chlorides .   451
   Poisoning by chlorine and chlo-
     rides, treatment of..........   451
   ----by Cicuta virosa.........   465
   ----by cocculus indicus.......   414
   ----by colchicum............   423
   --------symptoms of........   424
   --------treatment of........   424
   ----by preparations of conium. 465,6
     — by  copper  and  its  com-
     pounds .....................   433
     ------symptoms and appear-
     ances ......................   385
     ------treatment of........   385
     — by Coriaria myrtifblia ....   414
     — by Crbton Tiglium.......   389
     — by Cyclamen europaeum...   390
     — by Daphne Gnidium and
     Daphne Mezereum..........   390
     — by  Delphinium  Staphisa-
     gria........................   390
   ----by digitalis, first grade of.   393
   --------second grade of......   394
   --------third grade of.......   394
   --------treatment of........   395
   ----by empyreumatic oils ....   474
   ----by elaterium.............   391
   ----by inhaling aether........   407
   ----by euphorbia officinarum  .   390
   ----by the ferro-cyanates.....   402
   ----by fish..................   425
          — treatment of........   427
   ----by fool's parsley..........   475
   ----by preparations of gold ...   385
   --------treatment of........   386
   ----by hellebore.............   424
   --------treatment of........   425
   ----by hemlock dropwort.....   476
   ----by hyoscyamus..........   466
   ----by the hydrocyanates ....   402
   ----by Indian nut............   390
   ----by iodine, described......   382
   --------treatment of........   383
   --------appearances after death  3S3
   ----by  iodine  and  its  com-
     pounds.....................   452
   --------treatment of........   452
   ----by ipecacuanha and emeta   410
   --------treatment of.........   410
   ----by laburnum............   476
   ----by laurel water, &c.......   403
   ----by acetate of lead........   395
   |----by carbonate of lead......   396
   ----by iodide of lead.........   397
423----by the oxides of lead.....   397
   I----by  preparations  of  lead,
     mode of operation of........   398
     ------treatment of........   398
     ------appearances after death
     from.......................   397
     — bylime..................   383
     ------treatment of........   383
     — by Lobelia inflata........   445
     — by Lolium temulentum ...   477
     — by the Manchineel-tree ...   390
     — by mercurials............453-9
     -------symptoms and appear-
     ances in....................386,7
     -------antidotes useful in...   387
     -------treatment for.......387, 8
     — by metallic salts.........   384
     — by mineral acids.........373-6
     -------treatment of........377,8
     — by substances  taken by the
     mouth.....................   347
    ----by mushrooms, symptoms
     of..........................   475
     ------treatment of........   476
     — by narcotics.............461-74
     — by nux vomica...........   411
    ----by oil  of bitter  almonds,
      symptoms of................  403
    ----by opium,  morphia, and
      their preparations...........467-73
    --------appearances after death
      from.......................   471
     ------antidotes for........   472
    ----by oxalic acid...........378,435
     ------treatment of........   3S0
     ------appearances after death
      from.......................  379
     — by peach-blossom.........  404
     — by the bichromate  of pot-
      ash ........................  384
     — by nitrate of potash......  435
431
431
432

432
382
348

348

419

420
420
421
422 
1610          PO
INDEX.
PR
Poisoning by sub-nitrate of pot-
  ash........................   435
--------appearances after....   435
1---by oxalate of potash......   435
----by binoxalate of potash...   3M
---by sulphate of potash.....   435
----by cyanide of potassium ..   403
____by  prussic  acid,  appear-
  ances after death  from......   400
--------combinations of.....402-4
--------diagnosis  and opera-
  tion of..................... 401-2
--------the treatment of, first
  advised by the author.......   404
--------and the cyanides, Ac.
                            39S-404
----by the species  of ranuncu-
  lus.........................   391
----by Rhus Toxicodendron...   391
----by savine................   390
----by nitrate of silver.......   3SS
--------treatment of........   388
----by strychnia or strychnine   411
--------treatment of........   413
--------appearances after death
  from.......................   413
----by  the  species of strych-
  nos........................   411
----by sulphureted hydrogen,
  symptoms of................   473
--------appearances after death  474
----by tartaric acid..........   430
----by chlorides of tin........   388
----by tobacco, described.....   445
--------treatment of........   447
--------appearances after death  447
----by vegetable acrids.......   38S
----by vegetable acro-sedatives   447
----by injection of the veins ..   348
----by veratria..............   424
--------treatment of........   425
----by wounds...............   348
----by chloride and sulphate of
  zinc.......................   388
----by oxide of zinc..........   405
Poisoning, acute or  rapid......   361
----chronic or slow...........   361
----slow, by acetic acid.......   392
--------byalkalies..........   393
--------due consideration of,
  hitherto neglected..........   362
--------by mineral acids ....   392
Poisonous food, symptoms and
  treatment of................425-9
----insects and reptiles,  inju-
  ries from...................   481
--------treatment of........   482
----meats, kinds of..........   427
----serpents, their  effects, &c..   478
--------treatment  of  their
  bites and effects............480,1
Poisons, acrid and corrosive....   309
----acro-alterant, described.. .447-58
----circumstances   modifying
  the action of................ 357,8
----of prevention of the action
  of..........................   307
----of their actions...........   349
----action of, on  the  organic
  nervous system.............349-51
----chemical actions of.......   351
----of their  local and primary
  action......................   349
----nature of the local and
  primary action of...........   350
----of their remote and consec-
  utive actions...............   349
----producing a septic action..   354
----alterative effects of many.   353
----astringing the tissues.....   356
----augmenting the secretions
  and excretions..............   356
----Bibliog. and Refer........483,5
----classification of..........368,9
--------synopsis of..........482,3
----poisoning, and  poisoned,
  definitions of...............   346
----corrosive, diagnosis of___369-73
----depressing and paralyzing
                            392-405
----depressing effects  of cer-
  tain........................   352
----exhausting effects of cer-
  tain........................   352
Poisons, general effects of.....   362,Precepts, general therapeutical.   1133
____special effects  and treat-       ; Predisposing causes to disei^c .  u 045
  ment.......................   369----to insanity...............ii 665
     exciting or stimulating ...   352 Predominant states of morbid
     exciting and constringing. 410-14   action, ofthe removal  of, in_
354
----exciting and exhausting. .405-10
----injection  of, into the bow-
  els.........................   34S
--------into the  sexual and
  urinary organs.............   348
  — irritant, &c..............   356
  — irritating and depressing. .415-47
  ------described...........431-47
  — the media or channels by
  which they act..............   350
  — narcotico-acrid...........   474
----sedative,  operation of cer-
  tain........................
  — paralyzing and depressing.
----paralyzing  irritability and
  voluntary motions..........
  ------sensibility..........   353
----paralysis from............     26
----special operation of.......   353
----sympathetic operation of..   351
----removal of, by the stomach
  pump......................   36'
----refrigerating and sedative.   353
----septic or putro-facient___   477
--------operation and  effects
  of..........................477,8
--------source and nature of.  434,8
----stimulating  the  nervous
  systems....................  354,5
----symptoms caused by, should
  be carefully distinguished from
  diseases....................   360
----synopsis of the topics com-
  prised under................  346,7
Pollution, definition of........   485
----symptoms and signs of....   486
----synonymes..............   485
----involuntary, causes of. See,
  also, Spermatorrhoea........   4SS
--------treatment of........   490
----voluntary,  causes and oc-
  casions of..................   485
--------bad consequences- of .   48S
--------effects of, vary with
  the period of commencement.   480
--------treatment of........   489
----Bibliog. and Refer........   497
Polypi,  described.............   7S0
----cardiac, signs of..........ii. 256
--------treatment of........ii 256
----of the cavities of the heart a 254
----of the uterus, described...   1396
--------treatment of........   1396
----fibrous, of the uterus,  de-
  scription of.................   1396
--------treatment of........   1397
Pomegranate-bark, preparations
  advised for Taenia...........1552-3
--------methods of prescribing
  for Taenia..................1552-3
--------and  the  male - fern
  combined for Taenia.........   1553
Pork, poisonous effects from....   427
Porrigo.  See,  also, Tinea capi-
  tis.........................   1171
Positions of the heart, unnat-
  ural........................ii 262
--------causes of............a 262
Potash,  the hydriodate of, and
  potash advised  for rheuma-
  tism .......................689-90
  fevers......................i 1078
Pregnancy,  local  and  sympa-
  thetic changes consequent on.   497
  — influences of, on the course
  and treatment of chronic dis-
  eases ......................    605
----discharges from the vagina
  during.....................    498
--------treatment of........    499
----diseases incident to, Bib-
  liog. and Refer, to..........    50G
----disorders incident to......    497
----feigned, notice of.........i 1035
----hysteritis during.........    500
--------treatment of........    600
----influences of, on the course
  and treatment  of acute dis-
  eases"......................505,0
----inflammation of the cervix
  uteri during................   ] ;;70
----menorrhagia during......a 130
----disorders  of the nervous
  system during..............   503
----affections of the sexual or-
  gans caused by.............   498
--------treatment of........   498
----small-pox during.........   S95
----state of the female at the
  full period of...............    532
----sympathetic affections dur-
  ing........................  501-4
----spasm, pain,  &c,  of the
  uterus during...............   499
--------treatment of........    500
----and puerperal states as pre-
  disposing to disease.........i 648
Prevention  of pestilence, &c,
  means of...................   262
Principles of therapeutics......1131,2
----general, of therapeutics.. .1133-5
----special therapeutical.....1135-43
Procession of morbid  phenom-
  ena, described..............  j. CS1
Procidentia uteri, described___   13S9
----treatment of.............   1389
Proctitis, causes of............   64S
----definition of..............   646
----forms of,  described.......646-8
----symptoms of.............   646
----treatment  of its  several
  forms......................   649
Proctitis, acute  sthenic,  de-
  scribed.....................   646
--------terminations of......   647
----asthenic acute, history of .   647
----chronic and sub-acute___   647
--------terminations of......   647
----syphilitic and gonorrhceal.   64S
Productions and  secretions ad-
  ventitious to the ceconomy...  i 674
Professions and employments as
  predisposing to insanity.....a 560
Proglottis, or mature Twnia, de-
  scribed.....................   1522
Prognosis of disease, <fec.......1056-99
Prognostic symptoms in contin-
  ued fevers................i H32-6
Prolapse of the uterus, described  13S7
Prominence, lateral, ofthe ribs.  i. 367
Proofs  of the infectious  nature
  of puerperal fevers..........556-61
--------of the pestilences
  — nitrate of, poisoning by...   435
  -----symptoms and lesions      |                        n8 et pluries
  caused.....................   435, Prophylactics of scarlet fever ..  753-6
  — oxalate of, poisoning by...   435[----of fevers.............     i 1069
  — salts of, poisoning by.....   434 Prostate gland, Bibliog. and Ref  '  512
  — sulphate of, poisoning by..   435----calculi in the........        511
Potus Antiphlogisticus Diureti---------diagnosis of ""          512
  cus-................F-  588. Ap. 23 (--------treatment of........    512
----Aperiens.........F.  915. Ap. 33----cancerous diseases of         511
----Decocti Sarza? Comp. (Ti-      I________forms of                511
  sane de Feltz.).....   F.  589. Ap. 23----concretions in'the Veins' in
----Diureticus......F. 590,1. Ap. 23!   or near the .                    mo
----Febrifugus.....F.  592,3. Ap. 23----diseases of the'""'.......    506
  — Manna? et Tamarindomm      I----complications  o'f"it3"dlsl
                      F.  594^p. 23;   eases............               519
  — Refngerans ... „ . F.  595. Ap. 23|----haemorrhage from '.'.'..'.'.'. ]    MO
                                   ----inflammation of.  See, also!
                                      Prostatitis.................;    506
----Tamarindorum Compositus
                      F. 916. Ap. 33 
PR
INDEX.
PU           1611
Prostate  gland, organic  lesions
  of the......................    509
----enlargement of...........    509
--------treatment of........    510
----tubercular deposits in.....    510
----ulceration of.............    510
Prostatitis, appearances on dis-
  section .....................    508
----causes of................    500
----diagnosis of..............    60S
----complications of..........    609
----definition of.............    506
----prognosis of acute........    60S
--------of chronic...........    509
----acute, symptoms of.......    507
________treatment of........    509
----chronic, symptoms of.....    507
________treatment of........    509
Protection from pestilence?, <fcc,
  means  of...................    261
--------individual   measures
  for.........................    274
Proximate  cause of  fever, au-
  thor's views as to........i. 1060-69
Proximity of position a cause of
  sympathy..................  1037
Puerperal convulsions, described i
--------treatment of........i. 502
----diarrhoea, described......  1605
----diseases and fevers, Rib-
  liog. and Refer.............. 594,5
--------the causation of.....538,40
--------causes of the danger
  ous and fatal tendencies of...   540
--------described...........532-94
         influences and  agents
Prurigo, Bibliog. and Refer....   515
---causes of................   514
---definition and synonymes.   512
---description of its forms... .512,13
---diagnosis of..............   513
----local forms of............   513
---prognosis of..............   514
---treatment of.............   514
--------its varieties.........514,15
Pruritis,  definition of.........   515
----diagnosis of..............   510
----forms and states of.......   515
----treatment of.............   516
---of the vulva, described___   498
--------treatment of........   498
Prussic acid, poisoning by.....   398
--------symptoms of........   399
--------treatment of........   404
--------diagnosis of.........   401
--------modus operandi of...   402
--------period of death from .   401
-------— appearances after death
  from.......................
----relation between its effects
  and the quantity of the poison
----quantity of, requisite to de-
  stroy life...................   401
----and its  compounds, treat.
  ment of poisoning by........   404
Pseudo-hydatids or vesicles, de-
  scribed.....................ii. 295
Pseudo-jaundice, described.....ii. 348
----treatment of.............ii 355
Psoas muscles, inflammation and
  suppuration of.   See Psoitis..   516
Psoitis, Bibliog. and Refer.___   519
----causes of................   516
---definition of.............   516
----diagnosis of..............   517
---prognosis of..............   517
----symptoms of.............   516
---treatment of.............517-18
Psora, definition of.  See, also,
  Itch....................... ii. 710
Psoriasis, Bibliog. and Refer...
---&c., causes of............
----classification of its forms..
----definition and synonymes.
----description of
        predisposing to and exciting .   538
      --------of the prevention of..   540
      --------prophylactic measures
        against.....................   593
      ----females, treatment of small
        pox in......................   910
      Puerperal   fever,   congestive
        symptoms and local  origins of 507-9
      ----inflammatory symptoms of 564-6
      ----malignant, symptoms and
        cour^ of................... 570-9
      ----synochoid, consecutive af-
        fections  of..................   570
      --------origins and symptoms
        of..........................   507
      Puerperal fevers, their infectious
        nature.....................656-61
       — diagnosis  of their several
        states......................  5S2,4
       — pathological inferences re-
        specting....................    584
       — inquiries as to their pathol-
        ogy ........................579-81
       — periods of their occurrence
        after delivery...............    584
       — prognosis of their different
        forms......................  5S3,4
       — treatment of their inflam-
        matory forms...............    685
       ------of  their  malignant
        states......................    588
       -----------by turpentine...    5S9
       ------synochoid or interme-
        diate forms of...............586-8
       -----------with turpentine.  586-8
      Puerperal uterine haemorrhage,
        description of............ii  130-33
      ----mania, described........ii 628
      --------treatment of........ii. 633
      ----state, nervous and spasmod-
        ic affections of..............546,7
      --------pathology of.........   532
      --------secretions and excre-
        tions during................   536
      ---.----of small-pox in......   895
      Pulmonary disease, feigned... .i 1035
      Pulsation, nervous, of  aorta....  i. 79
      Pulsations at the epigastrium,
        causes of...................
      Pulse, of acceleration of the....   602
      ----Bibliog. and Refer.......   603
      ----in relation to the states of
        the blood...................  596,
      ----constricted or contracted,
        &c.........................   600
      ----state of,  after delivery, to
        be attended to..............   536
      ----states of development of the   000
      ----greatly affected by disease. 602,3
  , ..„----full, large, broad, open, <fec.   600
531-2----hard, firm, or sthenic.....   600
  519----in connection with the states
400

401
                                      of the heart................   598
                                      — historical notices as to the.   595
                                      — of inequality and irregular-
    formsof................. 521-41  ity of......................   002
---diagnosis of.............. 525,6----intermissions of the.......   603
---pathology of.............   526----influences of emottons of
----prognosis of..............   526
----treatment of.............   526
----regimen and diet in......   531
----remedies advised for......527-9
----local states of............   522
Psoriasis diffusa, described---   521
----guttata, described........   521
----inveterata, described.....   521
----leprajformis, synonymes ..   523
  mind upon..................   602
----states of, in phthisis......   1202
  — physiological  pathology of
  the...................;....   590
  — positions of the body, influ-
  enced by...................   601
  — precipitate,  rapid,  quick,
  sharp,  vibrating, &c.........
     rhythm, or frequency of...
syphilitica, described.....   524----semeiological notices of the
     treatment of........   529----influence of sex on the
Ptyalism, mercurial, diagnosis of 456,7
Puberty, causes of phthisis act-
  ing during and after........  1229
____causes  of phthisis  acting
  previously to...............1228,9
    influenced by sleep
---small,  soft,  compressible,
  feeble......................   600
  — effects of temperament and
  diathesis on the.............   601
Pulse, undulating, languid, <fcc.    601
  — vital  or  organic  nervous
  force, influencing the........  596, 8
  — vital power, depression of,
  influencing the.............    598
Pulveres Tonici........F. 663. Ap. 26
     Tonici-Aperientes .F. 644 Ap. 25
Pulvis Acidi Benzoici et Cam-
  phoras...............F.596. Ap. 24
----Aluminae et Quinae F. 597. Ap. 24
     Ammoniaco-Camphoratus
                       F. 917. Ap. 24
     Anticatarrhalis ...F. 918. Ap. 33
     Antihydropicus .. .F. 599. Ap. 24
     Antimonii et Camphorae
                       F. 600. Ap. 24
     Antimonialis Compositus
                       F. 601. Ap. 24
     Antiphlogisticus .. F. 602. Ap. 24
     Antispasmodicus (Stahlii)
                      F. 603. Ap. 24
----Aperiens.........F. 004. Ap. 24
     Aperiens.........F. 919. Ap. 33
     Asari Comp.......F. 605. Ap. 24
     Beliadonnae.......F. 000. Ap. 24
----Beliadonnae Compositus
                      F. 607. Ap. 24
  — Belladonnas Compositus
  (Hecker)............F. 608. Ap. 24
  — Bismuthi.........F. 609. Ap. 24
  — Bismuthi  Comp.  . .F. 610. Ap. 24
  — Boracis et Sabinae .F. 611. Ap. 24
  — Calomelanos cum digitale
                      F. 612. Ap. 24
  — Calumbae Comp.  . .F. 613. Ap. 24
----Calumbas et Ferri .F. 920. Ap. 33
     Camphorae........F. 614. Ap. 24
----Camphorae et Antimonii
                      F. 921. Ap. 33
  — Camphorae et Zinci F. 617. Ap. 24
  — Carminativus F. 616,17,18. Ap. 24
  _ Catharticus.......F. 619. Ap. 24
  — Cinchonae Comp.. .F. 620. Ap. 24
  — Cinchonas cum Soda
                      F. 021. Ap. 24
  — Corticis Cuspariae Composi-
  tus..................F. 622. Ap. 24
  — Cretae et Rhei Compositus
                      F. 633. Ap. 25
----Cretaceus........F. 624. Ap. 24
  — Cupri Ammonio-Sulphatis
  cumZinco..........F. 598. Ap. 24
  — Cyanidi Zinci.....F. 625. Ap. 24
  — Deobstruens......F. 626. Ap. 25
  — Diaphoreticus.....F. 922. Ap. 24
  — Diureticus......F. 627, 8. Ap. 25
  — Eccoproticus......F. 629. Ap. 25
  — Ecphracticus .. .F. 630, 1. Ap. 25
  — Excitans.........F. 032. Ap. 25
  — InfantiUs.........F. 633. Ap. 25
  — Ipecacuanhas   cum  Calo-
  melane..............F. 634 Ap. 25
  — Jalapas Compositus F. 635. Ap. 25
  — Jalapa; et Calomelanos
                       F. 636. Ap. 25
----Kermis Mineralis.. F. 637. Ap. 25
  — Kermis Mineralis et Cam-
  phoras...............F. 638. Ap. 25
----Kermis Mineralis Camphor-
  atus................F. 639. Ap. 26
----Lenitivus Hypochondriacus
                       F. 640. Ap. 25
----Lientericus.......F. 923. Ap. 34
----Lientericus*.......F. 041. Ap. 25
----Moschi Compositus F. 924. Ap. 34
----Myrrhas et Ipecacuanhas
                       F. 925. Ap. 34
----Nitro-Opiatus Ipecacuanhas
  vel Pulvis Doveri___F. 642. Ap. 25
----Purgans..........F. 643. Ap. 25
----Pro Torminibus.. .F. 926.  Ap. 34
----Refrigerans.....F. 644, 5. Ap. 26
----Resolvens, vel  Deobstruens
                       F. 646.  Ap. 25
----Resolvens (Stahlii) F. 927. Ap. 34
----Rhei Compositus .. F. 647.  Ap. 25
—» Rhei et MagnesiaB . F. 648.  Ap. 25
----Rhei et Sulph. Potasses
                       F. 649. Ap. 25
----Salinus...........F. 928. Ap. 34
----Scammoniae cum  Calo-
  melane.............F. 650. Ap. 25
----Scammoniae et Jalapae
                       F. 652. Ap. 25 
1612          PU                               INDEX.                              RE
Pulvis Sedativus.......F. 653. Ap. 25'Putro-adynamic puerperal fever,
----Senegas et Camphoras            |  treatment of................58S-94,-
                      F. 651. Ap. 25;Pyelitis, complicated  with dis-
----Sodas Compositus. .F. 053. Ap. 25
----Sodae cum Hydrargyro
                      F. 656. Ap. 25
----Sodae Nitratis Compositus
                      F. 929. Ap. 34
----Specificus Stomachicus
                      F. 657. Ap. 25
----Sulphatis Potassae et Ferri
                      F. 658. Ap. 26
----Sulphatis Quinae Antimoni-
  atus................F. 659. Ap. 26
----Sulphatis  Quina?  et  Mor-
  phias................F. 660. Ap. 26
----Sulphureti  Aureati  Anti-
  monii, vel  Deuto-Sulphuret.
  Antimo.............F. 661. Ap. 26
----Tonicus..........F. 662. Ap. 26
----Valerianae Compositus
                      F. 930. Ap. 26
----Valerianae et Zinci F. 665. Ap. 26 j Pyrosis, Bibliog. and Refer.___    61S
i Races, prevailing diseases in .._. i 405
                                         dark, the relations of cli-
                                      mate to.................... i. 406
  eased bladder, prostate, <fec... ii. 701--------phthisis in the......  1236
----from calculi or gravel.....ii. 75S--------pleurisy in the ......   316
____complications of..........ii. 761----white, the relations of cli-
----diagnosis of.......... ii 750,61   mate to.................... I 406
----prognosis of..............ii 761 Rachialgia, causes of..........   947
----several states of..........ii 759.----definition of..............   944
---treatment of, when  caused       I----diagnosis of..............   946
  by renal calculi.............ii 704'----nature of................   948
——with tumour from  collec-       i----prognosis of..............   947
  tion of matter in the pelvis of      ----treatment of.............94S-50
  the kidney, treatment of.....ii. 765!----hysterical, noticed........   945
Pyelitis, acute, description of... ii. 758 —     — treatment of........94S-50
         treatment of.........ii 703
----chronic, description of___ii. 75S
--------treatment of.........ii 764
Pyelo-nephritis, or inflammation
  of the pelvis, calices, and sub-
----rheumatic, gouty, and other
  formsof....................    946
--------treatment of........94S-50
Rachialgitis, definition of......    956
Radesyge, notice of...........ii 811
stance of the kidneys........ii 762 Ramollisement of brain........i 292
   description of.............ii 762 Ranunculus, species of, poison-
----Zinci Oxydi Compositus
                      F. 600. Ap. 26
----Zinci Sulphatis Compositus
                      F. 607. Ap. 20
Purgatives,   arrangement  and
  enumeration of.............   1146
----recommended for dropsy ..  i 710
----<fec, for inflammations .__ii 474
----in cases of insanity.......ii 607
----advised for taenia.........   1554
Purpura, appearances after death
  from.......................    60'
----Bibliog. and Refer........    610
----appearances of  the  blood
  and urine in................    607
----complications of with fever    000
--------with visceral disease.    600
--------treatment of........    609
----description  of............    605
----diagnosis of..............    607
----pathological relations of...  604,5
----prognosis of..............    607
----regimen and diet for......    609
■---synonymes  and definitions    604
----treatment of.............    609
----varieties of...............    604
----heemorrhagica, described..    605
----senilis, descriptions of ....    606
----simplex, description of....    605
----urticans, described.......    600
Purpurine, pathological relations
  of..........................   1326
Purulent collections, of the  ab-
  sorption and diminution of...   i. 24
----expectoration, as a sign of
  disease.....................   1092
Pus, recent, Bibliog. and Refer.    611
----characters of.............i  675
----or purulent matter   de
  scribed.....................ii 43S
----microscopic  appearances of    610
----different opinions of micro-
  scopists on  the development
  and forms of................    437
■---in diffusive  or asthenic ab-
  sce.-s.......................  i 17
----in chronic abscess........  i 18
----contained in sthenic abscess  i 16
----expectoration of, as a  sign
  of disease..........t........  1093
----in urine, appearances of...  1336
----formed  in veins..........  1447
----cells, described...........    774
Pustule, malignant, appearances
  after death.................   613
--------Bibliog. and Refer. ..   615
     causes of.................    616
     complications of..........    616
  — diagnosis of..............    616
----indications and  means of
  cure.......................    617
----nature of................    617
----symptoms of.............    615
----synonymes and  definition
of.
treatment of.
615
Gl
Q-
Quarantine, importance of.....ii. 417
--------for  preventing pesti-
  lence.......................267-71
----success  of, in the  United
  States......................267-71

                 R.
Rabies, appearences after death
  from.......................   623
----Bibliog. and Refer........640-42
----causes of.................   627
----the specific cause  of, ex-
  amined.....................   627
----can  it  be  communicated
  otherwise than by the bite of
  a rabid animal?.............   629
----can  it  be  communicated
  otherwise  than  by inocula-
  tion?.......................   629
----curative  means (?) advised
  for......................... 637-9
----description of............619, 20
----diagnosis of..............   625
----literary history of........   619
----medulla oblongata and spi
  nal cord in.................   624
---nature of, inquired into ...   630
---pathological inferences and
  remarks respecting.......... 632-3
---several means advised for
  preventing.................634-37
---prognosis as respects the
  bite of a rabid animal.......   626
--------when the disease has
  declared itself..............   626
---by what secretions  of the
  infected animal is the disease
  communicated ?.............   630
----symptoms of, in the  canine
  race......................623,632
  ------in the lower animals.    623
  ------its stages...........
     synonymts  and definition
  ing by.....................    391
Reaction, stage of, in fevers___i 1046
----and excitement, states of,
  described...................  i 659
Rectum, abscess of, treatment
  of..........................    653
----fistula in, treatment of ...    653
----foreign bodies in the......    643
----cancer or carcinoma of___    661
--------causes of............    662
--------symptoms of........    662
--------treatment of.........    662
----concretions in the........    644
--------treatment of........    644
----fistula of the, described ...    652
----inaction of the, symptoms
  of..........................    645
--------treatment of........    645
----invagination of upper por-
  tion of the..................    660
----symptoms of.............    661
--------treatment of........    661
----lacerations of the.........    644
——----treatment of........    644
----malformations of the.....    643
----polypi in the.............    657
--------symptoms of........    65S
--------treatment of........    658
----prolapse of, causes of.....    656
--------in children..........    655
------------treatment of....    657
--------the forms of.........  655,6
--------complicated with hes-
  morrhoids..................    656
--------treatment of........    657
----strictures of the..........    658
---organic or permanent stric-
  ture of the..................    659
--------causes of............    660
--------diagnosis of.........    659
--------symptoms of.........    659
             treatment of.........   660
         spasmodic stricture of the.   658
         ----treatment...........   659
         ulceration of.............   652
         ----causes of............   652
         ----symptoms of........   652
         ----treatment of........   653
    Rectum and anus, Bibliog. and
      Refer......................   663
    ----abscess of, described......650,1
         ----symptoms of........   651
         diseases of the...........   642
         functions of..............   643
620|----their inaction, causes of...   645
     ------symptoms of........   645
     ------treatment of........   645
     -----------of complicated
     cases.......................   646
618-
                                      of .
         causes of............   612----treatment of,  advised by
--------definition of.........   612|  the author..................   640
--------diagnosis of.........   614!
--------formsof............   613
--------prognosis of.........   614
--------symptoms of........   613
--------treatment of........   614
Pustules, description of........  dill   virus causing, act ?..........
Putrid animal matters, effects of       ----of the origin of  the  virus
  inoculation by..............   4451  causing....................
-— poisoning by.............   445 Race, human, considered in re-
Putro-adynamic fever, describedi. 1173 j  spect of phthisis...... ......  120S Reflex actions  and sympathies
—- treatment  of......       X 1211 —_ influence of, on small-pox.   S9G!   of the brain and spiSwrd
Putro-adynamic puerperal fever,       Races, the influence of climate
  course and terminations  of.. .570-83'  on...........
   ----curative (?)..........637-10,----inflammation of. 'see, also!
------prophylactic........633-37  Proctitis...                   646
— the animals capable of gen-      ---. relaxation of  .......       645
eratmg,de novo, the virus of.    629--------complications'..'......   645
— m what manner does  the
631

628
---- sympathies of............   643
-— syphilitic ulceration of the.   652
Reflected actions and sympathies
  divided into psychical, animal,
  and organic or vital.........    41
                       spinal cord.. 40,41
       — contractions, or reflex irri-
1. 4041  tation, respecting........u. 698, 701 
RE
INDEX.
SA           1613
276
Reflex sympathy, note on...... i 918
Refrigerants,  external and  in-
  tGrna1,-.....................  1145
----in fever, prescribed.......i. 1075
----for inflammation.........ii. 475
Regimen of patients in fevers "i. 1032
----physical  and  mental, pro-
  tective against pestilences  ...   276
Regimen and diet in the several
  forms of indigestion......ii 393-397
Relapses of fever, noticed......i. 1083
Relations of mind to the nervous
  system.................ii. 5S4-590
Relaxation of the palate.......
----treatment of.............
Religious   apprehensions,  as
  causes of insanity...........ii. 563
----consolation in  insanity.... ii. 622
Remedial means, and medicines
  to  be taken, against  pesti-
  lences ......................
Remedies, neglect of their phys-
  iological action retards thera-
  peutical knowledge..........   1131
.----notices of many, advised  for
  rabies......................634-40
----various, for scarlet fever. .763-767
Remittent, treatment of compli-
  cated states of..............i. 1108
Remittent of children, causes  of i 1115
---characterized...........i 1115
---description of............i. 1116
---diagnosis................i, 1117
---nature of................i. HIS
----regimen and diet.........i 1119
----terminations and prognosis i 1117
----treatment of.............i 1118
----acute, described..........i 1116
— adynamic, described......i. 1116
----chronic, description of___i 1117
Remittent  fevers,  appearances
  after death from............i. 1104
---Bibliog. and Refer......i  1121-2
----causes of.................i. 1100
----complications observed in . i 1103
----diagnosis of..............i. 1104
--------between,  and hasma-
  gastric or true yellow fever., .i. 1104
----terminations of...........i. 1103
----adynamic, and malignant.i 1102
--------treatment of........i 1107
----bilio-inflammatory........i. 1102
----complicated..............i»1103
----inflammatory............i 1101
----treatment of tlie inflamma-
  tory  and  bilio-inflammatory
  forms.................i. 1100,1107
----mild, described...........i. 1101
--------treatment of........i 1106
Remittents, causes  of..........i. 1100
----described................i 1100
Reparation of the consequences
  of inflammation.............ii. 469
Reptiles, poisonous,  notices of..    478
Respiration, auscultation of___i 200
----modes  and  states  of,  as
  signs of disease............1089-92
----morbid, sympathies of.. 1038,9,40
----symptoms afforded by___   108S
----quickness of,  symptomatic
  of phthisis..................   1200
Respiratory functions, effects of
  cold on.....................  i. 420
Respiratory organs,  the relations
  of their diseases  to  cachectic
  nephritis...................ii. 740
----diseases from causes acting
  on the.....................  i. 652
----disorders of, connected with
  gastro-enteritis............. ii 30
----of expectoration in their
  diseases....................  1094
—— diseased  states  in  fever,
  treatment of................i. 10S0
----ha'morrhage from......ii.  95-107
----signs  and symptoms fur-
  nished by..................   1088
Reitriction.s on localities afflicted
  with pestilence..............    275
Retchings, viewed as a symptom  1506
____anil vomiting,  considered..   1505
Retina, inflammation of.......i 1019
Retinitis, symptoms and course
  of......:...................i 1019
 Retinitis, treatment of.........i 1020
 Retrocedent, or displaced, gout.. ii 42
 Retroflexion of uterus.........  1391
 ----treatment of.............  1393
 Revaccination, remarks and facts
   respecting..................  1A20
 ----report of the  Academy of
   Sciences respecting..........  1421
 Revulsion, means of causing___i 21S
 Rheumatic arthritis, synonymes
   **••••-......................   66
 Rheumatic gout, chronic, symp-
   toms of.....................   667
 Rheumatism, Bibliog. and Ref.. 700,2
 ----of the blood in........... 675,6
 ---- of blood-letting in........   684
 ---- relation of, to cachectic ne-
   phritis .....................ii. 749
 ----exciting causes of........   679
 ----predisposing causes of___   67S
 ----its connection with chorea.   674
 ----of cinchona  and various
  other medicines in..........   687
----cinchona, and the alkalies
  advised for.................   6SS
----complications and extension
  of........................673-675
  — complicated with catarrhal
  fever, influenza, <fec..........   675
  — treatment of its complica-
  tions .......................   696
  — indications or intentions of
  cure in.....................   6S3
  — complicated with diaphrag-
  mitis .......................   672
----when  complicated with af-
  fection of the diaphragm, or of
  the pleura or peritoneum, the
  treatment of................   698
  — complicated with endocar-
  ditis .......................    673
  — description of............   664
  — diagnosis of..............   677
--------from, and connexion
  with, neuralgia.............    677
--------from scrofulous disease
  of joints....................    67
--------from secondaiy syphi-
  lis.........................    678
----of diaphoretics in.........    685
----of emetics and purgatives
  for.........................    685
----states of the excretions in.    675
----of the face...............   672
----complicated with affections
  of the head.................   673
--------with disease of  the
  heart or pericardium, treat-
  ment of.................... 697,
--------with influenza or catar-
  rhal fever..................    699
--------with disease of  the
  cerebro-spinal membranes ...    674
--------with  disease of the
  membranes  of  the brain  or
  spinal cord,  treatment of___696,8
----complicated with paralysis    674
--------pericarditis..........    673
--------with peritonitis......    675
--------with pleuritis........    674
----of the fibrous tissues of the
  loins and back..............    671
----external  means   advised
  for........................693-696
----in connexion with disorder-
  ed menstruation............    6
----of mercurials in..........    685
----metastasis of.............    673
----nature of................ 680,2
----of the neck..............    672
----of the fibrous envelopes of
  nerves.....................    671
----complicated with disease of
  the sexual organs...........    675
----associated with  affections
  of the sexual organs, treat-
  ment of....................    698
----inferences as to the pathol-
  ogy of......................    682
----regimen and diet in......    700
----remedies  recommended for  689-93
----of the special seats of.....    669
----the  structures chiefly  af-
  fected in...................669,70
 Rheumatism,  synonymes  and
   definition ot... ............   663
 ----synovial membrane of the
   joints chiefly affected in acute
   and sub-acute..............   670
 ----treatment  of,  advised by
   the author.................6S8,9
 ----acute, symptoms of.......   664
 --------prognosis of.........   678
 ----sub-acute, symptoms of...   666
 ----treatment of acute and sub-
   acute ......................   684
 ----cervical, described........   672
   — chronic, of the hands.....   669
   -------of hip-joint..........   669
   ------symptoms of.........   667
   ------treatment of.........   6S9
   — prognosis of chronic  and
   sub-acute...................   678
   — feigned..................i. 1036
   — gonorrhoeal, description of.   672
   ------treatment of.........   698
 ----periosteal, described......   671
 Rhus Toxicodendron, poisoning
   by.........................   391
 Rhythm, or frequency, of pulse.   601
 Ribs, lateral depression of......i 307
 --------prominence of....... i 307
 Rickets in adults,  described....   711
 ----appearances  after  death
   from....................... 706,7
 ----Bibliog. and Refer........   711
 ----causes of................   707
 ----complications of..........   705
 ----description of...........702-705
 ----diagnosis of..............   707
 ----nature of................   708
 ----prognosis of..............   707
 ----synonymes and definition ot   702
 ----prophylactic treatment of.   709
 ----treatment of.............   709
 --------with reference to the
   state of the urine............   709
 ----of the urine in...........   705
 Ringworm, description of......ii. 208
 Roseola.  See, also, Rose-rash.712-714
 Rose-rash,  Libliog. and Refer..   714
     causes of.................   714
     description of............712, 13
     diagnosis of..............   713
     forms or species of.......712-713
     synonymes and definition of   721
     treatment of.............   714
 Rottlera tinctoria,  the powder of
   its capsules, a remedy  against
   taenia.   See,  also,  Kamala-
   powder.....................  1.555
 Rubeola, Bibliog. and Refer. ..   716
  — description of............   715
  — relations of, to measles and
   scarlet fever................   715
  — nature of................   716
  — synonymes and definition of   714
  — treatment of.............   716
 Rumination,  human,  Bibliog.
   and Refer..................719-20
  ------causes of............   719
 --------literary history of ... 716,18
      — symptoms  of........   71s
      -—■ treatment  of........   719
   -----synonymes and defini-
   tion of.....................    716
 Rupia, causes of..............    720
     synonymes and definition of   720
     description of............    720
     diagnosis of..............    720
     prognosis of..............    721
     treatment of.............    721
     varieties of, described.....    720
 Rupture of coats of aorta.......   i. 87
 ----of the brain.............. j. 277
 --------. congenital...........i. 277
 ----of the heart..............jj. 257
     lesions producing.........ii. 25S
 ---partial, of the heart.......ii. 259
----of valves of the heart.....ii 259
--------causes and symptoms
  of-.........................ii. 259
Salines, of their use in phthisis.  1272
Salivary secretion, as a symptom
  of disease...................  jqt§
Salivation from mercurials....'.'   453 
1614          SA
INDEX.
SE
                                                                       ] Scrofula and tubercles, of their
                                                                   7501  identity....................   *-0
                                                                   7;;7----and tubercles, synon. and
inebv        ".TT"" .7.7.7.    3S4----treatment of............753-763   definit. of..................   797
iuy vy ......;J_  -__tu_,__                .^ita™„.i«         7,-,> :;____Bibliog. and Ref er........837,9
Salivation, diagnosis of.......456, 457 Scarlet fever,  immunity  from
----treatment of.............45S,9j  second attacks of............
Salts, corrosive alkaline, poison-       ----the sequelae of
----earthy, in urine, patholog-      ,--------of its sequelae........ 702,3
  ical relations of.............   1332
----metallic, poisoning by.....    3S4
Sanitary measures, objects of ..    263
Santonate of soda, advised for
  Ascaris lumbricoide3........   1554
Santonine, recommended for As-
  caris lumbricoides...........   1554
SapoOlei Crotonis Tiglii.F. 668. Ap. 26
----Terebinthinae.....F. 669. Ap. 26
----Terebinthinata .. .F. 670. Ap. 20
Sarcina ventriculi, vomitings at-
  tended by..................   14S7
Sarsaparilla, of its use in syph-
  ilis.........................   14s"
     curative
----preservative.........   7531
types aud  irregular forms
                                          ind tuberculosis,  regimen
                                       and diet in.................   S36
                                     Scrofulous  taint  influences the
  of.."."............~..........   727'  course, &c, of other diseases.   822
----treatment of the  irregular       !----treatment of.............828,30
  forms of....................750, 00 Scurvy, appearances on dissec-
----state of the urine in......   741   tion........................   S43
----with suppression of urine..   732----Bibliog. and Refer.........S56,8
----synon.  and definit. of.....   725----chemical  analysis of the
----anginose or  inflammatory,       I  blood in....................   843
  described......".............   729----exciting causes of........   848
---------treatment of........ 750,71----■ predisposing causes of.----845-8
____latent or masked.........   73-.'!-----• complications of..........   844
----malignant, described.....   730----description of............   841
Sausages poisonous effects of ..    42S1
Savine, poisoning by..........    390
Scalp, lesions of the...........  i 508
----syphilitic affection of.....   1468
----secondary syphilitic affec-
  tions of.....................   1468
Scarlatina  maligna,  treatment
  of..........................  75?, 9   tion of.....................ii. 1012
Scarlatina rheumatica,  Bibliog.        Scirrho-cancer, described.....769-779
  and Refer..................    724 Scirrho-cancroid growths, varie-
----causes of................    7231   tie3 of......................    709----treatment of."............  S54,6
----in children...............    7231 Scirrhous stage of cancer......  i 327 Sea-coast, considered in relation
     description of............  722,3 Scirrhous   and  other  morbid      |   to phthisis................1277,82
         treatment of.........  73s, '.<'----• diagnosis of..............   844
     mild form of.............    7'29 [----complicated with diarrhoea
---------treatment of.........    755J   and dysentery..............   S44
----description of regular.....    720 —- historical sketch of.......   839
---------of the several stages of 720, 7----■ nature of................   850
Scherlievo, syphilis of.........   1475----of old age, described......   606
Sciatica, synonymes and descrip-      .----means for  the prevention
                                       of..........................S50-54
                                       — prognosis of..............   s45
                                          synon. and definit. of.___   S39
----modifications of..........   723
----nature of................   724
----stagesof.................   722
----synon. and definit. of.....   721
----treatment of.............   724
Scarlet  fever, followed  by ana-
  sarca.......................739,40
----appearances  after  death
  from.......................   742
----Bibliog. and Refer........ 767, S
----of the blood in...........   741
----causes of.................   746
----predisposing causes of ... .74S-50
----complications of..........   733
----complicated with  convul-
  sions or coma...............   734
----intentions of cure for.....   755
----diagnosis of..............   744
----diseases consequent upon. .737-41
----followed by dropsy........739-40
---------by diseases  of the ear   738
----complicated with extension
  of disease to the.ears........   734
---------• with epistaxis.......   734
----■---- with  erysipelas,  gan-
  grene, &c...................   736
---------with  asthenic gastro-
  enteritis ....................   735
---------with  disease  of kid-
  neys.......................   733
     ----with peritonitis......   730
         • with asthenic pharyn
  growths, diagnosis of.......789,791 Sea-shore,  its  climate in  dis-
----and other tumours, defined   769J  eases....................... i 417
Scirrhus, or occult cancer...... i. 336,Sea-sickness, description of....  1509
----defined..................   769;----nature of................  1569
----of the liver...............ii s;i----pathology of.............  1509
----structure of..............   77s----prognosis of..............  150D
----treatment of............. i 340!----the remedial influence of..  1510
Sclerotitis.    See  Ophthalmia       ----treatment of.............  1512
  sclerotica...................i 1010 Sea-voyaging advised for phthi-
----arthritica, described......i 1013   sis.........................
---- rheumatica..............i 1012JSeasons and weather  disposing
Scolex, definition of...........  1521
----of Taenia, passing into ac-
1277
  to phthisis..................  1232
Secale cornutum, effects of.....   476
tivity......................  1525,Seclusion  of  the insane, how
                                     should it be carried out ?.....ii 592
                                        necessity of..............ii. 591
     of Bothriocephalus  latus,
  described...................  1526|
----of Tasnia solium, described  1528 Seclusion or quarantine, advan-
Scorbutus.   See, also. Scurvy. 839-8561  tages of, during pestilences ..   275
Scrofula.  See, also, Tubercles 797-S37, Secondary  syphilitic  eruptions
  — causes of, acting  chiefly         described...................  1467
  during early life...........S03-S10---------disease, diagnosis of..  1468
  — associated alterations with   823, Secretion  and  excretion, when
                                     '  excessive, causes of phthisis..  1239
                                 54!)----when excessive must be re-
                                 SlOl  strained....................  1139
                                     Secretions and productions, ad-
809
----relation  of,  to  cachectic
  nephritis...................ii,
----concurrent causes........
----climate,  occupations, <fec,
  causes of...................
----chemical composition of its
  structure ...................
----the several means of cure
  advised for.................S30-5
     of  the diathesis or taint of 70S, 9
816
gitis.......................    734----diseases allied to, attacking
       - with  disease  of  the
 pharynx and adjoining parts.
--------with  diffusive inflam-
 mation ofthe cellular tissue..
--------with pleuritis, peri-
 carditis, &c.................
--------with  asthenic pneu-
 monia......................
   ■ treatment of its complica-
821
S01
      the scrofulous diathesis.
73-^j----transmission of, to the fce-
   |   tus........................
733----caused  by  defective  food
   |   and air....................803-S07
730----hereditary nature of......    S07
   !----diseases of parents causing    802
730]----causes of, appertaining  to
      one or both parents..........    S00
802
  tions.......................  760, l|----gouty and aged parents be
----absence of the eruption of.    72*.  getting scrofulous children...
----the  appearances  of  the      \----mercurial cachexia  ofthe
  eruption of.................    T'Js>  parent causing..............   802
----without eruption.........    731----pathogenesis of...........   817
----forms of,  depending upon      '----of the patholog)- of......S11-S17
  states of vital power.........    729----is  it more prevalent  now
----literary history of........    725,  than formerly ?..............   826
 — of the period of incubation of   751----prevention of.............   826
----followed by disease of the
  kidneys, &c.................739-40'.
   - complicated  with asthenic
 laryngitis..................
— followed by  disease of the
 parotids....................    741
— specific poisons of........ 746,7
    prognosis of..............    745
■ causes of the taint of___799-S10
■ chief characters of its taint
----syphilitic taint ofthe pa-
      ventitious to the ceconomy... i 074
      — adventitious  to  the situa-
      tion ........................i 670
      —- alterations of,  depending
      upon  organic nervous influ-
      ence ....................... L 667
      — excrementitious, are under
      the influence of the  organic
      nervous system............. i. 668
      — of promoting the, in fever, i. 1077
      — misplaced................ i 670
      — morbid, susceptible of or-
      ganization..................i. 677
      — recrementitious, under the
      influence of the organic nerv-
      ous system................. i. 66T
    ----and exhalations, transform-
      ations of................... i. 669
    Sedatives, mental  and physical,
      enumerated................  1145
    ----in cases of insanity.......ii 612
    Sedentary  habits  and  occupa-
      tions cause disease.......... i 144
    Sensation, paralysis of.........    12
    ----and sensibility, signs of dis-
      ease furnished by...........  1072
79S|---------various perversions of 1072,3
    Sense, organs of, causes of dis-
      ease acting on.............. i 654
                                    1067
802
• of the propagation of.....  747, R--------medicinal
  rent causes
----treatment of its developed      I Senses, symptoms  furnished by
  fonns......................    829'Sensibility, conscious  or active.
--------hygienic............826, 2s----forms and modes of.
         local................   835
remarks  on  remedies ad
----mesenterica.  See, also, Me-
82S
vised for..................763-7661  senteric disease............. ii 983
inconscious or passive.....     41
organic, active, and passive     41
lesions of, in insanity, .ii 502-505
morbid, of the uterus.....   1361 
                SE

Sensibility and sensation,  their
  sympathies, &c.....           1052
Sensitive and motor powers "inl
  fluenced by different columns
  of the medulla spinalis.          38
Sentiments and feelings, as c'a'u's".
  ing disease...............   i 655
Septic  Pestilence.   See Pestil
  lence, Septic.............       217
Sepulture, viewed as productive
  of pestilence and disease.....   107
Sequelae of measles described...' ii 943
----of scarlet fever described ..   737
--------treatment of.........   762
Sero-enteritis.   See  Enteritis',
  description of...............ii. 664----definition of.............   875
Serous and synovial membranes   858----of excessive............     878
— surfaces, adhesions of.---  i 42----phenomena often attending
Serpents,  poisoning  by,  symp-        awakening from............   878
  t°ms of.....................478, 80----influences the pulse.......   602
      — antidotes  and  treat-      Sleeplessness, Bibliog. and Ref.
             INDEX.

Skin, functional alterations of.,
----functions of, as signs of dis.
  case.......................1062-4
----affections of the sebaceous
  glands of the...............    867
----hesmon-hage from the.....  ii. 87
  ------causes and history of.  ii. 87
  ------phenomena and treat-
  ment of....................  ii. 88
----organic lesions of the ..... 864,8
Sleep, accession  of, may be at-
SP
1615
863 Small-pox, semi-confluent.....   890
    ----discrete, eruption  of, de-
      scribed .....................   888
    --------modifications of......   889
    ----distinct,  or  benign,  de-
      scription of.................   8S5
    ----distinct,  the   successive
      stages of................... 886-8
    ----description of natural.....   885
     — after vaccination.........   890
             notices respecting....  1424
tended by morbid phenomena   8781 Smell, symptoms furnished by .  1071
   causes and accession of...  877,8 Smoking opium, effects of......   408
   circumstances  favourable
and unfavourable to.........   877
  ment of....................480,1
Serum infiltrated into the tex-
  tures of the heart...........ii 250
----in the urine..............  1335
Sex, as predisposing to disease.. i 646
---influence of, on the pulse..   601
Sexes, comparative liability  of
  the, to tuberculosis..........   825
Sexual organs, signs and symp-
  toms furnished by the.......  1097
----of female, signs furnished by  1098
     definition of..............   875
     during pregnancy........   504
     ----treatment of.........   504
 ---treatment of....
----complete, noticed
----partial, noticed...........   879
Sleep-waking, remarks  respect.
  ing........................    41
Small-pox,  with various abdom
  inal complications...........   984
     of second attacks of.......   905
    sympathies evolved by... 1053,55!----Bibliog. and Refer___.... 920-22
Shaking-palsy, description of...    25----efficient causes of.........  901,2
     treatment of
Sheath of nerves, rheumatism of   671
Shingles, description of........ii 267
Ships of war, protection of, from
  pestilence..................    273
Shock, Hibliog. and Refer......    863
----causes and phenomena of. 859,60
----description of;...........    859
----diagnosis of..............    861
----forms of.................859,60
----of the nervous system caus-
  ed by parturition............    535
--------treatment of........    537
----prognosis of..............    861
----treatment of.............    862
902

896
----predisposing causes of
----characters ofthe local affec-
  tion and fever of............
----with contamination of the
  circulating fluids............ 892,3
----complicated with  cerebral
  affection....................   893
----complications of.......... 891-5
----with bronchial and pulmo-
  nary complications..........   893
----with pleuritic and  cardiac
  complications............... 893,4
----treatment of the complica-
  tions of.....................   915
   causes of death from.
— diagnosis of.
----vital or nervous, defined ..   858
Sialogogues, enumeration of ...  11461----appearances of,  on dissec
Sibbens, description of.........  1473   tion........................   897
Sighing, as a symptom........  1095----epidemic prevalences of...   904
Sight, defects of, feigned......i. 1036----without eruption.........   889
Signs and  symptoms furnished       ----treatment during the prog-
  by the attitude  and counte-         ress of eruption.............   913
  nance......................  1057--------of the secondary fever
--------by the appearance of      |  of..........................   913
  the body...................   1057
Silver,  nitrate of, poisoning by.    3S8
Singultus,  description  of.  See
  Hiccough...................ii. 271
Sinking after parturition.......    540
Sinuses of the brain, lesions of..  i. 200
---of dura mater,  inflamma-
  tion of......................   1441
----of the vertebras, effects  of
  congestion of...............     40
Sites of  tumours  and morbid
  formations, respecting the ...    789
— in the foetus.............    895
— historical sketch of.......    883
— circumstances which favour
 and which oppose  the  infec-
 tion of.....................  903,4
— infectious  and contagious
 influences of................901-3
— treatment of the initiatory
 fever of....................    911
— inoculated, course of......    910
-------treatment of.........    917
    inoculation of the........905-910
Sivvens, description of.........   1473,----associated with other exan
Sketch, historical, of treatment          thematous maladies.........   895
  advised by authors for phthi-       |----complicated with  affection
  sis........................1240-50   of the mucous surfaces......   891
Skin, of absorption from.......   i 27:--------with ophthalmia.....   892
----alterations  of its  appear-       ----prevention of pitting by . .916,17
  ances and structure.........    864|----prognosis of..............   899
----bronzing of, connected with
  lesions of the supra-renal bod-
  ies........................1565-71
----changes of the colour of...    865
----changes in the texture of .    865
----affections of the cuticle and
  nails in diseases of..........    868
----diseases ofthe, Bibliog. and
  Refer.  .....................    874
----natural methodic arrange-
  ment of diseases affecting the 868-72
----classification of the diseases
  ofthe......................S68-74
________by Dr. J. II. Bennett.    S74
________by M. Rayer........    873
    . diseases of,  in connexion
with gastro-enteric disorders, ii. 33,----confluent, symptoms of.
          circumstances   influ-
  encing .....................   899
----pustule, described........   8S8
----treatment   of  petechial
  states......................   915
--------of the confluent states
  of..........................   914
----in the pregnant and puer-
  peral states..................   895
----in puerperal states,  treat-
  ment of....................   916
----synonymes and  definition
  of..........................   883
----with affection of the  cellu-
  lar tissue...................    891'----as signs of disease,
----treatment of.............    910'Specific causes of disease
8891-
 ----tobacco, injurious effects of  446
 Snakes, poisonous, their effects.478, SO
 --------antidotes  and  treat-
   ment ......................430,81
 Sneezing, as a symptom.......  1096
 Snuff, hurtful effects of........   446
 Social conditions causing insan-
   ity.........................ii. 572
 Softening of bones............ii. 1057
 --------treatment of........ii. 1057
 ----of the  brain.............. i. 292
 ---of the  digestive  canal.....i. 629
 ----of the  heart, various kinds
   of..........................ii. 221
 ----consequent  on  inflamma-
   tion........................ii 444
  — of the  pancreas...........     8
     of structures.............   922
     ----Bibliog. and Refer.  ..   925
  — grades and extent of.....922, 3
  — pathological causes.......   923
  — pathology of.............923-5
  — therapeutical indications  as
  to.........................   925
 Sol-lunar influence on disease  .. i. 650
 Solutio   Belladonnas  Ex-
  tracti...............F. 931. Ap. 34
  — Gambogiae Alkalina
                       F. 932. Ap. 34
  — Ilydro-Sulphatis Cal-
  cis..................F. 933. Ap. 34
 ----Iodinii (Lugol.)___F. 071. Ap. 20
  — Iodinii Caustica (Lu-
  gol.) ................F. 072. Ap. 26
  — Iodinii  Rubefaciens
  (Lugol.).............F. 673. Ap. 26
  — Morphias Hydrochlo-
  latis................F. 674. Ap. 26
  — Morphias Sulphatis. F. 675. Ap. 26
  — Refrigerans.......F. 934. Ap. 34
 Somnambulism,  remarks  re-
  specting....................    41
 Somnolency and sopor, feigned.i. 1036
 Soporifics in cases of insanity .. ii. 009
 Sorbefacients, enumeration of..
 Sounds, vocal, remarks respect-
  ing ........................
 Southeast of France, climate of.
 Southwest   coast  of  England,
  climate of.................. i 412
 Spain, climate of  south of,  ad-
  vised for phthisis...........  1278
 Spasm,  Bibliog. and Refer.___   933
 ----cautions  against blood-let-
  ting for....................   931
 ----efficient causes of........   928
 ----exciting causes of........   928
 ----predisposing causes of___   928
 ----congestive states of, their
  treatment..................  930
 ----definition of.............  926
 ----diagnosis of..............  929
 ----choice of emetics for......  931
 ----inflammatory, treatment of  931
 ----of intestines, symptoms of. ii. 684
  — of  involuntary and volun-
  tary muscles...............   928
----of involuntary structures..   927
  — of   the  oesophagus,  de-
  scribed ....................ii. 1050
---■ prognosis of..............   929
----of purgatives for.........   931
  — treatment of.............930-32
  ------with reference to path-
  ological causes.............. 932,3
  — varieties of, described.....   926
  — of voluntary muscles......   927
          See, also, Convulsions i 479
                               1006
                              i 65G
1148
 1499
i. 413
their mode of action......i. 657 
1616          SP
INDEX.
ST
Spodalskhed, notice of........."'i^U
Speech, defects and loss of.---  1501
----hesitations of........... •  l^jO
----impediments of, described.  1500
________treatment of........  150o
Speech and voice, disorders of..    15
________treatment of the af-
  fections of..................  "I52'?la
Spermatorrhoea, causes of.....   4n>
____consequences of..........   489
____symptoms of.............   48S
____treatment of.............490-92
Spermatozoa in urine, appear-
  ances of....................  1337
_________pathological   indica-
  tions of.....................  1337
Sphincter ani, spasm of........ii. 149
Sphincters, palsy of...........    10
----their states in palsy......    44
Spinal column, diseases of.....933-50
---------causes of............  935-8
,----examination of...........   935
----inflammation and caries of.  952-5
---------treatment of........955-0
----nervous  or  painful  affec
  tions of.  See, also, Rachialgia   944
----pathological relations of...  933-5
Spinal column and cord, Bibliog.
  and Refer..................  973-0
Spinal cord, apoplexy of the---908,9
--------prognosis of.........   909
--------treatment of........   9G9
----concussion of, symptoms  of  951
--------lesions produced by..   951
--------treatment, of........   951
----the functions of......
----haemorrhage in or upon the  90.-
----inflammation of.  See, also,
  Myelitis....................   901
----appearances caused by in-
  flammation of...............   962
----inflammation  of  its  mem-
  branes.  See, also, Meningitis
  Spinalis....................957-61
----chronic inflammation of its
  membranes.................959, 60
--------following the acute  ..   900
--------illustrative cases of..   900
----structural lesions of......
--------of dura mater of.....
--------of its membranes ....
----mechanism  and  functions
   of..........................
»— states of, in rabies........   624
_— reflex  actions and sympa-
   thies of.....................     40
i----tumours of various kinds
   affecting the................    969
.--------diagnosis and progno-
   sis of......................  972,3
--------symptoms caused by.    971
--------treatment of........   973
 Spinal curvatures, described.. .938-40
 ----treatment of.............   940
 Spinal irritation, described ....  945,6
 ----treatment of.............94S-50
 Spinal meningitis, described ...  957, S
 ----chronic, described........    959
 --------symptoms of........   959
 --------treatment of........   964
 Spinal nerves, effects of press
   ure on the roots of the.......    40
 Spinal neuralgia, described ....   945
 ----treatment of.............   94S
 Spina Ventosa, noticed........ii. 1000
 Spine.   See, also, Spinal Column   933
 ----pathological relations of... 933-5
 ----curvature ofthe, described. 938-40
 --------causes of............   940
 --------consequences of......   939
 --------prognosis of.........   940
 ----curvatures of, of couches
   and instruments for......... 943,4
 --------treatment of........940-43
 --------treatment advised ...   942
 --------history of their treat.
   ment......................   940
 --------hygienic treatment ad
   vised for...................   943
 ----anterior curvature of.....   939
 ----lateral curvature of.......   939
 --------treatment...........   941
 ----posterior curvature of.....  938
 ----inflammation and caries of 952-4
Spiritus iEtheris  Hydro-
  chlorici.............F. 676. Ap.26
____Ammonias Anisatus F. 677. Ap. 26
____Castorei  Ammonia-
  tus.................F.678. Ap.26
----Castorei Comp.  ... F. 679. Ap. 26
____Terebinthinatus.. .F. 6S0. Ap. 26
         Comp........F. 6S1. Ap.26
Spirometer, of the use of the, in
  diagnosis of phthisis........   1197
Spleen, abscess of.............    982
    alterations of its colour ...    992
     ----fibrous structure.....    990
     apoplexy of the..........    993
----atrophy of...............    992
     Bibliog. and Refer........    995
     congestion of the.........    980
____cystic formations in the...    993
     diseases of the...........976-95
     ----causes  of............    978
     ----change of air, &c, for   995
---------diet and regimen for.    995
----enlargement of...........    991
----haemorrhage in the.......    993
----hypertrophy of...........    991
----induration  of............    991
----purulent infiltration  of....    992
----inflammation of, synonymes
   and definition of.  See, also,
   Splenitis...................   981
----morbid formations in.....   992
—_ organic lesions of the.....990-94
--------their causes.........    990
--------proximate  causes of
   the........................   993
G50--------diagnosis of.
900
900
906

 43
  toms of.
  -------treatment of........   981!
Splenalgia, definition and symp-
  toms of.....................   980
  — treatment of.............   980
Splenitis, causes of............   981
    in children...............   984|
    complications of..........   985
    ----treatment of........   9S8
    definition of..............   981
    diagnosis of..............   985
  — prognosis of..............   985
    remedies advised for......980-8
994
     ■ prognosis of.........    994
     • their treatment......    994
■ physiological pathology of.    977
. painful affection of.......
■ softening of the..........    991
■ structure and functions of.    976
Sthenic    inflammation    ^°'  „ „•
  scrihod.................."•4,?<h?2
____nature of................II. 462
Stimulants, enumeration and ar-
  rangement of...........-•-.■•  11*'
____and antispasmodics  in in- ^
  sanity.......................ii 613
Stomach, alterations of its capa-
  city........................  1016
 ---Bibliog. and Refer.......1017, IS
 ____cancerous disease of the,
  symptoms  of................  1013
 ________treatment of........  1014
 ____catarrh of................ii. 3S0
 ____diseases of the.........990-1017
 ________complicating phthisis.  1211
 ____disorganization of........  1010
 ----foreign  bodies in.........  1017
 ----haemorrhage from.....ii. 108-11S
 ----hypertrophy of its coats...  1016
 ----inflammation of.  See, also,
   Gastritis...................  1000
 ---------causes of............  1000
 ----organic lesions of, described
                             1008-16
 ----painful affections of the.
   See, also, Gastrodynia.......   997
 ----perforation  and rupture  of
   the,  from corrosive poisons,
   diagnosis of................   370
 ----perforation from ulceration
   of, described................  1008
 ---------treatment of........  1010
 ----rupture or ulceration of its
   coats.......................  1016
 ----softening of, treatment of.  1011
 ---------appearances after death 1010
 ---------described............  1010
 ---------its symptoms........  1010
 ----ulceration of,  described ...  1009
 ---------symptoms of........  1009
 ---------treatment of........  1010
tubercular matter in.
993-
wounds of................  1016
tumours of...............    992 Stomatitis, Bibliog. and Refer..   1024
turgescence of the........    980----definition and synonymes.   1018
    definition  and symp-       ----phagedenica, described ...   1022
                            980,---------literary history of ...   1022
-------symptoms  and  diag-
 nosis of....................1022,3
-------treatment of........1023,4
— mercurialis, described ....  1020
— pseudo - membranacea, de-
 scription  and diagnosis of....  1019
-------causes of............  1020
-------treatment of........  1020
— simplex, described.......  1018
-------treatment of........  1019
— ulcerata, described.......  1021
-------treatment of........  1021
— sequelae, treatment of.____   987 Stomatorrhagia. See, also, Hn?m-
— treatment advised by pre-      I   orrhage from the mouth.....  ii. 94
 vious writers...............   988 Stone-pock, described.........  i. 35
— chronic, described........   983 Stools, biliary, &c.............  1088
--------terminations of......   984!----blood discharged in.......  1088
--------treatment of........   987----signs of disease furnished
        and sub-acute, treat-         by.........................1084-6
  ment of....................   987
  — asthenic or consecutive, de-
  scription of.................   983
  — acute,  appearances  after
  death......................   982
---------symptoms of........   982
         terminations of......   983
         treatment of........986,7
Spurred Rye, injurious effects of   476
Sputa, signs  according to their
  states......................  1094
Squamous eruptions,  classifica-
  tion of.....................   520
----pathology of.............   520
----treatment of.............520-30
Stammering, causes of.........  1501
----considered...............  1504
----described................  1503
----treatment of.............  1506
States of morbid action........ i. 659
Statistics, fallacious, of vaccina-
  tion........................  1424
Sterility, causes of............ii. 373
----definition of..............ii. 309
----pathology of.............ii. 373
----treatment of.............ii. 374
----Bibliog. and Refer........ii. 376
Sternum, depression of........i, 367
     serous, puriform, fatty, &c 1085,6
Strabismus, description of.....    14
Stramonium, poisoning by.....  459
---------treatment of........  460
Strangulation of the intestines . i 038
Strangury, described..........  1353
Strobila  of Taenia solium de-
  scribed.....................  1528
Strobila of tape-worm described.  1526
Strongylus, systematic descrip-
  tion of the genus............  1536
----gigas, systematic  descrip-
  tion of.....................  1536
---------symptoms of........  1536
---------treatment of........  1551
Structural  changes produced by
  age........................
Structure,  softening of ...... \'. [
----of tape-worms described ..
Structures, areolar and  others,
  haemorrhage into............jj. 143
----their  contamination  from
  absorption of morbid matters
  into the blood...............
----diseased, absorption from''.
----morbid  states of, ought to
  be altered, <fec...............
Struma.  See, also, Scrofula .' iio
i. 51
 922
1526
i. 28
L29
1141
-•=37 
ST
INDEX.
SY           1617
Strychnia,   appearances  after
  death from................    4lg
Strychnine, symptoms oif poison-
  ing by.....................   4H
Stuttering, considered.........  1501
.----treatment of..........'...'  1506
Stye described............V.'.'.l. 1250
Sub-acute,  acceptation of.....'. i. 683
Succussion  of the  trunk as  a
  means of diagnosis..........  1024
Suckling.   See, also, Lactation, ii. 772
Suicidal insanity described, .ii. 636-48
Suicidal monomania...........ii 650
----Bibliog. and Refer........ii 655
----causes of its frequency.... ii. 644
----exciting causes of........ii. 648
----circumstances andoccasions
  of..........................ii 636
----predisponent circumstances
  of..........................a 643
----indications of cure ih.....ii. 652
----physical means of cure of.. ii 652
----described.   See, also,  In
  sanity, Suicidal.............ii. 636
----causes and occasions of ... ii. 636
----epidemic occurrences  of... ii. 640
----in  connexion with mental
  disease..................ii. 637-43
----pathology of.............ii 649
--------physiological........ii 649
----influence of systems of phi-
  losophy in causing..........ii 644
----prevention  and repression
  of........................ii 654,5
---prognosis of..............ii. 651
----simulated................ii. 643
----statistics of............ii. 646,8
----surveillance and restraint, ii. 653
----treatment of.............ii 652
Suicide, interesting  case of at-
   tempted..............'......ii. 641
----modes of committing......ii. 647
----by murderers.............ii. 642
----mutual or associated......ii 642
Sulphur, of its combinations  in
  phthisis....................   1273
----with magnesia recommend-
  ed for rheumatism..........    691
Sulphureted   hydrogen   gas,
  symptoms of poisoning by___.    473
Sulphurets, alkaline, poisoning
  by.........................    436
--------treatment of........    436
Suppositorium Opiatum F. 682. Ap. 26
----Plumbi Comp.....F. 683. Ap. 26
Suppressed haemorrhoids, re-es-
  tablishment of..............ii. 158
Suppression of the menses.....ii. 968
----of urine, described........   1353
--------symptoms of........   1354
--------treatment of........   1355
Suppuration.   See,   also,  Ab-
  scess .......................   i 15
---.in the  brain.............. i 262]----reflected from  the organs
----the result of inflammation, ii. 4371  of sense by the cerebro-spinal
----in  the  liver,   description      I  system.....................  1034
  of........................ii. 850-2.----of reflex, note on..........i. 918
        - consequences and term-      j----and  sympathetic  associa

                                                                    1055
 Sycosis,  diagnosis and  symp-
  toms of.....................  1025
 ----treatment of.............1026,7
 Sympathetic associations  of dis-
  orders, arrangement of.....1029, 30
 -------— described, &c.   See,
  also, Sympathy............1027-53
  — disorders of animal motion  1053
  -------of sensation.........  1052
 Sympathies influenced by age..  1035
 ---. circumstances influencing.  1035
  — healthy and morbid  classi-
  fication of.................1029,30
  — agency of  ganglial nerves
  in.........................1030-33
  — direct nervous............  1034
  — the media or channels of. 1030-35
  — depending on the sexual or-
  gans .......................1053,5
  — influenced by physical pow-
  er, occupations, &c..........  1035
  -------by race.............  1035
  — of sensation  and  sensibil-
  ity.........................1052,3
  — influenced by sex........  1035
  -------by temperament, &c..  1035
  — morbid, arrangement of.. 1029,30
  -------of the brain and di
  gestive organs..............  1040
  -------of circulation........  1038
  —■----special  consideration
  of..........................  1030
  -------defined..............  1030
  -------of the heart and lungs  1038
  -------media of............  1033
  -------of the  digestive or-
  gans, &c....................
  -------implicating the  diges-
  tive  and assimilating organs .
---------of the hepatic organs
  and  functions...............1036-7
  -------of the urinary organs
  and  functions...............  1037
---------of respiration___1038,39,40
  — reflex,   remarks   respect-
  ing .......................40,1034
----definition and synonymes .  1027
  — from morbid states of the
  circulation..................  1034
  — from contiguity..........  1034
  — from continuity of surface
  or tissue....................  1034
  — kinds of, described.......  1028
  — from indirect modes or me
  dia.........................  1034
  — from vascular communica-
  tions.......................  1034
  — direct and reflex, described 1027, 8
  —■ reflected ganglial.........  1034
  — reflected by  spinal nerves
  from ganglial  irritation......  1034
  — reflected   phenomena  of
  mind.......................  1034
1036
  inations of................ii. 850-2
Supra-renal bodies, Bibliog. and
tions of disease, Bibliog. and
Refer.
  Refer......................  1572; Symptomatic abscess..........   i 18
---functions of..............  1560 j Symptomatology, <tc..........1056-99
---diseases of, definition of ..  1561----Bibliog.  and Refer.....1099,1100
--------prognosis of.........  1562|----classification of...........   1057
        structural...........  15601 Symptoms  of  disease,  history
--------symptoms  and  diag-
  nosis of....................   1561
---■ lesions of, enumerated and
  described...................   1565
---.----connected with bronz-
  ing of the skin..............   1562
----structure of, described....   1565
----table of cases illustrating
  organic diseases of..........   1568
 of.........................1056-99
— caused by organic  lesions
 of heart....................W86,7
— furnished  by  the  female
 sexual organs...............  1
________by the male sexual or-
 gans.......................  1097
___prognostic  of   continued
 fevers...................t 1132-36
________treatment of........   1572----prominent,  in  fever,  of
Surface of  the body,  appear-
  ances of, in disease..........  1059
Swelling  indicates organic dis-
their treatment..........i 1077-79
   when urgent or distressing
ought to be palliated........  1143
  ease in the region of the liver ii. 873 Syncope  desoribed.  See,  also,
Swooning.   See, also, Fainting.i. 1024|   Fainting...................i. 1024
----feigned
                                       : ainting
                                1032!----treatment of, described---i. 1027
SycosisTcauses d.'.'.'.'.'.'........   1026 Synochoid fever, causes of.....i 1184
—- definition and synonimies .   1024----exciting causes of ...__.....1. 1167
---description of............   *"";«~
     III.                         I0'~
predisposing causes of..... i. 1166
j Synochoid fever, with bronchial
   complication................i 1163
----with cerebral complication i 1164
----with enteric complication, .i. 1165
----with gastric complication, .i. 1165
----treatment  of its complica-
   tion ........................i 1203
----definitionot.............i 1162
----description of............i 1162
----circumstances  influencing
   or modifying................i. 1168
----determining influences of. .i. 1168
----mortality in.............i 1187
----prognosis and terminations
   of..........................ill85
----severe or complicated.....I. 1163
----terminations of...........i 1186
----treatment of.............i. 1202
----mild or simple...........i 1162
Synochoid puerperal fever, ori-
   gin and symptoms of........   567
Synochoid and  typhoid fevers,
   organic lesions from......i. 1188-90
----■----  pathological  conclu-
   sions as to..................i 1190
Synopsis of classification of pois-
   ons ........................ 482,3
Synovial-membrane affected in
   acute and sub-acute rheuma-
   tism  .......................669-70
Syphilis, its antiquity contended
   for.........................  1459
----dates of its first appearance
   in various parts of Europe ...  1460
----Bibliog. and Refer........  1492
----concurring, aiding, or de-
   termining causes of.........  1479
----efficient cause of.........  1478
----predisposing causes of___  1479
----in children...............  1472
----diagnosis of..............  1476
----history of................  1459
----immunity  from,  produced
   by its inoculation...........  1489
----its importation  from Africa
   into Spain..................  1460
---------from America asserted
   and disproved..............  1459
---- of infants  and  children,
   treatment of................  1489
----inferences as to its origin,
   propagation, varieties, and pa-
   thology ....................  1481
----of its introduction into Eu-
   rope by the Moors  and Jews..  1460
----the use  of iodine in,  first
   prescribed by  the author.....  1483
----literary history of........  1459
----the origin of, independently
   of gonorrhoea...............  1461
----testimonies in support of its
   origin in Europe............  1451
----the prevention of its consti-
   tutional contamination......  1483
----prognosis of..............  1477
----synonymes and definition.  1454
----treatment of.............  1486
--------history of...........  1482
--------by inoculation.......   1489
----varieties of, described.....   1473
----African, described........  1474
  — ^Ethiopian, described.....   1474
  — congenital,  described.....  1480
  -------author's experience re-
  specting....................   1481
----constitutional, diagnosis of  1476
     ----of iodine for.........   1483
     ----treatment of.........   1483
     hereditary,  described.....   1472
     primary, description of....   1465
    ----diagnosis of.........   1465
     ----of mercury in........   1483
    ----treatment of........   1483
    ---------non-mercuriaL..   1485
     secondary, described......   1466
    .—— diagnosis of.........   1472
    ----effects  of............   1466
    ____symptoms of described  1467
    ----treatment of.........   1485
    ---------local...........   1487
    tertiary, diagnosis of.....   1472
--------symptoms of described  1472
      — treatment of.........   1487
Syphilitic eruptions described ..   1466 
1618          SV                              INDEX.                              TI
Syphilitic squamous eraptions,      [Tape-worms,  generation  and       Tl.erapout.es, principle of, fun-
  treatmentof................  1487   growth of...................  1526   damental..............11|M3
----ulcera in the female......  1465----of their treatment........  1550--------.general............112JM8
Syphilization, its history and de-      iTartar-emetic, poisoning by....   431 ■—----—special •;...••......""Prf?
  scriDtlon          .  .......  14S9 Tartaric acid, poisoning by ....   436 Thoracic duct, lesions of......ii 1041
____as a preventive and cure..  1489!--------treatment of........   436 Thorax, examination  ot   See
Syphiloid  affections described.      JTaste, symptoms furnished by..  1071   ^hP?t......................  i 366
  See also varieties of Syphilis. .1467-8 Taxus baccate, poisoning by ...   477 Thorn-apple, poisoning by.....   459
Syrupus Antimoniatus.. F.  935. Ap. 34iTeeth, signs of disease furnished--------appearances after death
___ Belladonnas......F.  684. Ap. 261   by.........................  1075   from.......................   460
____Morphia Acetatis .F.  6S5. Ap. 26 Teething, symptoms of........  i. 48 Thread-worm, description of...   1537
____Morphiae Sulphatis F.  686. Ap. 26iTemperament  and diathesis, as       ----forms, sex, &c, of........   1537
____Papaveris........F.  687. Ap. 20   predisposing to disease......L 647----symptoms of.............   1537
____Potassii Sulphureti F.  688. Ap. 20--------to insanity..........ii 557 Throat, Bibliog. and Refer.---1166,7
____Quinae...........F.  6S9. Ap. 26'----affecting the pulse........   601----structural changes of.....   1163
----Rhei Compositus.. F.  690. Ap. 26 Temperature, as predisposing to       j----diseases of the..........1150-66
     Sennas et Mannae.. F. 691. Ap. 26
     Sulphureti Sodii... F. 692. Ap. 26

                 T.
Tabes, definition of............  1100
----dorsalis, description of....  1100
--------treatment of........  1101
----mesenteries.    See,  also,  _
  Mesenteric disease..........ii  9S3
Taenia, inferences respecting the
  treatment of................  1544
----kamala-powder, <fcc., a reme-
  dy against..................  1555
----male fern and pomegranate-
  bark combined for...........  1553
----various anthelmintic medi-
  cines advised for............  1554
----methods  of  treating with
  kousso.....................  1564
--------with male fern......  1551
--------with    pomegranate.
  bark.......................  1652
--------with oil of turpentine.  1553
----various drastic purgatives
  advised for.................  1554
----symptoms of.............  1546
----treatment of, with  pome-
  granate-bark and male  fern
  combined...................  1552
----preliminary treatment  ad-
  vised for...................  1552
----cysticercal  stage of,   de-
  scribed.....................  1527
----development of...........  1525
----eggs of, notices of........  1526
----embryos of, described.....  1525
----their generation and growth  1526
----nature, origin, and develop-
  ment of....................  1526
----experiments with various
  medicines on................  1550
----metamorphosis of.........  1520
----six-hooked brood of.......  1525
----description  of their struc-
  ture........................  1528
----symptoms and diagnosis of  1533
----of their treatment........  1550
----vesicular condition of.....  1525
Taenia lata, description of.   See,
  also, Worms................  1530
----systematic description of..  1529
----ova and embryos of.......  1529
----physiological relations of..  1530
----of its production in man...  1530
Taenia mediocanellata, systemat-
  ic description of.............  1532
----structure of..............  1532
----variety of, from the Cape
  of Good Hope...............  1533
Taenia nana, description of.___  1533
----serrata, noticed..........  1527
Tenia solium, proofs of the con-
  version of the  brood of, con-
  tained in its eggs, into Cysti-
  cercus cellulosa.............  1531
----description of............  1531
----systematic description of..  1530
----stages of its development..  1530
----the mature state of,  de-
  scribed .....................  1528
----synonymes of............  1528
Tape-worm colony, or strobila,
  described...................  1525
Tape-worms, treatment of.  See,
 disease..................... i 649
— very high, as a disinfectant   275
— of respired air, as a sign of      |
 disease.....................  1092
   . of the surface of the body
— haemorrhage from........  ii 94
— inflammation of, diet and
 regimen for.................  1163
— treatment of inflammation
 of..........................1160-3
  in disease..................   1060----inflammation of, with plas-
  — of paralyzed parts........     28]  tic exudation...............   H55
  — and humidity of climates..  i 39S----organic lesions,  treatment
  ------cause diseases.......  i 1511  of..........................   H65
Tenderness, as a symptom  of       Throat and fauces, signs of dis-
  disease.....................   1074:  ease furnished by...........   1078
Testes,  syphilitic  affections  of       .Throat, relaxed sore...........     1
  the........................   1470(--------treatmentof........     1
  — rheumatism of the........    675----syphilitic affections of,  de-
Tetanus, appearances after death       j  scribed.....................   1469
  from.......................   1100----syphilitic ulceration of....   1469
         in the spinal cord  in       jThrush, Bibliog. and Refer.___   1171
         .....................   1107----causes of................   1167
                                1113----definition of..............   1167
                                1112'----forms of.................   1167
                                    ----history and appearances of 1168,9
                                         symptoms of.............   1167
                                         treatment of.............   1169
 fatal.
— exciting causes of........
— predisposing causes of ....
— ofthe cerebro-spinal system
 and membranes in..........   1107'
— description of............   1101 •
   . diagnosis of.............1108,12|Thymic asthma described.....ii 779
-------from spinal arachnitis   1108 Tic douloureux described.....ii 1008
-------from hysteria........   1108,Tin, method of prescribing, for
-------from rabies..........   11081  Taenia......................   1549
— of the ganglia and sympa-       |----chlorides of, poisoning by..   3SS
 thetic nerves in.............   1106 Tinea capitis, Bibliog. andRefer-
     duration of..............   1106
     states of injuries causing..   1113
  — external means of treating 1118,9
  — of various internal  means
  for.........................1120,4
  — internal and constitutional
  means of treatment of......1119-23
  — of successive and combined
  measures..................1124-26
  — pathological inferences and
  remarks respecting.........1115,16
  — period between the inflic-
  tion of its cause, and appear-
  ance of the malady..........   1114
  — prognosis of..............   1114
----of sedatives, narcotics, &c.,
  for........................1120-23
  — terminations of...........   1105
  — treatment of convalescence
  from.......................   1126
  ------local...............1117,18
  ------prophylactic.........   1120
Tetanus, acute, described......1102,7
         of the pulse in.......   1104
         spasms of, described..   1103
         the symptoms during 1102,5
Tetanus infantum, appearances
  in fatal cases of.............   1100
  ------causes of............   1110
  ------description of........   1109
Tetanus, sub-acute or  mild ....   1105
Tetanus and Trismus, Bibliog.
  and Refer..................   1126
  — definition of.............   1101
----relations  of, to other dis-
  eases......................mo, 12
  — treatment of.............   1116
  — general  remarks on  the
  treatment of...............1116,17
  ences......................   1175
----causes of................   1173
----means of cure advised for.   1174
----definition of..............   1171
----its forms described.......1172,3
----treatmentof.............   1174
Tinea decalvans, &c., described   1173
Tinea favosa, &c., described ...   1172
Tinea tonsurans, description of.   1172
Tinctura Acetatis Ferri Compo-
  sita.................F. 693. Ap. 27
----Acetatis Morphias  Compo-
  site.................F. 634. Ap. 27
----iEtherea Valerianae
                      F. 695. Ap. 27
----Aloetica Alkalina  (Saxon
  Ph.)  ...............F. 606.Ap.21
----Alkalina Potassae, .F. 697. Ap. 27
----Alkalina Stibiatae .F. 69S. Ap. 27
----Amara...........F. 699. Ap. 27
----Ammoniaca Alkalina
                      F. 700. Ap. 27
----Astringens.......F. 936. Ap. 34
----Balsamica......F. 701, 2. Ap. 27
----Balsami Tolutani .F. 703. Ap. 27
----Belladonnas......F. 704. Ap. 27
----Benzoica Anodyna F. 705. Ap. 27
----Brucias...........F. 706. Ap. 27
----Calami...........F. 70T. Ap. 27
----Camphorae Thebaiaceae
                      F. 708. Ap. 27
----Caryophyllorum . .F. 709. Ap. 27
----Cascarillae  Alkalina
                      F. 710. Ap. 27
----Castorei Alkalina .F. 711. Ap. 27
----Centaurii cacuminum
                      F. 712. Ap. 27
----Cinchonae Sulphatis
                      F. 713. Ap. 27
Theomania, described.........ii 324----Conii........    F  714. Ap 27
Therapeia  generalis, a sketch      '----Digitalis uEtherea F. 715. Ap. 2T
™of.....;.• • -,.....:•••:■•■■■ -H2S-4S----Diosmee crenatae . .F. 716. Ap. 27
Therapeutical agents, classifica-       ----Diuretica.........F. 717. Ap. 27
                                      "on of.....................H44_8
                                    Therapeutics of climate........i 411
  also Taenia.................  1550----circumstances retarding the
----described.   See, also,  Tse-      ;   progress of................1129-31
  •"»........................  1526i----principles of............1131  33
----development of...........  15261--------Bibliog.and Refer.. 1149,50
----Ferri ^Etherea___F. 718. Ap. 27
----Fructiis Vanilla? . .F. 719. Ap. 27
----Galbani Composita F. 720. Ap. 27
----Gallas............F. 72L Ap. 27
----Iodinii Fortior___F. 722. Ap. 27
----Iodinii Mitior.....F. 723. Ap. 27 
TI                              INDEX.                              TU           1619
Tinctura Lobelias inflates
                       F. 724. Ap. 27
---Myrrhas Alkalina.. F. 725. Ap. 28
---Nervosa (Riemerii) F. 726. Ap. 28
---Nucis  Vomicae___F. 727. Ap. 28
---Opii Camphorata.. F. 728. Ap. 28
---Opii Composita ... F. 729. Ap. 28
.---Phellandrii.......F. 730. Ap. 28
---Quinae Sulphatis . .F. 731. Ap. 28
---Quina; Sulphatis Acid.
                       F. 732. Ap. 28
---Rhataniae........F. 733. Ap. 2S
---Rhataniae Aromatica
                       F. 734. Ap. 28
---Rhei Anisata.....F. 735. Ap. 2-s
.---Rhodii...........F. 736. Ap. 2S
---Sabinae Alkalina .. F. 737. Ap. 28
—- Sennae Amara___F. 738. Ap. 28
___Stramonii........F. 739. Ap. 28
___Strychniae........F. 740. Ap. 28
 ___Tabaci...........F. 741. Ap. 28
 ___Tabaci Composita. F. 742. Ap. 28
 Tissue, fibrous, structural changes
   of........................i 1230-2
 _______inflammation of.....i 1233
 Tissues,  chondroid  fibrous, de-
   scribed .....................   782
 ___chiefly affected in measles, ii. 946
 ___metamorphosis  or trans-
   formation of................i. 671
 ---mutations of............. i. 671
 ___various  transformations of,
   described..........*.......i 672,4
 Tobacco, poisoning by, described   445
 ___Virginian,  poisoning by...   446
 Tongue, diseases of the.......1176-84
 --- diseases of, Bibliog.  and
   Refer......................  1184
 ----symptoms   furnished  by
   the........................1075-8
 ----organic lesions of the.....  1181
 ----cancer of the.............  1182
 ____cancer of, diagnosis.......  1182
 --------treatment of........  1182
 ----enlargement of the.......  1183
 --------treatment of........  1184
 ----haemorrhage from........  1183
 --------treatment of........  1183
 ----induration of the.........  1183
 ________treatment of.........  1183
 ----inflammation  of, defined.
   See, also, Glossitis...........  1176
 ----neuralgia of..............  1176
 --------treatment of........  1176
 ----paralysis of, described___  1176
 --------treatment of.........  1176
 ----ulceration  of the.........  1181
 --------treatment of........  1182
 Tongue and muscles of speech,
   palsy of....................     15
 Tonicity in connexion with irri.
   tability.....................ii 694
 Tonics in  insanity............ii. 614
 ----various, advised in scarlet
   fever.......................    764
  ---vegetable, mineral, and sa-
   line........................  1145
 Tonsils,   enlargement  of the,
   ftc. .'.......  ...............  1152
 ----inflammation of.  See, also,
   Tonsillitis,................1150-52
 ----signs of disease  furnished
   by.........................  1079
  ----structural lesions of the...  1103
  ----syphilitic affections of---  1409
  Tonsillitis, causes of...........  1161
Trachea and larynx, disease of,       | Tubercular formations in bones ii 1058
  complicating phthisis........   1212 Tubercular, syphilitic, eruptions  1467
Tracheitis infantum.  See, also,
  Croup......................  i 519
Trades, employments, and con-
  ditions predisposing to phthisis   1229
Transformations of the exhala-
  tions and secretions.........  i 669
  — of tissues................i 671
Transmission, direct and reflex,
  of irritation.................ii. 698
Transports,  emigrant  vessels,
  &c, protection of, from pesti-
  lence.......................   2"
Travelling,  in first stage  of
  phthisis....................   1253
Trematoidea, definition of.....   1540
Trembling, description of.  See,
  also, Tremor................   1185
Trembling-palsy described.....     25
Tremor, Bibliog. and Refer. ...   1188
     causes of.................   1185
     definition of.............   1185
Tuberculosis, means of cure ad-
  vised for..................•. 830-6
  — relative frequency of, at dif-
  ferent periods of life.........   825
----comparative liability of the
  sexes to....................   825
  — comparative manifestations
  of, in different organs.......   824
  — prevention of............   820
  — treatment of  its developed
  forms......................   829
  -------hygienic............ 826-8
  —----local................   835
                                         medicinal...........828-35
                                Tubes, Fallopian, non-puerperal
                                  inflammation of.............  1375
                                Tumefied leg, feigned.........i. 1036
                                Tumour, fibrinous, described ..   783
                                    chronic mammary........ii 934
                                    ----treatment of.........ii. 935
                                    malignant, of bones......ii 1059
description of............  ll85JTumours.   See, also, Growths..   709
diagnosis................  1187----changes in, during  their
                                  growth.....................   788
                                ----effects produced by.......   789
                                    course and progress of.....   789
                                    or growths,  reproduction of  788
                                    seats or localizations  of...   789
                                    in the brain.............. i. 273
                                         of various kinds.....i. 274
— sanguineous, in bones... .ii 1058
— in the heart..............ii 263
—- in the region of the liver,
 &c........................ii.  872,3
— of the mamma, adipose.... ii 934
     of drunkards.............   1186
     forms of.................   1185
     nature of................   1186 -
     connected with palsy.....     25 -
     prognosis of..............   1187 ■
     as a sign of disease.......   1065 -
     treatment of.............   1187 ■
     from intestinal worms ....   1186 ■
     hysterical, noticed........   1186 •
     inflammatory............   1186 •
     metallic, &c..............   1186
 —. paralytic, treatment of....     48 ■
____senile and paralytic......   1186--------scrofulous...........n. 934
Trichina spiralis, the  brood of--------cartilaginous or osse-
  Tricocephalus  dispar........   1538  ous.......-.-•••;••• • • • • •; • • ii* ™S
____cysts containing, described  1537---------cystic and hydatidic  . u. 936
____description  of............   1536----of the ovaria, encysted and
     development and seat of..   1537  other......................ii. 1065
                             -  1519--------malignant..........n. 1065
                                15371----of nerves..............ii. 1003,4
                                1537 j----various, affecting the spinal
                                      cord.......................   969
                                1538---------symptoms of........   971
                                1538----of the uterus, described...  1396
                                      -------diagnosis and  symp-
                                      toms of.....................  1398
Trichomonas vaginalis, described
Tricocephalus, synonymes of...
----systematic description of..
Tricocephalus dispar, synonymes
  of...........................
----systematic description of..
Trismus, definition of.........   1101
     internal treatment of.....   1119
----duration of..............   1151
----definition of.............   1160
----means of cure advised for .   1160
----symptoms of.............   1151
----treatment of.............   1160
Toothache, causes and pathology
  0f.....\. ................ii. 1009
Trismus nascentium, description
  of.............!?...........  1109
Trochisci Nitro-Camphorati
                      F. 746.  Ap. 28
Trochiscus Astringens. .F. 937.  Ap. 34
____Catechu Extracti.. F. 743.  Ap. 28
----Ipecacuanhas.....F. 744.  Ap. 28
----. Lactucas.........F. 745.  Ap. 28
____Potasses Nitratis . .F. 747.  Ap. 28
----Zinci Sulphatis .. .F. 748.  Ap. 28
Troops  and  armies,  protection
  of, from pestilence.......... 272-3
Tubercle, notice of............ i 676
Tubercles.  See, also, Scrofula 797-S37
     alterations associated with   823
     their chemical composition   816
----growth and  progress of ... 813-15
----pathogenesis of...........   SI 7
 ---the pathology of..........811-17
 ___structure of, described ... .811-13
 --------displayed by the mi-
   croscope....................815,16
 ---ofthe vascular action caus-
   ing ........................  . 818
 ----in the brain..............  »• 273
                                         in brains of children......i 274
                                      -  - in the heart..............ii- 252
                                    ----in the liver..............ii- 810
                                    ____in the lungs, distribution
                                      of..........................  m5
                                    ________healing  process pre-
                                      sented by..................  1219
____described   See, also, Odon---------seats ot---.........  i-io
-_ aescnDea.  see,    ,.....^ ^________8oftened and liquefied _ 1217

-—varieties' of'.'.'............ii- I009----'»» *he pia-mater.......... i. 259
TorulasVn urine...............   133.;_ in the pia-mater and arach-
Torulas cerevisias in urine......   1338:  noid   ••■••••.............\fj£
Touch  svmntoms  furnished by      I----in the uterus.............  14UZ
  thei sen*? of™ • •..........•  1072 .Tubercles and Scrofula,  of their
Towns and cities, protection of,
identity...........■.........   S20
        - treatment of.........  1399
---atheromatous, described ..  i 45
---various means advised for
  cancerous..................792-96
---desmoid fibrous, described.   782
----fatty, diagnosis of........   791
----fibrous cancroid, described   781
----hasmorrhoidal, described ii. 145-7
--------treatment of.........ii. 153
----malignant and non-malig-
  nant, described.............769-84
----melanoid................  i 45
----melicerous...............  i. 46
----neuromatous  fibrous,  de-
  scribed.....................   782
----non-cancerous, prognosis of  792
--------treatment...........   794
----scirrhous and others, anat-
  omy of.....................   778
---------defined.............   769
---------pathological relations   784
---------regimen and diet for.   795
---------treatment of........ 792,6
----steatomatous.............  i. 45
----sarcomatous, described....   781
----syphilitic, noticed........  1470
Turpentine advised for chorea.. i. 393
----spirits of, advised in hamia-
  gastric fever...............204-209
----prescribed in haemorrhages,
  &c.   See Haemorrhage, plu-
  ries ........................  ii. 81
_________for inflammation___ii. 475
  __advised  for  the   several
  states of puerperal fevers---587-93
----spirits of, in malignant pu-
  erperal fevers............... 588,9
____methods  of treating Taenia
  with the oil of..............  1553
Turpentines,  of  their   use  in
7™ ^Wee^"'™--'- 271,2'Tuberc"ular "constitution predis-         phthisis...................  1273
from pestilences .  .. • • • • •       '          t0 and innuence3 other       ---their use in typhoid fevers
Trachea  and larynx
  of.
ii. 770
poses
maladies
i 1211,24 
1620           TU
INDEX.
UR
Tcsk and cod-liver oil, first rec-      .Typhoid fever, of certain medi-       Urinary  Calculi,  Bibliog. and
  ommended by the author for         cincs in the treatment of---1.1215   Refer......................  <£m
  chorea               ....... i 393|----treatment ofthe pulmonary      :----from foreign bodies.......  134i
Tympanum' deafness from dis-      !   complication of.............i. 120S Urinary  deposits, of the fonna-
  ease of the cavity of.........ii. 185--------rational.............i 1206;   tion, &c.  See, also, Depos.ts-
________from diseases of.__ii 1S2, 5
Tympanitis, appearances in fa-
  tal cases....................  1291
----Bibliog. and Refer.......  1292
----causes of................  1290
----pathology of.............  12S9
----signs and symptoms of....  1291
----synonymes and definition of  1289
----treatmentof.............  1291
Tympanitic and emphysematous
  affections, feigned...........i 1030
Types and forms of disease ....  i 682
Types of ague described.......i 10S6
Typhus, causes of.............i. 1184
----concurring and determining
  causes of.................i. 1184,5
----of chlorates, chlorides, &c,
  in..........................i.1218
Typhus fever, description of .. .i 1182
----exanthematic, described . .i. 1182
----contagious...............i 1181
----modifications  and  compli-
  cations of..................i. 1183
----mortality in............i 1185,7
----organic lesions from... .i 1188-90
----pathological conclusions.. .i. 1190
----prognosis, terminations, &c,
  of..........................i 1185
----of purgatives, &c, in.....i. 1216
----stages of...............i 11S2,3
----treatment  of  the  several
  stages of................i 1214,15
----of stimulants in..........i. 1217
----of turpentine in..........i. 1214
----terminations of...........i 1186
----of tonics, &c, in.........i 1217
----of antiphlogistic treatment
  in..........................i. 1215
----of certain medicines in the
  treatment of.............i 1215-24
----treatment of the premoni
  tory and invading stages ... .i. 1214
----treatment of irregular forms
  of..........................i 1214
Typhus gravior, or true........i. 1181
Typhoid fevers and typhus, Bib-
  liog. and Refer...........i. 1228,30
Typhoid fevers,  of  chlorides,
  &c, in.....................i. 1218
----of cinchona and quinine in. i 1217
----defined..................i. 1168
----of external means for.....i 1224
----of the use of fermented liq-
  uors in.....................i. 1223
----of the use of opium in.....i 1222
----of petechia and exanthema-
  tous eruptions in............i. 1172
----of purgatives in..........i 1216
----of regimen and diet in___i 1224
----relapses from.............i 1172
----of various saline medicines
  in......................i. 121S,22
----sequelae of...............i 1172
----of stimulants in.......i 1217,22
----of tonics in..............i. 1217
----of turpentine in..........i 1224
----treatment of.............i 1202
Typhoid fever,  with  cerebro-
  spinal complication..........i 1170
--------treatment of........i 1209
----with congestive complica-
  tions .......................i. 1174
----with gastric  and enteric
  complications...............i. 1170
----with malignant characters.i 1175
----with petechias............i 1173
----with putro-adynamic char-
   acters......................i. 1173
-------saline...............i 1220
-------appropriate   to  the
 stages......................i 1207
-------of tympanitic disten-
 tion in.....................i 1211
— complicated, described... .1. 1170
  urinary....................1321-3
Urinary disorders, feigned.....i 1037
Urinary  organs, affections  of,
  caused by paraplegia........    19
     haemorrhage from......ii 122-7
     morbid sympathies of.....  1037
congestive...............i 1170 Urine, acids contained in.....1319,21
     treatment of its complica-
  tions.......................i 120S]
----mild, described...........i 1169
----nervous, state of..........i 1170,
----treatment of nervous com-
  plication ...................I. 1209
----treatment in the nervous
  stage......................i. 1207
  .— severe or low.............i 1170
  — treatment of the varieties
  of..........................i 1208
Typhoid fevers, of the  use of
  wine  and  other  stimulants
  in..........................i 1222
U.
1401
                                         albumen and scrum in....   1335
                                      — albuminous, after and dur-
                                      ing scarlet fever............741,2
                                      — and its deposits, Bibliog.
                                      and Refer..................   1357
                                      — blood  and its elements in
                                      the........................   1335
                                      — blood-globules in.........   1335
                                      — bloody, pathology and treat-
                                      ment of...................ii  123-7
                                      — calculi or concretions in,
                                      described.................1339-45
                                      — chylous, described........   1337
                                      — colouring matter of.......   1320
                                      — the  chemical composition
                                      ofthe.....................1318-21
                                      — and its deposits described
                                                                1314-38
                                      — of blue and black matters
                                      in the......................   1335
                                      — of organic matters in the..   1335
                                      — states of, in dropsy.......  i. 701
                                      — of epithelium in..........   1337
                                      — diseased excretion of the..   1353
                                      — of the clinical examination
                                      of..........................1321,2
                                      — gravel in, defined and ex-
                                      plained ....................   1339
                                      — of the specific gravities of.   1316
                                      — confervoid   and   fungoid
                                      growth in..................   1338
                                      — haematosine in the.......   1336
                                      — hydatids in the..........   1338
Umbilical vein, inflammation of 1441----containing oxalate of lime.   132S
Unguenti Chlorureti Calcis            ----mellitic.   See, also,  Dia-
Ulcer, corroding, of t'.ie os uteri.
  — sloughing yyphilitic, of the
  throat.....................   1469
Ulceration of the brain........  i. 265
----of the digestive canal.....i. 630
----of the heart..............ii. 222
----resulting from inflamma-
  tion........................ii. 438
----of  the intestines from  en-
  teritis ....................ii.  673,6
----of the neck of the uterus..   1367
----syphilitic, described......   1464
----of vagina................   1430
Ulcers, feigned...............i 1037
----syphilitic, in tho female...   1465
----primary   syphilitic,   de-
  scribed .....................   1404
                      F. 938. Ap. 34
Unguentum Antimonii I'o-
  tassio Tartratis, vel Fe-
  brifugum.......F. 749,50,1. Ap. 28
----Argenti Nitratis  .. F. 752. Ap. 28
----Balsami Peruviani F. 753. Ap. 28
----Belladonna?.....F. 754, 5. Ap. 28
----Calomelanos et Cam-
  phorae ..............F. 756. A j). 28
----Calomelanos cum Cani-
  phora...............F. 757. Ap. 2S
----Camphoras Composi-
  tum ................F. 75S. Ap. 28
----Comitissae........F. 759. Ap. 28
----Cupri Acetatis___F. 760. Ap. 29
----Deobstruens___F. 701,2. Ap. 29
----Gallae Opiatum .. .F. 763. Ap. 29
----Gallse Opio-Camphora-
  tum................F. 764. Ap. 29
----Hypochloridis Sulphu-
  ris .................F. 765. Ap. 29
----Potassii Iodidi___F. 766. Ap. 29
----Iodinii...........F. 767. Ap. 29
----Iodinii Opiatum  .. F. 768. Ap. 29
----Iodidi Hydrargyri. F. 769. Ap. 29
----Iodidi Plumbi___F. 770. Ap. 29
----Nervinum........F. 771. Ap. 29
----Populeum .......F. 772. Ap. 29
----Populeum Composi-
  tum ................F. 773. Ap. 29
----ad Porriginem. .F. 774,5. Ap. 29
----Sulphureti Iodini.. F. 776. Ap. 29
----Zinci Iodatis......F. 777. Ap. 29
Unnatural  positions cause dis-
  ease........................  i 150
Urea, sources, quantity of the..   1318
--------treatment of.........i 1211 Urea, uric acid and urates in the
   complicated with affection
 of the respiratory organs.....i 1170
— of the antiphlogistic treat-
 ment of....................i 1210
— treatment of enteric  com-
 plication ...................i 1210
       - in the stage of excite-
  blood productive of disease of
  joints....................i  238-40
Uric acid, source, &c, of......  1319
----and its combinations, diag-
  nosis of....................1322,3
--------pathological relations
 .of................  .........1324,5
ment.......................i 12071 Urinary  bladder,  diseases  of.      !____
       of the intestinal com-
plication  ...................i. 12091
  betes.......................i 583
  — morbid, feigned..........i. 1037
  — mucus in, its appearances.   1337
----of oily or fatty matter in..   1337
----states of, in organic diseases
  of the liver.................ii. 874
----pathological  relations  of
  blood, or its elements, in the. 1335, G
----original views of author as
  to the pathology of.........1314-16
----physiological and  patho-
  logical relations of the......13J4-18
----containing  the phosphates,
  characters  of..............1330,32
----phosphatic,  from diseased
  bladder....................   1334
--------pathological states and
  relations of.................1332-4
--------therapeutical  indica-
  tions from..................1334-5
----purulent matter in, its ap-
  pearances ..................   1336
----state of, in  rheumatism ...   676
--------in rickets...........   705
----salts contained in........   1320
----appearances ofthe, in scar-
  let fever...................   741
----serous or albuminous.....   1335
----signs furnished by........   1096
--------furnished  by its  ex-
  cretion.....................   1090
----quantity of Bolid  materials
  in.........................   1317
----spermatozoa  in,  appear-
  ances of....................   1337
--------pathological relations
  and indications of...........   1337
----suppression of............   1353
--------symptoms of........   1354
--------in scarlet fever......    733
--------treatment of........   1356
----of the tints of the........   1317
----containing  uric  acid and
  its combinations............   1322
     worms in the.............   1338
 See Bladder.............1293-1313 \ Uro-cystitis, definition of'......   1300
— palsy of.................    16|Urticaria, causes of...........   1359 
UR                             INDEX.                              VE            1621
Urticaria, complications of.....   1359
----description of............   1358
----diagnosis and  prognosis of
                             1359,60
----treatment of.............   1360
----varieties of..............   1358
Uterine appendages, their in-
  flammation after parturition .    566
----sometimes the origin of syn-
  ochoid puerperal fevers......    567
----diseases, feigned.........i 1029
----hajmorrhage during deliv-
  ery ........................ii 132
--------in the puerperal states  130-3
____phlebitis,  symptoms  and
  history of,  in  the puerperal
  state.......................568-70
Uterus, Bibliog. and Refer.....   1412
----cancer of, causes of.......1402-7
--------forms of, described ..   1403
--------symptoms of........   1405
--------treatment of........   1407
----changes in, after parturition   535
----tubercular degeneration of  1402
----descent of the............   1387
____deviations of, symptoms of  13SS
--------treatmentof........   1393
----displacements of the......   1387
----enlargement of the body of  1374
----fatty formations of the....   1402
----flexions of the........___   1391
 —,-----treatment of........   1393
 ----haemorrhage from......ii 127—10
 ----hypertrophy of its neck ...   1367
 ----treatment of  hypertrophy
   and induration of its neck ...   1381
 Uterus, inflammations of.  See,
   also, Metritis...............   1365
 --------complications of the..   1379
 --------treatment of........   1380
 -------- of its body.  See, also,
   Metritis, non-puerperal......   1371
 --------of its  cervix  in ad-
   vanced life.................   1370
 -------------after parturition
   or abortion.................   1370
     ---------during pregnan
Uterus, follicular polypi.......  13971 Variola.  See, also, Small-pox..   883
     mucous polypi of.........  1397----discrete, described........   885
    • complex polypus of.......  1398----sine eruptione............   8S3
    -----treatment of........  1398Vascular action, the states of, to
                                      be closely observed in connex-
                                      ion with vital power........  1134
. retroflexions of...........   1391
-----treatmentof........   1393]
 rupture of the............    542 Vascular  system, the  relations
  — cause of.............    542   of its diseases to cachectic ne-
                                           symptoms of........   543
                                           • terminations of......   544
                                           treatment of........   544
                                   ---spasm, pain, etc., of the,
                                    during pregnancy...........   499
                                  --------treatment of........   500
                                  ----sometimes  the  origin  of
                                    synochoid puerperal fevers...   567
                                  ----tumours of the, described .   1398
                                  --------symptoms of........   1399
                                  ---------treatment of........   1400
                                  --------diagnosis............   1399
                                  ----ulceration of the neck of the   1302
                                  ----syphilitic ulceration of the
                                    neck of.....................   1267
                                  ---------treatment of........   1267
                                  Uvula, elongation  of the.......      1
                                  ---------treatment...........      1
                                  ----relaxation of the.........      1
                                  ---------treatment...........      1

                                                   V.
                                  Vaccination, its benefits  some-
                                    what over estimated........   905
                                  ----Bibliog. and Refer.......   1427
                                  ----description of............   1414
                                  ----decadence of the protective
                                    influence of.................   1421
                                  ----fallacious statistics of.....   1416
                                  ----history of................   1415
                                  ----imperfect................   1422
                                  ----operative measures for___   1425
                                  ----the protection  from,  not
                                    always persistent...........   905
                                  ----partial protection of......   1422
                                  ----of revaccinating..........   1423
                                  ----notices of small-pox after .   1422
                                  Vaccine-lymph, of its preserva-
                                    tion........................   1423
 cy.........................   1370 Vaccinia, defined and described   1414
------------in the unmarried   1370----history, &c, of...........   1415
-------of its cervix and os,       \----nature of................   141S
 described...................   1365!—------inferences as to1......   1420
— gonorrhceal inflammation of  1336----protective influence of____   1420
— ----treatment of........   1387 Vagina,  Bibliog. and Refer. ...   1420
— inflammation  of its neck,
 changes consequent on......  1367
-------constitutional  symp-
 toms of.....................  1369
-------treatment of.......1379-S1
------------during and after
 pregnancy..................  13S4
— inflammation  of the  neck
 and mouth of, lesions conse-
 quent upon.................  1366
-------causes of__.........  1366
-------symptoms of........  1366
— inflammation  of its inter-
 nal surface.................  1371
     contraction and obliteration
  of..........................   1430
----discharges  from,  during
  pregnancy.................   499
---------treatment of........   499
----diseases to which it is lia-
  ble.........................   1429
----gangrene of the..........   545
Vagina,  inflammation  of,  de-
  scribed.  See, also, Vaginitis.   1423
---------symptoms of........   544
---------terminations of......   514
---------treatment of........   545
----chronic inflammation of the  1431
--------treatment of........  1384:----perforations of the
1430
    inflammation  of,  during
 pregnancy..................
--------treatment of........
   . specific inflammations of..
    ----rupture of the............   542
 500]---------symptoms of........   543
 500--------treatment of........   544
13861----ulcerations of, described ..  1431
Uterus, inversion ofthe.......   545i Vagina and Vulva, diseases of,
___.____causes of............   545|  described...................  1428
________symptoms and diagno-       1 Vaginitis, causes of...........  1429
  sis of.......................1394-6,----complications of..........  1430
________treatment of......545,1395!----consequences  of..........  1429
____involution of.............   1375J----defined and described.....  1428
____irritable, described.......   1361----treatment of.............  1430
________symptoms of........   1361,----acute, described..;.......  1429
_________nature of...........   1363
_________treatment of........   1364
____neuralgia of, causes of....   1362
_________described...........   1362
_________diagnosis and progno-
    lof.
  phritis.....................ii 747
----severe disorder of, in rela-
  tion to gastro-enteritis.......  ii 31
----changes in, causing haemor-
  rhage ......................  ii 74
Vegetable acrids, poisoning by .   3SS
Vegetable molecules,  injurious
  effects of................... i 16S
Veins, alterations of their calibre  1442
----cancer of the.............  1443
----diseases of the............  1436
----entozoa in...............  1451
----fatty, suety, or atheroma-
  tous deposits in.............  1451
----gaseous fluids in.........  1451
----inflammations of the.  See,
  also, Phlebitis..............  1437
--------treatment of........  1442
  — lesions of their coats......  1450
  — lymph found in..........  1448
  — obliterations and contrac-
  tions of....................  1450
  — ossific deposits in.........  1451
  — perforation and  ulceration
  of..........................  1450
  — pus found in.............  144S
  — structural  lesions  of, de-
  scribed.....................  1447
  — symptoms furnished by...  1437
Vena cava, inflammation of....  1441
     obliteration of............  1441
Vena portee, inflammation of...  1441
Veneesection, &c., of recourse to,
  in phthisis..................  1274
Venereal acne described.......  i 36
Venereal  diseases, Bibliog. and
  Refer......................  1492
  — defined..................  1454
  — their history.............  1459
Venous sinuses of the vertebrae,
  congestion of the............
Ventilation, requisite attention
  to, insisted upon............
Ventricles of the heart, organic
  changes of the..............ii  235
--------terminations and prog-
  nosis ....................... ii  242
--------treatment of......ii. 242,44
Veratria, poisoning by.........    424
--------treatment of........   425
Vermes, general description of.  1519
Vermination described........ 1514
Vertebrae, diseased, predisposing
  and exciting causes of.......    952
--------complications,  conse-
  quences, and terminations of.   954
--------duration and prognosis
  of..........................   955
--------treatment of........   955
---- inflammation and caries of 952-6
 --------regiminal treatment of   956
----symptoms and diagnosis of
  diseases of the..............   953
----tubercular  disease of......   953
Vertigo, associations and states
  of......................... 1495
----Bibliog. and Refer....... 1498
----causes of................ 1496
----conditions  of, their treat-
  ment  ......................  1498
 40

266
                            1362!----phlegmonous, described...   1429
' ^ll'its treatment........  1364( Valves of the Heart, rupture of
 non-puerperal diseases of
                                    definition of..............  1495
                                    description of............  1495
asthenic, described.......   1429----diagnosis of its morbid con-
____treatmentof........   14311  nexions...................1496,97
chronic, described........   1430----in connexion with insanity ii. 535
gonorrhoeal, noticed......   1429:----morbid relations of.......  1496
     treatment of........   1431'----pathological states occasion-
  the...........-■  #l   .
____morbid sensibility of.
____polypi of, symptoms .
_________treatment of....
____fibrous polypi of.....
_________symptoms......
                                          ing........................   1496
                                          -------regulating  its treat-
       the.............'....".......ii 259|  ment.......................   1497
1361'--------causes of............ii. 259,----prognosis of..............   1497
1361----symptoms of their disease      ----treatment of.............   1497
13961                           ii 212,13----varieties and states of___   1496
inns----treatment of  hypertrophy      | Vesicles,  or  simple cysts,  de-
139S   from  diseased...............ii 243,  scription of.................ii 295
1399 Varicella, description of....... i. 369;----Graaffian, disease of.....ii 1063 
1622          VI
INDEX.
ZY
Vinum Aloes Alkalinum
                      F. 778. Ap. 29
----Aloes et Sodeo Compositum
                      F. 779. Ap. 29
----Anthelminticum.. F. 780. Ap. 29
    . Diureticum Anti-arthriti
1547

1547
                                                                                                       1407


                                                                                                       1370

                                                                                                       1521
  cum   ..............F. 7S1. Ap. 29,   warm seas, advised for phthisis  1277'----Bibliog. and Ref er.  ..... ii. 1561
____Ferri.............F. 939. Ap. 29----in first stage of phthisis...  1253'----cause a peculiar cachexia..  154b
____Ferri Citratum .. .F. 7S2. Ap. 29----advantages of, in  pulmon-      ----causes of.............---  *»*<
____Ferri Comp.......F. 783. Ap. 29   ary disease.............i. 417----predisposing causes of ....  1S»H
____Quinm...........F. 7S4. Ap. 29 "
Viper, symptoms of its poison .. ii 478
--------antidotes and  treat-
  ment  ......................480,1
Viscera, lesions, of, after dropsy i 692
Visceral neuralgia............ii. 1013
----various forms of.........ii. 1013
Vital action, dynamic states of. i. 659
Vital power or force, of support-
  ing, in fever...............ii 1070
----its   influence on  haemor-
  rhage....................... ii 73
----dynamic states of........ i 659
----various morbid states of .. i. 666
----perverted states of........i. 665
Vital power, or influence, when
  altered,  occasions   diseased •
  states of fluids and solids .... i 666
Vitality,  states of, affecting the
  pulse....................... 596,8
Voice, auscultation of......... i 202
----losses of, described........  1500
Voice and speech, Bibliog.  and
  Refer......................  1504
----affections of,  considered...  1500
--------treatment of........  1504
----physiological view of......  1499
Volition, organs of, signs  of dis-
  ease furnished by...........1065,6
Volvulus, described.  See Beua i 432
Vomicae in the lungs in phthisis  1218
Vomiting considered as a thera-
  peutical agent..............  1505
----diseases in which it may be
  beneficial..................1505-6
----caution required in  ascer-
  taining the causes of........  1506
----from gastro-colic  fistula,
  diagnosis of................  1508
----from gastro-intestinal  fis-
  tula........................  1507
Vomiting  and retching, defivf-      |Womb, cancer of, treatment of.
  tion of.....................  1506,----diseases of the, description
____from  sea-sickness.........  1510'   and treatment  of.   See, also,
____primary or idiopathic.....  1510:   Uterus.....................
Vomits, enumeration of........  1146! Worms,  their  alternations  of
Voyaging,  in  temperate  and      |   generation
Vulva, abscess of..............  1440'.----first class of, noticed .....-•  J•>-'»
----Bibliog. and Refer........  1436----embryos of, strayed, noticed  15l£
____diseases of, described.....  1428----intentions of cure after the
----inflammations of. See, also,      I   expulsion of................  1547
  Vulvitis....................  1435----of the generation of.......  1619
----structural and other lesions       ----of their origin............  1519
  ofthe......................  1440----general pathology of......  1523
____pruritisof...............   498----general prognosis of......  1523
________treatment of........   498'----kamala,  preparations   of,
____sanguineous tumour of the   5411   remedies for................  1543
--------symptoms of........   541:----prophylaxis, or prevention
--------treatment of........   542|   of..........................
Vulvitis, consequences of......  1434!----means for preventing the
____defined and described.....  14321   development of the ova of ...
----treatment of.............  1435----general  view of the symp-
----catarrhal, described......  14321   toms of.....................  1546
____eczematous, described___  1433----local or direct symptoms of  1546
     erythematous, described ..  1433----sympathetic    phenomena
----erysipelatous, described...   1433
--------treatment of........   1436
----gonorrhoeal..............   1435
--------treatment of........   1436
----irritable, described.......   1432
----pellicular, described......   1434
----phagedaenic or gangrenous   1435
--------nature, <fcc, of......   1436
--------treatment of........   1433
----phlegmonous, described...   1433
----pruriginous, described ....   1432
     treatment of catarrhal, ir-
 caused by..................   1546
— treatment of.............   1547
— the treatment advised after
 their expulsion.............   1559
— direct or curative treatment
 of..........................   1548
— general principles of treat-
 ment  for...................   1524
— in  the urine..............   1338
— cystic, described.........   1535
-------their generation and
 growth.....................   1524
of the mechanism of......  1505 Water-hemlock, poisoning by .
  ritable, and pruriginous.....  1434,----human, definition of......  1518
  — ulcerative or sthenic......  1433,----intestinal, classification of.  1522
                                    --------described...........  1518
                                    --------emigration of........  1520
                                880|--------metamorphoses of....  1522
                                878----mature nematode, described  1540
                                SSOl----round, described..........  1543
                                602----treatment of tape-worm...  1548
                                    ----thread, described........1537-40
  globules of the blood  .......1044-5 Wounds, voluntary...........i 1037
Water-brash. See, also. Pyrosis 615-1S
                W.
Wakefulness, complete, noticed
----partial, notices respecting.
----treatment of.............
Waking influences the pulse ...
Waste and  metamorphosis  of
   from organic lesions......  1507
— from poisons, caution as to  1506
— during pregnancy........   501
-------treatmentof........   501
— attended by sarcina ventri-
 culi........................  1511
-------treatment of........  1513
— from sea-sickness,  treat-
 ment of....................  1512
465
Waters, mineral, notices of sev-
                                     eral advised for phthisis.....1274,5
                                   Weaning remarks respecting...   i 48
                                                                 ii 776
                                   Weed, symptoms and treatment
                                     of..........................    548
                                   West of England, climate*of ...  i 412
                                   West and southwest of France,
                                     climate of..................  L 413
    • from sympathetic irritation  150SI West Indies, climate of........i 415
--------treatment of........  1511 Western islands, climate of....  i 414
----viewed as a symptom.....  1507 Whooping - cough.   See,  also,
Vomitings, &c., treatment  of,        Hooping-cough..............ii 273
  when  caused  by fermenting      Wines and beverages in indiges-
  ingesta and drunkenness ....  1512  tion........................ii 397
Vomiting and retching, Bibliog.      I Womb, cancer of, its causes....  1402
  and Ref er..................  1513]--------described...........   1402
----considered...............  1505:--------symptoms of........; 1403
Xanthine, pathological relations
  of..........................
1326
Yawning, as a symptom.......  1095
Yaws, description of...........  1473
----their intimate relations to
  syphilis....................  1473
----the source df syphilis.....  1473
Yew-tree, poisoning by........   477

                 Z.
Zinc, poisoning by............   438
----chloride and sulphate  of,
  poisoning by........  .......   388
----oxide of, poisoning by.....   405
Zymotic diseases, enumeration
  and notice of.............  1663
The Editor's additions will be found under the various eubjeets.
END. 
 
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fr<fc
 
LIBRARY OF MEDICINE
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NLM009884192